Every finding on record at Skyview Springs Rehab and Nursing Center

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for eight of 34 residents in the survey sample; Residents #94, #11, #29, #97, #106, #23, #35, and #46. The findings include: 1. For Resident #94, the facility staff failed to follow the comprehensive care plan for the administration of diabetic related medications as ordered. A review of the comprehensive care plan revealed one dated 9/2/23 for The resident has Diabetes Mellitus. This care plan included the intervention dated 9/2/23 for Diabetes medication as ordered by doctor . A review of the clinical record revealed the following orders: 1. An order dated 7/27/23 for Humalog (1) 10 units twice daily, before breakfast and lunch. 2. An order dated 7/7/23 for Humalog, dose per sliding scale, before breakfast and lunch. (Resident #94's glucose level was 217. The sliding scale dose order included, 200 - 249 = 2 units). On 11/01/23 at 8:20 AM, the Medication Administration task was conducted with LPN #5 (Licensed Practical Nurse) for Resident #94. The following was observed: 1. Humalog 10 units, scheduled, was administered after the resident had breakfast. 2. Humalog 2 units based on sliding scale, was administered after the resident had breakfast. On 11/1/23 at 2:49 PM an interview was conducted with LPN #5. When asked if Resident #94's insulin was administered in accordance with the physician's order of before breakfast, she stated it was not, because it was administered after breakfast. She stated that the resident won't take it before breakfast because he is afraid his glucose will drop. When asked if the doctor was aware of this, she stated that the doctor was aware but that this was still the order, so it should have been given before breakfast. When asked if the care plan was followed if it documented to administer diabetic medication as ordered, she stated that it was not. When asked what was the purpose of the care plan, she stated it was to make sure all the goals are being followed and the resident's needs are being met. The facility policy Care Planning - Comprehensive Person-Centered was reviewed. This policy documented, 2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process . On 11/1/23 at 4:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Regional Nurse Consultant, ASM #4 the Regional [NAME] President of Operations, and LPN #1 the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. References: 1. Humalog is used to treat diabetes. Information obtained from https://medlineplus.gov/druginfo/meds/a697021.html 42183 2. For Resident #11, the facility staff failed to implement the comprehensive care plan for ADL's (activities of daily living). Resident #11 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: peripheral vascular disease (PVD), right AKA (above the knee amputation) and diabetes mellitus. The most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an ARD (assessment reference date) of 9/25/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired. A review of the MDS Section G,functional status, revealed the resident was coded as requiring extensive assistance for bed mobility, transfer, dressing and hygiene; total dependence for bathing. A review of the comprehensive care plan dated 2/3/23 revealed, FOCUS: Resident has an ADL self-care performance deficit related to weakness and right leg amputation. INTERVENTIONS: Provide supervision and cuing as needed with ADLs. Physical assist as needed with ADLs. A review of the ADL document in Resident #11's medical record revealed showers were scheduled for Wednesday and Saturday. Review of the August 2023 record revealed missing documentation on 8/23/23 and 8/26/23. Review of the September 2023 record revealed missing documentation on 9/6/23 and 9/30/23. Review of the October 2023 record revealed missing documentation on 10/4/23, 10/7/23, 10/11/23, 10/18/23, 10/21/23, 10/25/23 and 10/28/23. An interview was conducted on 11/1/23 at approximately 11:00 AM with LPN (licensed practical nurse) #4. LPN #4 stated the purpose of the care plan is to lay out the care that each resident needs. Asked if the care plan was being implemented if there was no evidence of showers/bathing, LPN #4 stated, No, it is not. On 11/1/23 at 4:32 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM #4, the regional director of operations and LPN #1, the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. 3. For Resident #29, the staff failed to implement the comprehensive care plan for dialysis care and fluid restriction. Resident #29 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: ESRD (end stage renal disease) and diabetes. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 10/10/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G, functional status, revealed the resident was coded as being independent for eating, bed mobility, transfer, walking and locomotion. A review of the comprehensive care plan dated 10/4/23 revealed, FOCUS: Resident has ESRD and receives Hemodialysis at dialysis center on Monday-Wednesday-Friday. INTERVENTIONS: Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols. A review of the physician's orders dated 10/4/23 revealed, Dialysis at (specify place) on Monday, Wednesday, Friday. Fluid Restriction 1500 ml Daily every shift Record. Shift Intake AND every night shift Record 24-hr Intake. Assess Dialysis Fistula/Graft to Right forearm for Thrill and Bruit Daily and signs and symptoms of infection every shift. Check dialysis port to Right forearm each shift. Keep dressing dry on bath days. Do not remove dressing, this will be done at dialysis. Every shift. A review of Resident #29's October 2023 MAR (medication administration record) and TAR (treatment administration record) revealed no documentation of assessment of the dialysis fistula/graft for thrill and bruit, and for signs of infection, for day shift on 10/5/23, 10/6/23 and 10/27/23. A review of Resident #29's dialysis communication book revealed missing communication forms from the facility to the provider for six of twelve dialysis treatments: 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/27/23 and 10/30/23. An interview was conducted on 11/1/23 at 10:00 AM with RN (registered nurse) #1. RN #1 stated the purpose is to define the goals and interventions for each resident. She stated if the documentation of fluid restriction, bruit, thrill and dialysis site are missing, the care plan was not implemented. On 11/1/23 at 4:32 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM # 4, the regional director of operations and LPN #1, the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. 4. For Resident #97, the staff failed to implement the comprehensive care plan for oxygen therapy. Resident #97 was admitted to the facility on [DATE] with a diagnosis of COPD (chronic obstructive pulmonary disease). A review of the comprehensive care plan dated 10/4/23 revealed, FOCUS: Resident has altered respiratory status/difficulty breathing related to COPD and wheezing. INTERVENTIONS: OXYGEN SETTINGS: Oxygen as ordered. A review of the physician orders dated 10/22/23 revealed the following: O2 at 2LPM (liters per minute) via nasal cannula to maintain oxygen at 90% or above. Every shift for Hypoxia. An interview was conducted on 10/31/23 at 1:53 PM with LPN (licensed practical nurse) #3. Asked to look at the oxygen setting for Resident #97, LPN #3 stated, It is on 2.5 liters. I checked it this morning and it is at the same setting. Asked if care plan is being implemented if the orders are for 2 liters per minute, and the care plan documents oxygen as ordered, LPN #3 stated the care plan is not being implemented. On 11/1/23 at 4:32 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM # 4, the regional director of operations and LPN #1, the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. 5. For Resident #106, the staff failed to develop the comprehensive care plan for weights and bedrails. Resident #106 was observed in bed with one quarter bed rails on both sides of the bed on 10/31/23 at 12:00 PM, 11/1/23 at 9:00 AM, and 11/1/23 at 10:45 AM. A review of the comprehensive care plan dated 10/6/23 revealed, FOCUS: Resident is at risk for alteration in nutritional status related to new admission/facility adjustment, CKD, diuretic use for edema. INTERVENTIONS: Weights per protocol. A review of the physician orders dated 10/6/23 revealed the following: Daily Weight x3 (times three days) days, Weekly Weight x4 weeks, then monthly. A review of the weight documentation revealed no evidence of a weight documentation on 10/16/23, 10/23/23 and 10/30/23. An interview was conducted on 11/1/23 at approximately 11:00 AM with LPN (licensed practical nurse) #4. LPN #4 stated the purpose of a care plan is to lay out the care that each resident needs. When asked if weights and bedrails should be on the care plan, LPN #4 stated they usually are. When asked if the care plan is completely developed if it does not include information regarding weights and bedrails, LPN #4 stated it is not. On 11/1/23 at 4:32 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM # 4, the regional director of operations and LPN #1, the assistant director of nursing were made aware of the findings. No further information was provided prior to exit. 31753 6. For Resident #35 (R35), the facility staff failed to implement the resident's comprehensive care plan for diabetic medication. R35's comprehensive care plan dated 7/22/21 documented, (R35) has diabetes mellitus. Interventions: Diabetes medication as ordered by doctor . A review of R35's clinical record revealed a physician's order dated 3/13/23 for Jardiance (1) 25 mg (milligrams) by mouth one time a day for type two diabetes mellitus. A review of R35's October 2023 MAR (medication administration record) revealed the same physician's order for Jardiance. On 10/9/23 and 10/10/23, the MAR documented the code, 9= Other/ See Progress Notes. Nurses' notes dated 10/9/23 and 10/10/23 documented the medication Jardiance was not administered and was on order. On 11/1/23 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the purpose of the care plan is to allow for the most personalized care of each individual resident, and all care plans are available for nurses' review to ensure they are implemented. LPN #4 stated medications should be re-ordered from the pharmacy when there is a five-day supply of the medication left. LPN #4 stated that if a medication is not available for administration, then the nurses should pull the medication from the facility backup medication supply, and if the medication is not in the backup supply, then nurses should update the physician and resident's family. On 11/1/23 at 4:41 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. Reference: (1) Jardiance is used to lower blood sugar levels for people with diabetes mellitus. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a614043.html 7. For Resident #23 (R23), the facility staff failed to develop a comprehensive care plan regarding the resident's PTSD (post-traumatic stress disorder). R23 was admitted to the facility on [DATE] with a diagnosis of PTSD. R23's comprehensive care plan dated 11/7/21 documented the resident uses psychotropic medication related to PTSD, but failed to document any further information such as goals and interventions for the resident's PTSD. A psychiatry note dated 10/16/23 documented, Additional supportive psychotherapy interventions: Insight-oriented Psychotherapy, 1:1 Supportive therapy, Relaxation Techniques, Active Problem Solving, Positive Feedback, Encouragement, Sleep Hygiene . On 11/1/23 at 9:53 a.m., an interview was conducted with OSM (other staff member) #4 (the social services assistant). OSM #4 stated the purpose of the care plan is so that staff knows about the resident and everything that is going on. OSM #4 stated R23 does not display signs and symptoms of PTSD, but she felt the care plan should explain more regarding the resident's PTSD, such as the cause of the PTSD and potential signs and symptoms such as nightmares and flashbacks. OSM #4 stated R23's care plan should include goals and interventions for the resident's PTSD, and this should be based on each specific individual. On 11/1/23 at 4:41 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. 27660 8.a. For Resident #46, the facility staff failed to implement the comprehensive care plan for administering oxygen per the physician orders. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 8/2/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. The comprehensive care plan dated 9/29/2022 documented in part, Focus: The resident has altered respiratory status/difficulty breathing r/t (related to) hx (history) of malignant neoplasm of lung, hx of smoking. Requires HOB (head of bed) elevated due to SOB when lying flat .Oxygen as ordered. The physician order dated 2/15/2022 documented, Oxygen therapy at 1 L/min (liters per minute) via nasal cannula every shift for SOB (shortness of breath). Observation was made of R46 on 10/31/2023 at approximately 1:30 p.m. R46 was lying in bed with a nasal cannula in place with oxygen being delivered. The oxygen concentrator flowmeter was numbered two to ten, with two being the first number on the bottom and ten being the top number on the flowmeter. There were no lines below the number two to indicate any level of oxygen below two. The ball was set at the bottom of the flowmeter. The top of the ball was touching the line for two liters per minute. A second observation was made of the R46 on 11/1/2023 at 8:28 a.m. The oxygen concentrator was set with the top of the ball touching the line for two liters per minute. The resident had the nasal cannula in her nose. A third observation was made of R46 on 11/1/2023 at 12:00 p.m. with LPN (licensed practical nurse) #5. When asked what the oxygen was set at, LPN #5 stated that it was on one. When asked the locationin of the line indicating one liter per minute, LPN #5 stated, I guess I screwed up. I thought that it was below two and if I could feel oxygen coming out, then it was at one. LPN #5 was asked how to set the flow rate of the oxygen. She stated the line of the prescribed rate should go through the center of the ball. When asked if the oxygen was set according to the physician order, LPN #5 stated it was not. LPN #5 stated the purpose of the care plan is to make sure the resident's goals, both short and long term, are being followed for them to get the best care. When asked if R46's care plan was being followed for oxygen administration, she stated it was not. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM #4, the regional director of operations, and LPN (licensed practical nurse) #1, the assistant director of nursing, were made aware of the above concern on 11/1/2023 at 4:32 p.m. No further information was provided prior to exit. 8.b. For Resident #46, the facility staff failed to implement the care plan for administering treatments per the physician orders. The comprehensive care plan dated, 5/16/2023, documented in part, Focus: The resident has an ADL (activities of daily living) self-performance deficit r/t (related to) Fibromyalgia, prior CVA (stroke) with left hemiparesis and left hand/wrist contracture. The Interventions documented in part, CONTRACTURES: The resident has contractures of the left hand/wrist. Provide skin care to keep clean and prevent skin breakdown. The care plan further documented, Focus: The resident has potential for skin impairment r/t dermatitis, incontinence, candidiasis (1). Left hemiparesis and decrease in mobility. The Interventions documented in part, Administer treatments as ordered and monitor for effectiveness. The physician order dated 5/22/2023 documented, Ensure rolled up washcloth to inside of left grip at all times, change washcloth daily or as needed if soiled, every shift for contracture, skin protection. Observation was made of R46 on 11/1/2023 at 8:27 a.m. There was no washcloth in her left hand. The resident stated sometimes the staff remembers to put it in there and sometimes they don't. A second observation was made of R46 on 11/1/2023 at 11:54 a.m. No washcloth was noted in the resident's left hand. The resident's hand was warm and moist. An interview was conducted with LPN (licensed practical nurse) #5 on 11/01/23 12:00 p.m. When asked if R46 is to have a washcloth in her left hand, LPN #5 stated another nurse is doing the treatments for the day. When asked how the aides are informed about what is needed for R46, LPN #5 stated most of the aides know about it. LPN #5 was asked why the resident had the washcloth in her hand. LPN #5 stated, It's because she has a contracture and gets yeast infections in that hand. LPN #5 stated the purpose of the care plan is to make sure the resident's goal, both short and long term, are being followed for them to get the best care. When asked if the resident's care plan for the washcloth in the left hand was being followed, she stated it was not. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM #4, the regional director of operations, and LPN (licensed practical nurse) #1, the assistant director of nursing, were made aware of the above concern on 11/1/2023 at 4:32 p.m. No further information was provided prior to exit.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide dialysis care and services for one of 34 residents in the survey sample, Resident #29. The findings include: For Resident #29, the facility failed to monitor for fluid restriction and intake, failed to assess for bruit and thrill at the dialysis access site, and failed to maintain a complete communication system with the dialysis center. Resident #29 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease) and diabetes. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 10/10/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being independent for eating, bed mobility, transfer, walking and locomotion. A review of the comprehensive care plan dated 10/4/23, which revealed, FOCUS: Resident has ESRD and receives Hemodialysis at dialysis center on Monday-Wednesday-Friday. INTERVENTIONS: Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow per protocols. A review of the physician's orders dated 10/4/23, revealed, Dialysis at (specify place) on Monday, Wednesday, Friday. Fluid Restriction 1500 ml Daily every shift Record shift Intake and every night shift Record 24-hr Intake. Assess Dialysis Fistula/Graft to Right forearm for Thrill and Bruit Daily and signs and symptoms of infection every shift. Check dialysis port to Right forearm each shift. Keep dressing dry on bath days. Do not remove dressing, this will be done at dialysis. every shift. A review of Resident #29's October 2023 MAR (medication administration record) and TAR (treatment administration record) revealed no documentation of assessment of the dialysis fistula/graft for thrill and bruit, and for signs of infection, for day shift on 10/5/23, 10/6/23 and 10/27/23. A review of Resident #29's dialysis communication book revealed missing communication forms from the facility to the provider for six of twelve dialysis treatments: 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/27/23 and 10/30/23. A review of Resident #29's October 2023 MAR (medication administration record) and TAR (treatment administration record) revealed no evidence of fluid restriction being monitored or documented. An interview was conducted on 11/1/23 at 10:00 AM with RN (registered nurse) #1. When asked where bruit, thrill and dialysis site assessments are documented, RN #1 stated it would be documented on the TAR. When asked where fluid restriction and intakes are documented, she stated it would be documented on the TAR. She stated if there is no documentation, then the services were not provided. On 11/1/23 at approximately 11:00 AM, LPN (licensed practical nurse) #4 stated the fluid restriction on Resident #29 was discontinued by the dietician, She stated she was going to talk with the NP (nurse practitioner) about this. When asked to provide evidence that the fluid restriction was discontinued, LPN #4 stated, Let me search for it. On 11/1/23 at approximately 1:30 PM, Resident #29 was asked if his fistula was checked. Resident #29 stated, Yes, they check the bruit and thrill. When asked if he takes a communication book with him to dialysis, Resident #29 stated, Yes, they put papers in it here and at the dialysis center. When asked if he was on a fluid restriction, he stated he was not sure about that. He added: I watch what I drink, though. On 11/1/23 at 4:32 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM # 4, the regional director of operations and LPN #1, the assistant director of nursing were made aware of the findings. ASM #1 told the survey team there is no policy for dialysis care. A review of the facility's policy, ,Resident Hydration and Prevention of Dehydration revealed: Physician orders to limit fluids will take priority over calculated fluid needs. The dietitian may refer calculated needs to the physician if restrictions potentially increase a risk for dehydration. Nursing will monitor and document fluid intake as ordered by the physician/practitioner or per facility protocol. The dietitian will be kept informed of status. The interdisciplinary team will update the care plan and document resident response to interventions until the team agrees that fluid intake and relating factors are stabilized or resolved. A review of the facility's dialysis contract with Resident #29's provider revealed, Facility will send to provider documentation as to how the patient's care is managed and all medical records necessary to provide services. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a medication error rate of less than 5% for one of 34 residents in the survey sample; Resident #94. The facility had two medication errors out of 35 opportunities, resulting in a medication error rate of 5.71%. The findings include: For Resident #94, Humalog insulin was administered after breakfast instead of before breakfast, resulting in a medication error of not administering the medication at the right time as ordered by the physician. On 11/01/23 at 8:20 AM, the Medication Administration task was conducted with LPN #5 (Licensed Practical Nurse) for Resident #94. The following was observed: 1. Humalog (1) 10 units, scheduled, was administered after the resident had breakfast. 2. Humalog 2 units based on sliding scale, was administered after the resident had breakfast. A review of the clinical record revealed the following orders: 1. An order dated 7/27/23 for Humalog 10 units twice daily, before breakfast and lunch. 2. An order dated 7/7/23 for Humalog, dose per sliding scale, before breakfast and lunch. (Resident #94's glucose level was 217. The sliding scale dose order included, 200 - 249 = 2 units). When asked if Resident #94's insulin was administered in accordance with the physician's order of before breakfast, she stated it was not, because it was administered after breakfast. She stated that the resident won't take it before breakfast because he is afraid his glucose will drop. When asked if the doctor was aware of this, she stated that the doctor was aware but that this was still the order, so it should have been given before breakfast. When asked about the five rights of medication administration, she stated Right person, right medication, right dose, right route, right time. When asked if Resident #94's insulin was administered in accordance with those rights she stated it was not, because after breakfast was not the right time. A review of the comprehensive care plan dated 9/2/23 revealed, in part: The resident has Diabetes Mellitus .Diabetes medication as ordered by doctor . The facility policy, General Guidelines for Medication Administration was reviewed. This policy documented, .6. At a minimum, the 5 Rights - right resident, right drug, right dose, right route, and right time - should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and the medication is put away On 11/1/23 at 4:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Regional Nurse Consultant, ASM #4 the Regional [NAME] President of Operations, and LPN #1 the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. References: 1. Humalog is used to treat diabetes. Information obtained from https://medlineplus.gov/druginfo/meds/a697021.html

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to protect the dignity of 1 of 34 residents in the survey sample; Resident #65. The findings include: For Resident #65, the facility staff failed to provide eating assistance in a dignified manner. On the 9/15/23 quarterly MDS (Minimum Data Set) Resident #65 was coded as being severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring extensive assistance with eating. On 10/31/23 at 1:10 PM an observation was made of Resident #65. She was up in her recliner geri-chair in the dining room area, being fed by CNA #1 (Certified Nursing Assistant). CNA #1 was standing over the resident to feed her. There were empty chairs nearby where CNA #1 could have sat next to Resident #65 to feed her. On 1/11/23 at 7:50 AM an interview was conducted with CNA #1. When asked how one should be positioned when feeding a resident, she stated, In front of them. When asked if she should be sitting or standing, she stated, Sitting. When asked if she was sitting when she was feeding Resident #65, she stated, No, I was not. When asked why she was standing over the resident, she stated, I don't know. I guess I thought since she was in her geri-chair she was kinda leaned back a little but I know I should have been sitting. When asked if standing over a resident while feeding them is a dignity concern for the resident, she stated that it was. The facility policy, Dignity, was reviewed. This policy documented, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: . e. provided with a dignified dining experience On 11/1/23 at 4:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Regional Nurse Consultant, ASM #4 the Regional [NAME] President of Operations, and LPN #1 (Licensed Practical Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence periodic review of Advance Directives for three of 34 residents in the survey sample; Residents #78, #33 and #41. The findings include: 1. For Resident #78, the facility staff failed to evidence that periodic review was completed regarding the resident's Advance Directive wishes. Resident #78 was admitted to the facility on [DATE]. A review of the physician's orders revealed an order dated 4/24/23 for DO NOT RESUSCITATE - DNR, and an order dated 5/30/23 for hospice services. In addition, review of the clinical record revealed an Advance Medical Directive form dated 11/16/2020. Further review of the clinical record failed to reveal any evidence that the resident and/or resident representative was provided opportunity to review and make changes to the Advance Directive document, formulate a Living Will, or formulate / change other decisions such as organ donation, wishes for any life sustaining treatments, or whether or not to hospitalize if the resident experienced an acute medical condition. On 11/1/23 at 2:01 PM, an interview was conducted with OSM #3 (Other Staff Member) the Director of Social Services, and OSM #4 the Social Services Assistant. They stated that during quarterly care plan meetings they do ask residents or family about the resident's code status, whether or not to hospitalize the resident if needed, and if they have any questions, but they don't ask about formulating or changing Living Will or Power of Attorney documents, and other wishes the resident may have such as organ donation or life sustaining treatments. The facility policy, Advance Directives documented, 18. The Interdisciplinary Team will periodically [missing word] with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. On 11/1/23 at 4:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Regional Nurse Consultant, ASM #4 the Regional [NAME] President of Operations, and LPN #1 (Licensed Practical Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 31753 2. For Resident #33 (R33), the facility staff failed to conduct a periodic review of the resident's advance directives. R33 was admitted to the facility on [DATE]. A review of R33's clinical record revealed documents for a general power of attorney dated 3/30/12 and an advance directive for health care dated 3/26/14. Further review of R33's clinical record failed to reveal evidence that a periodic review of all aspects of advance directives was conducted with R33 or the resident's representative (only the resident's code status was reviewed). On 11/1/23 at 2:01 PM, an interview was conducted with OSM #3 (Other Staff Member) the Director of Social Services, and OSM #4 the Social Services Assistant. They stated that during quarterly care plan meetings they do ask residents or family about the resident's code status, whether or not to hospitalize the resident if needed, and if they have any questions. However, they don't ask about formulating or changing Living Will or Power of Attorney documents, and other wishes the resident may have such as organ donation or life sustaining treatments. On 11/1/23 at 4:41 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. 27660 3. For Resident #41, the facility staff failed to periodically review the resident's advance directives. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 9/6/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The physician order dated 6/1/2017 documented, DNR (do not resuscitate). Review of the clinical record failed to evidence documents related to advanced directives and documentation of any review of the resident's wishes for an advanced directive. On 11/1/2023 at 2:01 p.m., an interview was conducted with OSM #3 (Other Staff Member) the Director of Social Services, and OSM #4 the Social Services Assistant. They stated that during quarterly care plan meetings they do ask residents or family about the resident's code status, whether or not to hospitalize the resident if needed, and if they have any questions. However, they don't ask about formulating or changing Living Will or Power of Attorney documents, and other wishes the resident may have such as organ donation or life sustaining treatments. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM #4, the regional director of operations, and LPN (licensed practical nurse) #1, the assistant director of nursing, were made aware of the above concern on 11/1/2023 at 4:32 p.m. No further information was provided prior to ext.

Based on staff interview and clinical record review, the facility staff failed to notify the physician of a possible need to alter treatment for one of 34 residents in the survey sample, Resident #35. The findings include: For Resident #35 (R35), the facility staff failed to notify the physician when the resident's medication Jardiance (1) was not available for administration on 10/9/23 and 10/10/23. A review of R35's clinical record revealed a physician's order dated 3/13/23 for Jardiance 25 mg (milligrams) by mouth one time a day for type two diabetes mellitus. A review of R35's October 2023 MAR (medication administration record) revealed the same physician's order for Jardiance. On 10/9/23 and 10/10/23, the MAR documented the code, 9= Other/ See Progress Notes. Nurses' notes dated 10/9/23 and 10/10/23 documented the medication Jardiance was not administered and was on order. Further review of R35's clinical record failed to reveal the resident's physician was notified and made aware the medication was not available for administration. On 11/1/23 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the physician should be notified if a medication is not available for administration to see if the physician wants to adjust for an alternative medication that may be available, and so the resident can be monitored for any adverse effects from not receiving the medication. On 11/1/23 at 4:41 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. Reference: (1) Jardiance is used to lower blood sugar levels for people with diabetes mellitus. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a614043.html

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure a PASARR (Preadmission Screening and Resident Review) was completed for one of 34 residents in the survey sample; Resident #24. The findings include: For Resident #45, the facility failed to complete a PASARR. Resident #24 was admitted to the facility on [DATE]. A review of the clinical record revealed a Medicaid Funded Long-Term Care Services Authorization Form document dated 2/26/20. This document included 3. Pre-Admission Screening Information (to be completed only by Level I, Level II or ALF screeners) Level I/ALF Screening Identification? YES .Level II Assessment Determination? NO The document did not contain any of the questions and responses of the State PASARR screening form. On 11/1/23 at 2:30 PM, OSM #3 (Other Staff Member) the Director of Social Services, was asked about this document. She stated that it was all the facility had and that it did not meet the requirement of a PASARR. The facility policy Long-Term Services and Supports (LTSS) Screening, Preadmission Screening and Resident Review (PASRR) Policy was reviewed. This policy documented, Level 1 Screening: a. If a Level 1 Screening has not been completed prior to admission and the resident is already Medicaid member OR financially eligible by way of application as verified by the ePAS system, the Social Worker, Admissions Coordinator, or designee will request that the referral provider and/or Community Screening Team complete the screen prior to admission; b. If the resident is not Medicaid or Medicaid eligible by way of application, the nursing facility will be responsible for completion of the Level 1 screening . On 11/1/23 at 4:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Regional Nurse Consultant, ASM #4 the Regional [NAME] President of Operations, and LPN #1 (Licensed Practical Nurse) the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to follow professional standards of practice for one of 34 residents in the survey sample; Resident #94. The findings include: For Resident #94, the facility staff failed to administer Humalog as ordered by the physician. A review of the clinical record revealed the following orders: 1. An order dated 7/27/23 for Humalog (1) 10 units twice daily, before breakfast and lunch. 2. An order dated 7/7/23 for Humalog, dose per sliding scale, before breakfast and lunch. (Resident #94's glucose level was 217. The sliding scale dose order included, 200 - 249 = 2 units). On 11/01/23 at 8:20 AM, the Medication Administration task was conducted with LPN #5 (Licensed Practical Nurse) for Resident #94. The following was observed: 1. Humalog 10 units, scheduled, was administered after the resident had breakfast. 2. Humalog 2 units based on sliding scale, was administered after the resident had breakfast. When asked if Resident #94's insulin was administered in accordance with the physician's order of before breakfast, she stated it was not, because it was administered after breakfast. She stated that the resident won't take it before breakfast because he is afraid his glucose will drop. When asked if the doctor was aware of this, she stated that the doctor was aware but that this was still the order, so it should have been given before breakfast. A review of the comprehensive care plan dated 9/2/23 revealed: The resident has Diabetes Mellitus. This care plan included the intervention dated 9/2/23 for Diabetes medication as ordered by doctor . The facility policy, General Guidelines for Medication Administration, was reviewed. This policy documented, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer. On 11/1/23 at 4:30 PM, ASM #1 (Administrative Staff Member) the Administrator, ASM #2 the Director of Nursing, ASM #3 the Regional Nurse Consultant, ASM #4 the Regional [NAME] President of Operations, and LPN #1 the Assistant Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. References: 1. Humalog is used to treat diabetes. Information obtained from https://medlineplus.gov/druginfo/meds/a697021.html

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement interventions for the prevention of a decrease in range of motion for one of 34 residents in the survey sample, Resident #46. The findings include: For Resident #46 (R46), the facility staff failed to place a washcloth in the resident's left hand per the physician orders. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 8/2/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. In Section G, Functional Status, the resident was coded as having functional limitations in range of motion with impairment on one side of upper and lower extremities. The physician order dated 5/22/2023 documented, Ensure rolled up washcloth to inside of left grip at all times, change washcloth daily or as needed if soiled, every shift for contracture, skin protection. Observation was made of R46 on 11/1/2023 at 8:27 a.m. There was no washcloth in her left hand. The resident stated sometimes the staff remembers to put it in there and sometimes they don't. A second observation was made of R46 on 11/1/2023 at 11:54 a.m., no washcloth was noted in the resident's left hand. The resident's hand was warm and moist. An interview was conducted with CNA (certified nursing assistant) #4 on 11/1/2023 at 11:56 a.m. When asked if there was anything special that needed to be done for R46 related to her positioning, CNA #4 stated the resident likes a pillow under her left arm. CNA #4 was asked if the resident required anything special for her left hand. CNA #4 stated she remembered the resident had a brace at one time, and that she had a washcloth in that hand the other day. When asked how she finds out what a resident may need specific to that resident, CNA #4 stated: I just go on observation of how her hand is. An interview was conducted with LPN (licensed practical nurse) #5 on 11/01/23 12:00 p.m. When asked if R46 is to have a washcloth in her left hand, LPN #5 stated another nurse was doing the treatments for the day and had already signed it off. When asked how the aides are informed about what is needed for R46, LPN #5 stated most of the aides know about it. LPN #5 stated the purpose of the washcloth in the left hand is due to the resident's contracture, and the resident gets yeast infections in that hand. The comprehensive care plan dated, 5/16/2023, documented in part, Focus: The resident has an ADL (activities of daily living) self-performance deficit r/t (related to) Fibromyalgia, prior CVA (stroke) with left hemiparesis and left hand/wrist contracture .CONTRACTURES: The resident has contractures of the left hand/wrist. Provide skin care to keep clean and prevent skin breakdown Focus: The resident has potential for skin impairment r/t dermatitis, incontinence, candidiasis (1). Left hemiparesis and decrease in mobility .Administer treatments as ordered and monitor for effectiveness. The facility policy, Resident Mobility and Range of Motion, documented in part, POLICY: 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. 7. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and representative will be included in determining these goals and objectives. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM #4, the regional director of operations, and LPN (licensed practical nurse) #1, the assistant director of nursing, were made aware of the above concern on 11/1/2023 at 4:32 p.m. No further information was provided prior to exit. References: (1) Candidiasis is a fungal infection caused by a yeast (a type of fungus) called Candida. This information was obtained from the following website: https://www.cdc.gov/fungal/diseases/candidiasis/.

Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory services per the physician orders for two of 34 residents in the survey sample, Residents #46 and #97. The findings include: 1. For Resident #46 (R46), the facility staff failed to have the correct oxygen concentrator to provide oxygen at the physician prescribed rate. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 8/2/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is not cognitively impaired for making daily decisions. Observation was made of R46 on 10/31/2023 at approximately 1:30 p.m. R46 was lying in bed with a nasal cannula in place with oxygen being delivered. The oxygen concentrator flowmeter was numbered two to ten, with two being the first number on the bottom and ten being the top number on the flowmeter. There were no lines below the number two to indicate any level of oxygen below two. The ball was set at the bottom of the flowmeter. The top of the ball was touching the line for two liters per minute. The physician order dated 2/15/2022 documented, Oxygen therapy at 1 L/min (liters per minute) via nasal cannula every shift for SOB (shortness of breath). A second observation was made of the R46 on 11/1/2023 at 8:28 a.m. The oxygen concentrator was set with the top of the ball touching the line for two liters per minute. The resident had the nasal cannula in her nose. A third observation was made of R46 on 11/1/2023 at 12:00 p.m. with LPN (licensed practical nurse) #5. When asked what the oxygen was set at, LPN #5 stated that it was on one. When asked the locationin of the line indicating one liter per minute, LPN #5 stated, I guess I screwed up. I thought that it was below two, and if I could feel oxygen coming out, then it was at one. LPN #5 was asked how to set the flow rate of the oxygen. She stated the line of the prescribed rate should go through the center of the ball. When asked if the oxygen was set according to the physician order, LPN #5 stated it was not. The comprehensive care plan dated 9/29/2022 documented in part, Focus: The resident has altered respiratory status/difficulty breathing r/t (related to) hx (history) of malignant neoplasm of lung, hx of smoking. Requires HOB (head of bed) elevated due to SOB when lying flat .Oxygen as ordered. The facility policy, Oxygen Administration, documented in part, POLICY: The purpose of this procedure is to provide guidelines for safe oxygen administration .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .5.Turn on the oxygen at the number of liters / minutes as ordered by the physician/practitioner. The manufacturer's booklet for the Invacare Platinum 10 L (liter) Oxygen Concentrator documented in part, 1. Turn the flowrate knob to the setting prescribed by your physician or therapist. To properly read the flowmeter, locate the prescribed flowrate line on the flowmeter. Next, turn the flow knob until the ball rises to the line. Now, center the ball on the L/min line prescribed. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM #4, the regional director of operations, and LPN (licensed practical nurse) #1, the assistant director of nursing, were made aware of the above concern on 11/1/2023 at 4:32 p.m. No further information was provided prior to ext. 42183 2. For Resident #97, the facility staff failed to provide respiratory therapy as ordered. Resident #97 was observed with oxygen setting at 2.5 lnc (liters nasal cannula) on 10/31/23 at 12:00 PM and 10/31/23 at 1:53 PM. Resident #97 was admitted to the facility on [DATE] with diagnosis that included atrial fibrillation, multiple fractures and COPD (chronic obstructive pulmonary disease). The most recent MDS (minimum data set) assessment, a Medicare 5-day admission assessment with an ARD (assessment reference date) of 10/25/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired. Section G, functional, status coded the resident as being dependent for bed mobility, transfer, dressing and hygiene; total dependence for bathing. A review of the comprehensive care plan dated 10/4/23, revealed, FOCUS: Resident has altered respiratory status/difficulty breathing related to COPD and wheezing. INTERVENTIONS: OXYGEN SETTINGS: Oxygen as ordered. A review of the physician orders dated 10/22/23 revealed, O2 at 2LPM via nasal cannula to maintain oxygen at 90% or above. every shift for Hypoxia. An interview was conducted on 10/31/23 at 1:53 PM with LPN (licensed practical nurse) #3. When asked to look at the oxygen setting for Resident #97, LPN #3 stated it was on 2 liters. She stated: I checked it this morning and it is at the same setting. LPN #3 stated the middle of the flowmeter ball should be on the line for the correct number of liters. On 11/1/23 at 4:32 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM # 4, the regional director of operations and LPN #1, the assistant director of nursing were made aware of the findings. A review of the facility's Oxygen Administration policy revealed: The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to implement bed rail requirements for one out of 34 residents in the survey sample, Resident # 106. The findings include: For Resident #106, the facility staff failed to evidence a review of the risks and benefits of bedrails, and failed to obtain informed consent for the use of the rails. Resident #106 was observed in bed with one quarter bed rail bilaterally on 10/31/23 at 12:00 PM, 11/1/23 at 9:00 AM, and 11/1/23 at 10:45 AM. The most recent MDS (minimum data set) assessment, a Medicare 5-day admission assessment, with an ARD (assessment reference date) of 10/11/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. In Section G, functional status, the resident was coded as being independent for bed mobility and transfers. A review of the clinical record revealed no evidence of a bed rail evaluation or informed consent for Resident #106. An interview was conducted on 10/31/23 at 12:00 PM with Resident #106. When asked if she used the bed rails, Resident #106 stated, Yes, I use them to help turn and reposition myself. An interview was conducted on 10/31/23 at 1:00 PM with LPN (licensed practical nurse) #3. When asked the process to be followed for a resident's bed rails, LPN #3 stated, We do an assessment on the risks / benefits of the bed rails, obtain a consent and put it on the care plan. On 11/1/23 at 4:32 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM # 4, the regional director of operations and LPN #1, the assistant director of nursing were made aware of the findings. A review of the facility's Bed Rail Risk and Safety policy revealed, This organization will take measures to develop and implement a strategy to minimize the possibility of resident entrapment and or injury while using bed rails. This will include an evaluation of residents who have a need for or desire to use bed rails and that may have characteristics that place them at special risk for entrapment. If the resident's evaluation identifies him or her as appropriate for the use of bed rail(s), the following procedures will be followed: Educate the resident/resident representative on the risks and obtain consent for use. The resident and/or resident representative's consent for use of the bed rails will be documented in the medical record. The resident's representative will be notified as appropriate. The physician/practitioner will be notified and a specific order for the use of bed rails (identify how many / type of rails, which side or sides of the bed, and when they are to be in place) will be obtained. The reason for the bed rails and their proper use will be integrated into the comprehensive care plan and revised as necessary. No further information was provided prior to exit.

Based on staff interview, facility document review and clinical record review, the facility staff failed to provide pharmacy services for one of 34 residents in the survey sample, Resident #35. The findings include: For Resident #35 (R35), the facility staff failed to ensure the medication Jardiance (1) was available for administration on 10/9/23 and 10/10/23. A review of R35's clinical record revealed a physician's order dated 3/13/23 for Jardiance 25 mg (milligrams) by mouth one time a day for type two diabetes mellitus. A review of R35's October 2023 MAR (medication administration record) revealed the same physician's order for Jardiance. On 10/9/23 and 10/10/23, the MAR documented the code, 9= Other/ See Progress Notes. Nurses' notes dated 10/9/23 and 10/10/23 documented the medication Jardiance was not administered and was on order. On 11/1/23 at 2:19 p.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated medications should be re-ordered from the pharmacy when there is a five-day supply of the medication left. LPN #4 stated that if a medication is not available for administration, then the nurses should pull the medication from the facility backup medication supply, and if the medication is not in the backup supply, then nurses should update the physician and resident's family. A review of the facility backup medication supply list revealed Jardiance was not available in the supply. On 11/1/23 at 4:41 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility pharmacy policy titled, General Guidelines for Medication Administration documented, Medications are administered as prescribed . Reference: (1) Jardiance is used to lower blood sugar levels for people with diabetes mellitus. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a614043.html

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide complete and accurate documentation for two of 34 residents in the survey sample, Residents #11 and #106. The findings include: 1. For Resident #11, the facility staff failed to evidence complete and accurate documentation for showers/bathing. A review of the comprehensive care plan dated 2/3/23, which revealed, FOCUS: Resident has an ADL (activities of daily living) self-care performance deficit related to weakness and right leg amputation. INTERVENTIONS: Provide supervision and cuing as needed with ADLs. Physical assist as needed with ADLs. A review of the ADL document in Resident #11's medical record, revealed documentation for showers was missing for 8/23/23 and 8/26/23. Shower documentation was also missing for 9/6/23, 9/30/23, 0/4/23, 10/7/23, 10/11/23, 10/18/23, 10/21/23, 10/25/23 and 10/28/23. An interview was conducted on 10/31/23 at 3:00 PM with Resident #11. Resident #11 stated, They do not give me showers consistently. I do not think they like me. On 11/1/23 at approximately 11:00 AM, LPN (licensed practical nurse) #4 stated, This is the documentation we have on Resident #11's showers. She provided indivdual shower sheet records Resident #11. When asked if this documentation is to be included in the electronic medical record, LPN #4 stated, Yes, it is to be documented there. She stated if the documentation is not included in the electronic medical record, the medical record is not complete or accurate. An interview was conducted on 11/1/23 at 2:00 PM with CNA (certified nursing assistant) #2. When asked where shower and bathing are documented, CNA #1 stated, We document it on the CNA form in [the electronic medical record]. An interview was conducted on 11/2/23 at 8:00 AM with CNA #3. When asked where showers and bathing are documented, CNA #3 stated, It is to be documented in [the electronic medical record. Sometimes we document it on the shower sheets. She stated if the documentation is not included in the electronic medical record, the medical record is not complete or accurate. On 11/1/23 at 4:32 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM # 4, the regional director of operations and LPN #1, the assistant director of nursing were made aware of the findings. A review of the facility's Charting and Documentation policy, revealed, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, will be documented in the resident's medical record. The medical record will facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. No further information was provided prior to exit. 2. For Resident #106, the facility staff failed to evidence complete and accurate record for resident weights. A review of the comprehensive care plan dated 10/6/23 revealed, FOCUS: Resident is at risk for alteration in nutritional status related to new admission/facility adjustment, CKD, diuretic use for edema. INTERVENTIONS: Weights per protocol. A review of the physician orders dated 10/6/23 revealed, Daily Weight x3 days, Weekly Weight x4 weeks, then monthly. A review of the weight sheet in the electronic medical record and the October TAR (treatment administration record) revealed no evidence of weight documentation on 10/16/23, 10/23/23 and 10/30/23. On 11/1/23 at approximately 11:00 AM, LPN (licensed practical nurse) #4 stated, This is the documentation we have on Resident #106's weights. She provided individual weight sheets for Resident #106. A review of the sheets for 10/19/23 and 10/26/23 revealed documentation that Resident #106 had refused to have weights done. When asked if this documentation is to be included in the electronic medical record, LPN #4 stated, Yes, it is to be documented there. She stated if the documentation is not in the electronic medical record, the record is not complete or accurate. An interview was conducted on 11/2/23 at 8:00 AM with CNA (certified nursing assistant) #3. When asked where weights are documented, CNA #3 stated, It is to be documented in [the electronic medical record. She stated sometimes the staff document it on the weight sheets. She stated if the weights are not documented in the electronic medical record, the record is not accurate or complete. On 11/1/23 at 4:32 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional nurse consultant, ASM # 4, the regional director of operations and LPN #1, the assistant director of nursing were made aware of the findings. No further information was provided prior to exit.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident, for one of three residents in the survey sample, Resident #2. The facility developed and implemented an acceptable plan of correction, therefore this deficiency is cited at past non-compliance. The findings include: For Resident #2 (R2), the facility staff failed to ensure the resident was free from sexual abuse by another resident (Resident #1) on 7/16/2023. The facility synopsis of the event, dated 7/16/2023, documented, Incident type: Resident to resident sexual abuse. Describe Incident: (Name of R1) noted in (room number) with (Name of R2) with (R2's) penis in mouth performing oral sex. Residents separated immediately. The nurse's note dated, 7/16/2023 at 3:20 p.m. documented, At 1500 [3:00 p.m.] a nursing staff member came to nurse's station and notified this write and another nurse that (room number of R1) was noted to be in (room number of R2) with (R2) lying in bed and with (R1) performing oral sex to (R2). This write and another nurse down to room (room number of R2). STOP sign was covering doorway. (R1) was noted in his wheelchair beside (R2) and leaning over the bed providing oral sex. Upon the nurse stating (R1's) name, (R1) leaned up and turned and (R2) tucked his penis back into brief. Residents were separated immediately. Skin assessment performs with no skin issues noted. DON (director of nursing) and NP (nurse practitioner) notified immediately. (R1's) RP (responsible party) aware. (R2's) RP, (first name of RP), attempted to be contacted and notified with no answer. Message left for her to call facility back. APS (adult protective services) and VDH (Virginia Department of Health) notified with initial FRI (facility reported incident). Law enforcement notified. This write spoke with dispatch 905 at 1612 [4:12 p.m.]. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an assessment reference date of 6/23/2023, R2 scored an eight out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is moderately cognitively impaired for making daily decisions. In Section G - the resident was coded as requiring extensive assistant for most of his activities of daily living except eating in which he was independent after set up assistance was provided. The psychologist notes dated 7/19/2023 documented R2 could not recall the incident. An interview was conducted with R2 on 8/14/2023 at 12:52 p.m. R2 was asked about the incident of 7/16/2023 of another male resident performing oral sex on him and he stated he could not recall it and denied that it happened. R2's comprehensive care plan dated, 11/2/2021 and revised on 7/20/2023, documented in part, Focus: The resident has a behavior problem r/t (related to) a hx (history) of masturbating in public areas and getting agitated with staff when redirected. Hx of crawling OOB (out of bed), 'sits self on floor to go to bathroom,' throws objects in room, hitting staff/residents, hx of attempts to grab between female staff members legs while providing care. Hx of making inappropriate sexual comments to staff. Resident noted to have a hx of pulling out genitals in public at staff and residents. Resident has a hx of making sexual accosts towards staff/residents. 6/23/22: TDO [temporary detaining order] considered on this date to ER [emergency room ] with return [to facility]. The Interventions documented in part, Administer medications as ordered. Monitor/document for side effect and effectiveness. 7/20/2023: Alarm to door frame to notify staff of resident leaving room or staff/residents entering room for monitoring. Anticipate and meet the resident's needs. Attempt to redirect and explain to resident that sexual behaviors are not appropriate. Encourage resident to ring for toileting/urinal assistance when needed. Explain all procedures to the resident before starting and allow the resident to adjust to changes. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident disruptive behaviors. Offer snacks, TV on, provide activities of choice as needed. Offer privacy if resident feels need to address sexual urges. Offer urinal at bedside. Provide privacy as needed. Psych (psychiatric/psychological) consult for behaviors as needed. 6/24/2022: Stop sign to residents' door to deter other resident from entering this room. For Resident #1 (R1), on 8/14/2023 at 9:22 a.m. R1 was observed in bed with his wheelchair next to the bed. Observations were made of R1 on 8/14/2023 at 10:18 a.m. R1 was sitting on the side of his bed. There was no roommate in his room. Continuous observation was made of R1 from 10:18 a.m. through 10:59 a.m. The resident never exited his room. At 10:56 a.m. the alarm when off and two staff members went to the room. The resident never came out of the room and not visible in the hallway. Staff left and then reentered the room at 10:59 a.m. and left right afterwards. R1 was observed in his bed, lying across the bed on 8/14/2023 at 12:01 p.m. An interview was conducted with R1 on 8/14/2023 at 12:45 p.m. R1 was asked if he recalled an incident where he was having oral sex with another male resident. R1 stated he could not recall that. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 7/22/2023, R1 was coded as scoring a nine out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired to make daily decisions. In Section G - Functional Status, the resident was coded as being either independent or requiring only supervision for all his activities of daily living. The resident was coded as being independent for locomotion on and off the unit. For R1, the comprehensive care plan dated, 2/14/2023 and revised on 7/16/2023, documented, Focus: The resident has a behavior problem r/t (related to) being sexually active in hallways in front of other residents, becomes aggressive with wife when visiting and staff at times when he can't go home. Resident has noted to attempt to be sexually inappropriate with staff and is redirected. Resident hx [history] of sexual acts with another male residents. The Interventions documented, 7/19/2023: 1:1 with resident while out of his room until further notice. Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Explain all procedures to the resident before starting and allow the resident time to adjust to changes. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. 7/20/2023: Motion Sensor alarm to alert staff of resident being out of room. Psych [psychiatric or psychological] consults as needed. Re-educate resident on the inappropriateness of behaviors when occurring. 7/16/2023: Room move offered and resident and POA [power of attorney] accepted. An interview was conducted with OSM (other staff member) #1, the director of social services, on 8/14/2023 at 1:12 p.m. When asked if R2 had any history of sexual behaviors, OSM #1 stated, R2 was always nice. She stated the resident had a slick mouth regarding sexual behaviors but has never physically touched another resident. OSM #1 stated R2 was on one-to-one a while back, maybe over a year ago, due to his behaviors a while back. OSM #1 stated the care plan talks about sexual behaviors, but he hasn't touched anyone to her knowledge. An interview was conducted with LPN (licensed practical nurse) #1 on 8/14/2023 at 1:30 p.m. When asked what happened on 7/16/2023, LPN #1 stated she was at the nurse's station with another nurse doing their charting when a CNA (certified nursing assistant) came up the hall in a panic. She told me them they had to come down there, the CNA felt they were in the room doing something not good. The CNA told her she was going by the door but couldn't see if anything was going on. LPN #1 stated she and (name of RN -registered nurse - #1) ran down there. When she got to the doorway, we could see that the stop sign was in place. The resident had gone under it. She stated both she and (RN #1) saw a resident's head (R1) going up and down over (R2)'s private area. Once they saw what was going on they called out both resident names. The resident performing the oral sex lifted their head up, he was in his wheelchair, next to the bed of (R2) and turned and looked at them. LPN #1 stated (R2) took [sic] his privates into his brief. She stated they immediately separated them. LPN #1 stated she interviewed the male resident performing the oral sex and at first, he denied it but once she told him she saw what he was doing he didn't deny it at that point. The facility policy, Abuse documented in part, Policy: This organization recognized an respect that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation as defined in this subpart. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion and any physical, or chemical restraint not required to treat the resident's medical symptoms . 3 a. Prevention: The facility will not use verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion .4. Identification: b. Staff are encouraged to identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Immediately following ensuring the resident's safety, staff are to report any allegation or observation of abuse to their supervisor, director of nursing administrator or facility leadership member .Protection: a. In the event of an allegation or observation of abuse, the facility will immediately assess the residents, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. ASM (administrative staff member) #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional nurse consultant, were made aware of the above findings on 8/14/2023 at 3:44 p.m. The facility presented the following plan of correction: 1. Room change was completed on 7/16/2023 for Resident #1. Frequent monitoring was initiated on 7/16/2023 for both Resident #1 & Resident #2. Both Resident #1 & Resident #2 had skin assessments completed on 7/16/2023. After further discussion 1:1 initiated when Resident #1 comes out of room on 7/20/2023. 2. Situation reported to VDH, APS, Law Enforcement, Medical Director, Responsible parties, and Director of Nursing per policy. 3. All resident [sic] on north have the potential to be affected by the alleged deficient practice. The facility will conduct interviews on north for all interviewable residents with a BIMS score of 8 or greater screening for abuse and neglect. Non-interviewable residents will have skin assessments performed assessing for signs and symptoms of abuse. Any allegations of abuse and neglect will be immediately addressed in accordance with the facility abuse and neglect policy. 4. All nursing staff on will be education on resident #1 having alarm on doorway and staff to be 1:1 when he leaves his room until further notice. No staff will be allowed to return to work after 7/24/2023 until the abuse and neglect education is completed. 5. The facility will conducted an adhoc QAPI (quality assurance program improvement) meeting reviewing this plan by 7/24/2023. The attendees of the adhoc QAPI meeting will consist of the administrator, director of nursing services (DON), the medical director, the regional nurse consultant, Human Resources, and a certified nursing assistant. 6. The DON or designee will conduct interviews to validate understanding of reporting guidelines and investigating allegations of abuse 3 x week x 4 weeks. Any issues identified will be addressed immediately by DON/Designee and appropriate action will be taken. The DON/Designee will identify any trends or patterns and educate as needed. All findings will be discussed with QAPI committee at least quarterly. 7. Date of compliance 7/24/2023. All of the credible evidence was reviewed. Verification of above was made through observation, resident interviews, and staff interviews. Past non-compliance.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to promote self-determination to participate in activities and socialization with other resident for one of three residents in the survey sample, Resident #1. The findings include: Resident #1 (R1) only participated in an activity of choice 13 out of 28 days from 7/16/2023 through 8/14/2023. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 7/22/2023, the resident was coded as scoring a nine out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired to make daily decisions. In Section G - Functional Status, the resident was coded as being either independent or requiring only supervision for all his activities of daily living. The resident was coded as being independent for locomotion on and off the unit. In Section F - Preferences for Customary Routine and Activities, the resident was coded as the following items being very important to him: having books, newspapers, and magazines to read, listen to music he likes, to be around animals such as pets, to keep up with the news, do things with groups of people, do his favorite activities, go outside to get fresh air when the weather is good, and participate in religious services or practices. On 7/16/2023, due to an incident with another resident, R1's room was changed from one hall to another. An alarm was placed on the door to alert the staff when the resident came out of the room. R1 required supervision to attend activities. An interview was conducted with R1 on 8/14/2023 at 12:45 p.m. When asked if the alarm interfered with his life at the facility, R1 stated he isn't allowed to go play dominoes with (names of three residents). R1 stated he must find someone to take him to the other unit. When his wife comes, R1 stated, she takes him down there to play dominoes. But if his wife doesn't come, then he doesn't get to go play dominoes. R1 stated he missed his friends down on the (name of former) unit. He stated he liked to just sit and talk with a few of them. An interview was conducted with OSM (other staff member) #1, the director of social services, on 8/14/2023 at 1:12 p.m. When asked how the facility is meeting R1's needs of self-determination since the alarm was placed on the doorway to his room, OSM #1 stated, We go in and talk to him. I do room rounds every morning, Monday through Friday in his room. OSM #1 was asked if R1 was confined to his room, OSM #1 stated she has seen him out of his room with supervision. An interview was conducted with OSM #3, the activities director, on 8/14/2023 at 2:26 p.m. OSM #3 was asked to explain what activities R1 participated in prior to his move to the other unit, OSM #3 stated the resident would attend social gatherings, played dominoes with a group of residents in the evenings, bingo, coffee socials, dining programs in the evenings every day, and socialize with (name of a female resident). OSM #3 stated the resident was quite social, but his socialization had decreased after he was told he had to stay at the facility for long term care. OSM #3 was asked to explain what activities are being provided to R1 since 7/16/2023. OSM #3 stated, R1 has been in his room, activities stop in to see him but he's not on one to one for activities. She stated he watches television. OSM #3 stated the resident does go out for dominoes but since that happens after she leaves for the day, she's not sure how often he goes down there now. OSM #3 stated, I don't know honestly what to do with him for now. He's welcome to come to bingo but they need to send him with supervision as I'm not staffed for that. OSM #3 was asked to bring the documentation of R1's participation in activities since 7/16/2023. An interview was conducted with ASM (administrative staff member) #3, regional nurse consultant, and ASM #2, the assistant director of nursing, on 8/14/2023 at 2:44 p.m. When asked if R1 can come out of the room, ASM #3 stated, yes, the staff is supposed to be with him when he comes out. ASM #3 was asked if the resident knows that, and ASM #3 stated, I would think so. He still comes out to play dominoes. ASM #2 interjected that they had a hospitality aide stay late one day on the weekend so he could be supervised playing dominoes. OSM #3 presented the activity participation logs for July and August 2023 on 8/14/2023 at 3:12 p.m. The form documented the number of days for the following activities from 7/16/2023 through 8/14/2023: Activity Visits: 15 Television: 26 Walking/Strolling: 5 Social Events: 2 OSM #3 was asked to explain the events above. OSM #3 stated the activity visits is socialization with the resident, talking to them and asking if they want to participate in activities that day. Television is when they have observed the resident watching television. Social Events could be an ice cream social and if the resident didn't attend, she brings the ice cream cart to their rooms. The one-to-one documentation for R1 since July 16, 2023 documented the resident went to play dominoes on: 7/22/2023, 7/24/2023, 7/25/2023, 7/26/2023, 7/29/2023, 7/30/2023, 7/31/2023, 8/2/2023, 8/3/2023, 8/6/2023, 8/8/2023, 8/12/2023 and 8/13/2023. This is 13 out of 28 days. The facility policy, Resident Self Determination and Participation documented in part, Policy: Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life .1. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, values, assessments and plans of care including: activities, hobbies, and interests 2. In order to facilitate resident choices, the administration and staff: b. Gather information about the residents' personal preferences on initial assessment and periodically thereafter and document these preferences in the medical record .4. Resident are helped as need to engage in their preferred activities on a routine basis. ASM #1, the administrator, ASM #2, the assistant director of nursing, and ASM #3, the regional nurse consultant, were made aware of the above concern on 8/14/2023 at 3:44 p.m. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to notify the physician and/or responsible party for a change in condition for two of seven residents in the survey sample, Residents #1 and #4. The findings include: 1. For Resident #1 (R1), the facility staff failed to notify the responsible party of a fall in May 2022. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/1/2023, the resident scored a one out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely, cognitively impaired for making daily decisions. A nurse's note dated, 5/10/2022 at 3:31 a.m. documented in part, CNA (certified nursing assistant) retrieved this nurse that resident had fallen. Resident was found sitting on the floor in front of her wheelchair. Resident states that she slipped out of her wheelchair. Resident denies any pain. Resident assisted up x2 (by two staff members), placed in wheelchair and then assisted to bed. No injuries noted at this time. The nurse's note dated, 5/11/2022 at 12:50 p.m. documented, IDT (interdisciplinary team) note in regard to resident fall, resident will be encouraged to go to bed earlier in evening/nights. NP (nurse practitioner) and RP (responsible party) aware. The Fall Investigation, dated, 5/10/2022, documented the above nurse's note. The form documented, People Notified: POA Care (power of attorney), name and date: 5/13/2022 at 8:15 a.m. An interview was conducted with LPN (licensed practical nurse) #3 on 5/3/2023 at 9:41 a.m. When asked if she had contacted the responsible party after the fall on 5/10/2022, LPN #3 stated, she had forgotten to put it in her note. The above Fall Investigation was shown to LPN #3. LPN #3 stated, now she recalls, she didn't call the RP. She stated the next time she saw the RP she told them it was her fault that she didn't call them. LPN #3 stated, It's most likely that I didn't call her after the fall. When asked the normal process for notifying the RP after a fall, LPN #3 stated, if there are no injuries, we wait until the day shift comes on and then we sit down and notify the RP, not wanting to alarm them in the middle of the night. On 5/3/2023 at 10:08 a.m., an interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing, who wrote the nurse's note of 5/11/2022. When asked if she called the RP after the fall, ASM #3 stated, no. ASM #3 stated that she did not realize when she wrote the note of 5/11/2022 that the RP hadn't been called. Once she realized that the RP hadn't been called, she called the RP on 5/13/2022 at 8:15 a.m. When asked the normal process for notifying the RP of a fall, ASM #3 stated the nurse should call the RP and NP (nurse practitioner) after the resident has been assessed and cared for. The facility policy, Change in Resident's Condition documented in part, 1. The nurse will notify the resident's Attending Physician/practitioner on call when there has been a (an): accident of incident involving the resident .3. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in any injury including injuries of an unknown source .4. Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above findings on 5/3/2023 at 5:15 p.m. No further information was obtained prior to exit. 2. For Resident #4 (R4), the facility staff failed to notify the physician/practitioner of the resident's refusal to take ordered medications on multiple occasions. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/13/2023, the resident was coded as rarely/never being understood. R4 was coded as having no speech. 1. The physician order dated, 9/24/2022, documented: Levothyroxine Sodium Tablet 75 MCG (micrograms) (1); Give 1 tablet by mouth one time a day for low thyroid hormone. 2. The physician order dated, 4/21/2023, documented, Bactrim DS (double strength) Oral Tablet 800 - 160 MG (milligrams) (2); Give 1 tablet by mouth two times a day for right lateral chest abscess for 14 days. 3. The physician order dated, 4/21/2023, documented, Cipro Oral Tablet 500 MG (3); Give 1 tablet by mouth two times a day for abscess for 14 days. 4. The physician order dated, 10/31/2022, documented, Acetaminophen Liquid; Give 20.3 ml (milliliters) (4) by mouth every 8 hours for wound pain. 5. The physician order dated, 4/19/2023, documented, Acetaminophen Oral Tablet; Give 650 MG (4) by mouth every 8 hours for pain, 2 tablets oral every 8 hours for pain (325 mg tablet). 6. The physician order dated, 4/4/2023, documented, Baclofen Oral Tablet 5 MG (5); Give 1 tablet by mouth every 8 hours for muscle spasms. The April 2023 MAR (medication administration record) documented the above orders. 1. For the Levothyroxine, it was documented on the following dates at 6:00 a.m., a 9, indicating, Other/See Progress Notes. 4/1/2023 through 4/4/2023, 4/6/2023, 4/8/2023, 4/9/2023, 4/11/2023, 4/12/2023, 4/14/2023, 4/15/2023, 4/18/2023 through 4/20/2023, 4/24/2023, 4/26/2023 and 4/29/2023. 2. For the Bactrim DS, for the 9:00 a.m. dose on 4/22/2023, a 5 was documented, indicating, Hold/See Progress Notes. 3. For the Cipro tablets, a 9 was documented for the 5:00 a.m. dose on 4/22/2023 and 4/24/2023. 4. For the Acetaminophen Liquid, a 9 was documented for the following dates for the 6:00 a.m. dose, 4/1/2023, 4/2/2023, 4/3/2023. 4/4/2023, 4/6/2023, 4/8/2023, 4/9/2023, 4/11/2023, 4/12/2023, 4/14/2023, 4/15/2023, 4/18/2023, and 4/19/2023. For the 2:00 p.m. doses a 9 was documented on 4/11/2023 and 4/12/2023. A 5 was documented for the 2:00 p.m. dose on 4/14/2023. A 9 was documented for the following dates for the 10:00 p.m. dose on 4/3/2023. 5. For the Acetaminophen Tablets, a 9 was documented on the following dates for the 6:00 a.m. dose: 4/20/2023, 4/21/2023, 4/24/2023, 4/26/2023, and 4/29/2023. 6. For the Baclofen tablets, a 9 was documented for the 6:00 a.m. dose on 4/4/2023, 4/6/2023, 4/8/2023, 4/9/2023. 4/11/2023, 4/12/2023, 4/14/2023, 4/15/2023, 4/18/2023, 4/19/2023, 4/20/2023, 4/21/2023, 4/26/2023, and 4/29/2023. The progress notes/nurse's notes were reviewed. For all of the above dates and times it was documented, Resident refused to take medications. The following dates were the only documentation of notification to the NP or RP regarding the refusal of medications: The nurse's notes documented on 4/3/2023 at 5:33 p.m., Resident refused meds, NP/RP informed. The nurse's note dated, 4/17/2023 at 3:28 p.m. documented, NP/Hospice aware of residents refusal to take medications at times throughout the weekend. Resident often refuses medications at times. The nurse's note dated, 4/22/2023 at 3:10 p.m. documented in part, . Resident continues on x2 (two) ABT (antibiotics) for wound infection and resident refused to take any medications for this nurse. Unable to redirect to take medications multiple times. Resident kept trying to grab nurse's shirt to pull this nurse close to him. Educated resident that he cannot touch others, resident continued to try and grab nurses shirt. The nurse's note dated, 4/25/2023 at 2:21 p.m. documented in part, Fluids encouraged and refused. Refused Magic cup (frozen dietary supplement). x2. The nurse's note dated, 4/26/2023 at 6:28 a.m. documented in part, Encouraged fluids but refused. Resident refused meds this am. An interview was conducted with LPN (licensed practical nurse) #2 on 5/3/2023 at 1:37 p.m. When asked the process for when a resident refuses their medication, LPN #2 stated the nurse should try to go back and offer again. If the resident still doesn't take the medication, then you write a note and notify the physician, RP and the unit manager. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 5/3/2023 at 4:23 p.m. ASM #2 stated she could not account for why no one notified the doctor/NP and the responsible party of all the refusals. ASM #2 presented care plan that documents the resident does refuse care. When asked if the nurses should still notify the NP and RP even though the resident has a care plan for refusals, ASM #2 stated, there still needs to be documentation of the notification to both the RP and NP. The facility policy, General Guidelines for Medication Administration documented in part, Refusals of Medications: Medication refusal must be reported to the prescriber after 3 doses are refused, or in accordance with facility policy, and prescriber notification must be documented. The facility policy, Change in Resident's Condition documented in part, 1. The nurse will notify the resident's Attending Physician/practitioner or physician on all where there has been a refusal of treatment or medications two (2) or more consecutive times. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above findings on 5/3/2023 at 5:15 p.m. No further information was obtained prior to exit. (1) Levothyroxine is used to treat hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682461.html (2) Bactrim DS is used to treat certain bacterial infections. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a684026.html (3) Cipro is used to treat or prevent certain infections caused by bacteria. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a688016.html (4) Acetaminophen is used to treat fever and mild to moderate pain. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html (5) Baclofen is used to treat pain and certain types of spasticity. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682530.html

Based on staff interview, facility policy review, and clinical record review, it was determined the facility staff failed to follow professional standards of practice for following the physician orders, and for the administration of medications for two of seven residents in the survey sample, Residents #2 and #3. The findings include: 1. a. For Resident #2 (R2), the facility staff failed to follow the physician's order for notifying the physician/nurse practitioner when the resident's blood sugar was lower than 70 per the physician's order. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/21/2023, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The physician order dated, 8/24/20019, documented, Accu check (fingerstick blood sugar) every morning and as needed for DM2 (diabetes mellitus - type two), in the morning for n DM2; call if < (less than) 70 or > (greater than) 350. The MAR (medication administration record) for October 2022, documented the above order. On 10/4/2022 the fingerstick blood sugar was documented as 67. On 10/6/2022, the fingerstick blood sugar was documented as 69. The MAR for December 2022 documented the above order. On 12/7/2022, the fingerstick blood sugar was documented as 68. On 12/17/2022, the fingerstick blood sugar was documented as 63. Review of the nurse's notes for October and December 2022 failed to evidence documentation of notifying the physician or nurse practitioner. The comprehensive care plan dated, 5/26/2021, documented in part, Focus: (R2) has Diabetes Mellitus. The Interventions documented in part, Labs (laboratory tests) and blood sugar as ordered. Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) pf hypoglycemia (low blood sugar). An interview was conducted with LPN (licensed practical nurse) #2, on 5/3/2023 at 1:37 p.m. The above order and MAR was reviewed with LPN #2. When asked according to the physician order, what is the nurse to do if the blood sugar is outside the parameters, LPN #2 stated, you are supposed to call the doctor, nurse practitioner, responsible party and the unit manager and then write a progress note after you have done it. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 5/3/2023 at 4:24 p.m. When asked where the documentation of notifying the physician when the blood sugars above were out of the physician prescribed range, ASM #2 stated she could not find anything documented related to notifying the physician when the fingerstick blood sugars were outside the parameters. ASM #1, the administrator, ASM #2, and ASM #3, the assistant director of nursing, were made aware of the above findings on 5/3/2023 at 5:15 p.m. No further information was obtained prior to exit. 1.b. For R2, the facility staff failed to administer, Midodrine (used to treat sudden fall in blood pressure that occurs when a person assumes a standing position) (1) according to the physician orders. The physician order dated, 5/5/2022, documented, Midodrine HCL (hydrochloride) Tablet10 MG (milligrams); Give 1 tablet by mouth three tines a day for hypotension. Hold for SBP (systolic blood pressure) > (greater than) 110. The October MAR (medication administration record) documented the above order. On the following dates and times the SBP was over 110 and the medication was documented as given: 10/3/2022 at 9:00 a.m. - BP (blood pressure) - 126/74 10/6/2022 at 2:00 p.m. - BP - 120/69 10/7/2022 at 9:00 a.m. - BP - 113/69 10/7/2022 at 9:00 p.m. - BP - 141/72 10/8/2022 at 9:00 a.m. - BP - 128/67 10/17/2022 at 9:00 a.m. - BP - 118/68 10/17/2022 at 2:00 p.m. - BP - 118/68 10/18/2022 at 9:00 a.m. - BP - 118/64 10/18/2022 at 9:00 p.m. - BP - 118/68 10/21/2022 at 9:00 a.m. - BP - 128/74 10/22/2022 at 9:00 p.m. - BP - 136/68 10/25/2022 at 9:00 a.m. - BP - 116/66 10/27/2022 at 9:00 a.m. - BP - 117/68 10/27/2022 at 2:00 p.m. - BP - 114/63 10/27/2022 at 9:00 p.m. - BP - 119/68 10/28/2022 at 9:00 a.m. - BP - 126/74 10/28/2022 at 2:00 p.m. - BP - 121/70 10/28/2022 at 9:00 p.m. - BP - 116/68 The November 2022 MAR documented the above order. On the following dates and times, the SBP was over 110 and the medication was documented as given: 11/3/2022 at 9:00 a.m. - BP - 115/70 11/3/2022 at 2:00 p.m. - BP - 120/70 11/4/2022 at 9:00 a.m. - BP - 116/69 11/5/2022 at 9:00 a.m. - BP - 112/66 11/5/2022 at 2:00 p.m. - BP - 122/70 11/5/2022 at 9:00 p.m. - BP - 119/70 11/10/2022 at 9:00 a.m. - BP - 118/73 11/13/2022 at 9:00 p.m. - BP - 120/70 11/14/2022 at 9:00 a.m. - BP - 124/70 11/17/2022 at 9:00 a.m. - BP - 123/77 11/17/2022 at 2:00 p.m. - BP - 118/69 11/18/2022 at 9:00 a.m. - BP - 112/66 11/18/2022 at 9:00 p.m. - BP - 118/68 11/19/2022 at 9:00 p.m. - BP - 118/68 11/20/2022 at 9:00 p.m. - BP - 132/72 11/22/2022 at 9:00 a.m. - BP - 122/70 11/22/2022 at 2:00 p.m. - BP - 118/68 11/23/2022 at 2:00 p.m. - BP - 119/60 11/24/2022 at 2:00 p.m. - BP - 128/72 11/25/2022 at 9:00 p.m. - BP - 118/68 11/28/2022 at 9:00 p.m. - BP - 118/62 11/29/2022 at 9:00 a.m. - BP - 140/71 11/29/2022 at 2:00 p.m. - BP - 134/74 11/29/2022 at 9:00 p.m. - BP - 112/62 The December 2022 MAR documented the above order. On the following dates and times, the SBP was over 110 and the medication was documented as given: 12/1/2022 at 9:00 p.m. - BP - 114/60 12/2/2022 at 9:00 a.m. - BP - 115/54 12/2/2022 at 2:00 p.m. - BP - 118/68 12/2/2022 at 9:00 p.m. - BP - 130/54 12/3/2022 at 9:00 a.m. - BP - 123/60 12/5/2022 at 2:00 p.m. - BP - 118/64 12/8/2022 at 2:00 p.m. - BP - 118/77 12/9/2022 at 9:00 p.m. - BP - 120/68 12/10/2022 at 9:00 a.m. - BP - 118/62 12//10/2022 at 2:00 p.m. - BP - 124/68 12/14/2022 at 9:00 a.m. - BP - 118/62 12/14/2022 at 2:00 p.m. - BP - 118/78 12/15/2022 at 2:00 p.m. - BP - 118/68 12/18/2022 at 9:00 p.m. - BP - 124/68 12/20/2022 at 2:00 p.m. - BP - 119/68 12/22/2022 at 2:00 p.m. - BP - 114/68 12/23/2022 at 9:00 p.m. - BP - 124/68 12/30/2022 at 9:00 a.m. - BP - 116/70 12/31/2022 at 9:00 p.m. - BP - 118/70 The comprehensive care plan dated, 5/26/2021, documented in part, Focus: (R2) has the potential for altered cardiovascular status r/t (related to) cardiomyopathy, CHF (congestive heart failure), CAD (coronary artery disease), orthostatic hypotension, HTN (high blood pressure), pacemaker, and A-Fib (atrial fibrillation). The Interventions documented in part, Medications as ordered. An interview was conducted with LPN (licensed practical nurse) #2 on 5/3/2023 at 1:37 p.m. The above order for Midodrine was reviewed with LPN #2. When asked what steps the nurse should take when administering the medication, LPN #2 stated, this drug has parameters, the nurse has to take the blood pressure prior to the administration, if the blood pressure is greater than 110, then you hold the medication and write a note. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 5/2/2023 at 4:24 p.m. ASM #2 stated she had identified this as a concern. She has done education and in-services on this concern but has not educated all nurses yet. The facility policy, General Guidelines for Medication Administration documented in part, 6. At a minimum, the 5 rights - right resident, right drug, right dose, right route, and right time, should be applied to all medication administration and reviewed at three steps in the process of preparation: 1. when medication is selected, 2. When the dose is removed from the container, and 3. after the dose is prepared and the mediation is put away Medications are administered in accordance with written orders of the prescriber. ASM #1, the administrator, ASM #2, and ASM #3, the assistant director of nursing, were made aware of the above findings on 5/3/2023 at 5:15 p.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a616030.html. 2. For Resident #3, the facility staff failed to administer Gabapentin (2) although it was available in the back up medication supply. On the most recent MDS (minimum data set) assessment, an annual assessment, with an assessment reference date of 3/31/2023, the resident scored a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired for making daily decisions. The physician order dated, 5/17/2022, documented, Gabapentin Capsule 400 MG (milligrams) (used to treat seizures and pain); Give 2 capsule by mouth two times a day for Neuropathy. The April 2023, Medication Administration Record (MAR) documented the above order. For the 9:00 p.m. dose on 4/20/2023, the 9:00 a.m. dose on 4/21/2023, the 9:00 p.m. dose on 4/21/2023 and on 4/22/2023 for the 9:00 a.m. dose, a 9 was documented. A 9 indicates Hold/See Progress Notes. The Progress notes for the above doses documented, On order. The review of the list for the facility emergency/back up medication system, documented, Gabapentin 100 MG capsules - 13 caps (capsules) and Gabapentin 300 MG capsules - 7 capsules, currently in the emergency medication supply. An interview was conducted with LPN (licensed practical nurse) #2, on 5/3/2023 at 1:37 p.m. When asked the process for when a medication is not in the medication cart when it is time to be administered, LPN #2 stated, first, the nurse checks the overflow mediations (ones that don't fit in the medication cart), if not there, the nurse goes to the (name of emergency/back up medication system). If not there, then the nurse should notify the unit manager and they will call the pharmacy. LPN #2 further stated that if it is not given and there is no back up and it's not here from the pharmacy in a timely manner for the prescribed time, then the nurse should call the nurse practitioner or doctor and the responsible party and write a note. The list of medications in the backup system was reviewed with LPN #2. LPN #2 stated, the resident gets 800 MG, so I would have pulled two 300 MG capsules and two 100 MG capsules to equal their dose of 800 MG. An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 5/3/2023 at 4:21 p.m. ASM #2 was asked why the medication was not taken from the backup mediation system, ASM #2 stated, she can't say why they didn't put it from the (name of the backup medication system). The facility policy, General Guidelines for Medication Administration documented in part, 13. If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room and facility are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the emergency kit. ASM #1, the administrator, ASM #2, and ASM #3, the assistant director of nursing, were made aware of the above findings on 5/3/2023 at 5:15 p.m. No further information was obtained prior to exit. (2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a694007.html

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to implement the comprehensive care plan for one of seven residents in the survey sample, Residents #2. The findings include: 1.a. For Resident #2 (R2), the facility staff failed to implement the comprehensive care plan for administering the medication Midodrine Midodrine is used to treat orthostatic hypotension (sudden fall in blood pressure that occurs when a person assumes a standing position) (1). On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 3/21/2023, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. The comprehensive care plan dated, 5/26/2021, documented in part, Focus: (R2) has the potential for altered cardiovascular status r/t (related to) cardiomyopathy, CHF (congestive heart failure), CAD (coronary artery disease), orthostatic hypotension, HTN (high blood pressure), pacemaker, and A-Fib (atrial fibrillation). The Interventions documented in part, Medications as ordered. The physician order dated, 5/5/2022, documented, Midodrine HCL (hydrochloride) Tablet 10 MG (milligrams); Give 1 tablet by mouth three tines a day for hypotension. Hold for SBP (systolic blood pressure) > (greater than) 110. The October MAR (medication administration record) documented the above order. On the following dates and times the SBP was over 110 yet the medication was documented as given: 10/3/2022 at 9:00 a.m. - BP (blood pressure) - 126/74 10/6/2022 at 2:00 p.m. - BP - 120/69 10/7/2022 at 9:00 a.m. - BP - 113/69 10/7/2022 at 9:00 p.m. - BP - 141/72 10/8/2022 at 9:00 a.m. - BP - 128/67 10/17/2022 at 9:00 a.m. - BP - 118/68 10/17/2022 at 2:00 p.m. - BP - 118/68 10/18/2022 at 9:00 a.m. - BP - 118/64 10/18/2022 at 9:00 p.m. - BP - 118/68 10/21/2022 at 9:00 a.m. - BP - 128/74 10/22/2022 at 9:00 p.m. - BP - 136/68 10/25/2022 at 9:00 a.m. - BP - 116/66 10/27/2022 at 9:00 a.m. - BP - 117/68 10/27/2022 at 2:00 p.m. - BP - 114/63 10/27/2022 at 9:00 p.m. - BP - 119/68 10/28/2022 at 9:00 a.m. - BP - 126/74 10/28/2022 at 2:00 p.m. - BP - 121/70 10/28/2022 at 9:00 p.m. - BP - 116/68 The November 2022 MAR documented the above order. On the following dates and times, the SBP was over 110 yet the medication was documented as given: 11/3/2022 at 9:00 a.m. - BP - 115/70 11/3/2022 at 2:00 p.m. - BP - 120/70 11/4/2022 at 9:00 a.m. - BP - 116/69 11/5/2022 at 9:00 a.m. - BP - 112/66 11/5/2022 at 2:00 p.m. - BP - 122/70 11/5/2022 at 9:00 p.m. - BP - 119/70 11/10/2022 at 9:00 a.m. - BP - 118/73 11/13/2022 at 9:00 p.m. - BP - 120/70 11/14/2022 at 9:00 a.m. - BP - 124/70 11/17/2022 at 9:00 a.m. - BP - 123/77 11/17/2022 at 2:00 p.m. - BP - 118/69 11/18/2022 at 9:00 a.m. - BP - 112/66 11/18/2022 at 9:00 p.m. - BP - 118/68 11/19/2022 at 9:00 p.m. - BP - 118/68 11/20/2022 at 9:00 p.m. - BP - 132/72 11/22/2022 at 9:00 a.m. - BP - 122/70 11/22/2022 at 2:00 p.m. - BP - 118/68 11/23/2022 at 2:00 p.m. - BP - 119/60 11/24/2022 at 2:00 p.m. - BP - 128/72 11/25/2022 at 9:00 p.m. - BP - 118/68 11/28/2022 at 9:00 p.m. - BP - 118/62 11/29/2022 at 9:00 a.m. - BP - 140/71 11/29/2022 at 2:00 p.m. - BP - 134/74 11/29/2022 at 9:00 p.m. - BP - 112/62 The December 2022 MAR documented the above order. On the following dates and times, the SBP was over 110 yet the medication was documented as given: 12/1/2022 at 9:00 p.m. - BP - 114/60 12/2/2022 at 9:00 a.m. - BP - 115/54 12/2/2022 at 2:00 p.m. - BP - 118/68 12/2/2022 at 9:00 p.m. - BP - 130/54 12/3/2022 at 9:00 a.m. - BP - 123/60 12/5/2022 at 2:00 p.m. - BP - 118/64 12/8/2022 at 2:00 p.m. - BP - 118/77 12/9/2022 at 9:00 p.m. - BP - 120/68 12/10/2022 at 9:00 a.m. - BP - 118/62 12//10/2022 at 2:00 p.m. - BP - 124/68 12/14/2022 at 9:00 a.m. - BP - 118/62 12/14/2022 at 2:00 p.m. - BP - 118/78 12/15/2022 at 2:00 p.m. - BP - 118/68 12/18/2022 at 9:00 p.m. - BP - 124/68 12/20/2022 at 2:00 p.m. - BP - 119/68 12/22/2022 at 2:00 p.m. - BP - 114/68 12/23/2022 at 9:00 p.m. - BP - 124/68 12/30/2022 at 9:00 a.m. - BP - 116/70 12/31/2022 at 9:00 p.m. - BP - 118/70 An interview was conducted with LPN (licensed practical nurse) #2, on 5/3/2023 at 1:37 p.m. When asked the purpose of the care plan, LPN #2 stated, It's the guideline, that is individualized for each resident, to give proper care for each resident. When asked if the care plan should be followed. LPN #2 stated, yes. The facility policy, Comprehensive Assessments and the Care Delivery Process, documented in part, 1. Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions and then monitoring results and adjusting interventions. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the assistant director of nursing, were made aware of the above findings on 5/3/2023 at 5:15 p.m. No further information was obtained prior to exit. (1) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a616030.html,. 1.b. For Resident #2, the facility staff failed to implement the comprehensive care plan for monitoring the resident's blood sugar and notifying the physician of blood sugars out of the physician ordered parameters. The comprehensive care plan dated, 5/26/2021, documented in part, Focus: (R2) has Diabetes Mellitus. The Interventions documented in part, Labs (laboratory tests) and blood sugar as ordered. Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of hypoglycemia (low blood sugar). The physician order dated, 8/24/2019, documented, Accu check (fingerstick blood sugar) every morning and as needed for DM2 (diabetes mellitus - type two), in the morning for n DM2; call if < (less than) 70 or > (greater than) 350. The MAR (medication administration record) for October 2022, documented the above order. On 10/4/2022 the fingerstick blood sugar was documented as 67. On 10/6/2022, the fingerstick blood sugar was documented as 69. The MAR for December 2022 documented the above order. On 12/7/2022, the fingerstick blood sugar was documented as 68. On 12/17/2022, the fingerstick blood sugar was documented as 63. Review of the nurse's notes for October and December 2022 failed to evidence documentation of notifying the physician or nurse practitioner. An interview was conducted with LPN (licensed practical nurse) #2, on 5/3/2023 at 1:37 p.m. When asked the purpose of the care plan, LPN #2 stated, It's the guideline, that is individualized for each resident, to give proper care for each resident. When asked if the care plan should be followed. LPN #2 stated, yes. ASM #1, the administrator, ASM #2, and ASM #3, the assistant director of nursing, were made aware of the above findings on 5/3/2023 at 5:15 p.m. No further information was obtained prior to exit.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide sufficient staffing for one of seven residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1) the facility staff failed to have sufficient staffing during the evening and night shift 5/9/2022 through 5/10/2022. There were only two CNAs (certified nursing assistants) for a census of 55 residents on the South wing for the evening shift. There was only one CNA on the South Wing for the night shift from 11:00 p.m. until 3:00 a.m. At 3:00 a.m. two CNAs came in. There was only one nurse on the South Wing for night shift. R1 was found on the floor in their room, in front of the wheelchair at 2:20 a.m. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 2/1/2023, the resident scored a one out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is severely, cognitively impaired for making daily decisions. In Section G - Functional Status, R1 was coded as requiring extensive assistance of two staff members for moving in the bed and transfers. The resident was coded as not walking. The MDS assessment, a quarterly assessment, with an ARD of 5/10/2022, the resident scored a three out of 15 on the BIMS score, indicating the resident is severely, cognitively impaired for making daily decisions. In Section G - Functional Status, R1 was coded as requiring extensive assistance of one for moving in the bed and extensive assistance of two staff members for transfers. The resident was coded as not walking. The nurse's note dated, 5/10/2022 at 3:31 a.m. documented in part, CNA (certified nursing assistant) retrieved this nurse that resident had fallen. Resident was found sitting on the floor in front of her wheelchair. Resident states that she slipped out of her wheelchair. Resident denies any pain. Resident assisted up x2 (by two staff members), placed in wheelchair and then assisted to bed. No injuries noted at this time. The Fall Investigation, dated, 5/10/2022 at 2:21 a.m., documented the above nurse's note. The resident census for 5/9/2022 into 5/10/2022, on the South Unit, was 55. The Daily Schedule dated 5/9/2022 was reviewed. For the evening shift on 5/9/2022, there was one nurse from 3:00 p.m. - 11:00 p.m. There was another nurse that came in at 6:00 p.m. There was one CNA working the whole shift from 3:00 p.m. - 11:00 p.m. There was a CNA from 3:00 p.m. - 7:00 p.m. and another CNA came in at 7:30 p.m. and working until 3:00 a.m. The night shift, 11:00 p.m. to 7:00 a.m. There was one nurse and one CNA from 11:00 p.m. - 3:00 a.m. for the South Unit. Two CNAs came in at 3:00 a.m. An interview was conducted with OSM (other staff member) #3, the staffing coordinator, on 5/3/2023 at 8:46 a.m. The above Daily Schedule was reviewed with OSM #4. OSM#4 verified there was only one CNA from 11:00 p.m. to 3:00 a.m. OSM #3 was not employed at the facility in May 2022. When asked if it was adequate staffing to care for these residents, OSM #4 stated, no in her opinion. When asked if the facility utilizes agency staff, OSM #3 stated, yes at times. An interview was conducted with OSM #4, Human Resources, who was filling in with staffing during May 2022. The above schedule was reviewed. When asked the level of staffing the South will should have on each shift, OSM #4 stated for the day shift there should be two nurses on 7:00 a.m. to 3:00 p.m. and on 3:00 p.m. to 11:00 p.m. and one nurse for 11:00 p.m. to 7:00 a.m. For CNAs, there should be at least four on 7:00 a.m. to 3:00 p.m., two to three on 3:00 p.m. to 11:00 p.m. and two on 11:00 p.m. to 7:00 a.m. When asked if the unit was understaffed for 5/9/2022, OSM #4 stated, yes. On 5/3/2023 at 9:08 a.m. an interview was conducted with LPN (licensed practical nurse) #1, who worked the 3:00 p.m. to 11:00 p.m. shift, When asked about R1's normal bedtime schedule, LPN #1 stated the resident and roommate normally go to bed after dinner, the latest they stay up is until 9:00 p.m. When asked if she recalled if R1 was put to bed on 5/9/2022, LPN #1 stated the only thing she could think of it the resident wanted to stay up which is unusual for them. LPN #1 stated she didn't know why she [the resident] wouldn't have gone to bed. The CNA's that worked the evening shift on 5/9/2022 were no longer employed at the facility and unavailable for interview. An interview was conducted with LPN #3, the night shift nurse, on 5/3/2023 at 9:41 a.m. LPN #3 was asked to review the fall investigation and her nurse's note of 5/10/2022 at 3:31 a.m. When asked if the resident was in the wheelchair at the time of the fall, LPN #3 stated, the evening shift normally puts them to bed and didn't recall if (R1) was up in the wheelchair. LPN #3 stated the resident did slide out of her wheelchair a lot. She stated it would be unusual for the residents not to be in bed when she came on shift. When asked R1's normal bedtime, LPN #3 stated, R1's normal was to be in bed by 9:00 p.m. at the latest, maybe they refused. When asked where the wheelchair was located at the time of the fall, LPN #3 stated it was next to the bed. LPN #3 stated, once they put R1 to bed she stays put, R1 will sometimes throw a leg out but normally doesn't attempt to get out of the bed. When asked how many CNA's she had that night, LPN #3 stated she only had one until 3:00 a.m. LPN #3 stated she tried to help the CNA with rounds between her medication administration. When asked how many CNAs did, she normally have on the night shift, LPN #3 stated they try to have two but that didn't always happen. When asked if she felt it was understaffed that night, LPN #3 stated, Yes, we can't take care of these residents properly without the staffing. The CNA that worked the night shift from 5/9/2022 through 5/10/2022, was no longer employed at the facility and was unavailable for interview. An interview was conducted with ASM (administrative staff member) #3, the assistant director of nursing, on 5/3/2023 at 10:08 a.m. When asked if she was involved with the staffing, ASM #3 stated, mainly if she is on call, we discuss staffing with the holes (blanks where they need staff to work). When asked the staffing for 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m., ASM #3 stated it should ideally be two aides on each wing with one on each hall for 3:00 p.m. to 11:00 p.m. On 11:00 p.m. to 7:00 a.m. it should ideally be one for each all but at times we have only had one aide at night. ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, were made aware of the above findings on 5/3/2023 at 5:15 p.m. No further information was obtained prior to exit.

Based on observation, family interview, observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to develop and/or implement the comprehensive care plan for six of 51 residents in the survey sample, Residents # 10, # 41, # 88, # 52, # 11 and # 74. The findings include: 1. The facility staff failed to implement Resident # 10's comprehensive care plan for the use of fall mats. Resident # 10 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/16/2021, the resident scored 4 (four) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. On 02/06/2022 at approximately 2:22 p.m., an observation of Resident # 10 revealed they were lying in bed with a fall mat on the floor to the resident's left side. On 02/07/2022 at approximately 9:52 a.m., an observation of Resident # 10 revealed they were lying in bed with a fall mat on the floor to the resident's left side. On 02/07/2022 at approximately 2:10 p.m., an observation of Resident # 10 revealed they were lying in bed with a fall mat on the floor to the resident's left side. The current POS (physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Every shift. Order Date: 02/07/2022. Start Date: 02/07/2022. The comprehensive care plan for Resident # 10 documented in part, Focus: [Resident # 10] is at risk for falls r/t (related to) Gait/balance problems .Revision on: 10/29/2021. Floor mats at bedside on right side. Date Initiated: 06/14/2021. On 02/07/2022 at approximately 10:35 a.m., an interview was conducted with LPN (licensed practical nurse) # 1. When asked to describe the orientation of placing a fall mat on the right or left side of a resident's bed, LPN # 1 stated that it referred to the resident's left or right side. When asked what should happen if a resident's care plan documents a procedure or the use of a device/equipment, LPN # 1 stated, It should be implemented or in place. On 02/07/2022 at approximately 2:20 p.m., an observation Resident # 10's fall mat and interview was conducted with LPN # 1. When asked to describe the location of Resident # 10's fall mat LPN # 1 stated, It's on the left side of [Name of Resident # 10's] bed. After reviewing the comprehensive care plan for Resident # 10, LPN # 1 was asked if the care plan was being implemented for the placement of the fall mat. LPN # 1 stated no. The facility's policy Care Planning - Comprehensive Person-Centered documented, in part, 2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. On 02/07/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional vice president of operations, ASM # 4, vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. 2. Facility staff failed to implement Resident # 41's comprehensive care plan for the administration of oxygen at one liter per minute. Resident # 41 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/10/2021, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 41 as receiving oxygen in the facility during the look back period. On 02/06/2022 at approximately 3:23 p.m., an observation of Resident # 41 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on oxygen concentrator revealed an oxygen flow rate between 0.5 and 1 liters per minute. On 02/07/2022 at approximately 8:20 a.m., an observation of Resident # 41 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on oxygen concentrator revealed an oxygen flow rate between 0.5 and 1 liters per minute. On 02/07/2022 at approximately 2:15 p.m., an observation of Resident # 41 revealed they were lying in bed receiving oxygen by nasal cannula. Observation of the flow meter on oxygen concentrator revealed an oxygen flow rate between 0.5 and 1 liters per minute. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 12/01/2020. The comprehensive care plan for Resident # 41 dated 11/02/2021 documented in part, Focus: The resident has altered respiratory status/difficulty breathing r/t (related to) [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)]. Date Initiated: 11/02/2021 .OXYGEN as ordered. Date Initiated: 11/02/2021. On 02/07/2022 at approximately 2:30 p.m., an observation Resident # 41's flow meter on their oxygen concentrator and interview was conducted with LPN (licensed practical nurse) # 1. When asked the oxygen flow rate was for Resident # 41 who was receiving oxygen by nasal cannula LPN # 1 read the flow meter and stated, One and a half liters per minute. After reviewing the comprehensive care plan for Resident # 41's respiratory care, LPN # 1 was asked if the care plan was being followed. LPN # 1 stated no. On 02/07/2022 at approximately 5:00 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, ASM # 3, regional vice president of operations, ASM # 4, vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. 3. The facility staff failed to implement Resident #88's comprehensive care plan for implementing non-pharmacological interventions prior to the administration of [MEDICATION(S)] ([MEDICATION(S)]-acetaminophen) (1). Resident # 88 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/26/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident is cognitively intact for making daily decisions. Section J0400 Pain Frequency coded Resident # 88 as Frequently. Under J0600. Pain Intensity, it documented, A. Numeric Rating Scale (00-10) Ask resident: Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine. (Show resident 00-10 pain scale). Enter two-digit response. Enter 99 if unable to answer. Resident # 88 was coded a 6 (six). The POS (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 (one) tablet by mouth every 4 hours as needed for Pain. For pain 1-5 [NAME] 6-10 [MEDICATION(S)]. Order Date: 08/04/2020. Start Date: 08/04/2020. The comprehensive care plan for Resident # 88 dated 08/12/2021 documented in part, Focus: [Resident # 88] has the potential for pain/discomfort. Date Initiated: 08/12/2021 .Offer non-pharm (non-pharmacological) interventions for pain. Date Initiated: 10/27/2021. The eMAR (electronic medication administration record) for Resident # 88 dated January 2022 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 7:46 p.m.; 01/29/2022 at 1:45 a.m.; and on 01/31/2022 at 7:25 a.m. The eMAR for Resident # 88 dated February 2022 documented the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility's nursing progress notes for Resident # 88 dated 12/01/2021 through 02/07/2022 failed evidence documentation non-pharmacological interventions attempted for the dates Resident # 88 received 5-325 mgs of [MEDICATION(S)] listed above. On 02/06/22 at 2:10 p.m., an interview was conducted with Resident # 88 regarding their pain. Resident # 88 stated that they have arthritis pain in their hand and left knee. When asked if they receive pain medication as needed, Resident # 88 stated yes. When asked if nursing staff try to alleviate their pain before administering their medication Resident # 88 stated, No, they just give me the pain medication and say I hope it helps. On 02/08/2022 at approximately 11:04 a.m., an interview was conducted with LPN # 1. LPN # 1 was asked if there was documentation that non-pharmacological interventions were attempted prior to Resident # 88 receiving the physician ordered pain medication of [MEDICATION(S)]. LPN # 1 stated no. After reviewing the care plan for Resident # 88, LPN # 1 was asked if the care plan was implemented for the use of non-pharmacological interventions prior to the administration for the pain medication on the dates listed above. LPN # 1 stated no. On 02/08/2022 at approximately 1:50 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing and ASM # 4, vice president of clinical services, were made aware of the findings. No further information was provided prior to exit. References: (1) [MEDICATION(S)] is an opioid pain medication. An opioid is sometimes called a narcotic. Acetaminophen is a less potent pain reliever that increases the effects of [MEDICATION(S)]. The combination of acetaminophen and [MEDICATION(S)] is used to relieve moderate to severe pain. This information was obtained from the website: https://www.rxlist.com/[MEDICATION(S)]-5-325-drug/patient-images-side-effects.htm. 4. The facility staff failed to implement the comprehensive care plan for bathing for Resident #52. Resident #52 was admitted to the facility on [DATE]. On the most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 12/30/2021, the resident scored an 8 of 15 on the BIMS (brief interview for mental status), indicating the resident is severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as not having had a shower or bath during the lookback period. The comprehensive care plan dated 11/29/2021 documented, in part, Focus: The resident has an ADL self-care performance deficit r/t (related to) Dementia, Limited Mobility .BATHING/SHOWERING - Provide sponge bath when a full bath or shower cannot be tolerated. There was no documentation in the care plan that the resident has refused baths/showers. An interview was conducted with the resident's family member on 2/6/2022 at 3:11p.m. When asked if she had any concerns, the family representative stated she is concerned that her mother is not getting baths/showers. She stated that the staff is telling her that the resident is refusing them. The ADL (activities of daily living) records for the following months documented: - For November 2021, the resident received a bed bath on 11/24/2021. The activity (bathing) did not occur on 11/23/2021, 11/25/2021, 11/26/2021, 11/27/2021, 11/28/2021, 11/29/2021 and 11/30/2021. On the following dates, bathing did not occur, and Hair Only was documented: 11/26/2021, 11/28/2021, and 11/29/2021. - For December 2021 there were only six days of documentation of bathing. 12/1/2021 - the resident received a bed bath. 12/2/2021 - the resident did not receive any bathing. 12/3/2021 - the resident received a partial bed bath on day shift and a bed bath on night shift. 12/4/2021 - there was no documentation of any bathing. 12/5/2021 - the resident received a bed bath on night shift. 12/6/2021 - the resident received a bed bath on night shift. - For January 2022, the resident's showers were scheduled on the evening shift on Tuesday and Friday. There was no documentation until 1/14/2022. On 1/14/2022, 1/18/2022, 1/21/2022, 1/25/2022, and 1/28/2022, it was documented that the bathing activity did not occur; however, an S was documented for each date. - For February 2022, on 2/1/2022 and 2/4/2022 the bathing activity did not occur. For both of these, it was documented hair only. The nurse's notes from 11/22/2021 through 2/7/2022 were reviewed. There was no documentation of the resident's refusal of baths/showers. An interview was conducted with CNA (certified nursing assistant) #7 on 2/8/2022 at 9:03 a.m. The above ADL records was reviewed with CNA #7. CNA #7 was informed that family members had expressed concerns about the resident not receiving baths/showers. CNA #7 stated the resident refuses them. When asked how facility staff are to document a resident's refusal of a bath/shower, CNA #7 stated the staff has nowhere to document the refusal. She stated they were told to document the task was not completed, and then to document what should have been given. She stated the January 2022 documentation referenced above shows that the bath/shower did not occur, but that a shower should have been given. When asked if a resident refuses what action should the CNA take, CNA #7 stated, We have to tell the nurse. CNA #7 stated she has not seen the ADL records printed in this manner. At this time, LPN (licensed practical nurse) #3 was asked to provide any documentation that Resident #52 had received a bath/shower on the above referenced dates. An interview was conducted with LPN (licensed practical nurse) #1, on 2/8/2022 at 11:07 a.m. When asked the purpose of the care plan, LPN #1 stated it's a guide to patient care. When asked if it should be followed, LPN #1 stated, yes. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of clinical services, were made aware of the above concern on 2/8/2022 at 2:05 p.m. No further information was obtained prior to exit. 5. The facility staff to implement the comprehensive care plan for the placement of a pressure relieving device for Resident #11. The donut pillow was not in place per the comprehensive care plan. Resident #11 was admitted to the facility 7/11/2015. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/17/2021, the resident was coded as having short and long term memory problems and severely cognitively impaired for making daily decisions. In Section M - Skin Conditions, the resident was coded as having one stage III pressure injury. Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. (1). The comprehensive care plan dated 11/9/2021, and revised on 2/7/2022, documented in part, Focus: The resident has a pressure ulcer of left shoulder .Donut pillow to left ankle to alleviate pressure. Observation was made of Resident #11 on 2/7/2022 at 8:11 a.m. The resident was seated in a reclining chair with her legs bent at her knees. There was not donut pillow around the resident's left ankle. A second observation was made on 2/7/2022 at 3:31 p.m. The resident was in her bed with her covers over her. The donut pillow was noted on the top of her nightstand. CNA (certified nursing assistant) #6 came into the room. When asked if the resident was to have the donut pillow on her left ankle, CNA #6 stated that she always puts it on her. It's supposed to be on all the time. CNA #6 confirmed the donut pillow was sitting on the nightstand and not on the resident. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with LPN (licensed practical nurse) #8 on 2/7/2022 at 3:32 p.m. The above observation was shared with LPN #8. When asked if the physician ordered donut pillow should be in place as prescribed, LPN #8 stated, yes. When asked if the resident's care plan stating the donut pillow should be in place is being followed, LPN #8 stated, no. ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of clinical services, were made aware of the above concern on 2/8/2022 at 2:05 p.m. No further information was obtained prior to exit. References: (1) This information was obtained from the following website: https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf 6. The facility staff failed to develop a care plan for the use of oxygen for Resident #74. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/19/2022, the resident was coded as being severely impaired for making daily decisions. Section O documented the resident receiving oxygen at the facility during the look back period. On 2/6/2022 at approximately 2:15 p.m., Resident #74 was observed in bed wearing an oxygen nasal cannula with a humidifier bottle dated 2/4/22; the equipment was attached to an oxygen concentrator. Resident #74 was observed to be alert, awake and non-verbal. Additional observations of Resident #74 on 2/6/2022 at approximately 4:15 p.m. and 2/7/2022 at approximately 8:15 a.m. revealed oxygen being administered by nasal cannula as described above. The comprehensive care plan for Resident #74 failed to evidence documentation of oxygen administration. The physician order's for Resident #74 documented in part, Oxygen therapy at 2 (two) liters per minute via nasal cannula. Start Date: 1/18/2022. On 2/7/2022 at approximately 2:35 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that the purpose of the care plan was to guide the care of the patient. LPN #1 stated that oxygen should be included on the care plan. LPN #1 observed Resident #74's oxygen and stated it was set at 1.5 liters per minute, and that she would verify the orders and the care plan and correct this as needed. The facility policy Care planning documented in part, .2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process . On 2/7/2022 at 5:00 p.m., ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional director of operations and ASM #4, the vice president of clinical services were made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, interviews with local health-department staff, review of facility documents, and clinical record review, it was determined, that the facility staff failed to ensure the implementation of infection control practices and precautions, to prevent the spread of infection, and communicable disease during an identified outbreak of Coronavirus (COVID 19), on one of two facility units, (South unit), and for five of 15 sampled residents, (Residents #3, #13, #2, #5, and #14). The facility staff was not observed implementing standard and droplet precautions to prevent the spread of COVID 19 while providing care and services to COVID positive and negative residents, on the South unit. The facility staff failed to pull privacy curtains the full length of the bed in five of ten resident rooms in which COVID positive and negative residents resided together in the same room, resident room numbers, #220, #210, #206, #225, and #224. The director of nursing, ASM (administrative staff member) #2 failed to implement droplet precautions when caring for a COVID-19 positive and a COVID-19 negative resident. ASM #2 failed to wear gloves and a gown when putting an arm around Resident #3, who was COVID-19 positive. ASM #2 then sanitized her hands with alcohol gel and, without donning gloves or a gown, walked over to Resident #13, who was COVID-19 negative, put an arm around Resident #13, and assisted Resident #13 down the hall. The facility failed to implement droplet precautions by failing prevent Resident #3 and Resident #2, both COVID positive residents from wandering on the South unit without masks or PPE (personal protective equipment) (2). Resident #3, who was COVID-19 positive, was observed sitting at a table in common area accessible to both COVID 19 positive and negative residents. In the hallway, Resident #2 was observed self-propelling in her wheelchair, within three feet of Resident #13, who was COVID-19 negative and not wearing a mask. In the common area, Resident #2 sat within three feet of Resident #5, who was COVID-19 negative. As, a result of this failure, it was likely other residents were at risk of continued exposure and contracting COVID-19, which had already resulted in a COVID-19 positive status for over 60% (59 residents) of the current 109 resident population at the time of the survey, with one resident death, (Resident #8), attributed to COVID-19. This failure resulted in Immediate Jeopardy. On [DATE], at approximately 2:00 p.m., the facility failed to prevent Resident #14 from wandering from a COVID-19 positive area on the South Unit, through a set of fire doors, and to a nurses' station located directly across from a room housing COVID-19 negative residents, resulting in a situation of continued Immediate Jeopardy. In addition, the facility staff failed to implement infection control practice during incontinence care for one of 15 sampled residents, (Resident #15). The facility staff member failed to change gloves and to sanitize hands after cleansing Resident #15's perineal area (3) and handling the resident's soiled incontinence brief during incontinence care. Without cleaning hands or changing gloves, the staff member applied the resident's clean brief, helped pull the resident up in bed, and cleaned the resident's face with a wipe. The State Agency informed the facility on [DATE] at 10:42 a.m. of the Immediate Jeopardy situation. On [DATE] at 1:18 p.m., the Immediate Jeopardy was abated and lowered to a level II Isolated. The findings include: 1. On [DATE], the survey team began an abbreviated, remote FICS (focused infection control survey) at the facility. As a part of the remote survey process, the survey team contacted and interviewed staff members from both the local and central health department. On [DATE] at 11:21 a.m., OSM (other staff member) #1 was interviewed. She stated that, to her knowledge, no member of the local or central VDH (Virginia Department of Health) had been inside the facility. She stated that when she was first informed of COVID-19 positive residents at the facility; she sent them copies of the state health department guidance for long-term care facilities. OSM #1 stated that she made a phone call to connect with ASM (administrative staff member) #3, the administrator, and ASM #2, the director of nursing. At that time, ASM #2 and ASM #3 described the facility's layout, and stated that in addition to one resident who had been hospitalized and tested positive for COVID-19, the facility had identified four additional residents as symptomatic. OSM #1 stated the facility staff told her they had begun to implement a plan to make the facility's dining room the COVID-19 ward. OSM #1 stated it was the next day that the facility-wide and staff-wide testing for COVID-19 was performed, and then the results started coming back over the next few days. OSM #1 stated that on Thursday, [DATE], most all of the testing results had come back, indicating that over half the residents were COVID-19 positive, and 18 staff members were COVID-19 positive. She stated the facility then transferred 10 residents to the local hospital in an effort to, basically isolate them. OSM #1 stated the facility transferred the residents to the hospital to get them out of the facility and to stop the transmission inside the nursing facility. OSM #1 stated that she recommended, at that time, that the facility not try to do mass cohorting, as there were a significant number of COVID-19 positive residents on both units of the facility. When asked her professional response to the lack of mass cohorting of like residents, OSM #1 stated she had mixed feelings. She stated that moving residents can be disruptive to them, and that there is a risk of exposure to other residents during a move. OSM #1 stated there was some thinking that COVID-19 negative residents had already been exposed to [MEDICAL CONDITION] if their roommate was COVID-positive. OSM #1 stated, But I wonder how it is working in practice. I don't know the best way to assess if it is effective. She stated the best scenario would have been for COVID-19 positive residents to be placed with other positive residents, and vice versa for COVID-19 negative residents, but she was aware of staff limitations to implement fully the best scenario. OSM #1 stated the next best scenario would be to have the curtain pulled between residents, and for the staff to use different PPE (personal protective equipment) between residents. OSM #1 stated that her current understanding was that the facility was treating all residents as if they were COVID-19 positive. On [DATE], at 12:36 p.m., OSM #2, the director of the local health department, was interviewed. He stated that neither he nor any member of his staff had been inside the facility. OSM #2 stated one of his staff members had been up to the front door, but no further. When asked if he had any concerns about the way the facility was handling the outbreak, OSM #2 stated his concerns were about maintaining the staff and the quality of care they are giving. OSM #2 stated, I would not be horrified if you (State Survey Agency) made a site visit. But things seem to be better now than they were. On [DATE], at 12:47 p.m., OSM #3, a nurse epidemiologist from the state health department was interviewed. When asked about any concerns that she had for the facility, OSM #3 stated, They have a lot of COVID-19 there. OSM #3 stated the facility initially had a plan to use the dining room for COVID-19 positive patients, but she had expressed concerns to the facility staff about having adequate handwashing and toileting options available. OSM #3 stated the facility staff abandoned that plan because there were not enough staff members to do it. OSM #3 stated that once all facility residents had been tested and the results had come back, it was a situation where you found a lot of asymptomatic, positive residents. She stated this created a concern about how to move residents and about how to staff the move. OSM #3 stated, I can understand why they did not move or cohort residents. The staff was scared to come to work. OSM #3 stated, We backed off and let the facility take the lead. It was safer for the situation they were in. OSM #3 stated she had emphasized to the facility the need to change gown and gloves between negative and positive patients. On [DATE] at 1:10 p.m., a phone interview was conducted with ASM #4, a nurse supervisor for the local health department. She stated she had been in the facility parking lot during the previous week, and had observed staff wearing PPE outside in the parking lot. She stated her concerns about the facility, were primarily related to PPE usage, and about what kind of infection control is happening there. On [DATE] at 1:30 p.m., after the survey team entered the facility, ASM (administrative staff member) #1, the acting administrator, was interviewed about rooms, which housed both COVID-19 positive and COVID-19 negative residents. When asked how the staff knew which residents in a room were positive, and which residents, were negative for COVID-19, ASM #1 stated that resident nameplates had colored stickers. A pink sticker meant a resident was positive for [MEDICAL CONDITION]; a yellow sticker meant a resident was negative for [MEDICAL CONDITION]. On [DATE] at 1:40 p.m., an initial tour of the facility's South Wing was completed. The following room nameplates indicated that both a COVID-19 positive and a COVID-19 negative resident were housed in the same room: 220, 217, 214, 213, 210, 209, 206, 225, 224, and 223. In room [ROOM NUMBER], the curtain between the resident beds, was only pulled approximately ,[DATE] of way down the length of the beds. In rooms [ROOM NUMBER], the curtain between resident beds was pulled approximately ,[DATE] way down the length of the beds. In room [ROOM NUMBER], the curtain between resident beds was not pulled at all. On [DATE], ASM (administrative staff member) #2, the director of nursing, was observed walking in hallway of the South Unit. ASM #2 was wearing a mask, but no gloves or gown. ASM #2 approached Resident #3, who was not wearing a mask, and who was walking down the hall. ASM #2 put her right arm around Resident #3's shoulders, and guided Resident #3 back towards her room. ASM #2 sanitized her hands with alcohol gel. Still without gloves or gown, ASM #2 approached Resident #13, who was not wearing a mask, and who was standing still in the hallway near the nurses' station. ASM #2 put her right arm around Resident #13's shoulders, and walked with Resident #13 all the way to the resident's room. On [DATE] at 3:45 p.m., Resident #3 was observed sitting alone at a table in the common area. She was not wearing a mask. While no other residents were observed in the area at this time, this common area was accessible to any resident on the South Unit. On [DATE] at 4:00 p.m., LPN (licensed practical nurse) #1 walked into the common area where Resident #3 was sitting. LPN #1 was wearing mask, gown, and gloves. She approached Resident #3, and invited the resident to walk with her down the hall and to return to her room. When asked why she was inviting the resident to go back to her room, LPN #1 stated, She is one of the ones that is hard to keep in her room. LPN #1 stated the resident had been pretty compliant that day, and had three masks in her room. When asked why it was important for Resident #3 to wear a mask and to remain in her room, she stated the resident was at risk of spreading the COVID-19 virus. Review of the clinical records for Resident #3 and #13, remotely, revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of [DATE], the resident was coded as being moderately impaired for making daily decisions, having scored nine out of 15 on the BIMS (brief interview for mental status). She was coded as being independent for walking in her room and moving around on the unit. A review of Resident #3's nurse notes revealed a note on [DATE] stating that she tested positive for COVID-19. A review of Resident #3's care plan dated [DATE] and updated [DATE] revealed, in part: Droplet isolation precautions (6) from COVID-19 .Keep resident in room .Staff to wear PPE (personal protective equipment) at all times and maintain good hand hygiene .Behavior wandering - The resident is an elopement risk/wanderer r/t disoriented to place, impaired safety awareness, wanders aimlessly due to dementia .distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Further review of Resident #3's clinical record revealed the following nurse note dated [DATE]: Resident was given a mask for protection. Resident is confused and may take off and refuse mask. Further review of Resident #3's clinical record revealed the following nurse note dated [DATE]: Resident was given a mask for protection. At this time resident has mask on, but resident has advanced dementia and may take it off. Resident #13 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of [DATE], Resident #13 was coded as having severe impairment for making daily decisions, having scored only six out of 15 on the BIMS. She was coded as being independent for walking in the room moving around the unit. A review of Resident #13's laboratory test results received by the facility on [DATE] revealed that she tested negative for COVID-19. A review of Resident #13's care plan, dated [DATE] and updated [DATE] revealed, in part: BEHAVIORS (Resident #13) was in a physical altercation with another resident. Potential for further altercations with others and staff due to dementia with behaviors .provide redirection or distraction to minimize frequency or duration of behavior .Resident at risk for cross infection r/t (related to) actual/potential exposure to COVID-19 .Droplet isolation precautions from COVID-19 .Initiate social distance of 6 feet away from resident unless giving care .Keep resident in room .Staff to wear PPE at all times and maintain good hand hygiene .BEHAVIOR/WANDERING - The resident is an elopement risk/wanderer related to [MEDICAL CONDITION], known to wander when she was home .Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book .[MEDICAL CONDITION] - The resident has dementia causing impaired thought process r/t Alzheimer's .Cue, reorient, and supervise as needed .The resident needs supervision and assistance with all decision making. On [DATE] at 2:54 p.m., Resident #2 was observed sitting in a wheelchair in the common area watching television. Resident #2 was not wearing a mask. Resident #5 was observed sitting in a brown recliner watching television, and was within three feet of Resident #2. Resident #5 was wearing a mask. Resident #5 was asked his name and the location of the room. He answered the surveyor appropriately. When asked how often he watched television in the common area, he stated that he watched television right much. When asked if he always wore a mask, Resident #5 stated, Yes. An observation of this common area again at 3:05 p.m., revealed Resident #5 was no longer in the common area. Resident #2 remained there in her wheelchair, wearing no mask. On [DATE] at 3:12 p.m., Resident #2, who was COVID-19 positive and not wearing a mask, was observed self-propelling in her wheelchair, from the common area down the hall towards the nurses' station. As Resident #2 traveled down the hall, she passed within three feet of Resident #13, who was COVID-19 negative and not wearing a mask. Review of the clinical records for Resident #2 and Resident #5 completed remotely, revealed Resident #2 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of [DATE], Resident #2 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as being independently mobile with supervision and the use of a wheelchair. A review of Resident #2's nurse notes revealed a note on [DATE] stating that she tested positive for COVID-19. Resident #2's comprehensive care plan, dated [DATE] and updated on [DATE], revealed, in part the following: Resident exhibits signs of alteration in respiratory status and at risk for cross infection due to positive test for COVID 29 (sic) .Droplet isolation precautions for COVID-19 .Keep resident in room .Staff to wear PPE at all times and maintain good hand hygiene .The resident is able to propel herself independently in wheelchair at times, and other times requires supervision with occasional assistance .BEHAVIOR Noted with increased confusion. Resident refuses to wear face mask .Continue to encourage to wear face mask .Identify pattern of wandering: Is wandering purposeful, aimless or escapist? Is resident looking for something? Does it indicate the need for more assistance? .Cue, reorient, and supervise as needed. Resident #5 was admitted to the facility on [DATE], and was readmitted on [DATE]; [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a quarterly assessment with an assessment reference date of [DATE], Resident #5 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS. Resident #5 was coded as requiring the help of one staff member for moving around the unit. He was coded as using a walker for mobility. A review of Resident #5's nurse notes revealed a note dated [DATE] documenting that Resident #5 tested negative for COVID-19. Review of Resident #5's comprehensive care plan, dated [DATE] and updated on [DATE], revealed, in part the following: Resident is at risk for cross infection r/t (related to)actual/potential exposure to COVID-19 .Droplet precautions from COVID-19 .Initiate social distance of 6 ft (feet) away from resident unless during care .Keep resident in room .THOUGHT PROCESS Potential for thought processes impaired d/t (due to) prior stroke .Cue, reorient and supervise as needed. On [DATE] at 4:02 p.m., ASM #1 was interviewed about the process staff followed for the decision to leave COVID-19 positive residents in the same rooms with COVID-19 negative residents. She stated that the facility had undergone testing for all residents and staff. ASM #1 stated that when the results of the testing came back, the results indicated, Everyone had been exposed. She stated that at that time, the decision was made to leave all residents where they were, as more than 49 residents would have needed room changes to separate COVID-19 positive from COVID-19 negative residents. ASM #1 stated one of the facility's strategies of isolating COVID-19 positive from COVID-19 negative residents was to keep the curtain pulled between residents. She stated a staff member from the health department had instructed the facility to do this to maintain a barrier between COVID-19 positive and COVID-19 negative residents. When asked what it meant if the curtains were not pulled completely between COVID-19 positive and COVID-19 resident beds, ASM #1 stated the curtains should be pulled if both a COVID-19 positive and a COVID-19 negative resident were housed in the same room. When informed that interviews with the local health department had yielded information indicating that there was not enough staff to make resident room moves in order to separate COVID-19 positive and COVID-19 negative residents after the all-resident testing, ASM #1 stated, That is true - with 49 room moves and we had staff calling out. ASM #1 was informed that Residents #2 and #3, who were positive for COVID-19, were observed wandering the halls and common areas without a mask. ASM #1 stated, Yes, we have given them masks. It is hard to keep them in their rooms, though. When asked the facility was still responsible to implement infection control precautions to prevent the spread of COVID-19 from positive to negative residents, ASM #1 stated, Yes, they should stay in their room, and we keep giving them masks to use. Review of the Line List for COVID-19 Outbreaks, submitted by the facility for review by fax on [DATE], revealed, the following documented entry for Resident #8: - Name of resident (Resident #8), Unit or Room, N (no), Onset Date, ,[DATE], Cough (Y/N), N, Fever (Y/N), N, Shortness of Breath (Y/N), N, [DIAGNOSES REDACTED] (severe acute respiratory syndrome) COV-2 test result (+/-), + (positive), Respiratory Panel Test Result (+/-), - (dash), hospitalized (Y/N), N (no), died (Y/N), ,[DATE]. Under the section titled Notes: a + sign that was circled and handwritten note beside this documented, COVID-19, with staff initials. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), an annual assessment with an assessment reference date of [DATE], Resident #8 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). A review of Resident #8's clinical record revealed a nurse note dated [DATE] documenting that the resident had tested positive for COVID-19. Further review revealed a nurse note dated [DATE] documenting notification to the sons of the resident that the resident's condition had worsened. Further review revealed a nurse note dated [DATE] documenting the resident's death at 2:37 p.m. A review of the facility policy, Isolation - Categories of Transmission-Based Precautions, revealed, in part: Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others .Droplet Precautions .In addition to Standard Precautions, implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets (larger than 5 microns in size) that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning) .Resident Placement (1) Place the resident in a private room if possible .When a private room is not available, residents with the same infection with the same microorganism but with no other infection may be cohorted. When a private room is not available and cohorting is not achievable, use a curtain and maintain at least 3 feet of space between the infected resident and other residents and visitors. A review of the facility policy, Outbreak of Communicable Diseases, revealed, in part: Outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled .The nursing staff will be responsible for initiating isolation precautions as directed or as necessary; and confining symptomatic residents to their rooms as much as feasible, when indicated. A review of the facility policy, Topic: Caring for the Resident with a Suspected or Confirmed Case of COVID-19, revealed, in part: Residents with confirmed or suspected cases of COVID-19 will be cared for in accordance with guidelines as stipulated by the CDC. All efforts will be made to prevent transmission, treat symptoms, and provide necessary psychosocial support for infected resident (sic) .Patients with known or suspected COVID-19 will be transferred to the designated unit, and when feasible provided with a private room .Residents that have a confirmed case of COVID-19 can cohort with other residents who have a confirmed COVID-19 .The following measures will be implemented for residents with known or suspected COVID-19: a facemask will be placed on the resident and worn as tolerated, transmission based precautions will be instituted to include placement of isolation cart at entrance of room and signage on the door, caregivers will don appropriate personal protective equipment (PPE) - gown, mask, face/eye shield, gloves. A review of the facility's corporate document, Rapid Response Plans in Event of Confirmed Infection, revealed, in part: 1. Triggering the Risk Management Team to coordinate response. Key Goals: Reduce morbidity and mortality, minimize disease transmission, protect healthcare personnel, preserve healthcare system functioning. 2. Activate COVID-19/Observation Unit Assessment for affected patient. Isolate patient .Facility works with local DOH (department of health) on federal recommendations. A review of the facility's policy, COVID-19 (Coronavirus) revealed, in part: This guidance is based on the currently available understanding of COVID-19-nCOV related to disease severity, transmission efficiency, and shedding duration which is crucial in understanding [MEDICAL CONDITION] transmission and control .[MEDICAL CONDITION]' main means of spreading is thought to be person-to-person transmission. This includes, but is not limited to: people who are within about six feet of each other, respiratory droplets produced when an infected person coughs or sneezes. It can also be spread from contact with infected surfaces or objects .Preventative Measures .Patient Placement: Residents identified to have COVID-19 should be placed in an AIIR (Airborne Infection Isolation Room) or isolation room until transferred to a hospital or healthcare facility equipped with treating such infections and reported to local Board of Health. On [DATE] at 4:30 p.m., after the onsite visit was completed, the long-term care supervisor was notified of the survey team's observations and a conference call was completed with two additional supervisors and the survey team. On [DATE] at 6:49 p.m., it was determined that the facility's failure to implement infection control practices to prevent the spread of a communicable disease (COVID-19), resulted in a situation of IJ (immediate jeopardy). On [DATE] at 7:02 p.m., the survey team attempted to contact the acting administrator of the facility, ASM #1. The survey team was informed that the administrator had left for the day. On [DATE] at 8:25 a.m., 8:44 a.m., 9:21 a.m., and 9:23 a.m., the survey team attempted to contact ASM #1, the acting administrator. On [DATE] at 10:42 a.m., the administrator was reached by phone, and was informed of the concern for IJ. ASM #1 stated, I knew it was going to be this. She stated, the only way to fix this is to cohort the patients and round up the bodies to do this. ASM #1 was instructed to not begin moving residents or take any other action until the facility had submitted a POC (plan of correction), and the POC had been approved by the survey team and Long Term Care Supervisor. On [DATE] at 11:36 a.m., the surveyor received a call from OSM (other staff member) #1, the director of the local health department. OSM #1 stated he had received a most disturbing phone call from the CEO (chief executive officer) of the company that owns the facility. OSM #1 stated the CEO is very upset that they have received notification of some, sort of very bad, punitive measures that have financial implications. OSM #1 stated, I thought we were clear about all of this. He stated, I want to know what is going on, and asked what the facility CEO had been told. OSM #1 was informed that the only correspondence by the survey team, had been with ASM (administrative staff member) #1, a corporate staff member who is acting as the facility administrator and that ASM #1 had been informed of a concern for the facility's failure to implement infection control practices to prevent the spread of a communicable disease COVID-19. OSM #1 asked if the survey team was concerned because COVID-19 positive residents are in the same rooms with COVID-19 negative residents. OSM #1 was informed that observations made onsite on [DATE] raised concerns. OSM #1 then asked to be informed of those concerns, and was informed of the findings of curtains not closed between positive and negative residents, of positive residents roaming freely without PPE and coming into close contact with negative residents. OSM #1 was informed of the facility staff member without PPE in direct contact with a COVID-19 positive resident, with subsequent direct contact with a COVID-19 negative resident. OSM #1 stated that the CEO had not told him these things, and that there seemed to be more to this story. OSM #1 stated, Those things can be fixed. From [DATE] through [DATE], a review of the facility presented several POC (plan of correction) drafts, which were reviewed and declined, due to not meeting all the requirements. On [DATE], the facility presented the following plan of correction. 1. On [DATE], Resident #1 was redirected to her room by staff when observed outside of her room. Resident refuses to leave facemask in place. On [DATE], Resident #2 was redirected to her room by staff when observed outside of her room. Resident refuses to leave a facemask in place. On [DATE], Resident #3 was redirected by staff when observed outside of her room. Resident refuses to leave facemask in place. All care plans reflect refusal to wear facemask. On [DATE], curtains were not pulled between resident beds in cohorted rooms, room # 220, 216, 210, 216, and 225. Rounds on [DATE] showed privacy curtains pulled appropriately in room [ROOM NUMBER], 216, 210, 216, and 225 On [DATE], Nurse #1 observed having direct contact with two positive COVID 19 residents wearing only a facemask, no other PPE. Rounds on [DATE] completed by VP (vice president) of Clinical Services showed all staff wearing appropriate PPE while interacting with residents. Any negative resident has potential to be at risk for contracting [MEDICAL CONDITION] pathogens due to cohorting of positive and negative residents in the same areas within the facility 2. Room changes implemented to move residents to designated positive and negative areas within the facility. On North Unit, the unit will be divided into positive and negative zones, separated by a fire door. Two positive rooms will be outside the doors but will house non wandering residents that stay in their rooms. COVID positive Residents noted to wander will be housed behind the closed fire doors to prevent wandering into negative areas. South Unit will be divided by the hallway in front of the nurses' station with negatives and positives on either side of the unit. COVID positive Residents noted to wander will be housed behind the closed fire doors to prevent wandering into negative areas. Any positive rooms outside of fire door will house non wandering residents that stay in their rooms. Negatives with symptoms will be cohorted together. When optimal staffing present, Staff working with positive residents will only be assigned to the COVID zone with use of full PPE: One designated nurse on ,[DATE] and ,[DATE], and half of the scheduled CNA's. One nurse ,[DATE] and ,[DATE], one half of scheduled CNA's will be designated to the negative zone. ,[DATE] has only one nurse per unit, so that nurse will provide medications and complete assessments to negative residents first, and then complete same tasks on the COVID unit wearing appropriate PPE, half of CNA's will be assigned to COVID positive zone. This applies to both North and South Unit. Medication carts will be designated to the positive and negative areas, and will remain in their designated area. When staffing is less than optimal and staff must have assignments which include resid (TRUNCATED)

Based on observation, staff, interview, resident interview, facility document review, and clinical record review, facility staff failed to ensure six of 60 sampled residents, (Residents #32, #36, #45, #95, #48, and #101) were assessed and safe, for unsupervised smoking, to prevent accidents and injuries, and failed to ensure a safe environment for smoking residents, and others residing in the facility. On 11/12/19, during entrance, the facility administrator, ASM (administrative staff member) #1 stated the facility was a nonsmoking facility and presented the policy. On 11/14/19 at 9:14 a.m., Resident #32 and 36 were observed outside on the south unit, patio (on the facility premises) smoking, without staff supervision. The patio area had no receptacles to safely, extinguish and dispose of cigarettes, or safety equipment (fire extinguishers, fire blankets, etc.). The clinical records for both residents documented noncompliant smoking behaviors, but failed to evidence either resident had been assessed, as safe to smoke unsupervised. On 11/14/19, Residents #45, #95, #48, and #101, were identified as residents who smoke on a list provided by ASM #1, the administrator. Each resident had documented noncompliant smoking behaviors and the facility staff stated they were aware. The clinical records for Residents #45, #95, #48, and #101, failed to evidence they had smoking assessment completed or had been assessed as safe to smoke unsupervised. This resulted in Immediate Jeopardy (IJ) and SQC (substandard quality of care), which was identified in the area of Quality of Care on 11/14/19 at 1:56 p.m. The plan of removal for the immediacy was accepted on 11/14/19, at 7:30 p.m. The IJ was abated on 11/15/19 at 10:40 a.m., with the Scope and Severity lowered to Level II, Pattern. The findings Include: Surveyor A: 1. On 11/12/19 at 11:30 a.m., during the entrance conference, the ASM (administrative staff member) #1, the administrator stated that the facility is a non-smoking facility and provided the facility policy asserting the facility's non-smoking status. A review of the facility policy, documented the following: It is the policy of (name of facility) to be a non- smoking facility for residents. This smoke-free environment is to ensure that the environment exists from threat of Fire and of primary and secondary smoke. No Smoking will not be allowed inside the facility at any time. We do recognize that a resident has the right to smoke and this will be allowed, however they must go off campus. Their lighters must be kept at nurses' station and they must return them after they are finished smoking. The designated area for Visitors is outside at the front porch marked off with yellow tape. Staff members who smoke will only be allowed to smoke outside off the loading dock in the space provided. (Note - a tour of the facility, discussed in a later paragraph, revealed there was no area marked off with yellow tape.) This policy was noted as Revised (MONTH) 2019. On 11/14/19 at 9:15 AM, an observation was made of the South unit, patio area by bending down to look through one of three windows with blinds. The window the observation was conducted through had blinds closed 3/4 the way and revealed two residents (Resident #36 and #32) smoking on the south unit patio (on facility property). Resident #36 was sitting in a chair on the patio alongside Resident #32. Both residents were observed smoking. No staff members were assisting the residents. No safety devices such as a fire extinguisher or smoking aprons were observed in the smoking area. There were no cigarette disposal devices to safely extinguish and dispose of cigarettes. The inside of the building at this patio was the south unit living room / dayroom / dining area. There were three large windows located on the end wall of the building that faced this patio area. Two of the windows hand blinds closed all the way. The third window through which the observation was conducted had the blinds closed 3/4 of the way down. There were two doors, observed that led out from either side of the living room / dayroom / dining area. One door on the left and one on the right side, close to the large windows. Both doors required a keypad code to exit the building. The two residents who were smoking on the patio were not visible through the windows with the blinds all the way down. On one side of the living room / dayroom / dining area, at the last resident room, closest to the windows, LPN (licensed practical nurse) #8 was observed at a medication cart. When asked whom the two residents were outside on the patio, LPN #8 went over to the window through which the observation was made, and moved the blind to the side to see the residents. LPN #8 identified the residents that were smoking as Residents #32 and #36. There was no other staff noted in the area inside or outside of the building supervising the two residents. On 11/14/19 at 9:17 AM in an interview with CNA #3 (Certified Nursing Assistant), she was asked if the residents were allowed to smoke there. CNA #3 stated, I honestly don't know. On 11/14/19 at 9:44 AM, in an interview with ASM #2 (Administrative Staff Member, the Director of Nursing), ASM #2 stated, This is a non-smoking facility. It was non-smoking before I got here. I started June, (YEAR). When asked about assessing the residents for safe smoking, ASM #2 stated, We don't assess them because we are a non-smoking facility. When asked about the location of where residents, are instructed to smoke, ASM #2 stated, The sign (the property entrance sign that identifies the name of the facility located at the entrance to the parking lot) is off grounds. That is off-site for smoking for (name of facility). (Note: This sign is located in a mulched roundabout area where the street meets the parking lot. The street extends off the main road and goes up hill towards this mulched area marking the entrance to the facility parking lot) When asked if that is the only place, the residents can smoke, ASM #2 stated, Yes, to my knowledge. When asked if she had seen residents smoke elsewhere, ASM #2 stated, No. When asked if residents were assessed to determine if they were safe to smoke in these areas, ASM #2 stated, No because it is non-smoking facility. When asked about residents who smoke at the facility, ASM #2 stated, That I'm aware of, maybe five, (she then named the residents, including Resident #32 and #36). ASM #2 was asked when the facility was aware the residents were smokers. ASM #2 stated, I knew they were (smokers) before today. When asked if residents who are smoking should be, care planned, ASM #2 stated, Yes. Whenever we realize they are a smoker. When asked further about the care plans, as reviews had revealed the care plans were developed and/or reviewed/revised on this date (11/14/19), ASM #2 stated, I did the care plans this morning, I won't lie to you. I was told you (surveyors) were looking at smokers. When asked who updated the care plans, ASM #2 stated, I updated all of them. When asked who should have updated them before this date, ASM #2 stated, I thought social services would have updated the care plan. When asked if the facility has IDT (Interdisciplinary team) meetings, ASM #2 stated, Yes, I don't attend the meetings. When asked if the facility has weekly care plan meetings, ASM #2 stated, Yes, if they are not complying (with no smoking) we talk about it as a behavior. To my knowledge this is a non-smoking facility. Resident #32's [DIAGNOSES REDACTED]. The most recent MDS, an annual assessment, with an assessment reference date coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for bed mobility, transfers, dressing, and bathing. He required limited assistance of one staff member for toileting and personal hygiene. In Section G - Functional Status, the resident was coded as having impairments in his range of motion in his arm and leg on one side. Resident #32 was coded as being independent in moving on and off the unit with only set up assistance. The resident was coded as using a wheelchair for his locomotion. Under J1300, he was coded, no for tobacco use. A physician's order dated 4/3/19, documented, Nicotine Patch 14 mg (milligrams) daily for 2 weeks, and then decrease to 7 mg daily for 2 weeks and then discontinue. A review of the (MONTH) 2019 MAR (Medication Administration Record) revealed that the patch was provided. The comprehensive care plan dated 3/3/17 documented, Behaviors: (Resident #32) is aware this is a non smoking (Sic.) facility. The interventions included, 3/3/17 - Encourage pt (patient) not to smoke or ask visitors for cigarettes due to no smoking policy. 3/3/17 - Encourage (Resident #32) to not get cigarettes out of ashtrays out side (Sic.). 3/3/17 - Review smoking policy with resident as needed. There were no other interventions prior to the survey, for smoking. Further review of 6 months of notes in the clinical record revealed the following notes documented by the social worker: On 5/7/19, 5/14/19, 5/21/19, 5/28/19, 6/4/19, 6/18/19, 7/2/19, 7/12/19, 7/16/19, 7/30/19, 8/6/19, 8/14/19, and 8/26/19, that documented, (Resident #32) smokes when (Resident #32) knows a family member or friend must be with (Resident #32). (Resident #32) is wearing a nicotine patch, but continues to sneak smoke (Note the physician order for [REDACTED].) On 9/4/19 the following was documented, (Name of Resident #32) smokes when (Name of Resident #32) knows a family member or friend must be with (Name of Resident #32). (Name of Resident #32) is giving other residents cigarettes. (Name of Resident #32) has been educated. Denies this behavior On 9/17/19, 9/25/19, and 10//1/19 the following was documented, (Name of Resident #32) continues to smoke when (Name of Resident #32) has been educated on smoking policies. (Name of Resident #32) is providing cigarettes to other residents in the facility, and denies behaviors when questioned On 10/22/19, the following was documented, Resident continues to smoke when (Name of Resident #32) has been educated on smoking policies. Resident is providing cigarettes to other residents in the facility, and denies giving other residents cigarettes. Resident picking up cigarette butts in the parking lot to smoke. Resident denies this behavior On 11/7/19, the following was documented, resident continues to smoke when (Name of Resident #32) has been educated on smoking policies. (Name of Resident #32) is providing cigarettes to other residents in the facility, and denies behaviors when questioned. Resident also is picking up cigarette butts in the parking lot Review of the clinical record failed to evidence any smoking assessments for safe unsupervised smoking or any other interventions to address the residents continued smoking other than what is documented above. Surveyor B clinical record review of Resident #36 and interview: Resident #36, was admitted [DATE], [DIAGNOSES REDACTED]. Resident #36's admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 03/01/2019, scored Resident #36 at a 14 on the BIMS (brief interview for mental status), indicating minimal impairment. Resident #36 was coded as requiring supervision of one staff member for most ADLs (activities of daily living). Under J1900. Number of falls since admission or prior assessment, whichever is most recent, Resident #36 was coded with a 1 under: B. Injury (except Major) skin tears, abrasion, laceration, superficial bruises, hematomas, and sprains; or any fall -related injury that causes the resident to complain of pain. Resident #36's mobility device was coded as a walker. Resident #36's care plan documented interventions for the behavior of smoking as follows: Instruct Resident about smoking risks and hazards and about smoking cessation aids that are available, notify charge nurse immediately if it is suspected that resident has violated facility smoking policy (Non Smoking facility). These interventions were dated Initiated 02/22/2019 and Revised 02/26/2019. On 11/14/2019 at 12:00p.m., an interview was conducted with Resident #36 regarding his smoking habits at the facility. During this interview, Resident #36 stated that on one occasion he fell while ambulating himself to the spot staff had directed him to smoke, which was a mulch-covered area near the facility signage (the property entrance sign that identifies the name of the facility located at the entrance to the parking lot). Resident #36 stated that he became weak and just sort of sat down suddenly. When asked how he got back, Resident #36 stated that another resident who was out to smoke, Resident #32 who uses a wheelchair, had to wheel back to the facility and get staff for assistance. A review of Resident #36's medical record verified documentation of a fall without injury occurring on 09/04/2019. An entry dated 10/02/2019, documented IDT (interdisciplinary team) met to review fall when legs became weak while walking and he fell . Will continue on therapy caseload and no other falls have been reported. Team will continue to monitor. Resident #36's medical record, failed to evidence a smoking assessment to determine safety smoking and with unsupervised smoking. Surveyor A: On 11/14/19 at 10:12 AM, an interview was conducted with OSM #3 (Other Staff Member, Director of Social Services), regarding residents that smoked. OSM #3 stated, Usually, if I find out they are smoking, I have to tell them it is a non-smoking facility, which they already know. When asked what that means, OSM #3 stated, Not to smoke on the grounds. When asked about the location residents are allowed to smoke, OSM #3 stated, Past the sign in the roundabout off the property, and then the grass is off grounds (grass next to the south unit patio that Resident #32 and 36 were observed smoking on.) OSM #3 was asked what she does when a resident is identified as a smoker, OSM #3 stated, I let smokers know; they are told it's a non-smoking facility. I've been here a year and they have to turn their lighters back into the nurse, sign themselves out (as leaving the property to go smoke). The sign out book is at the nurse's station; they sign out and get a lighter from the nurse. When asked why the facility has them sign out, OSM #3 stated, To know they are out of the building and know where they are. When asked who is responsible for the residents once they are off the premises, OSM #3 stated, They are responsible for themselves. When asked about residents who have walkers or wheelchairs going out to the sign at the roundabout located at the top of a hill, OSM #3 stated, I don't personally think it's safe. When asked if residents are able to smoke without an assessment, OSM #3 stated, They (residents) shouldn't be smoking. When asked if the facility care plans smoking for residents, OSM #3 stated, Yes and we discuss it in care plan meetings. When asked what non-compliant means, OSM #3 stated, Being caught smoking on premises. When asked if the facility expects residents that are noncompliant with smoking to continue being noncompliant, OSM #3 stated, yes. OSM #3 was asked what the facility has done to ensure the safety of noncompliant smoking residents, OSM #3 stated, Taking their lighters. When asked if staff is aware residents are not to smoke on the premises and what they are supposed to do if they see residents smoking, OSM #3 stated, Tell the manager. When asked about safety concerns for noncompliant residents smoking on the premises, OSM #3 stated, Second hand smoke, it is unhealthy. I don't think they're going to burn themselves. When asked if the risk of burning themselves should be assessed, OSM #3 stated, Yes. OSM #3 was asked if any residents on oxygen smoke. She identified one resident (Resident #95 see write up below). When asked if there was any special education done regarding smoking with the use of oxygen, OSM #3 stated, Yes, not to smoke with oxygen. OSM #3 stated, (ASM #1, the Administrator) sent a letter out for our Christmas Party and it included something about the smoking. When asked where the staff smoke, OSM #3 stated, Off the loading dock by kitchen. When asked if this area is on the premises, OSM #3 stated, Yes. Note: The above referenced Christmas letter, dated 10/30/19, included a paragraph about smoking. This paragraph documented, The second item that you end to be aware of has to do with smoking. (Name of facility) is a non-smoking facility for the residents; however, we do recognize the fact that they do have the right to smoke. It is our policy to allow them to smoke off premises. The resident can not (sic) have a lighter or matches in their possession. If they chose (sic) to smoke these items must be kept at the nurse's station and they must sign themselves out and in when leaving to smoke and return these items. Visitors are not allowed to give smoking materials to a resident. If you have concerns regarding the smoking policy, please feel free to contact me. The Administrator signed this. On 11/14/19 at 10:45 AM, a premises tour to assess designated smoking areas was conducted with OSM #3. The tour began by exiting from the front doors, walking to the end of the sidewalk that went towards the north end of the building to the left when exiting the front doors. There were two ramp-like areas off the sidewalk to the parking lot along the sidewalk. Once past the parking lot, a roundabout area was mulched in with a curb all the way around it. A sign for the facility was positioned in the mulched area on the side facing the street, away from the parking lot. There were several cigarette butts observed in the mulched area. There was no cigarette disposal device located in this area. OSM #3 stated that the area below the sign, which was at the top of a hill, was designated as off premises where residents could smoke. This area was noted to be a hill that sloped down the street. Proceeding back towards the facility towards the south unit patio, multiple cigarette butts were observed throughout the parking lot. At the second column from main entrance, a plastic/fiberglass trashcan was observed with several small black cigarette butt marks on the outer covering of the trashcan. The patio area off the south unit was observed next (when exiting the building from the main entrance, this patio area would be to the far right of the building.) There was no cigarette disposal device located there. There was a couple of seating chairs and rocking chairs. There were dried leaves the on patio next to brick building. There was no sidewalk access directly to this patio area from the main entrance. Residents would have to go across the parking lot and a grassy area. OSM #3 stated that the residents are to smoke off the patio area (in the grassy areas that surrounded the patio on three sides) which is at the top of the hill. The grassy area off the front of the patio sloped downwards. The slope was noted to begin nearly immediately when stepping off the patio area. There was no flat area of grass. To the side of the patio (opposite side of the parking lot), was a tree, with an area that was very small and rocky. The two doors from either side of the south unit living room / dayroom / dining area that lead to this patio were noted to have no means from the outside to reenter the building. The doors required a keypad code to get out and there was no key pad on the outside to get back in. (This was the patio area noted earlier where Residents #32 and #36 were seen smoking.) None of the designated smoking areas for residents was noted to be a level, for residents with walkers, wheel chairs, or unsteady balance at risk of falling. None of the designated smoking areas contained a cigarette disposal device or emergency equipment in the event of a fire such as fire extinguishers and fire blankets. The patio area had no means to regain quick entrance into the facility in the event of a problem. The area by the roundabout required residents to [MEDICATION NAME] a parking lot and/or sidewalk, both of which were on a slight uphill slope, to regain entrance to the building at the main entrance. The roundabout area was not in sight of facility staff unless the staff was outside the building on the sidewalk. The patio area was in sight of facility staff if the blinds to the windows were open and staff happen to be on that end of the unit at the time. On 11/14/19 at 11:12 AM, an interview was conducted with LPN (licensed practical nurse) #9, regarding where the residents smoke. LPN #9 stated, There is supposed to be a smoking area but I don't know where they (residents) go. When asked about the resident's smoking materials, LPN #9 stated, I was told they are allowed to keep their cigarettes but the lighters are in the med (medication) room. When asked if any residents have had an incident or injuries from smoking, LPN #9 stated she was not aware of any. When asked if the facility completes assessments to determine safe unsupervised smoking, LPN #9 stated, They have not been done. LPN #9 then stated, To my understanding the patio area is a smoking area (south unit patio which is on the facility premises). LPN #9 stated, It alarms me. There is nobody out there. I don't know what they do with these cigarettes. When asked if staff are responsible for residents smoking out on the patio area, LPN #9 stated, That is a good question. It is on the property. We should be (responsible). When asked if she supervises a resident out on the patio, when she sees them smoking, LPN #9 stated, No. I am constantly going. When asked if there were any supplies and equipment to ensure the residents safety, like a smoking apron, ashtrays to extinguish cigarettes, LPN #9 stated, Not to my knowledge. On 11/14/19 at 11:30 AM, in an interview with ASM #1, the Administrator, when asked about the location of designated smoking areas for residents, ASM #1 stated, They can go out by the sign, and by the back of building patio area. ASM #1 stated, The ombudsman said the residents have right to smoke. They can go to edge of the patio (south unit patio) on the grass to smoke 25 feet from the building. This comes from State Fire Marshal's office. When asked if the grassy area by the patio was level, ASM #1 stated, Yes. When asked if that was facility property, ASM #1 stated, I can't answer that, but I think that once you get off the sidewalk it's not our property (no sidewalk was noted that connects the front door to the south unit, patio, only the parking lot). When asked about the area by the sign, ASM #1 stated, If they can walk down there and wheel their chairs down there, I would think it is ok. When asked if the identified sign area is at the top of a hill, ASM #1 stated, I wouldn't call it a hill, I would call it an incline. When asked if residents are at risk of rolling down the hill, ASM #1 stated, Yes. When asked about the facility's responsibility for the safety of the residents, ASM #1 stated, We do have responsibility when they are in our facility, but when they do something that is not compliant, then no. When asked about the facility policy for non-smoking, with designated smoking areas, ASM #1 stated, I've checked with the state ombudsman. I've thought about discharging them (residents that smoke), but the state ombudsman said it was their right. When asked if the fact that residents are non-compliant with their smoking policy relieves the facility from ensuring a safe environment for all residents and ensuring the safety of residents that smoke, ASM #1 stated, Yes, I do. Before we designated a smoking area, they were smoking everywhere. When asked if she expected the residents to sign out, ASM #1 stated, I've told them to, I don't check this. When asked why the residents need to sign out, ASM #1 stated, So we know they are going to be gone. When asked about one resident being responsible for another resident, ASM #1 stated, No resident should be responsible for another resident, but if the resident wants to do that -that is their right. On 11/14/19 at approximately 9:55 a.m., the survey team requested a list of residents who smoke from ASM (administrative staff member) #1, the administrator. At 10:35 a.m., ASM #1 provided a list of seven residents. Review of the clinical records revealed documentation of noncompliant smoking behaviors for six of these seven residents (the seventh newly admitted resident had a smoking assessment completed), (Residents #32, #36, #45, #95, #48, and #101), but failed to evidence the residents, had been assessed for smoking or assessed as safe to smoke unsupervised. The facility had no system for assessing the safety of residents who smoked and no system for providing supervision necessary to keep residents safe and failed to implement consistently their own smoking policy, resulting in a situation with the likelihood for serious harm and injury and the findings of immediate jeopardy with substandard quality of care. The findings of Immediate Jeopardy and substandard quality of care were confirmed on 11/14/19 at 1:26 p.m., during a phone call with the State Agency. On 11/14/19 at 1:56 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3 the regional vice president of clinical services were informed of the Immediate Jeopardy and subsequent SQC (substandard of care), finding and the needed to complete a plan of removal. On 11/14/19 at 7:40 p.m., ASM #1 presented an acceptable plan of correction. Plan of Correction: 1. Residents who are smoking have had a smoking assessment completed immediately. (Residents # 32, #36, #45, #48, #95, and #101) to determine their ability to smoke safely. Each had been deemed to be able to smoke safely. They will be allowed to smoke with supervision in the designated area. The care plans were updated. 2. An audit completed at 2:30 p.m. on 11/14/19 was conducted to identify other residents who may be smoking without knowledge. Two others were identified. These had smoking assessments completed; along with care plan updates. 3. Smoking Policy has been revised to ensure safe smoking. Residents who smoke will be informed and educated on the new policy. Department managers and Hospitality aides will be educated on the new policy. 4. A QAPI meeting was held regarding the new policy. A QAPI team will review the smoking policy quarterly and provide updates if needed. 5. (MONTH) 15, 2019 (Compliance date). The revised smoking policy documented in part: It is the policy of this facility to establish and maintain safe resident smoking practices. Residents will smoke under direct supervision of a staff member. Prior to, or upon admission, residents shall be informed that smoking is not permitted inside of the facility, but in the outside designated areas only. Policy Interpretation and Implementation Smoking Area: 1. The designated smoking area is located at the back of the facility, within the brick walls of the patio. 2. Indoor smoking is prohibited and all such rules, as they may apply, shall be strictly enforced. Smoking containers 1. Smoking chimney containers shall be available in designated smoking areas. 2. Cigarette butts will be placed in these containers. There is also a fire blanket and fire extinguisher available in the designated smoking area. Smoking Restrictions 1. The Attending Physician, Administrator and Director of Nursing Services (DNS) shall have the authority to make the determination as to what restrictions, if any, will need to be placed on the resident's smoking privileges. 2. Any restrictions placed on smoking privileges shall be noted on the care plan so that all personnel may be aware of smoking restrictions. 3. Smoking restrictions may be imposed on residents at any time if the Attending Physician, Administrator, and/or Director of Nursing determine that the resident is not able to smoke safely. 4. Smoking restrictions (such as need for smoking apron, or specific scheduled smoking times), shall not be assessed against any resident for the mere convenience of the staff, but for the safety and well-being of the resident. 5. Residents with smoking privileges will be discouraged from smoking outside during inclement weather including storms and temperature extremes. 6. Residents will be encouraged to wear appropriate clothing for the season and weather conditions when going outside to smoke. Review of Smoking Restrictions: 1. Smoking privileges shall be reviewed at least quarterly via smoking assessment by the Interdisciplinary Team. 2. All smoking privileges shall be so noted on the care plan. 3. Reclassifications of restrictions deemed necessary for the safety and well-being of the resident may be made at any time by the Attending Physician, Administrator, and/or Director of Nursing Services. Safety with oxygen: At no time shall oxygen be permitted to be in use, to include oxygen not turned on, in the smoking area. Smoking Times & assistance with smoking: 1. Residents will be allowed to smoke during specific smoking times under supervision. Smoking times will be from: 6:30-6:45 AM 9:30-9:45 AM 1:30-1:45 PM 6:30-6:45 PM 2. Residents will be allowed to smoke, in the designated smoking area, during scheduled times with their family member or visitor. The family member/visitor must agree to stay with the resident during the entire smoking period and follow smoking restrictions as identified and care planned for the resident. Family members or visitors may not supervise other residents to smoke at off-scheduled times. 3. Staff members will assist residents in/out of the facility to the smoking area and will have a communication device to use to call for assistance if any is needed. Smoking Articles: Residents shall not be permitted to retain any types of smoking articles, to include cigarettes, tobacco, lighters, matches, etc., either on his/her person or within his/her living or sleeping area, at any time. Purchasing of Smoking Articles for Residents: Staff members and volunteer workers shall be prohibited from purchasing any smoking articles for residents and bringing them to the resident unless approved by the facility Administrator or Director of Nursing. Periodic Checks for Smoking Articles: 1. This facility shall have the authority to make periodic checks to determine if residents have any smoking articles, on their person or in their room, that are in violation of our smoking policy. 2. Articles found shall be given to the Charge Nurse who in turn will store them for the resident and shall make appropriate documentation in the resident's medical record of such articles found and removed. 3. Residents shall be informed, by the person(s) removing such articles, as to why the articles are being taken, and shall do so in a courteous manner. It must be remembered that safety is of the primary concern and that smoking privileges are not being withheld from the resident. 4. Failure to comply with the smoking policy may result in a 30-day discharge notice Policy Revised 11/14/19 On 11/15/19, the plan of removal was verified by the surveyor's onsite. The education completed by the administration regarding the new smoking policy and procedures was verified. Interviews were conducted with the staff documented in the plan of correction, and additional staff including nursing and certified nursing assistants. All staff interviewed properly stated the revised smoking policy. Observation was made of the new designated smoking area and three of nine residents, identified as smokers were observed during the s (TRUNCATED)

Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to ensure a safe transfer into a shower chair to prevent accidents with injury for one of 43 residents in the survey sample, Resident #44. On 8/31/17, it was reported to the State Agency that Resident #44, was noticed to have bruising and swelling to his right ankle. Upon further review and investigation, the facility staff determined, Resident #44 sustained a [MEDICAL CONDITION] malleolus (expanded lower end of the fibula situated on the lateral side of the leg at the ankle (2)) of the right ankle, when staff transferred the resident, from a Gerri Chair into the shower chair and caught his right ankle underneath the bar across the bottom of the shower chair, resulting in harm. The findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: [DIAGNOSES REDACTED] ([DIAGNOSES REDACTED] is a neurological condition characterized by a slowly progressive deterioration of behavior, personality, or language. People with [DIAGNOSES REDACTED] have abnormal substances (called Pick bodies) inside nerve cells in the damaged areas of the brain. Pick bodies contain an abnormal form of a protein called tau. This protein is found in all nerve cells, but people with [DIAGNOSES REDACTED] have an abnormal amount or type of this protein. (1)), [MEDICAL CONDITION], contractures, depression and chronic pain. (Note: there was no [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, closest to the date of injury, on 8/31/17, was a quarterly assessment reference date of 7/28/17, coded the resident as rarely making himself understood and sometimes understands when spoken to, the resident was coded as having highly impaired vision. Resident #44 was coded as scoring a 0 on the BIMS (brief interview for mental status) score, indicating he was severely impaired to make daily cognitive decisions. The resident was coded as being totally dependent upon two staff members with physical assist for moving in the bed, and transfers. Resident #44 was coded as requiring one-person physical assist for moving on the unit, dressing, eating, toileting needs, personal hygiene and bathing. In Section G0400 Functional Limitation of Range of Motion, the resident was coded as having impairment on both sides of his upper and lower extremities. Resident #44 was coded as being 72 inches tall and weighing 203 pounds. The resident was not coded as having osteopenia** or [MEDICAL CONDITION]***. The Facility Reported Incident (FRI) dated 8/31/17, documented in part, Describe the incident, including location and action taken: (Resident #44) notice to have a bruise and swelling on R (right) ankle. Employee action initiated to taken: Investigation pending. The Conclusion of Investigation dated, 9/5/17, documented in part, Conclusion: A review of documentation and staff interviews indicate that the bruise and swelling to the right ankle of (Resident #44), that was noted on 8/31/17 occurred from the PVC reclining shower chair on 8/27/17 during a shower. The investigation produced that (Resident #44) did sustain an injury from the incident. POAs (power of attorneys)/RP's (responsible party) and MD (medical doctor) were notified. Staff is no longer allowed to use the reclining shower chair to give (Resident #44) a shower. (Resident #44) is to be showered using the shower gurney. Also in-serviced staff on the importance of reporting unusual incidents immediately and also taking precaution and being aware of the resident' that may not be safe during showering or ADL's (activities of daily living) and may need specialized equipment. The nurse's notes dated, 8/31/17 at 3:56 p.m. documented in part, CNA (certified nursing assistant) staff alerted this nurse of visible swelling or resident's right ankle. Unit supervisor and DON (director of nursing) notified and stat (immediate) X-rays ordered after primary care physician was informed by phone. Mobile imaging into facility for x-ray right ankle and foot. Resident's POA (brother) informed by phone that x-rays were ordered due to the [MEDICAL CONDITION] of right ankle. Resident rested in bed through shift. Immediate x-ray results indicated only soft tissue swelling of tight foot but preliminary results of right ankle indicate [MEDICAL CONDITION], malleolus without significant displacement. Orthopedics was consulted for treatment. The Patient Report dated, 8/31/17, documented in part, Right ankle, complete 3+views. Impression: 1. Acute fracture lateral malleolus without significant displacement. 2. Soft tissue swelling. #. Small calcaneal spur. Findings: There is osteopenia. The physician progress notes [REDACTED]. Fracture right lateral malleolus/good alignment/orthopedic schedule and elevate with ice per shift/no complaints of pain and Tylenol may be used or inform if concerned about higher level of pain and no ambulation/usually bedridden status. Circumstance of injury unclear and Administrator and Nursing Director aware and present during evaluation, investigation under progress, POA (power of attorney) aware. The comprehensive care plan dated, 11/5/15, and revised on 2/2/17, documented in part, Focus: ADL (activities of daily living) all Task. The Goals documented in part, (Resident #44) will be monitored to keep safe and free from accident/injury through [MEDICAL CONDITION] or falls daily. The Interventions documented in part, Total assist of 2 persons with transfers. (Resident #44) required total assist with bed mobility - use turning sheet to prevent shearing force - has extenders on bed to make long enough for him to be comfortable. Added to the care plan on 9/1/17, Use gurney only for bathing. There was no care plan addressing osteopenia or [MEDICAL CONDITION] for Resident #44. An interview was conducted with LPN (licensed practical nurse) #8, the nurse who wrote the note on 8/31/18. When asked to describe Resident #44's right ankle, LPN #8 stated, I notified the DON (director of nursing) who was also the wound and treatment nurse at the time. I reported it to her. I was concerned as he in particular, suffers from contractures. He likes to pull his legs up and I keep watching his heels for breakdown. We put everything in motion to get the x-ray, call the doctor, call the family and found out it was fractured. What I learned was that it occurred during a transfer into the shower chair, where his foot got caught. An interview was conducted with LPN #1 on 9/26/18 at 3:57 p.m. LPN #1 was asked to review the FRI as she was the one that wrote it. LPN #1 then stated, I was notified that he had swelling and bruising in his right ankle. After the investigation, it was decided that it was from a transfer into the shower chair. I was told a Hoyer lift was used. When I spoke with administrative staff member (ASM) #3, the resident's doctor, he said that with his condition his bones were soft and it was not unusual for a bedridden resident for this to happen. An interview was conducted with ASM #3, the resident's doctor, on 9/26/18 at 4:04 p.m. When asked about Resident #44's transfer status, ASM #3 stated the resident had been bedridden since admission to the facility. He stated he had known the resident for many years in the community. Because of his being bedridden, the resident would have softening of the bones. ASM #3 stated that with minimal trauma, he could be injured. He stated that the resident was a big guy. ASM #3 stated, One must weight bear in order to maintain bone health. (*Note the physician's progress note date 8/31/17 failed to evidence any documentation regarding the [DIAGNOSES REDACTED].) On 9/27/18 at 7:19 a.m., an interview was conducted with CNA (certified nursing assistant) #7, who assisted CNA # 9, with Resident #44's transfer with the shower chair. CNA #7 was asked how Resident #44 was transferred to the shower chair on 8/28/17. CNA #7 stated, He was in the Geri chair and he was moved to the shower chair. When asked how the resident was moved, CNA #7 stated he (Resident #44), was lifted by himself (CNA #7), and CNA #9. When asked if a mechanical lift was used to transfer the resident, CNA #7 stated that no lift was used. When asked if there was any strange placement of the resident's limbs, CNA #7 stated, He would retract his legs up. When asked if the resident frequently got his legs caught on the shower chair, CNA #7 stated, Yes. When asked if he remained in the shower room with CNA #9 and Resident #44, CNA #7 stated no he left the shower room. When asked where Resident #44's legs were when he left the shower room, CNA #7 stated the legs were under the (PVC) bar in the front of the shower chair. CNA #7 stated we no longer can use the shower chair and must use a lift to lift him. On 9/27/18 at 7:44 a.m., an interview was conducted with CNA #3; the CNA assigned to Resident #44 most days. CNA #3's written statement of the incident was reviewed. Her statement documented the finding of the bruise with the 11-7 CNA and reporting it to LPN # 8 on 8/31/17. When asked how Resident #44 is transferred, CNA #3 stated, He is a very big man and I'm not that tall, I always use a lift with a second person. When asked if he can be transferred with just two staff members without a lift, CNA #3 stated, I don't know how because he is a big man. Multiple calls were made to CNA #9 by this surveyor and on 9/27/18 at 8:34 a.m. ASM #2, the director of nursing, informed this surveyor that the facility had left several messages for CNA #9 to call the facility with no avail. CNA #9's statement was documented as follows: When I got him in the reclining chair (shower) the resident's foot got caught. It was under the bar of the chair and I pulled it out. He didn't make any noise, I didn't think it was hurt. I feel terrible. (*Note- there was no date on this statement but it refers to the 8/28/17, transfer of Resident #44 per interview with LPN #1). On 9/27/18 at 8:55 a.m. ASM #1, the administrator and ASM #2 the director of nursing, were made aware of the concern for harm. When asked for the incident report associated with this incident on 8/31/17, ASM #1 stated they could not find the incident report and attempted to contact the former director of nursing for that information but were unable to reach her. On 9/27/18 at approximately11:00 a.m. the reclining shower chair was observed with two other surveyors. The chair was made of PVC ([MEDICATION NAME] chloride (white plastic piping)*) piping and mesh seat and backing. The chair did have a PVC cross bar on the bottom front of the chair. The facility Operation Instructions for the Reclining Shower Chair Commode Models documented in part, Purpose: to shower patients who have difficulty sitting in a regular shower chair. Operating Information: The chair is more easily used if the backrest and leg rest are set in desired position before placing the user in the chair. BACKREST - the backrest has 2 positions; 1) sitting, 2) reclining. 1) The sitting position is attained by holding up the backrest while affixing the u=shaped pipe configuration to the top horizontal sides of the chair and then leaning the backrest back against it. 2) The reclining position is attained by holding up the backrest and dislodging the u-shaped pipe configuration, swinging it upward and back to a hanging position behind the chair. Then lean the backrest against the top horizontal pipe on the back of the chair. LEGREST - By unscrewing the large knobs on either side of the leg rest, you have loosened the leg rest enabling you to place it in the desired position. Place the leg rest at the desired angle and tighten the knobs, being careful not to over tighten. For uses with longer legs, you can extend the leg rest by pulling it outward. An interview was conducted with LPN #8 on 9/27/18 at 3:00 p.m. LPN #8 was asked to review the policy on the shower chair. When asked if the chair ever had leg rests, LPN #8 stated we needed to talk to someone who's been here longer than her. An interview was conducted with CNA #1 on 9/27/18 at 3:07 p.m. When asked if the shower chair had had leg rest, CNA #1 stated, I remember years back it had a mesh foot rest when it reclined the foot rest came up and supported the feet of the resident. An interview was conducted with OSM (other staff member) #7, the maintenance assistant, on 9/27/18 at 3:26 p.m. When asked if the shower chair had come with leg rest, OSM #7 stated, I imagine it would have come with them but I didn ' t know where they went to. I'm not sure what happened to them. OSM #7 went to check his records to see if he had performed any work on the shower chairs. On 9/27/18 at 3:35 p.m., OSM #7 returned and stated the chair was purchased on 5/26/10 and stated he had not performed any maintenance repairs on the chair. The facility presented education that was provided to all staff dated 9/21/17 and 9/4/17 that documented education on reporting pain, abuse, unusual occurrences, skin tears and bruises and also using a gurney to shower Resident #44. Documentation reviewed also evidenced the following: Also in-serviced staff on the importance of reporting unusual incidents immediately and also taking precaution and being aware of the resident' that may not be safe during showering or ADL's (activities of daily living) and may need specialized equipment. During interviews with the staff, all staff answered correctly, regarding interventions that were put in place by the facility for the resident, and residents to prevent any further injury. No further concerns or injuries were identified during the survey. PAST NON-COMPLIANCE. (1) This information was obtained from the following website: https://rarediseases.info.nih.gov/diseases/7392/picks-disease (2) This information was obtained from the following website: https://www.merriam-webster.com/medical/malleolus * This information was obtained from the following website: https://www.thefreedictionary.com/PVC **Osteopenia is a term to define bone density that is not normal but also not as low as [MEDICAL CONDITION]. This information was obtained from the website: https://www.ncbi.nlm.nih.gov/pubmed/ 807 ***[MEDICAL CONDITION] is a disease that weakens bones to the point where they break easily-most often, bones in the hip, backbone (spine), and wrist. [MEDICAL CONDITION] is called a silent disease because you may not notice any changes until a bone breaks. All the while, though, your bones had been losing strength for many years. This information was obtained from the website:

Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure interventions to prevent accidents were implemented and failed to provide adequate supervision to ensure a safe environment for three of 23 residents in the survey sample, Residents #5, #9 and #16. 1. Resident #5 fell on [DATE]. On 5/15/17 the nursing department requested a rehab (rehabilitation) screen as an intervention to prevent further falls for Resident #5. The rehab screen intervention was not completed until 6/15/17 (a month after it was requested). On 6/13/17 (prior to the completion of the rehab screen) Resident #5 sustained another fall that resulted in left pubic fractures, resulting in harm. 2. The facility staff failed to ensure adequate supervision of Resident #9, who attended a Vocational Day Program. The facility staff failed to ensure Resident #9 was signed out of the facility by the Vocational Day Program staff to identify his whereabouts. On 10/21/17, at 7:05 p.m., the facility staff identified Resident #9 was not at the facility, but could not determine if he was on a LOA (leave of absence) with family or out of the facility at the Vocational Day Program. A search of the facility was conducted, 911 was called and the police were notified. At 9:35 p.m., Resident #9 was found in a van unattended at the Vocational Day Program and was returned to the facility. 3. The facility staff failed to ensure two staff members provide bed mobility and transfer assistance to Resident #16, to prevent falls per the plan of care. On 2/17/17 and 7/21/17, only one CNA provided assistance to Resident #16 and on both occasions the resident was lowered to the floor by staff. The findings include: 1. Resident #5 fell on [DATE]. On 5/15/17 the nursing department requested a rehab screen as an intervention related to the fall. The rehab screen was not completed until 6/15/17. On 6/13/17 (prior to the completion of the rehab screen) Resident #5 sustained another fall that resulted in pubic fractures, increased pain and decreased mobility. Resident #5 was admitted to the facility on [DATE]. Resident #5's [DIAGNOSES REDACTED]. Resident #5's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 6/1/17, coded the resident's cognition as severely impaired. Section G coded Resident #5 as being independent with setup help only with transfers/toilet use and as requiring supervision with setup help only with bed mobility/walking in the room. The resident was coded as requiring extensive assistance of one staff with locomotion. Section G further documented Resident #5 utilized a walker and a wheelchair. Section J documented Resident #5 sustained one fall with injury- except major (including: skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains or any fall-related injury that causes the resident to complain of pain). Section J further documented Resident #5 reported rare pain rated as a three on a scale from zero to ten during the last five days. Resident #5's most recent MDS, a significant change in status assessment with an ARD of 7/14/17, coded the resident's cognition as severely impaired. Section G coded Resident #5 as requiring extensive assistance of two or more staff with bed mobility/toilet use and extensive assistance of one staff with transfers/locomotion on the unit. Section G documented the resident did not walk during the seven day look back period. Section G further documented Resident #5 utilized a wheelchair. Section J documented Resident #5 sustained one fall with injury-except major and one fall with major injury (including: bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma (1)). Section J further documented Resident #5 reported frequent pain rated as a six on a scale from zero to ten during the last five days. Review of Resident #5's clinical record revealed a fall risk evaluation completed on 5/31/17 that documented a score of five that indicated the resident was not at a high risk for potential falls. A nurse's note dated 5/11/17 documented, This writer called to room. Observed Resident sitting on floor on buttock with back against bedside table. Resident stated, 'I got up and fell on my bottom.' Denied hitting head. C/o (Complained of) small area mid black (sic) being kind of sore. Small red area noted. No other c/o voice (sic) . A nurse's note dated 5/15/17 and signed by LPN (licensed practical nurse) #1 (the staff development coordinator) documented, Note: Falls Committee Meeting Note- Resident was reviewed today in Falls Meeting a rehab referral was initiated. No other interventions were documented for Resident #5's fall. A form titled, NURSING TO THERAPY REFERRAL FORM and signed by LPN #1 on 5/15/17 documented a check mark under the nursing request physical therapy column beside the words, Falls or slips forward/side. The date, 5-11 was handwritten beside the check mark. The words note given another (fall) 6/13/2017 (name of the rehab director) and another (fall) 6/13 another (name of another rehab employee) were handwritten on the form. The therapist recommendations portion of the form was not completed by the rehab director until 6/15/17. A check mark was documented beside, OT (Occupational therapy) Orders requested. A nurse's note dated 6/13/17 documented, At 0510 (5:10 a.m.) this am, resident was heard yelling for help. Upon entering residents (sic) room, found resident sitting on the floor. Resident states, 'I rolled out of bed.' LUA (Left upper arm) hematoma appeared. Denies pain and has good movement in the extremity . A nurse's note dated 6/13/17 at 9:58 p.m. documented Resident #5 complained of left buttock pain. Tylenol was given with effect. A nurse's note dated 6/14/17 at 10:55 a.m. documented Resident #5 voiced no complaints of pain. A nurse's note dated 6/14/17 at 9:13 p.m. documented Resident #5 complained of pain in both lower extremities. Tylenol was given with positive results. A nurse's note dated 6/15/17 at 1:39 a.m. documented Resident #5 did not voice any complaints. A nurse's note dated 6/15/17 at 10:24 a.m. documented Resident #5 voiced no complaints of pain. A nurse's note dated 6/15/17 at 5:27 p.m. documented Resident #5 complained of left buttock pain from previous injury. Tylenol was given with effect. A nurse's note dated 6/15/17 at 8:00 p.m. documented, Resident c/o increased pain to Lt (left) hip and pelvic region. NP (Nurse practitioner) notified and new order received to x-ray hip and pelvis. (Name of mobile x-ray company) called . A nurse's note dated 6/15/17 at 8:35 p.m. documented, Resident continues with increased pain to Lt hip and pelvis with no effect from PRN (as needed) Tylenol. NP notified and order received for Norco (2) 5/325 mg (milligrams) q4hr (every four hours) prn and x (times) 2 Norco now . A nurse's note dated 6/15/17 at 9:44 p.m. documented, Resident has c/o pain in left hip and pelvis. Medicated for pain with Narco (sic) with positive results. X-Ray scheduled for 6/16/17 at 9 am (9:00 a.m.) . The bilateral hip/pelvis x-ray dated 6/16/17 documented, FINDINGS: Osteopenia (3) is evident. Old healed fracture of the right proximal femur (upper leg bone) is observed. There are fractures of the left superior and inferior pubic rami (pubic bones); mildly displaced. Heavy vascular calcification is evident. IMPRESSION: Left pubic fractures . A nurse practitioner note dated 6/16/17 documented, The patient is a 96- year-old white female, long-term care resident at (name of facility). I am asked by the staff to evaluate for the patient's complaints of pelvic pain status [REDACTED]. The patient was found on the floor and reported to the staff that she rolled out of the bed. I ordered an x-ray of her bilateral hips with pelvis and the results reveal an old healed fracture of the right proximal femur and fractures of the left superior and inferior pubic rami, mildly displaced. I called and spoke with the patient's granddaughter, (name), via the phone. There is no edema (swelling) or ecchymosis (bruising) noted to her pelvic area. There is some pain when the patient is repositioning in bed. She also has an ecchymosis to her left arm right above the elbow and has a skin tear to her left shin. When I come to see the patient, she is sitting up in bed and eating cereal and drinking milk. She appeared comfortable until she tries to repositioning (sic) and then she is grimacing with pain. I discussed with the granddaughter and we will try some Norco twice daily and q.4h. p.r.n. as I am afraid the patient will not ask for pain medication when needed. The patient has no other acute concerns today .ASSESSMENT AND PLAN: 1. Left superior and inferior pubic rami fracture, mildly displaced. I am ordering the patient Norco 5/325 mg tablets p.o. (by mouth) scheduled twice daily and q.4h. p.r.n. for acute pain. The patient now has safety alarms in place and she was also evaluated by occupational therapy . A physician's orders [REDACTED]. Must have assistance when out of bed. Another physician's orders [REDACTED]. Review of Resident #5's June 2017 MAR (medication administration record) revealed the resident received as needed Norco on the following days (in addition to scheduled pain medication): -Three times on 6/16/17 (at 4:10 a.m. for pain rated as a seven, at 11:27 a.m. for pain rated as a seven and at 7:37 p.m. for pain rated at a six). -Twice on 6/17/17 (at 3:39 a.m. for pain rated as eight and at 11:37 a.m. for pain rated as seven). -Once on 6/18/17 (at 2:47 p.m. for pain rated as eight). -Once on 6/19/17 (at 7:56 p.m. for pain rated as two). -Twice on 6/20/17 (at 2:10 a.m. for pain rated as three and at 9:41 p.m. for pain rated as two). -Once on 6/22/17 (at 8:00 p.m. for pain rated as two). -Once on 6/24/17 (at 3:20 a.m. for pain rated as two). -Twice on 6/25/17 (at 1:50 a.m. for pain rated as two and at 7:49 p.m. for pain rated as two). -Once on 6/26/17 (at 9:05 p.m. for pain rated as six). Resident #5's comprehensive care plan effective on 1/24/14 documented, Focus: FALLS: At risk for falls. At risk for falls related to: [DIAGNOSES REDACTED]. 6/13/17 found on floor, stated 'I rolled out of bed.' Hematoma to LUA (left upper arm). 6/15/17 c/o left hip and pelvis pain- left pelvis fractures .Goals: Falls will be avoided and safety will be maintained for (name of Resident #5). (Name of Resident #5) will not sustain serious injury if a fall occurs. Interventions: PT (Physical therapy) referral due to fall- Effective 5/12/2017 .OT (Occupational therapy) to evaluate and treat- Effective 6/15/2017 . Further review of Resident #5's clinical record revealed the following note from the rehab department: -6/15/17- Patient screened for OT services secondary to recent history of falls, weakness. Requesting OT eval (evaluation) and treat orders to address safety, fall prevention, and environmental modification as needed. The note was signed by the rehab director. The clinical record did not contain any further documentation from the therapy department except for a speech therapy screen dated 7/19/17. On 8/15/17 at 4:04 p.m. an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated after a resident falls, the nursing staff will refer the resident to the rehab department if the resident isn't already being seen by rehab. LPN #3 was asked how long of a period of time should it take for the rehab department to respond to a referral. LPN #3 stated she would have to find out because she didn't usually complete the referrals. LPN #3 stated LPN #1 (the staff development coordinator) usually completed the referrals. On 8/15/17 at 4:26 p.m. an interview was conducted with LPN #1. LPN #1 was asked what was done to prevent future falls when a resident has fallen. LPN #1 stated the facility staff always tries to put something in place and may implement interventions such as alarms and fall mats. LPN #1 stated the staff usually completes a rehab referral and may change a resident's alarm, implement a bowel and bladder program or change the time a resident is assisted out of bed. LPN #1 stated the intervention depends on the situation and staff looks at each individual case when determining the intervention. LPN #1 stated she tries to have nurses immediately implement an intervention after a resident falls and all falls and interventions are reviewed each week at the falls meeting. LPN #1 was asked what intervention was implemented after Resident #5 fell on [DATE]. LPN #1 stated Resident #5's fall on 5/11/17 was the first fall she had sustained and was an isolated situation so a rehab referral was initiated. LPN #1 stated the rehab referral was the only intervention implemented regarding the resident's fall. LPN #1 stated she filled out the referral form on 5/15/17 and placed the form in the rehab communication mailbox. LPN #1 stated when Resident #5 fell on [DATE] she realized she had not received the rehab referral back from the rehab department so she documented the 6/13/17 fall on her copy of the 5/15/17 referral form and gave the form to the rehab department again. LPN #1 was asked the facility processes for ensuring rehab referrals are completed. LPN #1 stated she keeps a copy of the referral on a clipboard until the rehab staff completes and returns the referral then she throws her copy away and puts the completed referral in a binder. LPN #1 was asked how long should it take for the rehab department to complete a referral. LPN #1 stated, I would hope in a day or two. LPN #1 stated sometimes she mentions incomplete referrals in the falls meetings and sometimes rehab staff will state a resident is not appropriate for rehab but this isn't always documented. When asked if Resident #5's incomplete rehab referral was discussed between the fall on 5/11/17 and the fall on 6/13/17, LPN #1 stated she didn't recall but she probably would have documented the discussion if it occurred. On 8/15/17 at 5:02 p.m. an interview was conducted with OSM (other staff member) #1 (the rehab director). OSM #1 stated he completed a rehab screen for Resident #5 on 6/15/17 but around that time the resident was put on bed rest so the rehab staff could not work with her. OSM #1 was asked the processes for ensuring rehab referrals are completed. OSM #1 stated there was a small amount of staff in the rehab department. OSM #1 stated him and OSM #2 (the physical therapist) were the only therapists. OSM #1 stated if the resident who is being referred is ambulatory then he usually passes the referral to OSM #2. OSM #1 stated OSM #2 attends the morning meetings and falls meetings. When asked if he attends the meetings, OSM #1 stated he does depending on his schedule but he was the only occupational therapist and the manager so usually OSM #2 attends the meetings. When asked how he is made aware of referrals, OSM #1 stated either LPN #1 hands him the referrals or places the referrals in the rehab communication box. OSM #1 was asked why Resident #5's 5/15/17 referral wasn't completed until 6/15/17. OSM #1 stated he honestly could not remember. On 8/15/17 at 5:11 p.m. an interview was conducted with OSM #2. OSM #2 was asked how she was made aware of referrals. OSM #2 stated she is verbally made aware in the morning meetings or the nursing department generates the referral form and places the form in the rehab communication box. OSM #2 was asked how long it takes for rehab staff to complete referrals after they are generated. OSM #2 stated sometimes the referrals sit and sometimes they are promptly acted on. OSM #2 stated the referrals are more promptly acted on if the resident is on rehab caseload or if the resident has a physical issue that the rehab staff can address. OSM #2 stated if the nursing department has addressed the fall or if the rehab staff can't affect the resident then the rehab staff drags the referral out longer than they should due to staffing and other commitments. OSM #2 stated there are times when she talks to staff and observes residents who have been referred but fails to document this. OSM #2 was asked if she remembered talking to staff or observing Resident #5 between 5/15/17 and 6/15/17. OSM #2 stated she couldn't remember. OSM #2 stated Resident #5 had fallen out of bed and remembered a discussion that the fall was more of a cognitive issue. When asked why the rehab referral dated 5/15/17 wasn't completed until 6/15/17 OSM #2 stated she couldn't give a reason and she may have talked to the resident and/or staff but she couldn't remember. On 8/15/17 at 5:55 p.m. ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above findings and the concern for harm. ASM #1 and ASM #2 were made aware they could provide further information. On 8/16/17 at 8:05 a.m. an interview was conducted with LPN #2 (a nurse who has cared for Resident #5). LPN #2 was asked to describe Resident #5's mobility status before and after the fall on 6/13/17. LPN #2 stated the resident began to decline and was weaker before the fall. LPN #2 stated before the fall Resident #5 would get up on her own but now the resident does less and less. LPN #2 stated after the fall, Resident #5 didn't get up and move around like she once did. LPN #2 stated she thought the resident was in bed for a while after she sustained the fracture. On 8/16/17 at 8:10 a.m. an interview was conducted with CNA (certified nursing assistant) #1 (a CNA who cared for Resident #5). CNA #1 was asked to describe Resident #5's mobility status before and after the fall on 6/13/17. CNA #1 stated before Resident #5's fall, she got up on her own, dressed herself, took herself to the bathroom and independently completed activities of daily living. CNA #1 stated the resident walked and had a walker but usually didn't use it. CNA #1 stated Resident #5, got around really good. CNA #1 stated after the fall on 6/13/17, Resident #5 was in a lot of pain and a lot more scared so staff had to help the resident. CNA #1 stated after the fall, Resident #5 was on bed rest for two to three weeks and was totally dependent on staff. The facility policy titled, Policy on the Fall Prevention Program documented, g. Occupational Therapy will screen for treatment, as indicated. h. Physical therapy will screen for treatment or for need to refer to restorative nursing to increase strength and mobility .6. After investigation of fall, make changes on interventions and approaches on the plan of care .10. A Falls Committee was established in January 2004 which is chaired by the Staff Development Coordinator and consists of the Director of Nursing, Physical Therapists, and MDS Nurses to review falls regularly . The facility policy titled, Occupational, Physical & Speech Therapy Orders & Clarification documented, New Orders: Any resident currently in the facility needing OT, PT or ST evaluations or screenings, will have an order entered into the electronic health record and the therapy Dept. will be notified. Upon completion of the initial evaluation the therapist will log into the electronic health record and place a clarification order for therapy. Following this, the resident will be recertified as ordered by the therapists and the appropriate paperwork completed . No further information was presented prior to exit. (1) A subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain. This information was obtained from the website: https://medlineplus.gov/ency/article/ 3.htm (2) Norco is used to treat pain. This information was obtained from the website: https://medlineplus.gov/ency/article/ 0.htm (3) Osteopenia is low bone mass. This information was obtained from the website: https://medlineplus.gov/bonedensity.html (4) An arrhythmia is a problem with the speed or rhythm of the heartbeat. [DIAGNOSES REDACTED](AF) is the most common type of arrhythmia. The cause is a disorder in the heart's electrical system. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=atrial+fibrillation 2. The facility staff failed to ensure adequate supervision of Resident #9, who attended a Vocational Day Program. The facility staff failed to ensure Resident #9 was signed out of the facility by the Vocational Day Program staff to identify his whereabouts. On 10/21/17, at 7:05 p.m., the facility staff identified Resident #9 was not at the facility, but could not determine if he was on a LOA (leave of absence) with family or out of the facility at the Vocational Day Program. A search of the facility was conducted, 911 was called and the police were notified. At 9:35 p.m., Resident #9 was found in a van unattended at the Vocational Day Program and was returned to the facility. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 6/2/17 coded the resident as having scored a zero out of 15 on the BIMS (Brief Interview for Mental Status), indicating the resident was severely impaired cognitively. Resident #9 was coded as being sometimes understood and sometimes understanding others. The resident was coded as having no speech. Review of Resident #9's PASRR (Preadmission Screening And Resident Review) completed on 2/5/16 documented, 1. nursing facility placement is appropriate; 2. intense specialized services are recommended; and 3. rehabilitation services (services of lesser intensity) are recommended. 4. INTENSE SPECIALIZED SERVICES RECOMMENDATION 12. Supported Employment. 14. Transportation to Specialized Services .It is recommended that the nursing facility actively collaborate with the local Community Services Board to explore the potential to engage services that allow him to transition back to a supported group home setting in the community. Review of Resident #9 care plan created on 3/17/16 and reviewed on 6/7/17 did not evidence documentation about the resident attending a vocational day program or that the resident had been left alone at the center for approximately five and a half hours on 10/21/16. Review of the nurse's notes dated 10/22/17 at 1:15 a.m. documented, Note: in report on 10 21 16 at 3pm that resident was LOA (leave of absence) and refused prune juice. at 1905 (7:05 p.m.) resident had not returned to facility. at 1905 R.P. (responsible party) (Name of responsible party) was called I check (sic) if resident was with family and no answer and then At 1920 (7:20 p.m.) (name of R.P.) was called to check to see if resident was with family and (name of R.P.) stated no. at 1940 (7:40 p.m.) (name of R.P.) arrived to facility and explained to (RP) resident had not returned. Multiple calls to (vocational day program Resident #9 attended) made with no success and multiple calls with family. family was reassured by staff. on call manager was called at 2026 (8:26 p.m.) in reference to. between 1940 (7:40 p.m.) and 2026 (8:26 p.m.) this writer attempted multiple times to call (vocational day program) with no success. at 2040 (8:40 p.m.) search of facility by staff for resident. 911 was called at 2045 (8:45 p.m.). resident returned amb (ambulatory -- walking) on own to facility. (* This note was written by LPN (licensed practical nurse) #14, the resident's nurse). Review of the weekly skin assessment dated [DATE] documented, 1 (inch) scratch and redness noted (on right arm). 2. redness noted around neck area. 4. redness noted (middle of abdomen). Review of the weekly skin assessment dated [DATE] documented, Skin Assessment. Color: Pink; Turgor: Fair; Texture: Dry; Temperature: Normal. There was no documentation regarding the redness noted on the skin assessment dated [DATE]. Review of the nurse's notes dated 10/22/16 at 8:12 a.m. documented, Resident was up at his bedside at 2300 (11:00 p.m.) Resident was cooperative through care and verbalized no c/o (complaints of) pain or discomfort at this time Resident has been pleasant and cooperative with staff this entire shift. Review of the police report dated 10/24/16 at 5:09 a.m. documented, On Friday October 21, 2016 at approximately 21:00 (9:00 p.m.) I, (name of officer) was dispatched to respond to the the (sic) (name of vocational day program) on (address of program center) for a report of a missing Male. Upon my arrival I found an employee from the (name of nursing facility) on scene. She advised me that one of their patients who goes to work for (name of the vocational day program center), had not been dropped back off that evening. She advised the patient was a male, (name of Resident #9). We then returned to (name of nursing facility) in order to gain more information on the missing male. I also asked dispatch to attempt to contact a representative of (name of the vocational day program). It was brought to my attention that (name of vocational day program) had taken its employees and patients on a field trip to the Shenandoah National Park that day. When I arrived at the nursing home, Staff was unable to provide me with a proper log in/log out sheet. According to staff, anytime someone picks up a resident, they are to sign their names and log them out. However, No one had done so for (name of Resident #9) Around this time, the manager (OSM (other staff member) #10) of the (vocational day program) contacted (name of responsible party's wife). (OSM #10) informed her that (Resident #9) had been located at the (vocational day program) I then traveled back to (the vocational day program). When I arrived, multiple employees were on scene. They had (Resident #9) inside, sitting on a couch. The employees claimed that they had found (Resident #9) sitting in a van in the parking lot. They claimed that (Resident #9) has a peculiar routine and that he often will go out to the vehicle and sit and wait to be taken back to the nursing home I questioned (OSM #10) about that day's events and why this may have happened. (OSM #10) explained that (Resident #9) was picked up around 8 am that day by employee (OSM #11, the vocational day program van driver). (Resident #9) was picked up in a gold minivan However, when the group traveled to the park they used a red minivan to get to and from. (OSM #10) claims that this confused (Resident #9) and that when it was time to go home, (Resident #9) walked out to the red van without anyone noticing he had done so. So when it was time for employee (OSM #11), to take the group back to the nursing home, (Resident #9) was not on the gold van. (OSM #10) claims that (Resident #9) must have been sitting inside the red van the entire time. I asked (OSM #10) if (the vocational day program) keeps some type of log of who is picked up, and dropped off in a day's time. She stated that they do not have any type of system that keeps a log of patient in and out. Review of the facility's investigation completed by the social services director employed by the facility at that time OSM (other staff member) #8 (no date included) documented: 8:30AM (Approximately) (Resident #9) Left (sic) (name of nursing facility) with a (OSM #11) staff member who reported that they were going for a ride. 5:30PM: (CNA (certified nursing assistant) #9) reported that while passing dinner trays she observed that (Resident #9) was not in his room and informed (LPN #14). (CNA #9) reported that (LPN #14) informed her that (Resident #9) was out of the facility with family. 5:30PM-6:00PM: (CNA #7) reported that she observed that (Resident #9) was not in his room when passing dinner trays .(CNA #7) informed the charge nurse (LPN #14) that (Resident #9) was not in his room. 6:30PM: (CNA # 10) reported that she observed that (Resident #9) was not in his room .She reported that she reported this information to (LPN #14) and was informed that (Resident #9) was out with family. 7:30PM: (CNA #10) reported to (LPN #14) that (Resident #9) was not in his room . 7:54PM: (Name of POA (power of attorney) was called by (LPN #14) and no answer . 8:00PM: (Resident's sister/POA) was contacted by (LPN #14). 8:05PM-8:10PM: (Resident's sister/POA) arrived at the facility and contacted (Resident's brother/POA) . 8:26PM: On-call Nurse (LPN #1) left a message with DON (director of nursing) (ASM (Administrative staff member) #2). 8:32PM: On-call Nurse (LPN #1) spoke with South Unit Manager (RN (registered nurse) #2) who was informed of the situation. RN #2 reported that she was on her way to (the vocational day program) to look for (Resident #9). 8:39PM: South Unit Manager (RN #2) contacted (LPN #1) and informed her to have the staff search the (nursing) facility and the grounds. 8:54PM: South Unit Manager (RN #2) called 911. 9:35PM: On-call Nurse (LPN #1) spoke with (OSM #10) who reported that (the vocational day program) staff found (Resident #9) on the bus at (vocational day program). Family reporting that they did not want (Resident #9) to return to vocational day program and request be in writing and posted. Review of the 10/21/16 document, revealed the following: Effectively (sic) immediately (Resident #9), is not to return to (name of vocational day program) under any circumstances. It was signed by the resident's POAs. Review of the facility Leave of Absence Sign Out/Sign In Log for October 2016, failed to evidence documentation of Resident #9 being signed out of the facility in the month of October 2016. The facility 24 hour report from 10/21/16, documented Resident #9 was on a LOA (leave of absence). An interview was conducted on 8/16/17 at 10:05 a.m. with LPN #3, the nurse who completed the skin assessment on Resident #9 on 10/21/16. When asked about the resident's skin condition, LPN #3 stated, He had a tiny little faint scratch on his lower arm. When asked about the red mark around his neck and on his abdomen, LPN #3 stated, It was up here (placing hands around front of neck) like he was rubbing. His belly was the same, a slight redness to it. Like he was rubbing. A telephone interview was conducted on 8/16/17 at 9:45 a.m. with CNA (certified nursing assistant) #2, the aide who cared for Resident #9 on 10/21/16 evening shift. When asked what she remembered about that day, CNA #2 stated, When he came back it had been raining and his clothes were a little bit wet. He had a jacket on; I think it was a family member's. He looked very startled and fidgety. He felt a little cold. I asked him if he was okay and if he wanted a shower to get warm and was he hungry. He didn't respond very well. When asked if she had told the resident's nurse when she could not find the resident, CNA #2 stated, Yes. We were told he was out with his family. His normal return time was off but we thought he was with family. When asked did she remember when she spoke to the nurse about the resident, CNA #2 stated, It was about 6:00 (p.m.) because he hadn't returned and he never returned back that late. A telephone interview was conducted on 8/16/17 at 10:50 a.m. with CNA #7, the aide who told the nurse that Resident #9 was not in his room when the dinner tray were being served. When asked if she remembered the incident with Resident #9 on 10/21/16, CNA #7 stated, Yes, when he was left on the bus. I went to the nurs

Based on observation, resident interview, staff interview, facility documentation, and clinical record review it was determined that the facility staff failed to provide adequate supervision, and implement interventions to ensure a safe environment in the facility free from resident to resident altercations and inappropriate physical contact of a sexual nature for four of 32 residents in the survey sample, Residents #14, #8, #16, and #15. 1. The facility staff failed to manage inappropriate, sexual behaviors exhibited by Resident #14 toward female residents and toward staff that provided care to the resident on a daily basis, and failed to protect female residents, specifically Residents #8, #16 and #15 from in appropriate physical contact by Resident #14. The sexual behaviors were identified as a problem by the psychiatrist and the physician. The facility interventions for medication, redirecting, monitoring / supervising, Resident #14 were ineffective. Resident #14 was observed being left with female residents unsupervised by staff on separate occasions. Resident #14 was observed getting out of a wheel chair and ambulating independently unassisted by staff, and was also observed displaying inappropriate sexual behaviors towards LPN (licensed practical nurse) #6, smacking her bottom, and attempting to place his open mouth on her breast. Resident #14's physician during an interview stated If he (Resident #14) is able to get up and walk around he is a risk to other females around him. Any females are at high risk. As a result, the identification of Immediate Jeopardy (Level 4 - pattern) was determined by the survey team on 8/13/15 at 4:25 p.m. The immediate jeopardy was abated on 8/13/15 at 7:40 p.m. reducing the scope and severity level of the remaining deficient practice to a Level 2 - pattern. 2. On 9/29/14 Resident #14 grabbed Resident #8's breast and on 1/19/15 Resident #14 grabbed Resident #8's left elbow. The facility staff failed to implement interventions to address the resident to resident altercations between Resident #8 and Resident #14. 3. On 1/28/15 Resident #14 touched Resident #15's breast. The facility staff failed to implement interventions to address the resident to resident altercation between Resident #15 and Resident #14. 4. On 5/7/15 Resident # 14 reached for Resident #16's breast missed and grabbed her arm. The facility staff failed to provide adequate supervision to implement interventions to address the resident altercation between Resident #16 and Resident #14. The findings include: 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].** (a process in which neurons in the cerebellum - the area of the brain that controls coordination and balance - deteriorate and die), dementia, high-risk sexual behavior, [DIAGNOSES REDACTED], osteoarthrosis and diabetes. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 6/24/15. Resident #14 was coded as scoring nine out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating that he was moderately cognitively impaired and coded as having inattention which fluctuates in severity. Section B coded Resident #14 as usually understood and usually able to understand. Under Section E, Behavior, Resident #14 was coded as a 3 (three) for behavioral symptom presence and frequency, indicating that physical behavior symptoms directed toward others (e.g., hitting, kicking, pushing, scratching grabbing, abusing others sexually) occurred daily. Section E further coded Resident #14's behavior as Significantly intrudes on the privacy or activity of others. Under Section G, Functional Status, Resident #14 was coded as 1/1 (supervision-oversight encouragement cueing, setup help only) for transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position). Resident #14 was coded 1/1 for walk in room, walk in corridor, locomotion on unit (supervision-oversight only, setup help only). He was further coded as able to stabilize self without staff assistance for moving from seated to standing position, walking and turning around. He was coded as having no was limitations with range of motion and was coded as not using mobility devices for mobility. The previous full MDS for Resident #14 was a significant change in condition assessment dated [DATE], which assessed the resident as understood and usually able to understand and coded Resident #14 as scoring an 11 out of a possible 15 on the BIMS a, indicating that he was moderately cognitively impaired. Section E, Behavior, coded Resident #14 as exhibiting physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching grabbing, abusing others sexually) occurring one to three days during the 14 day look back period. Section E further coded Resident #14's behavior as Significantly intrudes on the privacy or activity of others. Section G, Functional Status, coded Resident #14 as a 2/2 for walking in the corridor and locomotion on the unit (limited assistance with one person physical assist). He was further coded as not steady and only able to stabilize with staff assistance for moving from seated to standing position, walking and turning around. He was further coded as having no limitations with range of motion and using a walker and wheelchair for mobility devices. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 6/19/15. Resident #8 was coded as scoring 12 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating that she was cognitively intact. Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/12/15 coded the resident as scoring a six out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make to make daily cognitive decisions. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16's most recent MDS (minimum data set), an annual assessment, with an ARD (assessment reference date) of 5/7/15 was coded as a 15 out of 15 on the BIMs (brief assessment for mental status) indicating the resident was cognitively intact to make daily decisions. The following Facility Reported Incidents (FRIs) were submitted to the Virginia Department of Health Office of Licensure and Certification for allegations of abuse involving Resident #14: · Review of the facility's reported incident dated 9/29/14 documented; At approx (approximately) 9:40 a.m. (name of Resident #8) was sitting at the nurses' station in her w/c (wheelchair) talking to the LPN (licensed practical nurse) and CNA (certified nursing assistant) regarding her shower. (Name of Resident #14) walked up to the CNA and touched her buttocks. Staff informed him that was inappropriate and he went to walk away. However, as he walked away he reached out and grabbed (name of Resident #8's) breast. (Name of Resident #8) to him (sic) to stop and he did. Staff immediately told him that was inappropriate. Staff reported (name of Resident #14) smiled, waved and walked away. (Name of Resident #8) continued to talk to staff about her shower. A review of the conclusion for this incident revealed, in part, the following documentation: Consulted with the local APS (adult protective service worker) and Ombudsman following the incident regarding possible suggestions and interventions to assist in preventing similar incidents. (Name of Resident #14) is ambulatory and staff do not want to limit or alter that function with any medication changes. This writer implemented a daily activity log for staff to be able to monitor his participation in facility activities. Clear instruction given to the activity department to not allow (name of Resident #14) to be alone with any female residents during activities. There was no documentation provided from APS or the Ombudsman. · Review of the facility's reported incident dated 1/19/15 documented; (Name of Resident #14) grabbed the left arm at the elbow area of (name of Resident #8) as she propelled self past him in the hallway. (Name of Resident #8) asked (name of Resident #14) to let go however he would not until staff intervened. No injury sustained from either resident. Both residents RPs (responsible party) notified via telephone, both residents MDs (medical doctor) notified by fax. Social Services and DON (director of nursing) made aware. Both residents separated immediately. (Name of Resident #8) had no recollection of incident later when discussed further. Staff advised to continue 30 min (minute) rounds on (name of Resident #14) and keep all residents out of arms reach. · Review of the facility's reported incident dated 1/28/15 documented, in part; This writer was informed by the licensed nurse that the above named female resident (Resident #15) was inappropriately touched by the above named male resident (Resident #14). The female resident had just returned from a dialysis appointment and was looking for one of the licensed nurses. (Name of Resident #15) acknowledged that she had propelled herself near (name of Resident #14). A CNA (certified nursing assistant) near the area heard (name of Resident #15) state, You better stop or I'm going to knock you in the nose. The CNA turned around upon hearing (name of Resident #15) and removed (name of Resident #15) from (name of Resident #14). The CNA asked (name of Resident #15) if (name of Resident #14) had touched her to which (name of Resident #15) replied yes (name of Resident #15) informed this writer that (name of Resident #14) had touched her left breast. This incident was investigated by APS and the following recommendation was provided in a letter dated March 11, 2015 addressed to ASM (administrative staff member) #1, the administrator, which documented, in part, the following: We have taken your internal investigation into account and have considered other sexual-touching incidents involving (name of Resident #14) that were witnessed including touching staff providing care. I also have observed him (Resident #14) to quickly reach out and attempt to touch a passing staff member. This APS determination is Needs Protective Services and Accepts for sexual abuse. · Review of the facility's reported incident dated 5/7/15 documented, in part; Staff reported that (name of Resident #14) reached out and grabbed (name of Resident #16's) left breast as staff wheeled him by her following Bingo. Staff reported that they were assisting activities in taking residents back to their rooms. (name of Resident #16) reported she was waiting to get her Bingo prize when (name of Resident #14) reached out and grabbed her. However, (name of Resident #16) is adamant he reached for her breast, missed and grabbed her arm. No injuries noted. MD (medical doctor) and POA (power of attorney) notified. Review of the facility's investigation dated 5/14/15 concluded, A review of documentation, staff and resident interviews indicate that the incident between the two residents as reported on May 7th, 2015 did occur. However, (name of Resident #16) is adamant that (name of Resident #14) did not touch her breast, but grabbed her arm instead. No further incidents between the two residents have been reported. The investigation produced that neither resident sustained [REDACTED]. (name of Resident #16) reports no lasting emotional/psychological effects from the incident. POA of (name of Resident #14) contacted, (name of Resident #16) is her own RP (responsible party). MD notified. This incident was investigated by APS and the following recommendation was provided in a letter dated June 19, 2015 addressed to ASM (administrative staff member) #1, the administrator, which documented, in part, the following: This case is determined Needs Protective Services and Accepts, as it is felt that monitoring (name of Resident #14) is necessary to ensure that corrective actions have been taken by your facility to prevent reoccurrence. A review of Resident #14's social services notes revealed, in part the following documentation: · 10/2/14 Nursing staff reported that on September 30, 2014 resident (Resident #14) touched the buttocks of a staff member and grabbed the breast of a female resident. The incident was discussed with the DON (director of nursing), APS (adult protective services) worker and Ombudsman and it was decided to encourage resident to participate in all facility activities as to keep him occupied. The activities department was given a calendar to document his daily participation with activities and instructed to keep him away from other female residents during activities. Nursing staff were instructed to keep him away from other female residents and to continue with the thirty minute rounding sheet. · 11/18/14. Nursing staff notified this writer and the other SW (social worker) that resident was having increased behaviors; grabbing and touching at staff inappropriately. Resident was even attempting to touch a male staff member inappropriately whereas previously it has been female staff. Resident was sitting in a chair at the nursing station when both SW's requested he accompany them to his room to have a conversation; on the way to his room the resident continued to attempt to grab, smack and hug both SW's. Resident would continue to reach out at staff and request staff to sit on his lap and laugh inappropriately throughout the conversation. Spoke with the activities department and requested that they continue to watch him closely while in activities. Requested that they make sure he is the last person to be brought to group activities and the first to be returned to his room so as not to leave him alone with other residents for any period of time. · 12/4/14. Nursing staff reported to this writer that this resident bit a CNAs left breast while CNA was transferring this resident. · 1/6/15. Resident has expressed some behavioral concerns this assessment. Resident is difficult to redirect. · 3/31/15 Resident grabs and expresses inappropriate verbal statements to staff. Resident is difficult to redirect. · 4/30/15 Nursing staff reported that resident grabbed another female residents hand as she was wheeling past him in the hallway. In response the female resident grabbed tightly to the residents (Resident #14's) wrist, ultimately releasing with staff encouragement. · 5/8/15 On 5/7/15 this writer was notified by staff that following Bingo, staff were pushing resident (Resident #14) in the Geri chair out of the dining room back to his room. Resident reached out and grabbed the left breast of another female resident as they were wheeling by. A review of Resident #14's clinical record revealed, in part, the following physician notes; · 9/27/14 (Name of Resident #14) is displaying some hypersexual behavior with the nurses. When he is asleep, he behaves himself. We'll continue the same medications that he's on currently. Signed by ASM (administrative staff member) #4, Resident #14's attending physician. · 9/29/14 a report to physician. FYI (for your information) resident (Resident #14) when walking down hallway had grab (sic) a CNA buttock and another resident breast. Response written below GEEZ! signed by ASM #4, Resident #14's attending physician. · 11/20/14 Progress Note: (Resident #14) is having Risperidone (an antipsychotic medication used to treat schizophrenia) increased to 2 mg (milligrams) bid (two times per day) and is less agitated and less touching than before. Pt (patient) is in line with rules on the unit and is willing to not touch others. Pt is more sedated on the increased Risperidone and staff are happier with this because he is much less agitated than he was. Would recommend stopping Zoloft (an antidepressant) and adding Abilify (treats schizophrenia, bi polar disease and depression) 5 mg for inappropriate sexual behaviors towards staff and intrusiveness. Signed by ASM #5, the psychiatrist. · 12/11/14 Wrote order 12/11/14 to have Abilify increased to 5 mg qam (every morning) and qhs (every bedtime) but not done yet. Pt is still acting out as he did before so new medication increase needs to be initiated first. Signed by ASM #5, the psychiatrist · 12/23/14 Problems: 1. Hypersexual behavior with mild molestation disorder. (Name of Resident #14) was seen by psychiatry recently, who started him on Abilify because of his sexual aggressiveness and foul language. Nursing tells me that when he is at his worst, he is easily redirected. He has never injured anybody. It is a more or less grabbing and pinching which is something that we cannot talk him out of. Unfortunately the Abilify resulted in extreme lethargy and inability to eat. That has been discontinued. Plan: We will just keep him off his medicine for now and I will come up with something in the future if we (need him) (sic). Signed by ASM #4, Resident #14's attending physician. · 1/8/15 Progress Note: Pt is still acting out sexually at times but is not able to be given meds (medications) as they knock him out and he is a fall risk. Signed by ASM #5, the psychiatrist. · 1/17/15 Problems: Dementia with hypersexual behavior, somewhat improved with Depo-Provera (progesterone). He grabs (sic) somebody yesterday and would not let go. I talked to him today and he seems to understand, but I am not so sure. Signed by ASM #4, the physician. · 3/21/15 Problems: 4. Hypersexual behavior. He is not to be left alone with females however; he is going to be very grabby. He has not injured anybody. Plan: (Name of Resident #14) is (sic) very little insight into (with) (sic) hypersexuality. We will continue the current care plan. Signed by ASM #4, the physician. · 3/26/15 Pt is still at his baseline of flirty and touchy and does not seem any med (medication) will change this. Giving him meds to sedate him will not be answer either. Suggest we get psychologist in to work on a behavioral plan to reduce this behavior. Signed by ASM #5, the psychiatrist. · 5/21/15 Pt is still at his baseline of flirty and touchy and does not seem any med will change this. Staff has tried in-services with him but wo (without) any progress. Unclear how we can change this behavior wo behavioral therapist involved as no meds will touch this behavior. I told pt that if he does not stop this will add Seroquel if not better . Signed by ASM #5, the psychiatrist. · 5/22/15 (Name of Resident #14) is doing okay. Apparently his Depo-Provera seems to be controlling some of his hypersexual behavior which consists of grabbing and groping women including our staff. Signed by ASM #4, the physician. · 6/25/15 Pt is still at his baseline of flirty and touchy and does not seem any med will change this. Staff has tried in-services with him but wo (without) any progress. Unclear how we can change this behavior wo behavioral therapist involved as no meds will touch this behavior. He continues to be out of control and paranoid Signed by ASM #5, the psychiatrist. · 7/24/15 (Name of Resident #14) continues to grab the nurses inappropriately, but fortunately they understand the situation. We do have him on Depo-Provera in order to combat some of this behavior but unfortunately it has not worked great. He is on Namenda (used to treat dementia) and Donepezil (used to treat dementia) and I must say his condition has been stable. Plan: We will continue the current care plan Signed by ASM #4, the physician. Further review of Resident #14's clinical record revealed, in part, the following nurse's notes regarding inappropriate behaviors since the last survey 8/8/14 and the present: · 8/12/14 10:30 (no indication as to a.m. or p.m.) Focus: behavior. Resident grabbing CNA (certified nursing assistant) inappropriately while shower was being given. CNA told this resident it was inappropriate but resident laughed and continued to grab out. · 8/12/14. Focus: behavior. Touchy feely with staff, actions corrected. Resident laughed. · 9/24/14 10:00. Focus: behavior. Resident grabbing at staff inappropriately this a.m. (morning) and saying several comments to staff. When told it was inappropriate, began laughing and continued with behavior. · 9/29/14 10:30. Focus: Status. Resident was walking the hallway when grabbed a CNA buttock and then another resident (sic) breast, staff told this resident that it was inappropriate, but resident laugh and wave and kept walking the hallway. Family and MD (medical doctor) is aware and incident done. · 9/30/14 0900 (9:00 a.m.) Focus: behavior. Resident grabbing at CNA inappropriately while a CNA was giving resident a shower. Told resident it was inappropriate but laughed and would continue to occasionally grab at CNA. Locator tool in progress and (upward pointing arrow) by nurses station in chair with eyes closed. · 10/1/14 0800 (8:00 a.m.) Focus: behavior. Resident has been touching staff inappropriately today. Told him to keep his hands to himself, he just laughed. · 10/2/14 1000 (10:00 a.m.) Focus: behavior. Resident attempting to grab at staff. When told it is inappropriate, continues with behavior and laughs. (Upward pointing arrow) in (name of psychiatry group) at this time. · 10/3/14 0930 (9:30 a.m.) Focus: behavior. Resident attempting to grab at staff. When told it was inappropriate resident would laugh and walk away. Locator tool in progress. · 11/7/14 1945 (7:45 p.m.) Focus: behavior. Resident has been inappropriate with staff and agitating other residents. · 11/14/14 1250 (12:50 p.m.) Focus: behavior. Resident attempting to grab at a resident's daughter and shaking her. Easily re-directed, laughed when told it was inappropriate. Message left for SS (social services). · 12/4/14 1400 (2:00 p.m.) Focus: behavior. CNA was transferring resident when resident leaned forward and bit CNA's left breast. · 1/16/15 1820 (6:20 p.m.) Focus: status. Resident grabbed a female resident's L (left) arm @ (at) elbow area and would not let go until separated by staff. Even when female resident tried to pull her arm away. 0 apparent injuries to either parties (sic). Resident (Resident #14) laughed at situation. · 1/28/15 1530 (3:30 p.m.) Focus: status/behavior. This nurse was informed by CNA that this res (Resident #14) was in hallway with a female resident yelling at the female resident. c/o this resident (Resident #14) touching her inappropriately. (Name of ASM (administrative staff member) #4, the medical doctor) and family aware. · 3/4/15 2200 (10:00 p.m.) Focus: behavior. Resident has been sexually inappropriate with staff, tried to bite this nurse in the breast and grabbed at a CNA's crouch (sic) area. Asked resident to try not to behave this way, resident laughed. · 4/28/15 5:21 p.m. Note: resident has been very inappropriate with staff, touching and saying sexually inapp (inappropriate) comments. Staff unable to redirect. · 7/15/15 2:52 p.m. Note: Resident grabbing out at staff and laughs when told it is inappropriate. Resident also sexually inappropriate verbally. SS (social services) aware and resident spoken to, Resident also stating inappropriate comments to female residents. A review of Resident #14's clinical record revealed behavioral monitoring flow records which revealed, in part, the following recording of Resident #14's behavior during the following months, November 2014, December 2014, February - July 2015. Behavioral monitoring flow records were not provided for the months of August 2014 through October 2014 and January 2015. The behaviors being monitored on the behavioral monitoring flow record were identified as; inappropriate with residents and staff; inappropriate behavior with females; grabbing/touching; inappropriate contact with female residents and staff; and grab at females and inappropriate. The following provides the number of occurrences of the described behaviors during the months provided: · November 2014 - 271 occurrences on day shift; 103 occurrences on evening shift · December 2014 - 58 occurrences on day shift; 23 occurrences on evening shift · February 2015 - 90 occurrences on day shift; 13 occurrences on evening shift · March 2015 - 123 occurrences on day shift; 52 occurrences on evening shift · April 2015 - 122 occurrences on day shift; 45 occurrences on evening shift · May 2015 - 186 occurrences on day shift; 123 occurrences on evening shift · June 2015 - 206 occurrences on day shift; 118 occurrences on evening shift · July 2015 - 154 occurrences on day shift; 98 occurrences on evening shift The following observations were made of Resident #14; · 8/12/15 - At 3:25 p.m. Resident #14 was asleep sitting in a wheelchair in the hallway beside the nurses' station. His right side was against the wall and a bedside table was placed by his left side. A note taped to the table documented Please make sure this table is next to (Resident #14's room number) when in hallway. At 3:45 p.m. Resident #14 got up from the wheelchair unassisted by a CNA (certified nursing assistant), Resident #14 was able to walk unassisted to his room. The CNA had placed a gait belt around Resident #14 but was not observed using it. Resident #14 attempted to lean towards the CNA and tried to kiss her. Resident #14 was assisted to the bathroom. At 3:50 p.m. Resident #14 ambulated back to the wheelchair in the hallway, unassisted but with guidance from the CNA. Once Resident #14 was seated in his wheelchair the CNA left the area. There was no other staff in the area providing supervision between 3:50 p.m. and 4:00 p.m.; two female residents were seated in wheelchairs approximately 10 - 15 feet away from Resident #14. Resident #14 did have a tab alarm in place. · 8/13/15 - At 8:00 a.m. the resident was observed in the hallway with his right side against the wall and a bedside table on his left side. A second table was in front of him with his breakfast tray. Resident #14 was feeding himself breakfast. At 8:35 a.m. LPN #6 asked Resident #14 about going to the bathroom. Resident #14 got up from the wheelchair unassisted, and ambulated to the bathroom in his room without hands on assistance from LPN #6. LPN #6 waited outside of the bathroom door until Resident #14 was finished. When the resident came out of the bathroom LPN #6 assisted him with fastening his pants then guided him to the sink to wash his hands. Resident #14 smacked LPN #6's buttock and stated something inappropriate, LPN #6 told him that was inappropriate and not to touch her. While LPN #6 had her head turned away, Resident #14 leaned forward with his mouth open and reached for LPN #6's breast with his open mouth. · 8/13/15 - At 8:49 a.m. while seated in his wheelchair in the hallway beside the nursing station Resident #14 reached out his left arm to nurse passing by. At 9:20 a.m. activities staff took him up the hallway to participate in activities. There were several other residents in the room; Resident #14 was placed at an empty table with an empty chair placed beside his wheelchair. He was not the last resident brought to the room. At 10:40 a.m. following the activity other residents were moved out of the dining room and Resident #14 was left in the dining room alone with two male residents and one female resident, there was no staff supervision. At 10:45 a.m. the activities director came to get him. He was not the first resident out of the room. Resident #14 was placed back in the hallway next to the nurses' station. A review of Resident #14's care plan revealed, in part, the following documentation: Problem: Behavior symptoms: Socially inappropriate behavior. Effective: 1/28/2015. Resident exhibits socially inappropriate behavior as evidenced by inappropriately touching (sexually) others (female residents and staff). 4/29/15 (Name of Resident #14) touching another female resident's hand without permission. 5/7/15 grabbed a female resident's breast. Interventions: Document in the medical record the intensity, duration or frequency of behavior. Effective 1/28/15. Notify MD (medical doctor) for resident to be assessed medically for signs of inappropriate behavior. Effective 1/28/15. Social service evaluation and follow-up. Effective 1/28/15. Redirect negative behaviors. Effective 1/28/15. Refer for (name of psychiatric group) for consult. Effective 4/9/15. Administer medications as ordered by physician. Effective 1/28/15. Daily activity log showing participation in activities. Effective 1/28/15. Explain in simple terms to (name of Resident #14) why behaviors are inappropriate. Effective 1/28/15. When sitting in hall in Geri-chair, please place table beside (name of Resident #14's) chair at all times. Effective 1/28/15. Rounding checks every 30 minutes and document. Effective 1/28/15. Report any incident to DON (director of nursing), SS (social services) or Administrator who will notify all needed parties/authorities. Effective 1/28/15. When exhibiting inappropriate behavior, (name of Resident #14) may be moved to a quiet, safe environment for 20 minutes. Effective 4/9/15. 5/7/15 Staff will be reeducated on how to transport (name of Resident #14) to and from activities and other activities on an (sic) off unit to prevent incidents from occurring and to protect other resident's rights. Effective 5/11/15. On 8/12/15 at the end of day meeting with ASM #1, the administrator, and ASM #2, the director of nursing, an interview was requested to be arranged with ASM #5, the psychiatrist, for the next day. ASM #1 advised the survey team that ASM #5 would be available by phone as he was scheduled to see residents at the facility. On 8/13/15 at approximately 10:30 a.m. ASM #5 sent a message via the ADON (assistant director of nursing), also known as ASM #3, that he would not be able to speak to any of the state surveyors face to face or by phone. However, the psychiatrist would attempt to answer questions if we wrote them down and submit them to him. The psychiatrist would attempt to have answers to us the next day. On 8/12/15 at 3:35 p.m. an interview was conducted with CNA (certified nursing assistant) #7. CNA #7 was asked about Resident #14's behavior. CNA #7 stated that he was very sexual but doesn't do anything if he's in the hallway. Now that he's got that table there he can't reach anyone, we keep the table there just in case. CNA #7 was asked whether or not he was able to walk or propel himself, CNA #7 responded that he could walk and propel himself but the staff would hear him if he tries to get up to walk because of his alarm. It's rare that he takes off in the wheelchair. He has to be supervised at all times. On 8/13/15 at 10:50 a.m. an interview was conducted with CNA #5, regarding how she is made aware of the residents' special needs. CNA #5 responded that above the beds of the residents there was a code that indicated their level of function so she would know how much help they needed. CNA #5 was asked how she would know about a resident's behaviors. CNA #5 responded, I would know by the residents' reactions and they way they talk. CNA #5 was asked who in the facility had behaviors that she was aware of, CNA #5 responded, Resident #14 says inappropriate things to female residents a

Based on observation, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to ensure new interventions were put in place to prevent major injury for one of 26 residents in the survey sample, Resident #25. Resident #25 sustained a fall on 6/8/14. No new interventions were put in place to prevent further falls. The resident fell again on 6/19/14 and suffered a laceration to her head requiring staples. No new interventions were put in place after this fall. The resident fell on [DATE] and suffered a fracture to her scapula. The resident fell again on 7/15/14 and suffered a laceration to her chin. The chair alarm was not attached at the time of the fall. The findings include: Resident #25 was admitted to the facility on [DATE] with a recent readmission on 8/7/14 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 6/16/14, coded the resident as usually making herself understood and sometimes understanding others. The resident was coded as being severely impaired to make cognitive daily decisions. Resident #25 scored a three on the BIMS (brief interview for mental status), on a scale of zero to 15, 15 being cognitively intact. Resident #25 was coded as having periods of inattention and disorganized thinking. In Section E - Behavior, the resident was coded as having physical and verbal behavioral symptoms directed at others. Resident #25 was coded as requiring extensive assistance of one person for moving in the bed, limited assistance of one person for transfers and walking. The resident was dependent of one staff member for moving on the unit, dressing, toileting needs and bathing. The resident required supervision after set assistance for eating. Resident #25 was coded as being frequently incontinent of urine and occasionally incontinent of bowel. In Section J -Health Conditions, the resident was coded as having two falls with no injury and two falls with injury, except major. The resident was not coded as having a major injury. The nurse's note dated, 6/8/14 at 1725 (5:25 p.m.), documented, "Resident was out with family and came back around 1600 (4:00 p.m.); when daughters left, resident became agitated and was trying to get out of chair. When she slid and was sitting on the foot rest of the Broda chair. No injuries." Review of the comprehensive care plan dated, 10/23/13, documented, "Problem: Trauma, potential for fall risk." Handwritten on the care plan on 6/8/14, was "fall." However there were no new interventions documented or implemented to address this fall and to prevent further falls from occurring. The following interventions were documented on the care plan: Dated 10/23/13 - ? side rails up X2 (both sides) when in bed as an enabler for turning/positioning -administer medications as ordered; monitor for effectiveness/side effects - Respond to call light promptly; keep call bell within reach - Keep corridors, rooms well lighted - Keep adjustable bed in low position & locked for safe transfers, also lock W/C (wheelchair) during transfers - Keep environment free from obstruction Dated 7/5/13 - Bed/chair alarm & pressure sensing alarm, resident at times will take alarm off, refused to leave on and has devised a way to bypass pressure alarm by placing pocketbook on alarm to keep it from going off. Dated 7/15/13 - Wear appropriate footwear which at times she will refuse, likes to wear crocs Dated 9/4/13 - Geri Chair for trunk stability Dated 2/17/14 - OT (occupational therapy) for positioning for safety for decrease risk of falls Dated 2/27/14 - OT to treat for 30 days for positioning Dated 4/11/14 - Trail of Broda chair to help with positioning Dated 4/17/14 - Broda chair per order. No new interventions were documented on the care plan after 4/17/14. The list of falls since 4/17/14 was documented but no new interventions. The resident also had three falls between 4/17/14 and 6/8/14. The "Fall Investigation Post Fall" report dated, 6/8/14, documented, "22. Has the resident's Care Plan been updated?" A check mark was documented next to "Yes." Review of the care plan evidenced there was no revision and implementation of new interventions to prevent additional falls from occurring. The nurse's note dated, 6/19/14 at 2010 (8:00 p.m.) documented, "Resident alarm sounding, CNA (certified nursing assistant) came out of another resident's room and observed resident on floor on back with head in blood. Alert & speaking normally, 911 called. Pressure being held on head, pupils equal & reactive to light, Moves all extremities. Daughter (name of daughter) notified." At 2030 (8:30 p.m.) Left with rescue squad, stood with EMS (emergency medical system), talking." On 6/20/14 at 2:45 a.m. the nurse's note documented, "Resident returned to facility via (initials of ambulance service) DX: scalp hematoma & laceration of the scalp. Resident alert and talking." A physician's note dated 6/21/14 documented, "laceration on head has staples and no signs of infection." Review of the comprehensive care plan dated, 10/23/13, did not document any mention of the fall on 6/19/14. No new interventions were put into place to address this fall and to prevent additional falls from occurring. The "Fall Investigation Post Fall" report dated, 6/19/14, documented, "22. Has the resident's Care Plan been updated?" A check mark was documented next to "Yes." The nurse's note dated, 6/25/14 at 6:00 a.m., documented, "Resident's pressure alarm was sounding. This nurse went into resident's room & observed resident sitting on bathroom floor on her buttock with left arm in the toilet. Bruise noted to left thumb and redness noted to left upper arm." The note at 10:00 a.m. on 6/25/14 documented, "CNA called this nurse to resident's room, while CNA was toileting resident. Raised area approx (approximately) the size 6.3 x 7.5 (centimeters) to left upper back. Firm to the touch and tender. Resident c/o (complained of) back pain." At 11:00 a.m. Doctor ordered resident sent to the ER (emergency room ). At 11:05 a.m. the nurse documented, "Raised area to left upper back measure of 9 X 5.2." On 6/25/14 at 2100 (9:00 p.m.) the nurse documented, "admitted to (initials of hospital) Dx (diagnosis) Left scapula fracture and (an arrow pointing downward indicating low) BP (blood pressure)." The nurse's note dated 6/25/14, documented, "Panacea Original Mattress with 3" (inches) raised perimeter with bilateral egress area placed." Review of the comprehensive care plan dated, 10/23/13, did not document any mention of the fall on 6/25/14. A new intervention was put in place, as documented in the nurse's note, but was not placed on the care plan. The "Fall Investigation Post Fall" report dated, 6/25/14, documented, "22. Has the resident's Care Plan been updated?" A check mark was documented next to "Yes." The nurse's notes dated, 7/15/14 at 7:45 p.m. documented, "CNA (certified nursing assistant) heard noise from area where resident sitting in Broda chair. This nurse observed resident on floor stretched out - right side chin with 2 cm (centimeters) laceration, Right knee edema, bruising, light nose bleed. Assisted to chair and then to bed, where resident refused to let nurse apply ice, cool compress to chin, nose and knee. Did allow chin to be cleaned and steri strips applied. " The "Fall Investigation Post Fall" report dated, 7/15/14, documented, "15. What mechanical devised were in use at the time of the incident? What devises were in use? ' A check mark was documented next to "chair alarm." "Was the chair alarm working at the time of incident?" Next to this was documented, "Not attached." The "Fall Risk Assessment" documented a score of 18 on 3/26/14. A score of 10 or above represents High Risk. The score on 6/9/14 was documented as a 22. An interview was conducted with RN (registered nurse) #2, on 8/8/14 at 8:00 a.m. When asked about Resident #25's falls, RN #2 stated, "She does what she wants, it's hard to keep her in a chair. She can answer direct questions but remains confused. If she has to go to the bathroom, then she will have it in her mind and she will go 50 times. She is extremely unsteady on her feet but she can get out of the bed and the Broda chair. She likes to do things herself." An interview was conducted with the administrator, administrative staff member (ASM) #1 on 8/8/14 at 9:08 a.m. The timeline of falls presented to the surveyor at 8:00 a.m. was reviewed with ASM #1. When asked where the new interventions were documented that were put into place after the 6/8/14 and 6/19/14 fall to prevent additional harm, ASM #1 stated, "I'll get back with you." On 8/8/14 at 11:05 a.m., an interview was conducted with ASM #1, ASM #2, the director of nursing, and LPN (licensed practical nurse) #1, the MDS nurse. When asked who is responsible for updating the care plan, LPN #1 stated that she was responsible. When interviewed about the fall investigation forms documenting that the care plan has been updated, LPN #1 stated, "I put the actual fall on the care plan. There are not new interventions after each fall." When ask if any new interventions had been put in place after Resident #25's fall on 6/8/14, to prevent the resident from falling again. LPN #1 stated, "No, there were no new interventions put in place. We talked about it but we were trying to figure her out and we didn't do it." When asked what the facility did to prevent two injuries for Resident #25, the administrator and director of nursing did not answer. ASM #1 and ASM #2 were informed of the concern for harm on 8/8/14 at 12:00 p.m. The facility policy, "Policy and Procedure for Incidents and Accidents" documented, "Procedure: #5 Complete incident accident form and write a nurses (sic) note. Include time, what happened, any injuries that occurred, persons notified, and how care plan updated on the form. An intervention is to be on the incident report, also include a copy of the nurse's note when report completed for tracking." The facility policy, "Policy on the Fall Prevention Program" documented, "6. After investigation of fall, make changes on interventions and approaches on the plan of care." In Fundamentals of Nursing, 7th edition, 2009; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 5. "Client safety is a priority in health care. You need to protect clients from physical and emotional injury by continually assessing for and eliminating safety hazards. Clients fall due to many factors, such as improper transfer techniques, client age, side effects of medications, impaired mobility, or confusion. Learn your agency's fall prevention program for reducing client falls. Programs that use a multidimensional approach in designing fall prevention strategies have the greatest reduction in fall rates." COMPLAINT DEFICIENCY

Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide care and treatment for [REDACTED].#4. On 7/28/14, Resident #4 reported "One of the girls" hit her arm on the bed rail. Investigation into this incident was not initiated until 8/4/14. Resident #4's physician was not notified and treatment was not initiated until 8/6/14. On 8/6/14, the resident was diagnosed with [REDACTED]. The findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set), a significant change in status assessment with an ARD (assessment reference date) of 6/10/14, coded the resident as being cognitively intact. Resident #4 was coded as requiring extensive assistance of one staff member with activities of daily living such as bed mobility, dressing, toilet use and personal hygiene. The resident was coded as requiring limited assistance of one staff member with transfers and as independently eating with setup help only. On 8/6/14 at 9:08 a.m., an interview was conducted with Resident #4. When asked how the resident felt about the staff at the facility, Resident #4 stated "Some know what they are doing and some I wonder." Resident #4 stated early one morning on Tuesday or Wednesday about a week ago (the resident reported she gets her days mixed up), staff were putting a "diaper" (incontinence brief) on her and while turning her, a female employee that was described as a little heavier than the resident with black hair caught the resident's arm on the bed rail and her right shoulder "went back." Resident #4 stated she hollered out. Resident #4 stated she believed the employee did not intentionally hurt her. Resident #4 stated her shoulder still hurt and she had told many people (including LPN (licensed practical nurse) #3) about this incident. Review of the facility resident council meeting minutes dated 7/28/14 revealed the following documentation: "One complaint from (Name of Resident #4), she states one of the girls came in to turn her and hit her arm on the bed rail, doesn't know who or what time this happened at this time, will report this to the Director of Nursing." This information was documented by OSM (other staff member) #2, the Activities Director. Review of Resident #4's clinical record failed to reveal any documentation regarding the above incident. A nurse's note dated 8/6/14 at 1:05 p.m. documented, "Focus: R (right) shoulder pain. Resident c/o (complains of) R shoulder pain. States 'I can hardly hold a spoon or lift my arm.' (Name of Resident #4's physician) notified, new order for X-RAY. (Name of portable x-ray company) called. Will be in today to do X-Ray. Daughter called. No answer. Message left to return call." A physician's orders [REDACTED]. A nurse's note dated 8/6/14 at 5:30 p.m. documented, "X-ray report back- anterior dislocation R shoulder. MD (medical doctor), resident & family aware." A nurse's note dated 8/6/14 at 6:00 p.m. documented, "(Name of Resident #4's physician) ordered to send to ER, family aware." A right shoulder x-ray report dated 8/6/14 documented, "Impression: Anterior shoulder dislocation." Dislocations are joint injuries that force the ends of your bones out of position. The cause is often a fall or a blow ..... . You can dislocate your ankles, knees, shoulders, hips, elbows and jaw. Dislocated joints often are swollen, very painful and visibly out of place. You may not be able to move it. A dislocated joint is an emergency. If you have one, seek medical attention. (This information was obtained from the website: <http://www.nlm.nih.gov/medlineplus/dislocations.html>) The ER (emergency room ) "History" dated 8/6/14 with a time of 1323 (1:23 p.m.), documented in part: "Chief Complaint Patient presents with shoulder pain. HPI (history of present illness) Sent here for trx (treatment) of right ant (anterior) should diloc (dislocation) of ?? age.... Name of DR (doctor) seems to think it was within the last day, nh (nursing home) records imply it was longer ago. Pt .(patient) only c/o (complains of) pain in the shoulder. No numbness in arm." Physical exam: Musculoskeletal: She exhibits tenderness (right shoulder tender and dec (decrease) rom (range of motion))." "MDM (Medical Decision Making) Dislocated shoulder, right initial encounter: [DIAGNOSES REDACTED]. Pt (patient) was [MEDICATION NAME] and given propofol 75 iv (intravenously) and I was able to relocate her shoulder, xray probably relocated. Pt in sling and back to nh (nursing home)." Propofol or Diprivan is an intravenous sedative-hypnotic agent for use in the induction and maintenance of anesthesia or sedation. (<http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=4756>) Discharge instructions from the local emergency department and dated 8/6/14 documented, "Your [DIAGNOSES REDACTED]. Ice to shoulder tonight..." Further review of Resident #4's clinical record revealed a physician's orders [REDACTED].#4 received [MEDICATION NAME]/[MEDICATION NAME] for right shoulder pain on: 7/31/14, 8/2/14, 8/3/14 and 8/5/14. On 7/27/14 the resident was administered [MEDICATION NAME]/[MEDICATION NAME] for pain as ordered however the reason for administering the pain medication and the location of the resident's pain was not documented on the eMAR. Resident #4's comprehensive care plan updated on 8/6/14 documented, "8/6/14 c/o (complaint of) Rt (right) shoulder pain. Sent to ER for eval (evaluation). Dx (diagnosis) dislocated Rt shoulder. 8/6/14 X-ray Rt shoulder- completed. 8/6 Left arm sling until MD D/C (discontinues). 8/6 Rt shoulder ice pack tx (treatment) every 1-2 hours x (times) 20 min. (minutes) first day. 8/6/14 ice pack Q (every) D (day) for next 2 days after first day..." On 8/6/14 at 2:33 p.m. an interview was conducted with OSM #2 (the Activities Director). OSM #2 reviewed the resident council meeting minutes dated 7/28/14 and stated she reported the documented incident regarding Resident #4 to the Director of Nursing within the next day or two but she didn't exactly remember when. On 8/6/14 at 3:35 p.m., ASM (administrative staff member) #2 (the Director of Nursing) was asked for any investigations regarding Resident #4. ASM #2 stated on Monday (8/4/14), OSM #2 reported to her that Resident #4 reported her shoulder was hurt when she was turned in bed. ASM #2 was unable to provide a written investigation and stated she was still writing the incident down. When asked if the incident was abuse or neglect, ASM #2 stated Resident #4 said she knew the employee didn't mean to do it and she didn't feel it was intentionally done. On 8/6/14 at 3:48 p.m., OSM #2 stopped this surveyor in the hall and stated she forget to tell this surveyor that she had left a note on ASM #2's desk the day Resident #4 reported the incident instead of verbally reporting the incident to ASM #2. When asked what timeframe this incident should have been reported, OSM #2 stated, "I just try to report right away. I left a note. I didn't see (name of ASM #2). It was late in the day." On 8//7/14 at 10:40 a.m., OSM #2 reviewed the resident council meeting minutes dated 7/28/14 and was asked if Resident #4 reported any further information. OSM #2 stated, "That's about it. She said it happened at night but was not sure who or when." When asked if the resident reported whether she thought the act was intentional, OSM #2 stated Resident #4 told her she didn't think the employee meant to hurt her but that staff gets in a hurry. On 8/7/14 at 10:55 a.m., ASM #2 stated she did not find OSM #2's note regarding Resident #4 until Monday (8/4/14). ASM #2 stated she did not have a written investigation; she was "Going to do everything first." ASM #2 stated she talked to Resident #4 on Monday or Tuesday of that week (8/4/14 or 8/5/14) and Resident #4 reported somebody had turned her in the bed on the "One to three shift." Resident #4 reported to ASM #2 a female had turned her to change her and rolled her on her right shoulder. Resident #4 reportedly yelled out and the female turned her back and didn't say she was sorry. ASM #2 stated the resident had described the female but she (ASM #2) was still trying to determine who the female was. ASM #2 stated Resident #4 said the incident occurred last Monday or Tuesday but it had to have happened before then due to the incident being reported to OSM #2 on 7/28/14. ASM #2 stated Resident #4 held her shoulder up and said "I can only move it this far." ASM #2 stated the resident also has arthritis. According to ASM #2, during her interview with Resident #4, the resident stated she had reported an employee hurt her shoulder to two nurses (one of the nurses being LPN #3). ASM #2 stated she questioned the two nurses and they both stated Resident #4 did not report an employee hurting her. ASM #2 stated LPN #3 stated Sunday morning Resident #4 asked for pain medication because her right shoulder was hurting. ASM #2 stated LPN #3 reported the resident lays on her right side so she told the resident that maybe she had slept on her right arm and the resident smiled. ASM #2 stated she talked to CNA (certified nursing assistant) #1 (the restorative aide) either Tuesday or Wednesday morning and CNA #1 stated on Sunday she noticed Resident #4 could not perform range of motion (exercise) with her right upper extremity. ASM #2 stated she reviewed the facility 24 hour report from 7/27/14 and nothing regarding the incident was documented. A copy of the note OSM #2 left for ASM #2 was provided to this surveyor. The undated note documented, "(Name of ASM #2), Just to let you know (Name of Resident #4) said someone turned her in the bed and hurt her arm. She doesn't know who but I had to put it in Resident Council notes. Thanks (Name of OSM #2)." On 8/7/14 at 7:15 a.m., Resident #4 was lying in bed with her eyes closed. A sling was observed on her right arm. On 8/7/14 at 7:55 a.m., an interview was conducted with LPN #3. LPN #3 stated she came to the facility on the previous Sunday (8/3/14) and Resident #4 told her that she had to get a pain pill in the middle of the night because of her right shoulder. LPN #3 stated this was unusual. LPN #3 stated she felt the resident's shoulder and it was tense. LPN #3 stated Resident #4 stated her shoulder was stiff but did not report anything about an employee hurting her shoulder. LPN #3 stated she thought the resident's shoulder was hurting because she "lays funny (in the bed)." LPN #3 stated she asked the resident about her right shoulder and she said she had been moving it around and it wasn't as loose as usual. LPN #3 stated the resident reported the scheduled dose of pain medication LPN #3 gave her that morning had took the edge off. LPN #3 stated she was off on Monday and Tuesday but she went in to see Resident #4 on Wednesday morning (8/6/14) to ask her about a CNA hurting her shoulder and the resident stated she thought she had told LPN #3 but she had told so many people that she didn't remember who she had told and who she had not told. LPN #3 stated she told Resident #4 she was contacting her doctor and asked if she wanted an x-ray. LPN #3 stated the resident stated she would like an x-ray and she could barely hold a spoon. LPN #3 stated she received an order for [REDACTED].#4's life, LPN #3 stated on day shift the resident does everything for herself so she wasn't sure if the sling would impact the resident's level of care. LPN #3 stated Resident #4 "wants independence; sometimes she wants help and sometimes she doesn't." On 8/7/14 at 10:55 a.m., an interview was conducted with CNA #2 (a day shift CNA who routinely cares for Resident #4). CNA #2 stated prior to Resident #4 having a sling, she (CNA #2) would put briefs and socks on the resident, assist her with sitting up in bed, dressing, bathing and grooming. CNA #2 stated the resident could stand by herself and wheel herself in a wheelchair. CNA #2 stated during the previous morning (8/6/14), she heard in report that two people were supposed to assist Resident #4 because her shoulder was hurting. CNA #2 stated that same morning, Resident #4 stated to be careful with her shoulder because it was hurting. When asked if the sling had impacted the resident's level of care, CNA #2 stated during that morning (8/7/14), she had to provide Resident #4 a little more extensive assistance with personal hygiene and had to open sugar and cut her food up. On 8/7/14 at 11:05 a.m., an interview was conducted with CNA #1 (Resident #4's restorative aide). CNA #1 stated on 8/3/14, Resident #4 refused to perform bilateral upper extremity range of motion. CNA #1 stated the resident stated "The girl" rolled her too hard to change her, hurt her right shoulder and she had reported that to the nurse. CNA #1 stated on 8/6/14 Resident #4 was unable to complete right upper extremity range of motion because her shoulder hurt. On 8/7/14 at 11:40 a.m., the Administrator and Director of Nursing were made aware of the above findings. Policies regarding physician/responsible party notification, turning and positioning, and assessment and treatment of [REDACTED]. On 8/7/14 at 12:05 p.m., Resident #4 was sitting in a recliner with a sling on her right arm. Resident #4 stated she was given a sling at the emergency room the previous night. The resident reported she had shooting pain down her arm two or three times that day. When asked if she was having any more difficulty since she was given the sling, Resident #4 reported she was right handed and had more difficulty using the bathroom but the "girls" were helping her. On 8/7/14 at 1:50 p.m., ASM #2 stated the facility did not have a policy regarding turning and positioning or resident assessment and treatment. On 8/7/14 at 2:20 p.m., ASM #2 stated she had called to the facility on Tuesday evening and told staff two people had to care for Resident #4 and stated a CNA had turned the resident on her arm. The facility policy titled "Notification of Resident Change in Status" documented, "(Name of facility) will immediately inform the resident, if applicable, consult with the resident's physician, notify the resident's legal representative or an interested family member when there is a change in the resident's status. Notification will be made by a licensed staff member if there is a resident injury, a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly, any change in medications, or a decision to transfer or discharge the resident from the facility." No further information was presented prior to exit. *This information was obtained from the website: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a 6.html