Every finding on record at South Boston Health & Rehab Center

Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide adequate supervision and ensure the environment was free of accident hazards to prevent residents from exiting the facility without staff knowledge and resulted resulting in one resident (Resident #3- R3) having eloped the facility for an undetermined amount of time. The deficient practice had the potential to affect residents identified at risk for elopement residing on two of the three occupied units, which resulted in the identification of Immediate Jeopardy (IJ) and substandard quality of care. Immediate jeopardy began on 1/17/25 and when removed on 12/4/25, the scope and severity was lowered to a level two, isolated (D). The findings included: On 12/3/25 at 11:45 AM, R3 was observed in the hallway outside of his room and was observed to self-propel his wheelchair without any staff assistance. R3 propelled himself into his room to converse with the surveyor. When asked about a known elopement that occurred in January 2025, R3 said, That was a long time ago. R3's recall of the events from that incident were not limited and the resident was unable to state where he went, who found him, how long he was gone, the purpose of leaving, or how he returned to the facility. On 12/3/25, a clinical record review was conducted of R3's medical record. This review revealed that R3 had been admitted to the facility on [DATE]. R3's diagnosis included, but were not limited to alcohol abuse, disorientation, anxiety disorder, personal history of nicotine dependence, and other symptoms and signs involving cognitive functions and awareness. According to the assessment completed by nursing on R3's admission, the resident was not identified to be at risk for wandering. On 11/15/24 an Elopement Observation assessment was completed by the director of nursing (DON) for R3. The entry on the assessment read, Wander guard placed d/t [due to] exit seeking behaviors without safety awareness. MD/RP [medical doctor and responsible party] aware. A physician order was entered on 11/19/24, which remained an active order at the time of survey for R3 and read, Safety/Wanderguard: Electronic bracelet for safety-check functioning daily, Special Instructions: Check bracelet functioning daily. On 1/3/25, a nursing note entry in R3's chart read, Wanderguard in place d/t [due to] exit seeking behaviors/wandering. IDT [interdisciplinary] Team. On 1/16/25 at 9:10 PM, a nursing note entry read, alerted by staff of inability to locate resident in either room, on unit or on frequently visited unit, code green called , staffed [sic] stated last visualization was between 1900- 2100 [7PM-9PM], head of count of all active residents, all were accounted for except current resident, code green initiated per policy, after 15 minutes search both within facility and outside grounds, police notified to aid in search and recovery, at this time RP [responsible party] was also notified of resident elopement, RP stated she was on the way to the facility to aid and recovery. Wanderguard to remain in place. IDT Team. According to a nursing note entry dated 1/16/25 at 10:17 PM, it read, Notified by police department at 2217 resident was located behind Tractor Supply, noted to be wearing Navy blue zipped up hoodie, shirt, flannel pajamas pants, socks, green sneakers, black beanie, stated he comes out here all time with his friends and the doctor to told him to get his exercise, voiced no c/o [complaint of] pain or discomfort, alert and orient, able to follow simple commands, shoes and wheelchair wheels covered in dirt, refused to return to facility with police escort, staff and sister left facility to recover resident. On 1/16/25 at 10:30 PM, the nursing staff recorded the following, 2230: resident returned to facility without incident. family present at bedside, VS 98.2 126-22-140/98Larm-95%RA. Thorough head to toe assessment completed with bilateral lower extremities cold to the touch, pulse palpated, pulses strong bounding. No s/sx [signs or symptoms] of hypothermia. Alert and verbal to name. Remains able to follow simple commands with no complaints of pain/discomfort. Staff notified that resident is one on one while awake and 15 minute checks while sleeping. MD [medical doctor] aware of elopement and return to facility. Order received to send to ER [emergency room] for eval and treat. According to a follow-up progress note entry on 1/18/25, the doctor noted, Pt [patient] was missing for an undisclosed amount of time- not specifically 4 hours. Follow-up notes indicate that the resident refused to go to the ER for evaluation. According to additional progress notes following the elopement of R3 on 1/16/25, there was evidence that the facility was attempting to find alternate placement in a secured facility. On 1/17/25, there was a social services progress note that indicated R3 had left on 1/7/25 for a doctor appointment and no alarm went off. On 1/17/25 On 1/17/25, R3 had another Elopement Observation assessment conducted, R3 scored eight, which noted they were at continued risk for elopement. No further Elopement Observations had been conducted at the time of survey since 1/17/25. On 12/4/25 at 8:45 AM, during interviews with the facility staff, two certified nursing assistants (CNA's) who did not want to be identified, verbalized that as recent as Thanksgiving, R3 had gone out of the facility on leave of absence and did not have a wander guard on at that time. They were very vocal and convinced about R3 not having a wander guard and said they knew because the family just took the resident out of the door without any staff having to silence the alarm or put in a code. On 12/3/25 at 8:50 AM, the surveyor visited R3 in the activity room and observed a wander guard on his right ankle. On 12/3/25 at 4:10 PM, an interview was conducted with the facility's maintenance director. When asked about the wander guard system and door locks, the maintenance director explained that the door from unit two going to the therapy gym used to have an alarm but when the facility re-opened the building official said they had to disable it, which they did. Then he went on to explain that the exit door by the therapy gym leading outside did not have any type of alarm at the time of the elopement. On 12/3/25-12/4/25, the facility submitted a binder to include evidence of their response and implemented plan of correction following R3's incident of elopement. According to the facility's submitted evidence they conducted a head-to-toe assessment of R3 and placed him on 1:1 monitoring while awake and 15-minute checks when asleep. A 100% head count of all residents was conducted to ensure all residents were accounted for. Elopement assessments were reviewed to ensure accuracy and All exit doors checked to ensure that alarm system on doors with system are working correctly on 1/17/25. Systemic change: Maintenance to order on 1/17/25 and place scream alarm to be placed on double doors going to therapy gym wing to alert staff that resident going to an unsupervised area of the building. Facility staff were educated on the elopement policy. Education was also provided to nursing to not remove residents' wander guards when the residents goes on a leave of absence. Elopement drills were conducted. Within the facility submitted binder of their investigation was data of the weather in the area on the day of the elopement. The maximum temperature for the day was 39 degrees Fahrenheit, and the low was 13 degrees. The temperature according to the facility submitted documentation at the time R3 was found and the hours prior was 25 degrees. Within the facility's documents of the incident was a release of responsibility which indicated R3 most recent leave of absence prior to the elopement was on 1/2/25. According to the facility's Root Cause Analysis Results (RCA), it read, Wander guard was not in place and not noticed by nurse checks for placement. Resident exit seek during day and staff not on put on high alert that was exit seeking [sic]. Door he believed went out does not have any type of alarm on the door and is out of the visual path of staff. Staff member had removed his wander guard when went on a LOA [leave of absence] and new one not placed on return. On 12/3/25-12/4/25, interviews were conducted with multiple nursing staff to include licensed nurses and certified nursing assistants. The facility staff were unable to identify which residents were at risk for elopement and had wander guards. On 12/4/25, at 9:25 AM, a follow-up interview was conducted with the facility's maintenance director. The maintenance director explained that following R3's elopement they were able to determine which door the resident exited from because they followed the wheelchair's tire marks. He explained that they did not have alarms on the doors and therefore no one knew the resident had exited the facility. The maintenance director explained that the following day he ordered and once arrived installed Screamer alarms on the doors that would give a loud auditory alarm if the doors were opened, until the company [contractor] came and installed the magnetic locks on the doors. The magnetic locks were installed on 3/26/25. On 12/4/25 at 9:45 AM, the facility's maintenance director and surveyor conducted a tour of the facility to ensure that the door locks and/or alarms were operating properly to alert staff if a resident identified to be at risk for elopement and with a wander guard would be able to exit the facility. During the tour it was noted that two exit doors (a door in the corridor between the 300 and 400/500 units and a door in the living room area on the 500 unit) which both lead to a courtyard were identified to have no lock, alarm, or other device to alert staff if someone exited into the courtyard. During the tour, it was observed that from the courtyard there was an exterior gate that led to a side parking lot. The gate had a locking system, but it was not operational, which would allow residents to exit directly into the parking lot with no system of alerting staff. In response to this finding, the maintenance director reported that after the fire the facility had over two years ago, the lock was not re-installed when they reopened. On 12/4/25 at 10:55 am, the above concern regarding the facility having two exit points into a courtyard that was not secured nor supervised was discussed with the administrator. The administrator stated, During the elopement we just looked at this area [the area near therapy gym where R3 was thought to have exit from]. The administrator provided the surveyor with a quote where they had contacted a contractor about repairing the lock on the courtyard gate but had no anticipated time of when the work will be initiated or completed. The facility's policy titled, Elopement/Unauthorized Absence Policy, with a review date of 7/2/25, was reviewed. According to the policy, it read in part, The facility will identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. Assessment: 1. All residents will be assessed for the risk of elopement using the Elopement Observation on admission, quarterly, and as needed. According to R3's clinical record, an elopement observation on assessment was conducted on admission and on 1/17/25. R3 had no evidence of quarterly assessments being conducted following the assessment on 1/17/25. At the time of survey, R3 had only had two elopement observations conducted. On 12/4/25 at 1:30 PM, the survey team determined the facility was in immediate jeopardy (IJ) and immediate action by the facility was needed to protect residents from accident hazards. The facility administrator and director of nursing were made aware of the IJ findings and provided with a copy of the IJ template. The identification of IJ also identified a substandard quality of care. The facility's non-compliance at an IJ level began on 1/17/25. The facility staff failed to maintain the facility in a manner to prevent accident hazards/elopement of residents by having a means of egress that was not secured or enabled to notify staff when someone exited. The facility had one resident (R3) with cognitive impairments successfully elope from the facility, which jeopardized serious adverse outcomes. The facility has self-identified five residents as being at risk for elopement. At the time of survey there remained a means of egress where any resident, particularly those who have already been identified as an elopement risk, could exit without staff knowledge or supervision. This puts all residents at risk for elopement, thereby serious injury, serious harm, serious impairment or death. On 12/4/25 at 3 PM, the facility provided an acceptable IJ removal plan. The facility's removal plan read, The immediate action by [facility name redacted] to ensure the safety of all the residents, as well as those who have been identified as risk for elopement, to ensure that none are able to exit the facility without staff knowledge or supervision. The facility has installed 2 screamer door alarms to the Unit 5 living room area door and the breezeway exit door to the courtyard. The doors will alarm when opened to alert staff of exiting. These door alarms were installed on 12/4/25 by maintenance director at 2:08 PM. Education completed with all on duty staff on 12/4/25 and off duty staff on 12/4/25 via phone calls and will have all staff that unable to reach via phone be in-serviced before they come on duty. Anticipated time of completion for education with all on duty staff is 3:30 PM. On 12/4/25 at 3:30 PM, Surveyor verified all residents had a current elopement risk assessment and those identified at risk had wander guards in place. Surveyor verified that the two identified doors had an alarm installed that would provide an auditory alarm to notify staff when the doors were opened. Surveyor verified and reviewed that the facility staff currently on duty had been educated regarding the installation of the door alarms on the two doors. Staff interviews were conducted with ten staff members to verify receipt of education and knowledge of the door alarms and how to respond when an alarm is activated as well as the elopement protocol. The immediacy was removed at 3:45 PM on 12/4/25, at which time the scope and severity was lowered to a level two isolated. No additional information was provided.

Based on resident interviews and staff interviews, the facility staff failed to ensure residents received mail timely and on weekends for three of three nursing units. The findings included: On 5/20/25 at 2:45 p.m., a group interview was conducted with fourteen residents in attendance. During the meeting, multiple residents residing on three of three nursing units, expressed concern and frustration that many times they do not receive mail on Fridays or weekends. One resident said that he doesn't get his Friday newspaper until Monday. On 5/20/25 at 3:27 p.m., an interview was conducted with the activities director (AD). The AD stated that her department is responsible for passing out resident mail. The AD said, On Fridays, the mail has been running later. So, the Saturday person passes it out, or they put the mail in my box, and the part-timer [part-time activity assistant] doesn't know where that is. So, sometimes it is Monday before it is passed out. AD confirmed that there are times that residents do not receive their newspaper from Friday until Monday. On 5/21/25 at 10:31 a.m., an interview was conducted with the activity assistant, (other employee #1- OE1). OE1 was asked about resident mail and said, I leave at 5 during the day and if it comes before we leave, I distribute it. If someone in the office gets it, they put it in the mailbox and lock the door and we don't have keys to that. The only key I have is to my office. When asked about mail delivery, OE1 stated that the mail delivery is very sporadic. OE1 explained that she always checks the mailbox and that sometimes on Sundays there is mail in the box from the prior day and she would distribute it. On 5/21/25 at 4:30 p.m., during an end of day meeting, the facility administrator, director of nursing and regional nurse consultant were made aware of the above concern. The facility policy regarding resident mail was requested. No further information was received prior to completion of the survey.

Based on observations, staff interviews and facility documentation, the facility staff failed to label and store medications properly on three of five medication carts inspected. The findings included: The facility staff was storing new insulin pens in the medication cart and not in the refrigerator per instructions on the label and was not putting an opened date on an eye drop bottle. On 5/20/25 at 3:40 p.m., an observation was made of the three medication carts on unit 300. A registered nurse, RN#1, assisted unlocking medication cart #1 on unit 300. Observed one bottle of eye drops that had no open date on the eye drop bottle. On medication cart #2, observed two unopened insulin pens that were being stored in cart instead of being in the refrigerator, according to the directions on the label. A licensed practical nurse, LPN#4 assisted with unlocking medication cart #3. Observed three insulin pens that were being stored in the medication cart and not in the refrigerator, as the label instructed. On 5/20/25 at 3:45 p.m., an interview was conducted with RN#1. RN#1 stated that she was aware that insulin pens should be stored in the refrigerator until needed. RN#1 stated she was aware that the eye drops are supposed to be dated when you open the bottle and she said, We usually put an open date and discard date on the bottle. On 5/20/25 at 3:50 p.m., an interview was conducted with LPN#4. LPN#4 said, The insulin pen should be stored in the refrigerator until needed and when opened then it can go in the cart and dated. LPN#4 stated opened dates was supposed to be on the insulin pens. LPN#4 opened and checked the insulin pen and she said, It was new and should be in the refrigerator until needed. On 5/21/25 at 3:25 p.m., an interview was conducted with LPN#2. LPN#2 stated any medications that was opened needs to be dated with the opened date. She stated that insulin pens were to be stored in the refrigerator until the insulin pen is needed, and then placed on medication cart, and when opened needs to be dated with the opened date. A review of facility documentation was conducted. The facility document titled, Common Medication Storage Guidance and Terminology, read in part, .safe and secure storage includes abiding by proper temperature controls as well as maintaining appropriate light and humidity exposure. On 5/21/25 at 4:48 p.m., an end of day meeting was conducted with the administrator, director of nursing and the regional nurse consultant and they were made aware of the above concerns. No additional information was provided prior to the exit conference.

Based on observation, staff interview and facility document review, the facility staff failed to store and prepare food in a sanitary manner in the main kitchen. The findings include: On [DATE] at 9:04 a.m., accompanied by the dietary manager (other staff #4), the main kitchen was inspected. Stored and available for use in the dry storage area were four 8-quart containers of dry cereal, not in the original packaging. The cereal had no label indicating the date opened or a discard date. There were two partially used packages of gravy mix and an opened package of corn meal with no date label indicating when opened. Eighty-four 8-ounce cartons of whole milk were stored and available for use in the walk-in refrigerator with expiration date of [DATE]. The 3-compartment since was observed in use with pots/pan soaking in the wash and sanitizer sections of the sink. The dietary manager checked the sanitizer concentration at this time with the concentration measured at 100 ppm (parts per million). There was no supply of sanitizer connected to the sink pump at this observation. The dietary manager stated the sanitizer ran out and a new bucket had not been connected yet. A storage rack was observed with prep/service pans identified by the dietary manager as ready to use. Three 8-quart plastic containers were stored on this rack nested and wet. There was a large stainless pan stored wet with water standing on the pan rim. On [DATE] at 9:27 a.m., the dietary manager (other staff #4) was interviewed about the kitchen observations. The dietary manager stated all food items were supposed to be labeled when accessed with a date opened and a discard date. The dietary manager stated that out of date milk was supposed to be discarded when it expired. The dietary manager stated pans were not supposed to be stored nested and wet. On [DATE] at 4:12 p.m., the dietary manager was interviewed about the 3- compartment sink in use with the sanitizer concentration of 100 ppm. The dietary manager stated the sanitizer concentration was supposed to be between 200 ppm and 400 ppm. The dietary manager stated the sanitizer was low because the sanitizer ran out and a new supply had not been connected to the sink pump. The facility's policy titled Food Preparation and Handling Policy (revised [DATE]) documented, .food items are prepared by methods designed to maintain safe temperatures, avoid cross-contamination, prevent food borne illness, conserve maximum nutritive value, and develop and enhance flavor .PHF/TCS [potentially hazardous food - time/temperature controlled for safety] foods are kept refrigerated except when being handled. Refrigerated foods will be .Appropriately labeled and dated . The facility's policy titled Dish Machine Use Policy (revised [DATE]) documented, .Employees will follow standards of practice to ensure that all utensils and dishes are washed and sanitized .Dishes should not be nested unless they are completely dry . The facility's policy titled Manual Ware Washing Policy (revised [DATE]) documented the recommended sanitizer concentration was 200 to 400 ppm with use of test strips. This policy documented that wet pans, dishes and other small wares should not be stacked or nested until allowed to air dry. These findings were reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on [DATE] at 4:30 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and facility documentation review, the facility staff failed to implement an infection control program that included infection surveillance, affecting residents on 3 of 3 nursing units. The findings included: On 5/21/25 at 3 p.m., an interview and meeting was conducted with the facility's infection preventionist (IP), who was designated as the responsible person over the infection control program. Review of the facility's infection control management program and documentation revealed that the facility only a system of tracking residents who had infections treated with an antibiotic and completed logs titled, Antibiotic Use Tracking Sheet. The IP confirmed that no logs had been completed for the current month of May as it was their process and is only done as a look-back after the end of the month. The IP also confirmed that residents who develop signs or symptoms of infection are not tracked, only if they are prescribed an antibiotic is the antibiotic use tracked. When questioned about the purpose of infection surveillance and monitoring, the IP confirmed that it is to identify symptoms and identify trends and infections, so they can take measures to break the chain of infection and prevent it from spreading. The IP also stated it allows them to educate staff who may be a factor in the transmission of infections/bacteria. During the above interview, a discussion was held regarding if infection surveillance is not done and only the residents who are treated with antibiotics are reviewed at the conclusion of the month, it doesn't allow the facility to be pro-active and prevent the spread of infection as it is occurring. The IP verbalized understanding and agreement. The IP did state that she reviews the 24-hour report daily but had nothing to provide as evidence of infection surveillance. A review was conducted of the facility policy titled Infection Prevention and Control Program Policy. The policy read in part, . The Infection Preventionist's responsibilities for infection prevention and control include, but may not be limited to conducts surveillance of staff and residents for facility-associated or community associated infections and/or communicable diseases . On 5/22/25 at 11 a.m., the facility administrator and director of nursing were made aware of the above findings that facility staff had failed to develop and implement a system of surveillance designed to identify possible communicable diseases or infections before they can spread to others in the facility. No additional information was provided.

Based on staff interview, clinical record reviews, and facility documentation review, the facility staff failed to implement an antibiotic stewardship program which affected residents on three of three units and failed to follow antibiotic stewardship for two residents (Resident #16-R16 and Resident #61-R61), who were actively receiving antibiotics. The findings included: 1. The facility staff failed to implement a facility wide antibiotic stewardship program to reduce the risk of development of antibiotic-resistant organisms. On 5/21/25 at 3:06 p.m., the surveyor met with the facility's Infection Preventionist (IP) who oversees the facility's infection control program. The antibiotic stewardship program was reviewed. The IP was asked to explain the purpose and importance of antibiotic stewardship and stated, If we suspect someone has a UTI [urinary tract infection] or other type of infection, we start an event in the computer, the nurse or unit manager can contact me and I will start the event, the event uses McGreer criteria and determines if we should start an antibiotic. If they don't meet the criteria, we can still ask the doctor if they want to treat them with antibiotic or not. Sometimes the doctor will want to treat based on clinical symptoms. When asked, what is the reason for the McGreer criteria being utilized? The IP said, We don't want to create these super bugs that become resistant to antibiotics. When asked if that is a concern, why does the doctor want to treat outside of that? The IP smiled and didn't respond. When asked how often that is happening that residents are being treated and do not meet criteria, the IP again smiled and didn't respond. The IP was asked if she found that a specific provider is prescribing outside of McGreer criteria more than the other, the IP said, No. The IP went on to explain that she discusses with the providers daily if the person meets criteria or not. She explained, I will go to them and say the results are less than 100,000 [referring to lab results] do you still want to proceed with doxycycline? When asked if that conversations should be held prior to treatment being started, the IP said, It should be. When asked if it is, the IP said, Sometimes. Sometimes they will start prophylactic ahead of culture results. The IP showed the surveyor tracking forms titled, Antibiotic Use Tracking Sheet that listed residents who had been prescribed antibiotics. On the spreadsheet it was noted that multiple residents were being treated with antibiotics prior to cultures being obtained and residents were being treated when they did not meet McGreer's criteria for antibiotic use. Review of the Antibiotic Use Tracking Sheets revealed the following: In September 2024, ten residents were treated with antibiotics and four of the ten did not meet McGeer criteria for treatment with an antibiotic. In October 2024, twenty-two residents were treated with antibiotics. According to the report/tracking form, sixteen had incomplete data and didn't indicate if they met criteria or not and two were noted to have not met criteria for antibiotic use. In November 2024, fourteen residents were treated with antibiotics and seven didn't meet the criteria for antibiotic use. In December 2024, nine of the nineteen residents did not meet McGeer criteria, and one resident's information was incomplete and didn't indicate if the criteria was met or not. For January 2025, eight of thirty residents did not meet McGeer criteria for antibiotic use. In February 2025, eleven of the twenty-seven residents did not meet criteria and there was one resident whose data was incomplete and noted a question mark for if McGeer's criteria were met. In March 2025, sixteen residents were prescribed antibiotics and half (eight) did not meet criteria. For April 2025, seventeen residents were prescribed antibiotics and seven were noted to have not met McGeer criteria. Two residents had no details about whether they met the criteria or not. The IP had no data for May and indicated that the form is completed after the month's end. 2. For R16, the facility staff failed to follow antibiotic stewardship with regards to the prescribing of antibiotics. On 5/21/25, the surveyor selected two residents from the survey sample that were currently being treated with antibiotics for review. According to Resident #16's (R16) clinical records, on 4/14/25, R16 complained of foul-smelling urine and pain during urination. There were no other documented symptoms following 4/14/25. A uranalysis was ordered and obtained on 4/15/25. According to physician orders and medication administration records, on 4/18/25, he was prescribed nitrofurantoin macrocrystal 100 mg, once daily from 4/18/25-4/22/25. According to the culture and sensitivity report which was reported on 4/17/25, the bacteria was susceptible to Nitrofurantoin. On 4/21/25, R16 was seen by his attending physician, who is also the medical director of the facility, and he ordered Bactrim DS 800-160mg, twice daily, which was added in addition to the nitrofurantoin macrocrystal, and was administered from 4/21/25-4/28/25. There was no indication that the IP or other facility staff had discussed duplicate therapy with the medical doctor. According to R16's clinical record, there were no other reported signs or symptoms of infection or discomfort following the physician's note dated 4/21/25. On 5/6/25, the nurse noted that an order was received to obtain a urinalysis with culture and sensitivity. The urinalysis was noted to be negative. On 5/19/25, there was an entry that the resident was out of the facility for an appointment with urology. Upon return he had an order for Cephalexin 250mg twice daily for seven days for positive nitrates. There was no documentation that R16 had any symptoms associated with this. On 5/22/25, the IP provided an Event Report for R16, dated 5/19/25. According to the form, R16 had no signs or symptoms, and the form noted, Does NOT meet McGeer's criteria. The IP had no evidence that she had reviewed and discussed R16's lack of meeting criteria for treatment with an antibiotic had been reviewed with the medical doctor/provider. 3. For Resident #61- R61, the facility prescribed antibiotics when the resident did not meet criteria for treatment and failed to test for COVID-19 when the resident displayed symptoms of COVID. On 5/21/25-5/22/25, a clinical record review was conducted of R61's chart. This review revealed that R61 was prescribed cefuroxime axetil tablet, 250 mg, twice daily on 5/19/25. According to the progress notes on 5/17/25, R61 had gone on leave of absence with family. On 5/19/25, there was a progress note entry that read, New orders received for guaifenesin 10ml every 6 hours as needed for cough. Loratadine 10mg PO [by mouth] daily. Cefuroxime 250 mg by mouth twice a day for 7 days for acute bronchitis . There were no preceding notes regarding any symptoms. On 5/19/25, the doctor saw R61 and noted, Patient seen for cough and congestion. Nonproductive cough has nasal congestion and sneezing. No Fever. No nausea vomiting. Appetite is good . Resp: [respiratory assessment] unlabored, ausc reveals nl [normal] breath sounds without wheezing, no rhonchi . On 5/20/25, R61 was seen again by the doctor, whose progress note read in part, . Patient seen for reevaluation of cough and congestion. Seems to be less congested today with a nonproductive cough . On 5/21/25, R61 was visited again by the medical provider and the note read in part, Patient seen for reevaluation of cough and congestion. Much less nasal congestion with a nonproductive cough . On 5/22/25, the medical provider note read in part, Patient seen for reevaluation of cough and congestion. Up in a chair in his room eating breakfast. Looking stronger and less congested but still with a cough . According to R61's physician orders there was an order dated 9/2/24, that remained an active order that read, May test for COVID-19 as needed. There was no indication within the progress notes or medication administration record that R61 was tested for COVID-19 following the development of symptoms. According to the Event Report dated 5/19/25, provided by the Infection Preventionist, it noted Does NOT meet McGeer's criteria. The IP had no evidence that she or any other staff had discussed the lack of meeting criteria with the physician. On 5/22/25 at 8:09 a.m., an interview was conducted with the facility's medical director/doctor. When asked about antibiotic stewardship, the doctor said, We follow McGeer criteria exclusively, you know it is required in long-term care. For a UTI [urinary tract infection] we have to have two symptoms and for a URI [upper respiratory infection] we usually want three symptoms, and we wait for culture results before we start antibiotics. The medical director was notified of the above findings specifically with regards to the antibiotic use tracking and that month over month, residents are being prescribed and treated with antibiotics when they do not meet criteria. The doctor said, I never do that! Maybe the nurse practitioners are doing it. When asked what the risks are of prescribing antibiotics when residents do not meet criteria, the medical director said, You develop antibiotic resistance. When asked if he had discussed antibiotic stewardship and McGeer criteria with the other providers, the medical director said, I have not talked to them, but I will. Review of the facility's policy titled, Antimicrobial Stewardship Program Policy with a revision date of 6/26/24, was conducted. According to the policy, which read in part, Antimicrobials stewardship will focus on improving antibiotic/antimicrobial use by avoiding unnecessary or inappropriate antibiotics .The antimicrobial stewardship process will be overseen and managed by the Infection Preventionist who works collaboratively with the medical director, consulting pharmacist, nursing and administrative leadership to also implement the Antimicrobial Stewardship Program . 2. Protocols for antibiotic use: Assessment of resident change in condition using standardized infection criteria (revised McGeer's Criteria), Notification of Physician/clinician by facility clinical staff . On 5/22/25 at 11 a.m., the above findings were reviewed with the facility administrator and director of nursing. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 vaccines to three residents (Resident #147-R147, Resident #145-R145, and Resident #146-R146) in a survey sample of five residents selected for immunization review. The findings included: For R145, R146, and R147, the facility staff failed to have evidence of providing education regarding the benefits and risks of the vaccine and offer the COVID-19 vaccine. On 5/21/25, a sample of five residents was selected for review for immunization status. A clinical record review was conducted for each resident. The review revealed the following: According to the preventative health care tab of R145, R146, and R147''s clinical record there was no information regarding their COVID-19 vaccination status or that they had received any education or been offered the COVID-19 vaccines. On 5/21/25 at 3 p.m., an interview was conducted with the facility's infection preventionist (IP), who was also a registered nurse. The IP stated immunizations are important because the residents live in a tight closed community and organisms can spread. The IP said, We want to keep them safe and up to date on vaccines because those microorganisms tend to spread rapidly. The IP went on to explain she looks up the Vaccination status of residents on the state of Virginia's immunization information system (VIIS) portal and then enters the data into the resident's electronic record under the preventative health care tab. When asked if she puts the VIIS into the clinical record, she stated no. During the interview with the IP, the IP accessed the VIIS for each resident. According to the VIIS for R145 he had not received any COVID-19 immunizations previously and was eligible to receive immunization. According to the VIIS for R146, he received the initial COVID-19 vaccines in March 2021, and was eligible/due for booster doses. According to the VIIS for R147, she had not received any COVID-19 vaccines and was past-due for vaccination. The IP stated that she had not discussed immunization with the residents. On 5/22/25 at 9:30 a.m., the IP told the surveyor that she had talked to R146's family and they were coming in that day to review/discuss immunizations with the resident. The IP stated that R145 had been sent to the hospital following the IP meeting with the surveyor on 5/21/25, so she wasn't able to talk with that resident. According to the facility policy titled, Resident Vaccination Policy with a revision date of 11/27/23, it read in part, The date of historical vaccinations will be documented in the health record immunization portal on admission and as information becomes available . The infection preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered . Consents/refusals/medical ineligibility will be documented in the health record . According to the Center's for Disease Control and Prevention (CDC) document titled, Staying Up to Date with COVID-19 Vaccines it read in part, .Who needs a COVID-19 vaccine: Reminder: Everyone ages 6 months and older should get the 2024-2025 COVID-19 vaccine. This includes people who have received a COVID-19 vaccine, people who have had COVID-19, and people with long COVID. Importance of staying up to date Getting the 2024-2025 COVID-19 vaccine is important because: Protection from the COVID-19 vaccine decreases with time. Immunity after COVID-19 infection decreases with time. COVID-19 vaccines are updated to give you the best protection from the currently circulating strains. Getting the 2024-2025 COVID-19 vaccine is especially important if you: Never received a COVID-19 vaccine. Are ages [AGE] years and older. Are at high risk for severe COVID-19. Are living in a long-term care facility. Are pregnant, breastfeeding, trying to get pregnant, or might become pregnant in the future. Want to lower your risk of getting Long COVID . Accessed online at: https://www.cdc.gov/covid/vaccines/stay-up-to-date.html On 5/22/25 at 11 a.m., the above findings were reviewed with the facility administrator and director of nursing. No additional information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents were free from chemical restraints and unnecessary psychotropic medications for one resident (Resident #63-R63) in a survey sample of 23 residents. The findings included: For R63, who had an increase in psychotropic medication doses and the addition of new psychotropic medications, the facility staff failed to have supporting documentation to warrant the increase in medications and failed to have adequate monitoring for psychotropic medication use, which resulted in R63 having unnecessary psychotropic medications. On 5/20/25, in the mid-morning, R63 was visited in her room. R63 was lying in bed, was observed to be very confused and unable to answer questions appropriately. On 5/21/25 and 5/22/25, a clinical record review was conducted of R63's chart. R63 was admitted to the facility on [DATE]. According to physician orders and medication administration records (MAR) from R63's admission, R63 was ordered Lorazepam 0.5 mg twice daily for generalized anxiety disorder. R63 was also ordered Citalopram 5 mg once daily for major depressive disorder, recurrent, mild. According to R63's MAR's, the facility did not initiate medication monitoring for the use of psychotropic medications on admission, and did not start monitoring the antianxiety and antidepression medications until 9/13/24. According to the August 2024 behavior monitoring, R63's only documented behaviors were on 8/27/24 and 8/31/24, which noted R63 was cursing at others. According to R63's progress notes, an entry, dated 8/29/24, read, Resident very aggressive towards staff this morning, combative, and verbally abusive while being changed this morning. In September, on 9/4/24 and 9/6/24, the facility noted they provided redirection and other interventions, but no details were noted as to the behavior for which they had provided the interventions. A progress note entry dated 9/11/24 noted, NP [nurse practitioner] in facility and seen resident today about increased agitation. Provider increased Ativan from 0.5 mg BID [twice daily] to 1 mg BID . On 9/16/24, R63 was seen by the psychiatric nurse practitioner, who gave orders to increase R63's Celexa from 5 mg to 10 mg daily. No documentation written by the psychiatric nurse practioner was found for the medication increases on those dates. According to the CNA documentation, on 9/20/24 it was noted, resident started hitting when trying to do ADL [activities of daily living/routine care] and on 9/23/24, it noted, hitting and yelling. R63 had one documented instance of cursing at others on 9/22/24 and the additional notes noted, hit CNA [certified nursing assistant] and tried to bite CNA. According to the nursing progress notes on 9/25/24, there was an entry that read, New order- start hydroxyzine 25mg po [by mouth] q [every] 6 hours prn [as needed] for agitation and anxiety . On 10/7/24, nursing progress notes had an entry that read, Psych NP in at this time. New orders d/c [discontinue] Hydroxyzine, start Depakote Sprinkles 250 mg po BOD for mood d/o [disorder] . On 10/23/25, the nurses documented, Staff attempted to get resident up for the day. Upon getting into wheelchair resident began kicking, cussing and screaming . Resident placed back in bed. Currently quiet and going back to sleep. According to the MARs, in October R63 had six occasions of behaviors, in November two occasions of behaviors, December two occasions, January three instances, February three instances, March three instances, April none, and in May one instance of having behaviors. All the instances of documented behaviors on R63's MAR were documented by the same nurse and had no accompanying progress note to detail the type of behaviors observed or non-medication interventions used. According to the ADL documentation by the certified nursing assistants, in October, R63 had 3 instances of behaviors that included cursing, combative, throwing items, and talking to self. In November, R63 had 2 instances of cursing. In December, there was one instance of disrobing and one instance of screaming. In January 2025, R63 had one instance of hitting and spitting and one instance of cursing. In February and March, the CNA's documented no behaviors. In April, the CNA documentation noted that R63 had one documented instance of cursing and in May, one instance of cursing, one instance of screaming, and one of being combative during a bath. Of the dates of the documented behaviors documented by the CNA, only one date coincided with the documentation by the nurse, which was 1/24/25. On 5/22/25, the facility provided the survey team with the psychiatry progress notes. According to the progress note dated 10/7/24, R64 was . alert and oriented x 1 and is unreliable historian to provide review of symptoms due to her severely advanced dementia, severe cognitive impairment and increased confusion. Her last mental health review was 9/16/24 where her Celexa was increased. Staff deny any issues with the previous medication change. On 9/25 she also started on Hydroxyzine PRN to help with anxiety and agitation. Staff report she is eating and sleeping well. They rate her anxiety and depression both as mild. Patient had behavior of hitting a CNA in the face; and has physical aggression with redirection almost daily per staff. Per staff her mood disorder is moderate, and these behaviors also occurred at previous facility . She continues to have poor memory, poor insight and judgment, disorganized thoughts, impaired reasoning, and difficulty answering all questions, but no distress was noted. At that time, the provider recommended to discontinue the Hydroxyzine and start Depakote sprinkles 250 mg BID for mood disorder. The progress notes from the psychiatric NP from 9/16/24 and 9/25/24, the dates when the antipsychotic medications were increased, were not provided. On 5/22/25 at 8:09 a.m., an interview was conducted with R63's attending physician, who is also the medical director. When asked about the use of psychotropic medications and the increase in doses and additional psychotropic medications when R64 was a new admission to the facility and adjusting to new surroundings, the medical director said, She does have some behaviors. She was falling a lot and acting out a lot. Lately, it is more depression, not so much behavioral. She hasn't had overt behavior in a while. She had behaviors when she first came in. When asked about adjustment to a new facility and new care providers, and about falls being an indication for psychotropic medications, the medical director stated that She [R63] had falls and medication refusals that were related to anxiety. When we increased her Ativan, the falls went away. In her case, it killed her anxiety. When asked about dose reductions, R63's doctor said, Usually we are keyed in by pharmacy recommendations and we haven't seen one on her. I don't know why. You are right, we haven't done one on her. On 5/22/25 at 10:24 a.m., an interview was conducted with the psychiatric nurse practitioner (psych NP). When asked about R63's increase in psychotropic medications and addition of Depakote, when there were only a few entries in R63's clinical record regarding any behaviors, the psych NP referenced her notes and said that the staff had reported daily aggression to her. When asked about gradual dose reductions, the psych NP stated that recommendations had been made but the medical doctor declined them and said in this facility she and the medical providers do both the gradual dose reductions and respond to pharmacy recommendations. According to the facility policy titled, Psychoactive Medication Policy, with a revision date of 5/10/24, which read in part, A. Residents receiving psychoactive medication will have a Behavior/Intervention Flow Record (BFR) initiated on admission or whenever psychoactive meds are ordered using the batch order process in the electronic record . B. Nurses will document on the following each shift: a. Number of behavior episodes b. Specific non-medication interventions used . C. The behavior/Intervention Flow Record will be updated with any changes in psychoactive medication, dosage, new behaviors, and/or side effects by the nurse on duty at the time of the change . D. The resident's plan of care will be reviewed and updated with any changes in behavior and/or treatment. E. Residents receiving psychoactive medications will be reviewed, at a minimum, every quarter by the IDT team to determine the effectiveness of the medication and interventions . e. If gradual dose reduction of the medication has not been attempted within the last six months, the provider will be contacted to consider a GDR . On 5/22/25 at 11 a.m., the above findings were reviewed with the facility administrator and director of nursing, specifically noting the lack of supporting documentation to warrant the increase in medications, the lack of adequate monitoring for psychotropic medication use, and that a gradual dose reduction had not been attempted to support continued use of either antipsychotic. No additional information was provided.

Based on staff interview, clinical record review and facility document review, the facility staff failed to include initial care needs for a PICC (peripherally inserted central catheter) and a suprapubic catheter in the baseline care plan for one of twenty-three residents in the survey sample (Resident #145). The findings include: Resident #145 (R145) was admitted to the facility with diagnoses that included MRSA (methicillin resistant staphylococcus aureus), hematuria, history of sepsis, anemia, bladder cancer, diabetes, hypertension and rhabdomyolysis. The minimum data set (MDS) dated [DATE] assessed R145 as cognitively intact. R145's clinical record documented that the resident was admitted with a PICC for administration of intravenous antibiotics and that the resident had a suprapubic urinary catheter. The resident's baseline care plan dated 5/13/25 included no mention of the PICC or the suprapubic catheter. Initial care needs regarding bowel/bladder included toileting assistance but made no mention of the urinary catheter. The baseline plan listed R145 was on contact precautions for infection control but made no mention of care needs related to the PICC. On 5/21/25 at 11:05 a.m., the registered nurse unit manager (RN #3) was interviewed about R145's baseline care plan. RN #3 stated R145 was admitted with a PICC and a suprapubic catheter. RN #3 reviewed the baseline care plan and stated he did not see the PICC, or catheter listed on the baseline care plan. RN #3 stated the nurse that completed the admission assessment was responsible for initiating the baseline care plan. On 5/21/25 at 2:32 p.m., the director of nursing (DON) was interviewed about R145's baseline care plan. The DON stated the baseline care plan included initial care needs based upon items marked on the admission assessment. The facility's policy titled Interim/Baseline Care Planning Policy (revised 3/24/25) documented, .The baseline care plan will include the minimum heath care information necessary to care for a resident including, but not limited to .Initial goals based on admission orders .Physician orders .Dietary orders .Therapy/Rehab services .Social Services .Resident goals . This finding was reviewed with the administrator, DON and regional nurse consultant during a meeting on 5/21/25 at 4:30 p.m., with no further information presented prior to the end of the survey.

Based on observation, staff interview and clinical record review, the facility staff failed to follow physicians orders for two of 23 residents. The Findings Include: 1. The nursing staff did not notify the physician of weight changes for Resident #19 (R19). Diagnoses for R19 included; Heart Failure, hypertension, acute kidney failure, Acute respiratory failure. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 2/27/25. R19 was assessed with a cognitive score of 10 out of 15, indicating moderately impaired. An active physician order dated 12/10/24 for R19 read: Weights: Daily Special Instructions: Contact HHC [name of doctor] at [phone number given] if wt [weight] gain increases by 3# [pounds] in 1 day, or 5# [pounds] in 1 week. Once A Day. The physician named in the order was a cardiologist and was not part of the staff at the facility. R19's weights were then reviewed and indicated R19 had weight gain above parameters on 5/2/25, 5/3/25, and 5/8/25. Review of R19's progress notes did not indicate the physician named in the order was notified. On 5/22/25 9:25 a.m., license practical nurse (LPN #3) was interviewed. LPN #3 verbalized that notifications to physicians are documented in the residents progress notes. LPN #3 then reviewed R19's progress notes and could not find documentation regarding notification of change in weights. On 5/24/25, the above information was presented to the director of nursing and administrator and also was unable to find notification in regards to the dates presented above. No other information was presented prior to exit conference on 5/24/25. 21875 2. Resident #144 was not administered medications as ordered by the physician. Resident #144 (R144) was admitted with diagnoses that included atrial fibrillation, COPD (chronic obstructive pulmonary disease), lung cancer, congestive heart failure, anxiety, depression, hypertension, respiratory failure and atherosclerotic heart disease. The minimum data set (MDS) dated [DATE] assessed R144 as cognitively intact. On 5/20/25 at 10:22 a.m., R144 was interviewed about quality of care since her admission to the facility. R144 stated she was admitted on [DATE] around 6:00 p.m. and that she did not receive her heart and sleep medications on the evening of her admission. R144 stated around 8:30 p.m., she asked the certified nurses' aide (CNA #3) caring for her about getting her medications. R144 stated the CNA told her that the nurse would be in shortly to give medications. R144 stated she never received the evening/bedtime medications. R144's clinical record documented physician orders for medications that included the following, with doses scheduled to start on the evening of 5/16/25. Trazadone 50 mg (milligrams) - take one table every night at bedtime. Eliquis 5 mg - administer one tablet twice per day. Midodrine 10 mg - one tablet three times per day, (scheduled to be administered at 6:00 a.m., 2:00 p.m. and 10:00 p.m.) R144's medication administration record (MAR) documented the trazadone, Eliquis and midodrine were not administered on the evening of 5/16/25. The MAR documented the midodrine was also not administered on 5/17/25 at 6:00 a.m. On 5/21/25 at 11:15 a.m., the registered nurse unit manager (RN #3) was interviewed about R144's concern about missing medications on the evening of 5/16/25. RN #3 reviewed the resident's MAR and stated the evening doses of trazadone, Eliquis and midodrine were not listed as given. RN #3 stated the medications orders were entered on 5/16/25 and some of the medications had to come from pharmacy. RN #3 reviewed the list of medications in the backup supply and stated that Eliquis, trazadone, and midodrine were available. RN #3 stated the nurse should have accessed the medications from the backup supply for administration on the evening of 5/16/25. On 5/21/25 at 7:35 p.m., the licensed practical nurse (LPN #5) caring for R144 on the evening/night of 5/16/25 was interviewed. LPN #5 stated R144 arrived on 5/16/25 around 6:00 p.m., prior to her shift starting at 7:00 p.m. LPN #5 stated she entered R144's orders into the electronic health record, with medication orders sent to the pharmacy. LPN #5 stated she knew the trazadone, Eliquis and midodrine were scheduled for evening/bedtime administration. LPN #5 stated when she went to access these medications from the backup supply, the Omnicell (backup medication supply) was not working. LPN #5 stated she was not sure what was wrong but that the unit would not turn on. LPN #5 stated, If I could have accessed them [medications], I would have given them. When asked if she called anyone about accessing the backup supply, LPN #5 stated she did not call anyone, as she thought the day shift was already aware the Omnicell was down. On 5/21/25 at 8:17 a.m., the unit manager (RN #3) was interviewed about LPN #5's report that she was unable to access R144's medications from the backup supply. RN #3 stated sometimes the Omnicell required a reset and that a reset button just needed to be pushed to reset the unit. RN #3 stated there was a service number posted on the Omnicell in case of any malfunction. RN #3 stated LPN #5 should have contacted the service number or supervisor so that the medications could have been accessed and given as ordered. The Omnicell inventory list dated 3/21/25 documented trazadone 50 mg, Eliquis 5 mg and midodrine 10 mg tablets were available in the backup supply. The facility's protocol for accessing the Omnicell automated dispensing unit for backup medications (undated) documented, .Contact the Pharmacy in the event of a power outage, software, or other issue that prohibits ADU [automatic dispensing unit] access by normal means . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 5/21/25 at 4:30 p.m., with no further information presented prior to the end of the survey.

Based on staff interview, clinical record review, and facility documentation review, the facility staff declined a pharmacy recommendation for a dose reduction of a psychotropic medication but gave no rationale for the decline for two residents (Resident #63-R63 and Resident #59-R59) in a survey sample of 23 residents. The findings included: 1. For R63, who was on multiple psychotropic medications, the pharmacy consultant gave recommendations to conduct gradual dose reductions, which the doctor declined the recommendation but gave no reason for not conducting dose reductions. On 5/20/25 in the morning, R63 was visited in her room. R63 was observed lying in bed and was noted with significant cognitive impairments and was not able to answer questions appropriately, would respond with non-sensical responses. On 5/21/25, a clinical record review was conducted. This review revealed that R63's current and active physician orders included the following medications: Ativan 1 mg twice daily, Citalopram 10 mg/5 ml, give 7.5 ml (15 mg) every day, and Depakote Sprinkles 125 mg, give 2 capsules (250 mg) twice daily. According to the census tab and progress notes, R63 was admitted to the facility on [DATE]. R63 was on Ativan and Citalopram on admission, and the doses were increased within three weeks of R63's admission. Then on 10/7/24, the Depakote was added for mood disorder. According to the progress notes, the pharmacist made recommendations to the medical provider for medication changes on 10/28/24 and 3/17/25. The recommendation for 10/28/24 was not found in the clinical record. On 5/22/25 at 8:00 a.m., a request was made of the facility administrator to provide the surveyor with the pharmacy recommendation from 10/28/24 for R63. The pharmacy recommendation dated 3/17/25 read, [R63's name redacted] has received lorazepam 1mg bid [twice daily]. Recommendation: Please attempt a gradual dose reduction (GDR) to 0.5 mg bid if clinically appropriate. Rationale for Recommendation: Dose reductions should occur in modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence (e.g., GDR is attempted in 2 separate quarters, with at least 1 month between attempts . The Physician's response noted a check mark in the box that read, I decline the recommendation above because GDR is clinically contraindicated for this individual as indicated below. (NOTE: Please check option #1 or #2 AND provide patient-specific rationale on the lines below.) The box of option #1 was checked, which read, Continued use in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW . The patient specific rationale was blank. The medical doctor, who is also the medical director of the facility, signed the recommendation on 3/25/25. On 5/22/25 at 8:09 a.m., an interview was conducted with R63's primary care physician/doctor (MD), who was also the medical director of the facility. When asked about gradual dose reductions, the MD said, Usually the pharmacy recommends those, we haven't gotten one on her and I don't know why. When advised that R63 had only increases in medication shortly after her admission and no reductions had been attempted, the doctor said, You are right, we haven't done one on her. On 5/22/25 at 11 a.m., the facility administrator and director of nursing were made aware of the above findings. According to the facility policy titled, 9.1 Medication Regimen Review with a revision date of 6/1/24, read in part, 1. The consultant pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information made available in the resident's health record . 6. Facility should independently review each resident's medication regime directly from the resident's medical chart and with interdisciplinary care team members, resident, or responsible party, as needed . 9. Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR . 9.2.1 If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the resident's health record . No information regarding the recommendation dated 10/28/24 was provided prior to the conclusion of the survey and no additional information was provided. 28106 2. The facility did not provide a rationale for a gradual dose reduction of Seroquel for Resident #59 (R59). The Findings Include: Diagnoses for R59 included; Dementia, major depression, and mood disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 3/8/25. R59 was assessed with a cognitive score of 8 out of 15, indicating moderately impaired. Review of R59's current medications indicated R59 was ordered 12.5 MG of Seroquel (antipsychotic) every night for mood disorder. The order was dated 11/6/25. Review of pharmacy recommendations indicated, through consultation reports, a gradual dose reduction (GDR) of seroquel on 2/18/25 and 5/16/25 had been recommended. On the Consultation Report, the physician had placed a check mark indicating not to do a GDR. The form asks for a patient-specific rationale descibing why a GDR attempt is likely to impair function or cause psychiatric instability . On the Consultation Report dated 2/18/25, the rationale for not doing a dose reduction was due to family request. There was no rationale provided on the Consultation Report dated 5/16/25. A policy titled Medication Regimen Review (MRR) read in part: For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP. On 5/24/25, the above finding was presented to the director of nursing and administrator. No other information was presented prior to exit conference on 5/24/25.

Based on staff interview and clinical record review, the facility staff failed to maintain a complete clinical record for one resident (Resident #63-R63) in a survey sample of 23 residents. The findings included: 1. For R63, the facility staff failed to maintain a complete clinical record to include pharmacy recommendations and the provider's response to the recommendation. On 5/20/25 in the morning, R63 was visited in her room. R63 was observed lying in bed and was noted with significant cognitive impairments and was not able to answer questions appropriately, responded with non-sensical responses. On 5/21/25, a clinical record review was conducted. This review revealed that R63's current and active physician orders included the following medications: Ativan 1 mg twice daily, Citalopram 10 mg/5 ml, give 7.5 ml (15 mg) every day, and Depakote Sprinkles 125 mg, give 2 capsules (250 mg) twice daily. According to the census tab and progress notes, R63 was admitted to the facility on [DATE]. R63 was on Ativan and Citalopram on admission, but the dose was increased within three weeks of R63's admission. Then on 10/7/24, the Depakote was added for mood disorder. According to the progress notes, the pharmacist made recommendations to the medical provider for medication changes on 10/28/24. The recommendation for 10/28/24 was not able to be located in the clinical record. On 5/22/25 at 8:10 a.m., a request was made to the facility administrator to provide the surveyor with the pharmacy recommendation from 10/28/24 for R63. On 5/22/25 at 11 a.m., the director of nursing acknowledged they were still working on the pharmacy recommendation for R63. On 5/22/25 at 11:30 a.m., the corporate staff inquired about any outstanding documents the survey team had requested and were made aware that the surveyor was waiting for a pharmacy recommendation from 10/28/24 for R63. No additional information was provided prior to the conclusion of the survey.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to have evidence of residents being provided education and offered flu and pneumococcal immunizations for two residents (Resident #145-R145 and Resident #146-R146) in a survey sample of five residents reviewed for immunizations. The findings included: For R145 and R146, the facility staff failed to educate residents on the benefits and potential side effects of immunization and offer flu and pneumococcal immunizations as ordered by the physician. On 5/21/25, a sample of five residents was selected for review for immunization status. A clinical record review was conducted for each resident. The review revealed the following: According to the preventative health care tab of R145's clinical record, there was no information regarding R145's flu or pneumococcal vaccination status, that they had received any education or been offered the pneumococcal vaccine. R145's physician orders included orders dated 5/13/25 that read, Immunizations: Offer high dose flu vaccine annually unless the provider orders standard dose . May administer pneumococcal vaccine unless contraindicated. According to the preventative health care tab of R146's chart, there was no data regarding the flu vaccine, and it indicated R146 received a Prevnar 13 vaccine for pneumonia in 2010. R146's physician orders included orders dated 5/5/25 that read, Immunizations: Offer high dose flu vaccine annually unless the provider orders standard dose . May administer pneumococcal vaccine unless contraindicated. On 5/21/25 at 3 p.m., an interview was conducted with the facility's infection preventionist (IP), who was also a registered nurse. The IP stated immunizations are important because the residents live in a tight closed community and organisms can spread. The IP said, We want to keep them safe and up to date on vaccines because those microorganisms tend to spread rapidly. The IP went on to explain she looks up the Vaccination status of residents on the state of Virginia's immunization information system (VIIS) portal and then enters the data into the resident's electronic record under the preventative health care tab. When asked if she puts the other VIIS into the clinical record, she stated no. During the interview with the IP, the IP accessed the VIIS for each resident. According to the VIIS, R145 was past due for the pneumococcal 23 vaccine and had no record of being immunized for either pneumococcal immunizations. The IP confirmed that she had not provided any education or offered the pneumonia vaccine to R145. According to the VIIS, R146 was past-due for the pneumococcal 23 vaccine, the pneumococcal conjugate vaccines, and was eligible to receive both after 4/27/24. The record indicated R146 last received the pneumo-conjugate 13 and pneumococcal 23 vaccines on 3/29/2010. R146 was also due for the influenza immunization, and his last dose was administered 11/26/12. The facility had no evidence of providing any education regarding immunizations or offering either to R146. When asked about this, the IP stated that R146 has confusion and was waiting for the confusion to clear up to ask him. When asked who was making treatment decisions and consented to care and treatment for R146, she indicated his family. When asked why they had not been asked about immunizations and educated if they were being asked about other care decisions and authorizations, the IP didn't respond. On 5/22/25 at 9:30 a.m., the IP told the surveyor that she had talked to R146's family and they were coming in today to review/discuss immunizations with the resident. The IP stated that R145 had been sent to the hospital, so she wasn't able to talk with that resident. According to the facility policy titled, Resident Vaccination Policy with a revision date of 11/27/23, it read in part, The date of historical vaccinations will be documented in the health record immunization portal on admission and as information becomes available . The infection preventionist will track resident immunizations and holds the responsibility for ensuring resident's vaccination history is reviewed with/by their providers and that vaccines are administered timely when ordered . Consents/refusals/medical ineligibility will be documented in the health record . According to the Centers for Disease Control and Prevention (CDC), a document titled, Adult Immunization Standards was reviewed. The document read in part, The National Vaccine Advisory Committee developed the Standards for Adult Immunization Practice to reflect the critical need for all health care professionals - whether they provide immunization services or not - to take steps to ensure that adult patients get the vaccines they need. These standards are important because: Adult vaccination coverage is low. Many adults are not aware that they need vaccines. A health care professional's recommendation is the strongest predictor of whether a patient gets vaccinated. There are often missed opportunities for vaccination because many health care professionals are not assessing vaccination status. CDC encourages all health care professionals to implement these standards into their practice. 1. Assess the immunization status of all your patients at every clinical encounter . Stay informed. Get the latest CDC recommendations for adult immunization. Evaluate how your practice is doing. Review a sample of patients' charts or analyze electronic health record data for your practice to see whether your patients are receiving needed vaccines. Use reminders to help your practice stay on top of needed vaccines. Generate reminders using a computer system (electronic health record) or immunization registries or make a note of needed vaccines on a patient's chart. 2. Make clear recommendations for vaccines that patients need. For some patients, a recommendation may not be enough. Share important information to help patients make informed decisions about vaccinations . 3. Administer vaccines or refer your patients to a vaccination provider. Recommend and offer vaccines at the same visit. Research shows that when patients receive a vaccine recommendation and are offered the vaccine at the same time, they are more likely to be vaccinated. Implement standing orders or protocols.Ensure patients' vaccine needs are routinely reviewed, and patients get reminders about vaccines they need . 4. Document vaccines received by your patients in their medical records and in immunization information systems (IIS) . Accessed online at: https://www.cdc.gov/vaccines-adults/hcp/imz-standards/index.html On 5/22/25 at 11 a.m., the above findings were reviewed with the facility administrator and director of nursing. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to protect a resident's right to be free from sexual abuse for one resident (Resident #8 - R8) in a survey sample of 10 residents, which resulted in harm for R8. The findings included: On 10/22/24, during an entrance conference conducted at 1:45 p.m., the facility administrator was asked to provide any and all information the facility had with regards to a sexual assault. Following the entrance conference, the facility administrator stated that the incident binder with the facility's investigation and response to the sexual assault had been misplaced following a fire the facility had in August 2023. The administrator provided the surveyor with a binder and stated that it contained the information they had been able to re-create. According to the binder, R8 was the victim and R9 was the alleged perpetrator, identified as Resident #9 (R9). The survey team was also provided with a listing of current residents, it was noted that neither R8 or R9 were current residents of the facility and therefore were not able to be interviewed. On 10/23/24, a closed record review was conducted of R8's chart. This review revealed an entry by registered nurse #1 (RN #1) dated 12/17/22 at 12:25 p.m., that read, Recorder in room and observed male resident having sexual intercourse with resident in her bed with resident's legs spread open with one to each side of resident's waist. Bed noted to be at lowest position with cover on floor. Observed male resident with pants and brief down around his knees. Recorder stated for male resident to stop and get off of her. Male resident proceeded to stop engaging in the sexual activity, got off of resident and was noted be to be fully erect. No bodily fluid observed on penis. Male resident then stood up from bed, pulled up his pants and briskly walked out of resident's room and up hallway. Resident noted to have a flat affect to face. When asked what happened, resident stated, he hurt my breast and [NAME] Pam hurt. Resident observed lying flat in the bed with hospital gown raised up to her breasts exposing the underside of the breast. Resident's brief noted to be undone and exposing vagina. Resident assured that he would not be coming back into the room and covered with a sheet for privacy. Recorder called for staff member to stay with resident while recorder exited room and returned to nurse's station. There were multiple entries in R8's clinical record on 12/17/22, which included notification to the family of the incident, the doctor, who was on-site and gave an order to send R8 to the emergency room , as well as the police being notified. An entry dated 12/17/22 at 1:21 p.m., read, This writer called [hospital name redacted] ER [emergency room ] to give report to nurse. After telling the nurse that the resident had been raped and would need a rape kit. This writer was told that [hospital name redacted] hospital could not accommodate the resident and could we send the resident to another facility. 911 transport was made aware of what the nurse had said. 911 driver stated that they could not bypass this hospital per their protocol and would first need to go to [hospital name redacted] ER. On 12/17/22 at 7:51 p.m., an entry was made by the physician into R8's chart that read in part, Pt [patient] raped by another resident this afternoon. No bleeding or injuries noted. The RP of both parties were notified, and pt was transferred to ED for forensic exam . A/P [active problem(s)]: 1. Non-consensual intercourse - forensic exam pending, but initial examination was normal. Perpetrator was turned over to legal authorities 2. OCD [obsessive compulsive disorder] with severe intellectual inability -chronic (food obsession); continue supportive care. Will continue to redirect behaviors. 3. Bipolar disorder - chronic, continue clomipramine and valproic acid . 6. MDD [major depressive disorder] chronic; continue sertraline; trazodone for sleep . Following R8's return to the facility on [DATE], there were multiple entries that indicated R8 appeared in no distress and was at baseline. According to a progress note dated 12/21/22, by a nurse practitioner, R8 was seen for abdominal pain. The note read in part, Asked to see re abd [abdominal] pain. Onset this morning. When queried she points to epigastric region as focus. Upon palp, flinches and guards to lower abd, suprapubic and pelvic palpation. Unable to do speculum exam. Outer vaginal canal, labia and surrounding skin w/o bleeding, discharge, skin tears or abrasions, no labial bruising . She does have significant cognitive and communication deficits . PMHx [past medical history]- Severe MR/DD [mental retardation and developmental disabilities], OCD/Bipolar/ anxiety . A/P [assessment/plan] Diffuse Abdominal pain, lower pelvic focus- no new GYN [gynecology] findings externally. Will obtain AXR [abdominal x-ray] r/o [rule out] GI/bowel issue, pelvic sono re pain, vaginal and urine cultures. #. Heartburn- will add Pepcid 20mg bid x 7 days then decr to qhs [every bedtime] (she does use prn topicals often). #. S/P [status post] sexual assault 12/18/22- forensic exam reportedly negative. No Sperm, no Trichomonas/fungal elements on vag swab/smear. Chlamydia/ Syphilis P per [hospital name redacted] documentation. Request results. On 10/23/24 at 4:03 p.m., an interview was conducted with RN #1. RN #1 reported that on 12/21/22, R8's roommate (resident #10- R10) came to the nursing station and was mumbling saying that she couldn't go to her room because . that man was on top of her roommate. RN #1 reported that she immediately went to R8's room and she observed R9 in the bed, on top of R8. R9 had his pants down, was on the bed on top of R8, and was making the . back and forth motion and was groping her breasts. RN #1 reported that R8's gown was pulled up; her breasts were exposed, and her incontinence brief was undone on one side. RN #1 reported that she told R9 to get off of her and when he stood up, she noted R9 had an erection. RN #1 said she was not aware if R9 made sexual penetration of R8 or not but it was sexual assault regardless. RN#1 stated that she observed R9 pull up his pants and exit the room. RN #1 reported that she called the following, the doctor, police, director of nursing, unit manager, administrator, and family of both residents. During the above interview with RN #1, she reported that R8 was cognitively impaired and would not have been able to give consent to any sexual activity. RN #1 reported that R9 was able to ambulate independently, would refuse medications and care at times, and that staff had to redirect him often. RN #1 reported that following the incident R9 was taken into custody by the police and did not return to the facility. RN #1 reported that she had to go to court numerous times because the case kept being postponed but the last time was told she didn't have to come back anymore because it was dismissed, and that they had said that they were both cognitively impaired. On 10/24/24, a clinical record review was conducted of R9's closed record. According to a progress note written by a psychiatric mental health nurse practitioner on 12/12/22, prior to the incident, the note indicated R9 had diagnosis to include but not limited to, PTSD (post-traumatic stress disorder), alcohol abuse, schizoaffective disorder, psychosis, anxiety disorder, and sexual dysfunction. The note read in part, Patient is a [AGE] year-old male seen for follow-up with a psychiatric history of schizoaffective disorder, insomnia, PTSD, and inappropriate sexual behavior . He is alert and oriented x 2 [to person and place] and is reliable historian . His last mental health review was on 11/28/22 where he was stable . Since last review, patient had documented behaviors of resistance to care and walking away from the facility and would not come back with guidance from the police officer or staff. Staff also requested that R9 be seen for increased agitation, verbal and physical abuse, and combativeness at times. Staff also indicated paranoid delusions and documented that the patient will frequently state everyone is trying to kill me . Patient's PTSD is stable per staff and states that he has had not any further inappropriate sexual behaviors other than remarks to staff that are not sexual but continuing to be complementing .Care plan: Recommendation: The patient's inappropriate sexual behaviors are controlled on Provera . Within the documents tab of R9's chart there was a document titled, [R9's name redacted] email about case requesting approval for BDWO [bad debt write off]. That document was email correspondence from the business office manager to the administrator dated 8/7/23. Within the email, it read in part, . [R9's name redacted] had a history of criminal behavior prior to his admission to our facility and according to what I can recall on this case, it took a long time to get his social security reinstated. It may have been that [R9's name redacted] owed money back to the social security office and this is why the check was short in the month of February. As you recall, he left our facility on December 17, 2022, due to assault to one of our residents and currently is waiting trail This is a special circumstance, and the ex-resident is not currently receiving social security since he is considered to be an inmate. On 12/17/22 at 12:50 p.m., there was an entry made by the facility administrator that read, Late Entry: Alerted by staff members by phone regarding sexual activity of resident with female resident of facility. Resident reportedly left room of involved resident and walked out of facility. Staff advised to keep resident in sight continually pending arrival of police to facility. RP Cousin- [name redacted] at facility at approximately 3 pm. Spoke with her briefly regarding personal belongings which she will pick up at a later date. Another progress note dated 12/17/22 at 1:32 p.m., read, Resident's RR [responsible representative], [name redacted], returned call to the facility. RR was made aware by Dr. [doctor's name redacted] that the resident [R9]was found having sex with another resident that could not give consent. RR stated that she is on her way to facility per Dr. [doctor's name redacted]. A note dated 12/17/22 at 3 p.m., read, Resident in back of police car under police custody. Officer stated that the resident [R9] will be charged and taken to local jail. On 10/24/24, the facility provided an as worked schedule for 12/17/22. Upon review, it was noted that two nurses and two certified nursing assistants (CNAs) worked that day on the unit where the sexual assault occurred. RN #1 was documented being one of them, but the other nurse was no longer employed by the facility. The two CNAs were identified as CNA #3 and CNA #4. A telephone call was placed to CNA #3 and a message left, but no return call was received prior to conclusion of the survey. On 10/24/24 at 10:51 a.m., an interview was conducted with the activities director (AD). The AD was asked about R8, and she reported that R8 .wanted food all the time and would attend activities. When asked if R8's demeanor or activity attendance changed following the incident on 12/17/22, the AD stated, No, not with us. The AD went on to say that R8 was . mentally challenged and didn't talk about it and I'm not sure she knew what was going on. On 10/24/24 at 10:58 a.m., an interview was conducted with the facility's former administrator (Administrative Employee #3- AE #3), who was the administrator on 12/17/22. AE #3 reported that following the incident R8 was sent to the hospital for evaluation and R9 left in handcuffs, never to return. AE #3 reported the facility compiled a full binder of information regarding the incident and it was . packed away nice and neat. AE #3 reported that following the fire that occurred in Aug. 2023, the binder was stored in a safe in the therapy gym and was not aware it was not able to be located following the facility re-opening. AE #3 reported that the social worker interviewed all alert residents, residents who were not interviewable had head to toe assessments conducted. When asked where that information was documented, the AE #3 stated, it was documented on paper and put in the binder, but she hoped it was also in the clinical records. When asked about the fire, AE #3 reported that there was no internal damage within the facility other than a panel box in the kitchen, but that the damage sustained was to an exterior electrical room and the generator. No smoke was inside the building and the sprinkler system did not engage within the facility; therefore the records were intact following the fire and were just stored away for safekeeping since the facility was going to be closed and not occupied. The AE #3 reported on 9/15/23, when her employment ended the binder with all of the information the facility did in response to the sexual assault was in the therapy gym. On 10/24/24 at 1:33 p.m., a telephone call was held with the adult protective services (APS) worker. The APS worker was aware of the sexual assault incident on 12/17/22. She stated that R9 was . arrested and put in jail but due to his cognitive deficits, charges may have been dropped, indicating that she wasn't completely sure. The APS worker stated that the incident never went to the investigation phase with her office because . he was arrested, a need no longer existed. The APS worker went on to state that both residents were incapacitated. On 10/24/24 at 1:58 p.m., an interview was conducted with CNA #4. CNA #4 was asked about the incident on 12/17/22 regarding R8 and R9. CNA #4 stated, she remembered bits and pieces. CNA #4 went on to report that R8's roommate had said, that crazy man is on top of [R8's name redacted]. CNA #4 reported that RN #1 started running to R8's room. CNA #4 said, when R9 came out of the room, he was trying to go out the front door and they had me stand at the door and the police pulled up then. CNA #4 reported that when the police asked R8 what happened she pointed to her breasts. CNA #4 reported that R9 used to get mad and throw tantrums, he was off that week, acting crazy like he wasn't taking his meds, calling people the B word. When asked about R9's behaviors CNA #4 reported the behaviors were only towards staff, not towards other residents until the incident on 12/17/22. When asked about R9's cognitive status, CNA #4 said, He was aware of things, but he was off a little bit. When asked about R8's functional status, CNA #4 said, She didn't talk too much, it was like a grown person in a kid's body, she had a kid mentality. When asked how R8 was following the incident, CNA #4 said, I don't think she was aware, but shortly after that, they sent her somewhere else. On 10/23/24-10/24/24, a review of the facility provided binder as evidence of their investigation and submission for consideration of past non-compliance was reviewed. Within the binder was a cover letter that read in part, This will serve as our plan of abatement for [facility name redacted] to: An allegation of sexual abuse made on 12/17/2022. Allegation background: An allegation of sexual abuse was made between resident #1 (female victim) and resident #2 (male perpetrator). Employee #1 observed resident #2 on top of resident #1 having sexual contact and she is unable to give consent. Employee #1 stopped the contact immediately. #2- Fire and building closed for over a year for remodeling and FRI investigations misplaced during the time . The document went on to list action that was conducted, which included R8 being sent to the hospital, R9 being taken into police custody. The document went on to read, To identify like residents that have the potential to be affected the SS [social services] director/designee completed interviews on capable residents to ensure no other resident had any sexual interactions. To identify like residents with cognitive deficits that have the potential to be affected, licensed nurses/designee had skin checks completed and observed for changes in behaviors, signs of withdrawal or change in normal activity for non-interview able residents. To prevent this from happening again the DON [director of nursing]/designee will educate current staff of the abuse policy and procedures with emphasis on types of abuse. Newly hired staff will be educated on abuse policy through the onboarding procedure. To monitor and maintain ongoing compliance, the DON/designee will conduct resident interviews on 10 capable residents weekly x 4 then monthly x 2 to identify any unreported incidents of abuse. Results will be taken to QAPI [quality assurance performance improvement] for review and revision as needed. (this monitoring is what is missing due to the fire and remodeling- validated that was completed by regional staff that are still in place). To monitor and maintain ongoing compliance the NHA [nursing home administrator]/designee will complete abuse questionnaires on five random employees weekly x 4 then monthly x 2 to determine continued education needs of staff. Results will be taken to QAPI for review and revision as needed. (this monitoring is what is missing due to the fire and remodeling- validated that was completed by regional staff that are still in place). Search was held by many of the regional staff and administrative staff at [facility name redacted] for the missing binder with all the evidence that demonstrated this imcident was properly investigated and mitigated. The binder is not able to be located after the fire last year in 2023 and the building being closed for over one year for remodeling. All contents of the building was packed up and moved or stored. Binder recreated on 9/10/2024 with the information that could be printed out of the system and any materials that could be found. An Ad hoc QAPI meeting was held on 12/19/2022 and again on 9/13/2024 to review event and QAPI plan with the medical director and IDT [interdisciplinary team] . Alleged DOC [date of compliance] 12/20/2022 . On 10/24/24, a sample of residents who were residents of the facility at the time of the 12/17/24 incident, was reviewed. This review revealed the following: 1. Resident #2 (R2) had BIMS (brief interview for mental status) score was 13 out of 15, which indicated she was cognitively intact according to the minimum data set (MDS) assessment with an assessment reference date (ARD) of 9/25/22. Within the clinical record there was no evidence that the social services staff conducted an interview with R2 following the incident on 12/17/22, to determine if she had been a victim of abuse. 2. Resident #3 (R3) had a BIMS score of 15 out of 15, indicating intact cognition, according to the MDS with an ARD of 11/6/22. There was no evidence within the clinical record that R3 was interviewed following the incident on 12/17/22. 3. Resident #7 (R7) had a BIMS score of 14 out of 15, indicating intact cognition, according to the MDS assessment with an ARD of 11/1/22. Within the clinical record, there was no evidence of R7 having been interviewed my social services staff regarding abuse. 4. For Resident #10 (R10), who was interviewable according to a BIMS score of 15 out of 15, indicating intact cognition, according to the MDS with an ARD of 9/24/22. There was no indication within the clinical record that R10 was interviewed following the incident on 12/17/22. 5. For Resident #5 (R5) who had a BIMS score of 9 out of 15, indicating moderate cognition, there was no indication that social services interviewed R5, and a weekly skin check was not performed until 12/22/22. On 10/24/24 at 11:35 a.m., the facility administration and Regional Director of Clinical Services were advised that the submission of evidence for past non-compliance was missing a lot of the material needed to verify that the facility had made the necessary corrections. On 10/24/24 at 1:24 p.m., the administration team presented the survey team with additional information they had gathered in an effort to show that the facility had achieved past non-compliance. The information provided included the following: 1. Forms titled, Weekly Skin Evaluations for various residents, which the RDCS said they had printed for some of the residents but didn't print all of them. The documents had dates of completion from 12/17/22-12/23/22. 2. Forms titled, Tub & Shower Audit Tool that read, F675- Quality of Care. These documents were dated 12/23/22-3/13/23 and each page listed 5 residents and was an audit of . documentation present for receiving tub or shower or documentation present for refusal of tub or shower. 3. Forms titled, Braden Scale/Weekly wound asmt/Weekly skin asmt [assessment] with dates from 12/23/22-3/13/23, listed 2-3 residents and was an audit to indicate if a Braden scale completed, weekly wound assessments completed, and a comment section. Throughout the audits were multiple occurrences where they noted the Braden scale had not been completed. Each of the entries noted that weekly skin assessments were being conducted as indicated by the response yes and the audit forms noted, F686 Treatment/Svcs to prevent/heal P/U [pressure ulcers]. 4. The administrator also provided a printout that she stated, . is Relias [computer based] training on abuse, which was completed in January and February 2023. On 10/24/24 at 2:15 p.m. through 2:45 p.m., interviews were conducted with licensed practical nurses (LPN) #1, #2, and #3, as well as registered nurses #3 and #4, which confirmed that skin assessments and Braden scales are conducted weekly on all residents as part of facility protocol. Review of the Relias computer-based abuse training was compared to a facility staff listing that the facility administrator provided, and it was noted that several employees had only received/taken training titled, Fraud, Waste, and Abuse while others had training titled, Preventing, Recognizing, and Reporting Abuse. There were a few staff members who were identified that had not received either training. According to the facility policy titled, Virginia Resident Abuse Policy which read in part, The facility will not tolerate the abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone . Definitions: . Sexual abuse: includes, but is not limited to, non-consensual sexual contact of any type, sexual harassment, sexual coercion, or sexual assault .3. Prevention & Identification. Facility's procedures will include . f. The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs, g. The supervision of staff to identify inappropriate behaviors. h. The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self-injurious behaviors . On 10/24/24, during the exit conference the facility administrator, director of nursing, and RDCS were made aware that without the credible evidence of resident interviews, skin assessments conducted in response to the abuse incident, staff abuse education, and the audits for monitoring, the survey team would be unable to confirm past non-compliance. No additional information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to have credible evidence of a complete and thorough investigation being conducted following an incident of sexual assault involving two residents (Resident #8- R8 and resident #9-R9) in a survey sample of 10 residents. The findings included: For R8, who was sexually assaulted by R9, the facility staff failed to have credible evidence of a complete and thorough investigation of the incident. On 10/22/24, the survey team was provided with a listing of current residents, it was noted that R8 and R9, were neither a current resident of the facility and therefore were not able to be interviewed. On 10/22/24, during an entrance conference conducted at 1:45 p.m., the facility administrator was asked to provide all information the facility had with regards to a sexual assault. Following the entrance conference the facility administrator stated that the incident binder with the facility's investigation and response to the sexual assault had been misplaced following a fire the facility had in August 2023. The administrator provided the surveyor with a binder and stated that it contained the information they had been able to re-create. According to the binder R8 was the victim and R9 was the perpetrator. On 10/23/24, a closed record review was conducted of R8's chart. This review revealed an entry by registered nurse #1 (RN #1) dated 12/17/22 at 12:25 p.m., that read, Recorder in room and observed male resident having sexual intercourse with resident in her bed with resident's legs spread open with one to each side of resident's waist. Bed noted to be at lowest position with cover on floor. Observed male resident with pants and brief down around his knees. Recorder stated for male resident to stop and get off her. Male resident proceeded to stop engaging in the sexual activity, got off resident and was noted be to be fully erect. No bodily fluid observed on penis. Male resident then stood up from bed, pulled up his pants and briskly walked out of resident's room and up hallway. Resident noted to have a flat affect to face. When asked what happened, resident stated, he hurt my breast and [NAME] Pam hurt. Resident observed lying flat in the bed with hospital gown raised up to her breasts exposing the underside of the breast. Resident's brief noted to be undone and exposing vagina. Resident assured that he would not be coming back into the room and covered with a sheet for privacy. Recorder called for staff member to stay with resident while recorder exited room and returned to nurse's station. There were multiple entries in R8's clinical record on 12/17/22, which included notification to the family of the incident, the doctor, who was on-site and gave an order to send to the emergency room , and the police being notified. An entry dated 12/17/22 at 1:21 p.m., read, This writer called [hospital name redacted] ER [emergency room ] to give report to nurse. After telling the nurse that the resident had been raped and would need a rape kit. This writer was told that [hospital name redacted] hospital could not accommodate the resident and could we send the resident to another facility. 911 transport was made aware of what the nurse had said. 911 driver stated that they could not bypass this hospital per their protocol and would first need to go to [hospital name redacted] ER. On 12/17/22 at 7:51 p.m., an entry was made by the physician into R8's chart that read in part, Pt [patient] raped by another resident this afternoon. No bleeding or injuries noted. The RP of both parties were notified, and pt was transferred to ED for forensic exam . A/P [active problem(s)]: 1. Non-consensual intercourse - forensic exam pending, but initial examination was normal. Perpetrator was turned over to legal authorities 2. OCD [obsessive compulsive disorder] with severe intellectual inability -chronic (food obsession); continue supportive care. Will continue to redirect behaviors. 3. Bipolar disorder - chronic, continue clomipramine and valproic acid . 6. MDD [major depressive disorder] chronic; continue sertraline; trazodone for sleep . On 10/23/24 at 4:03 p.m., an interview was conducted with RN #1. RN #1 reported that on 12/21/22, R8's roommate (resident #10- R10) came to the nursing station and was mumbling saying that she couldn't go to her room because that man was on top of her roommate. RN #1 reported she immediately went to R8's room and she observed R9 in the bed on top of R8. RN #1 reported she told R9 to get off her. RN #1 reported R8's gown was pulled up; her breasts were exposed, and her incontinence brief was undone on one side. R9 had his pants down and was on the bed on top of R8 and was making the back and forth motion and was groping her breasts. RN #1 told R9 to get off of her and when he stood up, she noted R9 had an erection. RN #1 said she was not aware if R9 made sexual penetration of R8 or not but it was sexual assault regardless, she observed R9 to put his pants on and he exited the room. RN #1 reported she called the following, the doctor, police, director of nursing, unit manager, administrator and family of both residents. During the above interview with RN #1, she reported that R8 was cognitively impaired and would not have been able to give consent to any sexual activity. She reported R9 was able to ambulate independently, would refuse medications and care at times and they had to redirect him often. RN #1 reported that following the incident R9 was taken into custody by the police and did not return to the facility. RN #1 reported she had to go to court numerous times because the case kept being postponed but the last time was told she didn't have to come back anymore because it was dismissed, and they said they were both cognitively impaired. On 10/24/24, a clinical record review was conducted of R9's closed record. According to a progress note written by a psychiatric mental health nurse practitioner on 12/12/22, prior to the incident, the note indicated R9 had diagnosis to include but not limited to, PTSD (post-traumatic stress disorder), alcohol abuse, schizoaffective disorder, psychosis, anxiety disorder, and sexual dysfunction. The note read in part, Patient is a [AGE] year-old male seen for follow-up with a psychiatric history of schizoaffective disorder, insomnia, PTSD, and inappropriate sexual behavior . He is alert and oriented x 2 [to person and place] and is reliable historian . His last mental health review was on 11/28/22 where he was stable . Since last review patient had documented behaviors of resistance to care and walking away from the facility and would not come back with guidance from the police officer or staff. Staff also request the patient to be seen for increased agitation, verbal and physical abuse and combativeness at times. Staff also indicate paranoid delusions and states that the patient will frequently state everyone is trying to kill me. Patient's PTSD is stable per staff and states that he has had not any further inappropriate sexual behaviors other than remarks to staff that are not sexual but continuing to be complementing .Care plan: Recommendation: The patient's inappropriate sexual behaviors are controlled on Provera . On 12/17/22 at 12:50 p.m., there was an entry made by the facility administrator that read, Late Entry: Alerted by staff members by phone regarding sexual activity of resident with female resident of facility. Resident reportedly left room of involved resident and walked out of facility. Staff advised to keep resident in sight continually pending arrival of police to facility. RP Cousin- [name redacted] at facility at approximately 3 pm. Spoke with her briefly regarding personal belongings which she will pick up at a later date. Another progress note dated 12/17/22 at 1:32 p.m., read, Resident's RR [responsible representative], [name redacted], returned call to the facility. RR was made aware by Dr. [doctor's name redacted] that the resident was found having sex with another resident that could not give consent. RR stated that she is on her way to facility per Dr. [doctor's name redacted]. A note dated 12/17/22 at 3 p.m., read, Resident in back of police car under police custody. Officer stated that resident will be charged and taken to local jail. On 10/24/24 at 10:58 a.m., an interview was conducted with the facility's former administrator (Administrative Employee #3- AE #3), who was the administrator on 12/17/22. AE #3 reported that following the incident R8 was sent to the hospital for evaluation and R9 left in handcuffs, never to return. AE #3 reported the facility conducted a full binder of information regarding the incident and it was packed away nice and neat. AE #3 reported that following the fire that occurred in Aug. 2023, the binder was stored in a safe in the therapy gym and was not aware it was not able to be located following re-opening of the facility. AE #3 reported that the social worker interviewed all alert residents, residents who were not interviewable had head to toe assessments conducted. When asked where that information was documented, the AE #3 stated, it was documented on paper and put in the binder, but she hoped it was also in the clinical records. When asked about the fire, AE #3 reported there was no internal damage within the facility other than a panel box in the kitchen, the damage sustained was to an exterior electrical room and the generator. No smoke was inside the building and the sprinkler system did not engage within the facility; therefore the records were intact following the fire and were just stored away for safekeeping since the facility was going to be closed and not occupied. The AE #3 reported on 9/15/23, when her employment ended the binder with all the information the facility did in response to the sexual assault was in the therapy gym. On 10/23/24-10/24/24, a review of the facility provided binder as evidence of their investigation and submission for consideration of past non-compliance was reviewed. Within the binder was a cover letter that read in part, This will serve as our plan of abatement for [facility name redacted] to: An allegation of sexual abuse made on 12/17/2022. Allegation background: An allegation of sexual abuse was made between resident #1 (female victim) and resident #2 (male perpetrator). Employee #1 observed resident #2 on top of resident #1 having sexual contact and she is unable to give consent. Employee #1 stopped the contact immediately. #2- Fire and building closed for over a year for remodeling and FRI investigations misplaced during the time . Within the facility provided binder, it read in part, .Search held by many of the regional staff and administrative staff at [facility name redacted] for the missing binder with all the evidence that this event was investigated. The binder is not able to be located after the fire last year in 2023 and the building being closed for over one year for remodeling. All contents of the building was packed up and moved or stored. Binder recreated on 9/10/2024 with the information that could be printed out of the system and any materials that could be found. An Ad hoc QAPI meeting was held on 12/19/2021 and again on 9/13/2024 to review event and QAPI plan with the medical director and IDT [interdisciplinary team] . Alleged DOC [date of compliance] 12/20/2022 . There was no evidence of any witness statements, staff or resident interviews, resident assessments, reports regarding the status of criminal charges for R9, etc. According to the facility policy titled, Virginia Resident Abuse Policy which read in part, . 7. Once the Administrator and DOH [department of health] are notified, an investigation of the allegation or suspicion will be conducted. a. Time frame for investigation. The investigation must be completed within five (5) working days from the alleged occurrence. b. Investigation protocol. The person investigating the incident should generally take the following actions: i. Interview the resident, the accused, and all witnesses. Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident (including other residents, family members); and employees who worked closely with the accused employee(s) and/or alleged victim the day of the incident. ii. If there are no direct witnesses, then the interviews may be expanded . iii. Obtain written statements from the resident, if possible, the accused, and each witness. iv. Obtain all medical reports and statements from physicians and/or hospitals, if applicable. Review the resident's records . c. Documentation: Evidence of the investigation should be documented . On 10/24/24 at 2:30 p.m., the facility administrator stated to the survey team, We aren't denying it occurred, we know it was reported and he [R9] went to jail. She [R8] went to the hospital. I remember hearing about the book. I know the investigation was done, [company name redacted] is good about sending nurse consultants to help with investigation. The building was closed for a year, and we only opened two months ago. I know everything is not in there but please take into consideration we had a fire and were closed for a year. I feel we have provided evidence that an investigation was done for past non-compliance. On 10/24/24, during the exit conference the facility administrator, director of nursing, and RDCS were made aware that without the credible evidence of an investigation, the survey team would be unable to accept past non-compliance. No additional information was provided.

Based on observations, staff interview, and facility documentation review, the facility failed to provide functional furniture appropriate for resident use in 2 rooms (rooms 208 & 323), on 2 of 4 units. The findings included: On 10/24/24 a tour and observations of the nursing units 2 and 3 was conducted. The observation revealed that the closet door in room [ROOM NUMBER] had a broken hinge, preventing the closet door from closing. The closet door handle was also broken. During the tour, it was also observed that the closet door in room [ROOM NUMBER] was ajar. Closer inspection noted that the hinge was broken, preventing the closet door from being closed. On 10/24/24 at 11:45 a.m., a meeting with the administrator, director of nursing, and the regional director of clinical services was conducted. When these above findings were reported to the facility staff, the administrator stated, We have been painting the building and trying to replace the door handles and hinges as we go along. On 10/24/24 a review of facility documentation was conducted. The facility document titled, Resident Rights and Facility Responsibilities. read in part, .it is the facility's policy to comply with all resident rights, and to communicate these rights to residents and their designated representatives. No additional information was provided.

Based on resident interviews, staff interviews, and clinical record review during a complaint investigation, the facility staff failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents #1 through #8 and Residents #10 through #24 were not administered assessments, medications and/or treatments as ordered by the physician. The findings include: On 07/12/2022 the survey team identified that a nurse who was assigned rooms 200 through 214 on Unit 2 did not report to work as scheduled on 05/29/2022 at 7 p.m. These rooms were without a nurse for approximately 4 hours until the on-call nurse (RN #2) reported to work. During this time 26 residents did not receive physician ordered assessments, medications and/or treatments. 1. Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #4 as moderately impaired for daily decision making with a score of 12 out of 15. Resident #4's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Accuchecks three times a day. [MEDICATION(S)] 10 mg at bedtime for [CONDITION(S)] [MEDICATION(S)] Ointment apply to lower extremity at bedtime for dry skin [MEDICATION(S)] 125 mg two times a day for tremors [MEDICATION(S)] Capsule 100 mg give two capsules at bedtime for [CONDITION(S)] [MEDICATION(S)] 100 unit/1ml Insulin Pen inject 40 units subcutaneously at bedtime for diabetes [MEDICATION(S)] 10 mg give 1 tablet at bedtime for sleep [MEDICATION(S)] 25 mg give 1 tablet by mouth two times a day for hypertension [MEDICATION(S)] 125 mg give 1 tablet by mouth 4 times per day for gas relief and abdominal pain Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Three interview attempts were made with Resident #4 on 07/12/22 at 11:30 a.m. and 1:45 p.m., however during both times Resident #4 closed his eyes and went to sleep; at 3:45 p.m., Resident #4 stated, come back tomorrow. On 07/13/2022 at 8:30 a.m., 11:00 a.m., and 1:30 p.m., Resident #4 was observed sleeping and was not interviewed. 2. Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] was the discharge assessment and assessed Resident #5 as moderately impaired for daily decision making with a score of 12 out of 15. Resident #5's closed clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Nebulization Solution 2.5 mg/3 ml inhale one vial orally via nebulizer three times a day for wheezing/shortness of breath [MEDICATION(S)] Sulfate Tablet 325 mg give 1 tablet by mouth two times a day for supplement Singular Tablet 10 mg give 1 tablet by mouth at bedtime for asthma. Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #6 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #6 as severely cognitively impaired for daily decision making with a score of 4 out of 15. Resident #6's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Sulfate Tablet 325 mg give 1 tablet by mouth two times a day for [CONDITION(S)] [MEDICATION(S)] Capsule 100 mg give 1 capsule by mouth three times a day for DM II (type 2 diabetes) for [CONDITION(S)] [MEDICATION(S)] HCI Tablet 1000 mg give 1000 mg by mouth every morning and bedtime for DM II (type 2 diabetes) [MEDICATION(S)] Tablet 40 mg give 1 tablet by mouth at bedtime for [CONDITION(S)] [MEDICATION(S)] HCI tablet give 75 mg orally at bedtime for depression Vitamin B-6 Tablet 25 mg give 1 tablet at bedtime for restless legs Resident #6's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] was the discharge assessment and assessed Resident #7 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #7's closed clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Resident #8 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #8 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #8's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] HCI Tablet 10 mg give 1 tablet by mouth at bedtime for [CONDITION(S)] [MEDICATION(S)] 10 mg Tablet give 1 tablet by mouth at bedtime for [CONDITION(S)] Resident #8's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/12/2022 at 1:45 p.m., Resident #8 was interviewed regarding the missed doses of medications. Resident #8 stated, that weekend we didn't have a nurse for a few hours on second shift and I missed my medications. Resident #8 was asked if he experienced any symptoms because of the missed medications. Resident #8 stated, no, not that I can remember. 6. Resident #10 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #10 as severely cognitively impaired for daily decision making with a score of 6 out of 15. Resident #10's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Calcium 40 mg give 1 tablet by mouth at bedtime for [CONDITION(S)] [MEDICATION(S)] 10 mg tablet give 1 tablet by mouth two times a day for dementia with [CONDITION(S)], anxiety, and depression [MEDICATION(S)] 6.25 mg give 1 tablet by mouth two times a day for hypertension [MEDICATION(S)] Tablet 100 mg give 100 mg by mouth two times a day for mood disorder Resident #10's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Resident #11 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #11 as moderately independent for daily decision making. Resident #11's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Accuchecks AC and HS (before meals and at bedtime for diabetes) Foley output documentation every shift related to neuromuscular bladder dysfunction [MEDICATION(S)]-[MEDICATION(S)] eye drops - 1 drop in each eye two times a day for [CONDITION(S)] [MEDICATION(S)] Flextouch Solution (Insulin) inject 44 units subcutaneously at bed for diabetes [MEDICATION(S)] 500 mg give 1 tablet by mouth two times a day for [CONDITION(S)] [MEDICATION(S)] Solution eye drops 1 drop in each eye at bedtime for [CONDITION(S)] [MEDICATION(S)] 5 mg tablet give 1 tablet at bedtime for [CONDITION(S)] [MEDICATION(S)] eye drops 1 drop in each eye at bedtime for [CONDITION(S)] Resident #11's (MAR) did not include verification that the accuchecks were completed as ordered nor documented the above medications were not administered on the evening of 05/29/2022 as ordered/scheduled. 8. Resident #12 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #12 as moderately impaired for daily decision making with a score of 11 out of 15. Resident #12's clinical record included May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Accucheck FBS (finger blood sticks) and at 8 pm two times a day for diabetes [MEDICATION(S)] HCI Solution 0.1% 1 spray in both nostrils two times a day for nasal congestion [MEDICATION(S)] HCI Solution 2% eye drops 1 drop in each eye two times a day for [CONDITION(S)] [MEDICATION(S)] 100 unit/1ml Insulin inject 26 units subcutaneously at bedtime for diabetes [MEDICATION(S)] Solution 0.005% eye drops 1 drop in each eye at bedtime for [CONDITION(S)] [MEDICATION(S)] Tablet 5 mg give 1 by mouth at bedtime for [CONDITION(S)] Resident #12's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/13/2022 at 1:15 p.m., Resident #12 was interviewed about the missed doses of medications. Resident #12 stated he did not remember if he missed any medications. Resident #12 continued and stated, the nurses come in and give me my medications because I can't keep up with them all. 9. Resident # 1 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 7/2/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. According to a review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 0.5 mg Tablet - Give 1 tablet by mouth at bedtime for anxiety. [MEDICATION(S)] 100 unit/ml insulin pen - Inject 14 unit subcutaneously at bedtime related to type 2 diabetes mellitus. [MEDICATION(S)] Solution 0.005% - Instill 1 drop in both eyes at bedtime for [CONDITION(S)]. [MEDICATION(S)] 3 mg Tablet - Give 2 tablet by mouth at bedtime for [CONDITION(S)]. Rhopresse Solution - Instill 1 drop in both eyes at bedtime for end stage [CONDITION(S)]. [MEDICATION(S)] 50 mg Tablet - Give 1 tablet by mouth at bedtime for [CONDITION(S)]. Accu checks every morning and at bedtime related to type 2 diabetes mellitus. The following medications were ordered for two times a day with administration times of 0800 (8:00 a.m.) and 2000 (8:00 p.m.) were not administered at 8:00 p.m. : Acidophilus Probiotic Capsule - Give 1 tablet (sic) by mouth two times a day for supplement. [MEDICATION(S)] - [MEDICATION(S)] solution 2-0.5% - Instill 1 drop in both eyes two times a day for [CONDITION(S)]. [MEDICATION(S)] 5 mg Tablet - Give 1 tablet by mouth two times a day related to [CONDITION(S)]. [MEDICATION(S)] Suspension - 1 spray in each nostril two times a day for allergic rhinitis. [MEDICATION(S)] Discus 100 mcg/blist - 1 inhalation two times a day for asthma. [MEDICATION(S)] R 100 unit/ml - Inject as per sliding scale. (NOTE: According to the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] .) At 10:20 a.m. on 7/13/2022, Resident # 1 was interviewed regarding the events of 5/29/2022. Asked if he had any consequences from not receiving any of his medications, Resident # 1 said, I have anxiety. It bothered me that I did not get my medication for that. Asked if he got accu-checks for his diabetes, the resident said that he did not. Resident # 1 went on to say that, The 11 p.m. nurse came on and said she was only giving her medications, that she wasn't doing what the second shift should have done. 10. Resident # 2 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to an Annual Minimum Data Set, with an Assessment Reference Date of 6/9/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. According to a review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Acidophilus Capsule - Give 1 capsule by mouth two times a day for gut health. [MEDICATION(S)] 10 mg Tablet - Give 0.5 (one half) tablet by mouth two times a day for spasms. [MEDICATION(S)] Sulfate Tablet 325(65 Fe) mg - Give 1 tablet orally two times a day for [CONDITION(S)]. [MEDICATION(S)] 750 mg Tablet - Give 1 tablet by mouth every 12 hours for seizures. At 9:45 a.m. on 7/13/2022, Resident # 2 was interviewed regarding the events of 5/29/2022. Asked if not receiving his medications that evening caused him any discomfort, the resident said, The pain was not too bad, but I could not sleep. I did not sleep at all that night. The guy that was supposed to give medications did not come in that night. 11. Resident # 13 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 6/23/2022, the resident was assessed under Section C (Cognitive Patterns) as having short and long term memory problems with severely impaired daily decision making skills. According to a review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet 50 mg - Give 1 tablet by mouth at bedtime for [CONDITION(S)]. The following medications, ordered for two times a day with administration times of 0800 (8:00 a.m.) and 2000 (8:00 p.m.), were not administered at 8:00 p.m. during the Evening Shift on Unit 2 on 5/29/2022: [MEDICATION(S)] 5 mg Tablet - Give 1 tablet by mouth two times a day related to [CONDITION(S)] and [CONDITION(S)]. [MEDICATION(S)] 25 mg Tablet - Give 1 tablet by mouth two times a day related to hypertensive kidney disease. The following medication, ordered for three times a day with administration times of 0800 (8:00 a.m.), 1400 (2:00 p.m.), and 2000 (8:00 p.m.), was not administered at 8:00 p.m. during the Evening Shift on Unit 2 on 5/29/2022: [MEDICATION(S)] Tablet 0.5 mg - Give 1 tablet by mouth three times a day for restlessness and agitation. 12. Resident # 14 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a Medicare 5-Day Minimum Data Set, with an Assessment Reference Date of 5/3/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. According to a review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Tablet 5 mg - Give 1 tablet by mouth at bedtime for [CONDITION(S)]. 13. Resident # 15 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 6/28/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 13 out of 15. According to a review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Capsule 100 mg - Give 1 capsule by mouth at bedtime for constipation. Famotidine Tablet 20 mg - Give 1 tablet by mouth one time a day for GERD (gastroesophageal reflux disease), at bedtime. [MEDICATION(S)] Tablet 5 mg - Give 1 tablet by mouth at bedtime for [CONDITION(S)]. [MEDICATION(S)] Tablet 100 mg - Give 1 tablet by mouth at bedtime for major depressive disorder. The following medications, ordered for two times a day with administration times of 0800 (8:00 a.m.) and 2000 (8:00 p.m.), were not administered at 8:00 p.m. during the Evening Shift on Unit 2 on 5/29/2022: [MEDICATION(S)] Solution Pen-injector 100 unit/ml - Inject 45 unit subcutaneously two times a day for diabetes mellitus. [MEDICATION(S)] Tablet 400 mg - Give 1 tablet two times a day for supplement. [MEDICATION(S)] Tablet 25 mg - Give 0.5 (one half) tablet by mouth two times a day for hypertension. The following medication, ordered for three times a day with administration times of 0800 (8:00 a.m.), 1400 (2:00 p.m.) and 2200 (10:00 p.m.), was not administered at 10:00 p.m. during the Evening Shift on Unit 2 on 5/29/2022: [MEDICATION(S)] Aerosol Solution 108 mcg/act - 2 puff inhale orally three times a day for wheezing or SOB (shortness of breath). Resident # 15 also had the following order for four times a day at 0800 (8:00 a.m.), 1200 (12 noon), 1600 (4:00 p.m.), and 2000 (8:00 p.m.), was not done at 8:00 p.m. during the Evening Shift on Unit 2 on 5/29/2022: Accu checks AC and HS four times a day for diabetes mellitus. 14. Resident # 24 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to an Annual Minimum Data Set, with an Assessment Reference Date of 6/19/2022, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 11 out of 15. According to a review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 40 mg Tablet - Give 1 tablet by mouth at bedtime for [CONDITION(S)]. The following medications, ordered for two times a day with administration times of 0800 (8:00 a.m.) and 2000 (8:00 p.m.), were not administered at 8:00 p.m. during the Evening Shift on Unit 2 on 5/29/2022: [MEDICATION(S)] Sodium 100 mg Capsule - Give 1 capsule by mouth two times a day for constipation. [MEDICATION(S)] 50 mg Tablet - Give 1.5 (one and one half) tablet by mouth two times a day for hypertension. On 7/12/22 at 2:20 p.m., the registered nurse unit 2 manager (RN #1) was interviewed about staffing and missed medications on the evening of 5/29/22. RN #1 stated on 5/29/22 a nurse did not show up for work at 7:00 p.m. as scheduled. RN #1 stated a nurse from unit 3 came over and worked the back hall portion of unit 2 but there was no nurse on the front hall from 7:00 p.m. until 11:00 p.m. RN #1 stated there were usually two nurses working the evening shift on unit 2. RN #1 stated the house supervisor was notified on 5/29/22 around 9:00 p.m. that a nurse did not report to work. RN #1 stated a nurse was called in to work on unit 2 but she was not sure when she arrived at the facility. On 7/12/22 at 2:35 p.m., the Director of Nursing (DON) was interviewed about no nurse on a portion of unit 2 on the evening of 5/29/22. The DON stated LPN #3 was supposed to come in on 5/29/22 at 7:00 p.m. and he was a no show. The DON stated the second shift supervisor (RN #3) called another nurse to come in but RN #2 did not report until 11:00 p.m. The DON stated she was not notified on 5/29/22 about LPN #3 not reporting to work or that there was no nurse for rooms 200 through 214, the rooms occupied by the 26 residents in the survey sample, from 7:00 p.m. until 11:00 p.m. The DON stated 5/29/22 was the Sunday of Memorial Day weekend and she was not aware that LPN #3 did not show up for work until Tuesday 5/31/22. The DON stated no staff members reported that residents did not get medications and/or treatments that evening. The DON stated no missed medications showed on her standard reports because the report design required a code entry for missed medications. The DON stated if she had known at the time there was no nurse, she would have come in and made sure resident care was provided. 15. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #3 as cognitively intact. On 7/12/22 at 11:30 a.m., Resident #3 was interviewed about staffing and getting medications timely. Resident #3 stated over a month ago there was no nurse on his unit during the evening shift and no residents got their medications or treatments. Resident #3 stated that evening a nurse called in late and then did not show up for work. Resident #3 stated he missed his 8:00 p.m. and 9:00 p.m. medications because there was no nurse on the hall from 7:00 p.m. until 11:00 p.m. Resident #3 stated the medications missed included his sleeping pill and pain medication. Resident #3 stated he asked the nurse that came in at 11:00 p.m. about the missed medications and the nurse told him she was not giving evening medications but would only give the medications for the night shift (11:00 p.m. to 7:00 a.m.). Resident #3 stated that staffing at times was a problem and he did not like missing his medications. Resident #3 denied any sleep problems or increased pain from the missed medications. Resident #3's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 80 mg (milligrams) at bedtime for [CONDITION(S)] [MEDICATION(S)] [MEDICATION(S)] 6.25 mg at bedtime for sleep/[CONDITION(S)] Prostat supplement 30 ml (milliliters) for wound healing [MEDICATION(S)] diskus 50 mcg (micrograms) inhale two times per day for asthma [MEDICATION(S)] 800 mg three times per day for [CONDITION(S)] Resident #3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 16. Resident #16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #16 as cognitively intact. Resident #16's closed clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 10 mg at bedtime for [CONDITION(S)] [MEDICATION(S)] 3 mg at bedtime for [CONDITION(S)] Pepcid 20 mg at bedtime for GERD [MEDICATION(S)] 137 mcg/spray, 1 spray each nostril two times per day for allergies Fish oil 1000 mg two times per day for hypertriglyceridemia [MEDICATION(S)] Flex Touch insulin (100 units/ml) inject 30 units subcutaneous two times per day for diabetes [MEDICATION(S)] nebulizer (2.5 mg/3 ml) 0.083%, inhale 1 vial orally via nebulizer every 8 hours for [CONDITION(S)] Klor-Con (potassium chloride) 30 milliequivalents three times per day for [CONDITION(S)] [MEDICATION(S)] 800 mg three times per day for [CONDITION(S)] [MEDICATION(S)] 2 mg three times per day for muscle spasms Blood sugar/Accucheck before meals and at bedtime for diabetic management Resident #16's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 17. Resident #17 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #17 as cognitively intact. Resident #17's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 20 mg at bedtime for [CONDITION(S)] [MEDICATION(S)] 10 mg at bedtime for depression [MEDICATION(S)] 5 mg two times per day for [CONDITION(S)] prevention Mucinex 600 mg two times a day for chest congestion [MEDICATION(S)] 0.2% eye drops, instill 1 drop in both eyes two times per day for conjunctival [CONDITION(S)] for 90 days Cleanse left great toe wound with saline, dry, apply TAO (triple antibiotic ointment) with dry dressing each evening for wound care Resident #17's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12 22 at 3:45 p.m., Resident #17 was interviewed about any missed medications and staffing. Resident #17 stated she remembered there was a shift with no nurse on the floor but she did not recall the date. Resident #17 stated that evening she missed her bedtime medications but did not have any problems following the missed medicines. 18. Resident #18 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #18 as cognitively intact. Resident #18's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] calcium 5 mg at bedtime for [CONDITION(S)] [MEDICATION(S)] 600 mg every 8 hours for [CONDITION(S)] Eye vitamin two times per day for supplement Resident #18's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 19. Resident #19 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #19 with severely impaired cognitive skills. Resident #19's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 5 mg at bedtime for [CONDITION(S)] [MEDICATION(S)] 300 mg at bedtime for [CONDITION(S)] prevention [MEDICATION(S)] 24 mcg two times per day for [CONDITION(S)] [MEDICATION(S)] 10 mg two times per day for hypertension [MEDICATION(S)] 600 mg two times per day for [CONDITION(S)] [MEDICATION(S)] 1200 mg three times per day for [CONDITION(S)] [MEDICATION(S)] 2 mg three times per day for anxiety Resident #19's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 20. Resident #20 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #20 with severely impaired cognitive skills. Resident #20's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 200 mg at bedtime for [CONDITION(S)] [MEDICATION(S)] 25 mg two times per day for hypertension Resident #20's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 21. Resident #21 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #21 with severely impaired cognitive skills. Resident #21's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Med Pass 2.0 four times per day TED support hose on in morning and off each evening Resident #21's medication and treatment administration records documented the above supplement/treatment orders were not implemented on the evening of 5/29/22 as ordered/scheduled. 22. Resident #22 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident

Based on staff interviews and clinical record review during a complaint investigation, the facility staff failed to provide a physician ordered snack for weight management for 5 of 26 in the survey sample. Resident #7, #25, #18, #20, and #21 did not receive their HS snack as ordered by the physician. The findings include: On 07/12/2022 the survey team identified that a nurse who was assigned rooms 200 through 214 on Unit 2 did not report to work as scheduled on 05/29/2022 at 7 p.m. These rooms were without a nurse for approximately 4 hours until the on-call nurse (RN #2) reported to work. During this time 26 residents did not receive physician ordered assessments, medications and/or treatments. 1. Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] was the discharge assessment and assessed Resident #7 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #7's closed clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #7's care plan included the focus area: The resident has a potential nutritional problem r/t (related to) diet restrictions, mechanically-altered diet, dysphagia, fluid restriction. Goals included: The resident will maintain adequate nutritional status. Interventions included: .provide snack at HS (bedtime) . Resident #7's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident # 25 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 4/19/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively impaired, with a Summary Score of 04 out of 15. Resident # 25's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Medpass three times a day for weight gain 120 mls - Medpass 2.0 TID (three times a day) with meds. The administration times were listed as 1000 (10:00 a.m.), 1400 (2:00 p.m.), and 2200 (10:00 p.m.). According to the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 25's care plan included the following problem (focus): Potential for alteration in nutrition and hydration related to: dietary restrictions, nutritional risk for weight loss d/t (due to) poor PO (oral) intake, receives mechanically altered diet. The goal for the problem was: Resident will have stable weight through next review. Included as a intervention to the stated problem was the following: MedPass 2.0 120ml PO TID with medications. 3. Resident #18 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #18 as cognitively intact. Resident #18's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Food snack at bedtime for weight maintenance Provide HS [bedtime] snack nightly Resident #18's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18's plan of care (print date 7/12/22) documented the resident had nutritional problems and potential for nutrition problems. Interventions for weight management included, .Explain and reinforce to the importance of maintaining the diet ordered. Encourage compliance .Serve diet as ordered .Snacks as per order . 4. Resident #20 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #20 with severely impaired cognitive skills. Resident #20's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . High calorie ice cream by mouth twice daily for snack every day and evening shift Encourage fluids by mouth every 2 hours while awake each day and evening shift Resident #20's treatment administration record documented the ice cream and fluid encouragement were not provided on the evening of 5/29/22 as ordered/scheduled. Resident #20's plan of care (print date 7/12/22) documented the resident had a potential for nutritional problems due to diet restrictions. Interventions to ensure adequate nutritional status included, .Serve diet as ordered .Serve supplements as ordered . 5. Resident #21 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #21 with severely impaired cognitive skills. Resident #21's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Give sandwich or high calorie snack every evening at bedtime. Resident #21's treatment administration record documented the high calorie snack was not provided on the evening of 5/29/22 as ordered/scheduled. Resident #21's plan of care (print date 7/12/22) documented the resident had nutritional problems due to dementia, cognitive impairment and diet restrictions due to dysphagia. Interventions to maintain adequate nutritional status included, .High-Calorie snack at HS [bedtime] .snack and beverage daily .per MD order .

Based on resident interview, staff interview, and clinical record review during a complaint investigation, the facility staff failed to administer medications and/or treatments for pain management for 26 of 26 residents in the survey sample. Residents #1 through 26 were not provided physician ordered pain assessments or medications/treatments. The findings include: On 07/12/2022 the survey team identified that a nurse who was assigned rooms 200 through 214 on Unit 2 did not report to work as scheduled on 05/29/2022 at 7 p.m. These rooms were without a nurse for approximately 4 hours until the on-call nurse (RN #2) reported to work. During this time 26 residents did not receive physician ordered assessments, medications and/or treatments. 1. Resident #4 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #4 as moderately impaired for daily decision making with a score of 12 out of 15. Resident #4's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's care plans included a focus area for: The resident is on pain medication therapy, at risk for pain r/t (related to) impaired mobility, hx (history) [CONDITION(S)] (stroke) with right sided [CONDITION(S)], [CONDITION(S)], hx of migraine headaches. Resident has active orders to aid with pain Goals Included: The resident will be free of any discomfort or adverse side effects from pain medications through review date. Interventions Included: .Observe and assess pain level, document as ordered . Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Three interview attempts were made with Resident #4 on 07/12/22 at 11:30 a.m. and 1:45 p.m., however during both times Resident #4 closed his eyes and went to sleep; at 3:45 p.m., Resident #4 stated, come back tomorrow. On 07/13/2022 at 8:30 a.m., 11:00 a.m., and 1:30 p.m., Resident #4 was observed sleeping and was not interviewed. 2. Resident #5 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] was the discharge assessment and assessed Resident #5 as moderately impaired for daily decision making with a score of 12 out of 15. Resident #5's closed clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's care plans included a focus area for: At risk for pain/discomfort r/t generalized discomfort, GERD, constipation, [CONDITION(S)]. Resident receives scheduled pain medication. Goals included: Resident will have decreased pain AEB (as evidenced by) verbalizes relief/no non-verbal signs of pain through next review. Interventions Included: .assess for increased, decreased pain . Resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Resident #6 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #6 as severely cognitively impaired for daily decision making with a score of 4 out of 15. Resident #6's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6's care plans included a focus area for: Resident has potential for pain/discomfort r/t GERD, RLS (restless leg syndrome), [CONDITION(S)]. Receives scheduled pain medication. Goals Included: Resident will express pain level within satisfactory levels. Interventions Included: .administer medications per MD order .Assess for verbal and nonverbal signs and symptoms relating to pain Resident #6's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Resident #7 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] was the discharge assessment and assessed Resident #7 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #7's closed clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7's care plans included a focus area for: Resident has pain/potential for pain/altered comfort r/t pressure ulcer, [CONDITION(S)], CKD stage 5, [CONDITION(S)], pruitis. Goals Included: Resident will express pain level within satisfactory limits through next review. Interventions Included: .assess for verbal and nonverbal signs and symptoms relating to pain . Resident #7's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Resident #8 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #8 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #8's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8's care plans included a focus area for: At risk for pain r/t GERD, hx of [CONDITION(S)], impaired mobility, [CONDITION(S)], [CONDITION(S)]. Goals Included: Resident will have pain managed with pharmacological and non-pharmacological measures this quarter with review ongoing. Interventions Included: . assess for increased, decreased pain. Resident #8's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/12/2022 at 1:45 p.m., Resident #8 was interviewed regarding the missed doses of medications and pain assessment. Resident #8 stated, that weekend we didn't have a nurse for a few hours on second shift and I missed my medications. Resident #8 was asked if he experienced any symptoms because of the missed medications. Resident #8 stated, no, not that I can remember. 6. Resident #9 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #9 as severely cognitively impaired for daily decision making. Resident #9's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 7. Resident #10 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #10 as severely cognitively impaired for daily decision making with a score of 6 out of 15. Resident #10's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10's care plans included a focus area for: Resident has history of [CONDITION(S)] and is at risk for Depression, Pain, Skin Breakdown. Goals Included: Resident will express relief from pain through next review . Interventions Included: .assess for s/s (signs/symptoms) of pain . Resident #10's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Resident #11 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #11 as moderately independent for daily decision making. Resident #11's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's care plans included a focus area for: At risk for pain r/t (related to) [CONDITION(S)], GERD, right sided [CONDITION(S)]. Goals Included: Resident will have pain managed to an acceptable level through the quarter with review ongoing. Interventions Included: .access for increased,decreased pain . Resident #11's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 9. Resident #12 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #12 as moderately impaired for daily decision making with a score of 11 out of 15. Resident #12's clinical record included May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12's care plans included a focus area for: The resident has a potential for pain r/t (related to) Arthritis, GERD, peripheral [CONDITION(S)], nasal congestion, several teeth extracted. Goals Included: The resident will verbalize adequate relief of pain through the review date. Interventions Included: .assess/record pain per routine and prn, assess/record/report to Nursing any s/sx (signs/symptoms) of non-verbal pain . Resident #12's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 10. Resident # 1 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 7/2/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Resident # 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Document pain every shift. (If pain present document in progress note) Every shift for pain monitoring. [MEDICATION(S)] capsule 100 mg. Give 1 capsule by mouth three times a day for leg pain. The [MEDICATION(S)] administration times were 0600 (6:00 a.m.), 1400 (2:00 p.m.), and 2200 (10:00 p.m.). There was no documentation to indicate the pain assessment was conducted during the evening shift on 5/29/2022, or that the [MEDICATION(S)] was administered at 10:00 p.m. on 5/29/2022. Resident # 1's care plan included the following problem (focus): The resident is at risk for Pain/Discomfort r/t (related to) Dx (diagnosis) of [CONDITION(S)], failure to thrive, Dysphagia, GERD (gastroesophageal reflux disease), c/o (complaint of) pain to bilateral knees, contractures to bilat(eral) knees, muscle weakness. The goal for the problem was: The resident's c/o pain or discomfort will resolve with use of interventions thru next review; Resident will have no adverse side effects from pain medication through the review date. Interventions to the stated problem included the following: Assess and document pain level as per MD order and prn; Administer medication/treatments as ordered. Monitor/document side effects and effectiveness. 11. Resident # 2 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to an Annual Minimum Data Set, with an Assessment Reference Date of 6/9/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Resident # 2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Document pain every shift. (If pain present document in progress note) Every shift for pain monitoring. [MEDICATION(S)] capsule 600 mg. Give 1 capsule by mouth three times a day for leg pain. [MEDICATION(S)]-Acet(aminophen) 5mg-325mg Tablet - Give 1 tablet by mouth two times a day for pain. The [MEDICATION(S)] administration times were 0600 (6:00 a.m.), 1400 (2:00 p.m.), and 2200 (10:00 p.m.). The [MEDICATION(S)] administration times were 0800 (8:00 a.m.) and 2000 (8:00 p.m.). There was no documentation to indicate the pain assessment was conducted during the evening shift on 5/29/2022, that [MEDICATION(S)] was administered at 10:00 p.m. on 5/29/2022, or that [MEDICATION(S)] was administered at 8:00 p.m. on 5/29/2022. Resident # 2's care plan included the following problem (focus): Pain-At risk for pain/discomfort related to Hx (history): [CONDITION(S)] disks, cervical spinal stenosis, [CONDITION(S)], contracture to bilateral wrist, muscle spasms to legs, wounds-on pain medication, complains of abdominal pain at times. The goal for the problem was: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions to the stated problem included the following: Administer analgesia/medications per orders; Assess/record pain per routine and prn. At 9:45 a.m. on 7/13/2022, Resident # 2 was interviewed regarding the events of 5/29/2022. Asked if not receiving his medications that evening caused him any discomfort, the resident said, The pain was not too bad, but I could not sleep. I did not sleep at all that night. 12. Resident # 13 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 6/23/2022, the resident was assessed under Section C (Cognitive Patterns) as having short and long term memory problems with severely impaired daily decision making skills. Resident # 13's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Document pain every shift. (If pain present document in progress note) Every shift for pain monitoring. There was no documentation to indicate the pain assessment was conducted during the evening shift on 5/29/2022. Resident # 13's care plan included the following problem (focus): The resident is at risk for pain r/t (related to) generalized pain. The goal for the problem was: The resident will be free of any discomfort or adverse side effects from pain medication through the review date. Interventions to the stated problem included: Administer medication as ordered; and, Ensure resident is at a level of comfort at which they desire. Assess for increased pain or breakthrough and notify MD if occurs. 13. Resident # 14 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to a Medicare 5-Day Minimum Data Set, with an Assessment Reference Date of 5/3/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Resident # 14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Document pain every shift. (If pain present document in progress note) Every shift for pain monitoring. There was no documentation to indicate the pain assessment was conducted during the evening shift on 5/29/2022. Resident 14's care plan included the following problem (focus): Resident is at risk for pain/discomfort r/t L2 fracture, cancer metastasis. The goal for the problem was: Resident will verbalize adequate relief of pain through the next review date. The following was included as an intervention to the stated problem: Assess for verbal and nonverbal signs and symptoms related to pain: grimacing, guarding, crying, moaning, increased anxiety, changes in usual routine, sleep patterns, functional abilities, decreased ROM (range of motion), loss of appetite, withdrawal/resistance to care. 14. Resident # 15 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 6/28/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 13 out of 15. Resident # 15's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Document pain every shift. (If pain present document in progress note) Every shift for pain monitoring. [MEDICATION(S)] Capsule 300 mg - Give 1 capsule by mouth three times a day for [CONDITION(S)]. The [MEDICATION(S)] administration times were 0600 (6:00 a.m.), 1400 (2:00 p.m.), and 2200 (10:00 p.m.). There was no documentation to indicate the pain assessment was conducted during the evening shift on 5/29/2022, or that [MEDICATION(S)] was administered at 10:00 p.m. on 5/29/2022. Resident # 15's care plan included the following problem: Pain: The resident has a potential for pain/discomfort r/t [CONDITION(S)], GERD, hx pressure ulcers, contractures, constipation, [CONDITION(S)], [CONDITION(S)], myoclonic jerking, impaired mobility. The goal for the problem was: The resident will verbalize adequate relief of pain through the review date. The following was included as an intervention to the stated problem: Administer analgesia/medications per orders. Assess and document pain as per DR order and prn. 15. Resident # 24 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to an Annual Minimum Data Set, with an Assessment Reference Date of 6/19/2022, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 11 out of 15. Resident # 24's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Document pain every shift. (If pain present document in progress note) Every shift for pain monitoring. [MEDICATION(S)] Capsule 100 mg - Give 1 capsule by mouth two times a day for nerve pain. The [MEDICATION(S)] administration times were 0600 (6:00 a.m.) and 2000 (8:00 p.m.). There was no documentation to indicate the pain assessment was conducted during the evening shift on 5/29/2022, or that [MEDICATION(S)] was administered at 8:00 p.m. on 5/29/2022. Resident # 24's care plan included the following problem (focus): At risk for pain r/t GERD, complains of back pain at times, constipation, impaired mobility, acute LLE (left lower extremity) distal tibial and fibular fracture. The goal for the problem was: Resident will have decreased pain through next review. Interventions to the stated problem include: Assess for increased, decreased pain; Meds as ordered. 16. Resident # 25 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 4/19/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively impaired, with a Summary Score of 04 out of 15. Resident # 25's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Document pain every shift. (If pain present document in progress note) Every shift for pain monitoring. There was no documentation to indicate the pain assessment was conducted during the evening shift on 5/29/2022. Resident # 25's care plan included the following problem (focus): At risk for pain/discomfort r/t generalized discomfort, GERD. The goal for the problem was: Resident will have decreased pain AEB (as evidenced by): verbilizes relief/no non-verbal signs of pain through next review. Included as an intervention to the stated problem was: Assess for increased, decreased pain. 17. Resident # 26 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 6/25/2022, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 12 out of 15. Resident # 26's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Document pain every shift. (If pain present document in progress note) Every shift for pain monitoring. The resident's Treatment Administration Record included the following order: Biofreeze Gel 4% Menthol (Topical Analgesic) - Apply to back and bilateral ext(remities) topically at bedtime for pain. There was no documentation to indicate the pain assessment was conducted during the evening shift on 5/29/2022, or that the Biofreeze Gel was applied at bedtime on 5/29/2022. Resident # 26's care plan included the following problem (focus): The resident has a potential for pain r/t arthritis, hematoma, GERD. The resident has scheduled and PRN pain medication ordered to assist with pain management. The goal for the problem was: The resident will verbalize adequate relief of pain through the review date. Interventions to the stated problem included the following: Administer analgesia/medications per orders; Assess/record pain per routine and prn; and, Biofreeze Gel 4% - Apply to back and bilateral ext topically at bedtime for pain. 18. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #3 as cognitively intact. On 7/12/22 at 11:30 a.m., Resident #3 was interviewed about staffing and getting medications timely. Resident #3 stated over a month ago there was no nurse on his unit during the evening shift and no residents got their medications or treatments. Resident #3 stated that evening a nurse called in late and then did not show up for work. Resident #3 stated he missed his 8:00 p.m. and 9:00 p.m. medications because there was no nurse on the hall from 7:00 p.m. until 11:00 p.m. Resident #3 stated the medications missed included his sleeping pill and pain medication. Resident #3 stated he asked the nurse that came in at 11:00 p.m. about the missed medications and the nurse told him she was not giving evening medications but would only give the medications for the night shift (11:00 p.m. to 7:00 a.m.). Resident #3 stated that staffing at times was a problem and he did not like missing his medications. Resident #3 denied any sleep problems or increased pain from the missed medications. Resident #3 stated this occurred around the end of May 2022. Resident #3's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Document pain level every shift [MEDICATION(S)]-acetaminophen 5-325 milligrams every 8 hours for leg pain. Resident #3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3's plan of care (print date 7/12/22) documented the resident was at risk of pain due to history of nerve pain, hip/back pain, right side hemaparesis/[CONDITION(S)] and peripheral vascular disease. Interventions to minimize discomfort/pain included, Monitor for effectiveness of pain meds to ensure lowest effective dose .Pain medication as ordered by MD . 19. Resident #16 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #16 as cognitively intact. Resident #16's closed clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Document pain level every shift Check placement of [MEDICATION(S)] patch every shift for pain [MEDICATION(S)] sodium gel 1%, apply to knees topically every 6 hours for pain Resident #16's medication and treatment administration records documented the above medications/assessments were not administered and/or performed on the evening of 5/29/22 as ordered. Resident #16's plan of care (print date 7/12/22) documented the resident was at risk of pain/discomfort due to [CONDITION(S)], muscle spasms and used controlled medication for pain control. Interventions to minimize discomfort/pain included, Administer medications as ordered; assess and document pain as per MD order . 20. Resident #17 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #17 as cognitively intact. Resident #17's clinical record documented May physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Document pain level each shift for pain monitoring Resident #17's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12 22 at 3:45 p.m., Resident #17 was interviewed about any missed medications and staffing. Resident #17 stated she remembered there was a shift with no nurse on the floor but she did not recall the date. Resident #17 stated that evening she missed her bedtime medications but did not have any problems following the missed medicines. Resident #17's plan of care (print date 7/12/22) documented the resident had potential for pain due to [CONDITION(S)], spinal stenosis, venous insufficiency, fluid retention and functional [CONDITION(S)]. Interventions to maintain satisfactory pain levels included, .Assess for verbal and nonverbal signs and symptoms relating to pain: grimacing, guarding, crying, moaning, increase anxiety . 21. Resident #18 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #18 as cognitively intact. Resident #18's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Document pain level every shift for pain monitoring Resident #18's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #18's plan of care (print date 7/12/22) documented the resident had chronic pain due to phantom pain and [CONDITION(S)]. Interventions to minimize pain included, .Assess/record pain per routine and prn [as needed] . 22. Resident #19 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #19 with severely impaired cognitive skills. Resident #19's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Document pain level every shift for pain monitoring Resident #19's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19's plan of care (print date 7/12/22) documented the resident had potential for pain/discomfort due to chronic back wound, irritable bowel and [CONDITION(S)]. Interventions to minimize pain included, .Assess for verbal and nonverbal signs and symptoms relating to pain: grimacing, guarding, crying, moaning, increase anxiety . 23. Resident #20 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #20 with severely impaired cognitive skills. Resident #20's clinical record documented May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Document pain level every shift for pain monitoring Resident #20's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #20's plan of care (print date 7/12/22) documented the resident was at risk of pain/discomfort due to arthritis, impaired mobility and [CONDITION(S)]. Interventions to minimize pain included, .assess/document pain per routine and prn .assess/record/report to Nurse resident complaint of pain or requests for pain treatment .assess/record/report to Nursing any s/sx [signs/symptom

Based on resident interviews, staff interviews, and clinical record review during a complaint investigation, the facility staff failed to provide sufficient nursing staff to ensure care and services were provided to help maintain the highest practicable well-being of each resident for a total of 26 out of 26 residents in the survey sample. Residents #1 through #26 did not receive physician ordered/scheduled assessments, medications and/or treatments on the evening of 05/29/2022 after a nurse did not report to work. The findings include: On 07/12/2022 the survey team identified that a nurse who was assigned rooms 200 through 214 on Unit 2 did not report to work as scheduled on 05/29/2022 at 7 p.m. These rooms were without a nurse for approximately 4 hours until the on-call nurse (RN #2) reported to work. During this time 26 residents did not receive physician ordered assessments, medications and/or treatments. The clinical records for the residents who resided in rooms 200 through 214 were reviewed by the survey team regarding missed assessments, medications and/or treatments on the evening of 05/29/2022 when no nurse provided care/services on a portion of Unit 2 (Rooms 200 - 214) for approximately 4 hours. Residents #1 through #26 missed scheduled assessments, medications, and/or treatments that included: blood sugar checks for diabetic management, catheter care, [CONDITION(S)] care, oxygen therapy/respiratory care, pain assessments, and weight management. Medications that were not administered included a variety of medications for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician ordered treatments not provided included topical medications/creams for dry/chaffed skin and pressure ulcer prevention/care. Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #3 as cognitively intact. On 7/12/22 at 11:30 a.m., Resident #3 was interviewed about staffing and getting medications timely. Resident #3 stated over a month ago there was no nurse on his unit during the evening shift and no residents got their medications or treatments. Resident #3 stated that evening a nurse called in late and then did not show up for work. Resident #3 stated he missed his 8:00 p.m. and 9:00 p.m. medications because there was no nurse on the hall from 7:00 p.m. until 11:00 p.m. Resident #3 stated the medications missed included his sleeping pill and pain medication. Resident #3 stated he asked the nurse that came in at 11:00 p.m. about the missed medications and the nurse told him she was not giving evening medications but would only give the medications for the night shift (11:00 p.m. to 7:00 a.m.). Resident #3 stated that staffing at times was a problem and he did not like missing his medications Resident #8 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #8 as cognitively intact for daily decision making with a score of 15 out of 15. On 07/12/2022 at 1:45 p.m., Resident #8 was interviewed regarding the missed doses of medications. Resident #8 stated, that weekend we didn't have a nurse for a few hours on second shift and I missed my medications. Resident #8 was asked if he experienced any symptoms because of the missed medications. Resident #8 stated, no, not that I can remember On 7/12/22 at 2:20 p.m., the registered nurse unit 2 manager (RN #1) was interviewed about staffing and missed medications on the evening of 5/29/22. RN #1 stated on 5/29/22 a nurse did not show up for work at 7:00 p.m. as scheduled. RN #1 stated a nurse from unit 3 came over and worked the back hall portion of unit 2 but there was no nurse on the front hall from 7:00 p.m. until 11:00 p.m. RN #1 stated there were usually two nurses working the evening shift on unit 2. RN #1 stated the house supervisor was notified on 5/29/22 around 9:00 p.m. that a nurse did not report to work. RN #1 stated a nurse was called in to work on unit 2 but she was not sure when she arrived at the facility. On 7/12/22 at 2:26 p.m., licensed practical nurse (LPN) #1 that worked on the unit 2 on the evening of 5/29/22 was interviewed. LPN #1 stated she came from the unit 3 and was assigned to work the back hall of unit 2 (rooms 215 through 235). LPN #1 stated LPN #3 was supposed to come in at 7:00 p.m., work until 7:00 a.m. and cover the front hall of the unit (rooms 200 through 214). LPN #1 stated LPN #3 called in and said he was going to be late. LPN #1 stated she proceeded with passing medications to her assigned residents and around 9:00 p.m. realized that LPN #3 did not show up. LPN #1 stated she went to the second shift supervisor (RN #3) and told her that LPN #3 had not shown up to work. LPN #1 stated the supervisor called and texted LPN #3 and got no response. LPN #1 stated RN #2 was called in and showed up around 11:00 p.m. LPN #1 stated there was no nurse on the front hall of unit 2 on 5/29/22 from 7:00 p.m. until 11:00 p.m. LPN #1 stated no residents made her aware that they had not received medications that evening. LPN #1 stated there was a schedule at the nursing desk to know who was scheduled to work. LPN #1 stated LPN #3 had called in late before but this time did not come in. LPN #1 stated concerning the evening of 5/29/22, I was doing good to take care of my patients. On 7/12/22 at 2:35 p.m., the director of nursing (DON) was interviewed about no nurse on a portion of unit 2 on the evening of 5/29/22. The DON stated LPN #3 was supposed to come in on 5/29/22 at 7:00 p.m. and he was a no show. The DON stated the second shift supervisor (RN #3) called another nurse to come in but RN #2 did not report until 11:00 p.m. The DON stated she was not notified on 5/29/22 about LPN #3 not reporting to work or that there was no nurse for rooms 200 through 214 from 7:00 p.m. until 11:00 p.m. The DON stated 5/29/22 was the Sunday of Memorial Day weekend and she was not aware that LPN #3 did not show up for work until Tuesday 5/31/22. The DON stated no staff members reported that residents did not get medications and/or treatments that evening. The DON stated no missed medications showed on her standard reports because the report design required a code entry for missed medications. The DON stated if she had known at the time there was no nurse, she would have come in and made sure resident care was provided. Resident #17 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #17 as cognitively intact. On 7/12/22 at 3:45 p.m., Resident #17 was interviewed about any missed medications and staffing. Resident #17 stated she remembered there was a shift with no nurse on the floor but she did not recall the date. Resident #17 stated that evening she missed her bedtime medications but did not have any problems following the missed medicines. Resident #23 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] assessed Resident #23 as cognitively intact. On 7/12/22 at 4:45 p.m., Resident #23 was interviewed about staffing and any problems with her medications and/or treatments. Resident #23 stated she remembered the evening of 5/29/22 and thinks she missed all of her evening medications. The resident stated there was no nurse on the hall after 7:00 p.m. on the evening of 5/29/22 because someone did not show. Resident #23 stated she recently fell following a [CONDITION(S)] and was concerned about not getting her [CONDITION(S)] medication as ordered. On 7/12/22 at 4:50 p.m., the survey team met with the administrator, DON and corporate nursing consultant to discuss the situation with no nurse on the evening of 5/29/22 on a portion unit 2. The DON stated the RN that came in on 5/29/22 at 11:00 p.m. gave the night shift medications but not the bedtime/evening medications. The DON stated nobody reported to her that the medications/treatments on 5/29/22 from 7:00 p.m. to 11:00 p.m. were not done. The DON stated she and the administration find out the medications/treatments were not administered when a news article was printed in the local newspaper on 6/29/22. The DON stated the article listed several residents that did not have a nurse and did not get medicines/treatments on the evening of 5/29/22. The corporate consultant stated when the article came out, they investigated the situation and started a plan of correction. The corporate consultant stated the RN supervisor made a round on residents in rooms 200 through 214 on the evening of 5/29/22 to ensure safety but no medicines or treatments were administered. Resident # 2 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to an Annual Minimum Data Set, with an Assessment Reference Date of 6/9/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. At 9:45 a.m. on 7/13/2022, Resident # 2 was interviewed regarding the events of 5/29/2022. Asked if not receiving his medications that evening caused him any discomfort, the resident said, The pain was not too bad, but I could not sleep. I did not sleep at all that night. The guy that was supposed to give medications did not come in that night. Resident # 1 in the survey sample was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 7/2/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. At 10:20 a.m. on 7/13/2022, Resident # 1 was interviewed regarding the events of 5/29/2022. Asked if he had any consequences from not receiving any of his medications, Resident # 1 said, I have anxiety. It bothered me that I did not get my medication for that. Asked if he got accu-checks for his diabetes, the resident said that he did not. Resident # 1 went on to say that, The 11 p.m. nurse came on and said she was only giving her medications, that she wasn't doing what the second shift should have done. On 7/13/22 at 2:00 p.m., the house supervisor on the evening of 5/29/22 (RN #3) was interviewed. RN #3 stated she worked the floor on unit 1 on the 3:00 p.m. to 11:00 p.m. shift on 5/29/22. RN #3 stated she routinely was the house supervisor on the evening shift on Monday through Friday and worked on the floor every other weekend. She said she was working the floor on 5/29/22 on unit 1 and was available to help with emergencies because she was the only RN in the building. RN #3 said on 5/29/22 around 9:00 p.m., LPN #1 reported to her that LPN #3, who was scheduled to work from 7:00 p.m. until 7:00 a.m. on the front hall of unit 2, had not reported to work. RN #3 stated around 9:13 p.m., she called the on-call nurse (RN # 2) and asked her to come to work. She stated RN #2 had not reported to work as of 10:00 p.m. RN #3 said RN #2 arrived to work on unit 2 sometime around 11:00 p.m. RN #3 stated she made a round on unit 2 to be sure no residents were in distress. Regarding medications/treatments, she stated she remembered LPN #1 (caring for patients in rooms 215 through 235), saying that she could not pass out all the medications because there were too many residents. RN #3 said after rounding and contacting the on-call nurse, she went back and worked on her unit. RN #3 continued to say there was a lot going on that evening and she did not notify the DON or administration about the nurse not reporting to work. When asked about any thoughts or plans for how residents without a nurse on unit 2 would get medications and/or treatments, RN #3 stated she did not have an explanation about why the medications/treatments were not provided. On 7/13/22 at 2:25 p.m., the DON was interviewed again about no nurse and missed medications/treatments on 5/29/22. The DON stated again she and the administration were not aware nursing services were not provided to a portion of unit 2 on 5/29/22 until the newspaper article on 6/29/22. The DON stated RN #2 should have given the bedtime medications when she reported to work at 11:00 p.m. but she only gave medications scheduled from 11:00 p.m. until 7:00 a.m. On 7/13/22 at 2:30 p.m., the DON met with the survey team and presented a correction plan initiated on 6/29/22 regarding the lack of staffing and medications/treatments not administered as ordered on the evening of 5/29/22. The correction plan documented the facility was not in compliance with the specific regulatory requirement(s) .at the time the situation occurred .There is sufficient evidence that the facility corrected the noncompliance and is in substantial compliance . The plan to address lack of staff and medications and/or treatments not provided as ordered on the evening of 5/29/22 included the following: 1. Residents on parts of Unit 2 missed scheduled medications that fell between hours of 7:00 p.m. and 11:00 p.m. on 5/29/22. Nursing failed to follow orders . Nurses involved received 1:1 education and disciplinary action. An audit of unit 2 residents was completed and the medical director reviewed the charts and medications of residents involved with no negative outcomes noted. Verbal interviews were conducted with involved cognitively intact residents and skin assessments were completed for residents unable to be interviewed. 2. Missed medication administration audit was completed with 100% of residents to ensure no others missed medications/treatments on the evening of 5/29/22. 3. LPN/RN staff educated starting on 6/30/22 on following physician orders, abuse/neglect, medication administration audit calendars, medication administration procedures and notifying administration of staffing issues that impact care. LPN/RN staff out on any type of leave will be educated immediately upon return, prior to the beginning of their shift and education added to new hire orientation requirements. 4. DON/designee to complete missed medication administration audit daily for 12 weeks. Additional audits to be conducted by the unit manager or designee at change of shift to ensure compliance with audit findings reviewed in quality assurance process improvement meetings for three months. Date of compliance was 7/3/22. Clinical record reviews for residents included in the survey sample during the current survey found no further concerns regarding the facility not providing adequate nursing staffing. As-worked schedules for the months of June and July were reviewed and did not document any concerns. The survey team did not receive any onsite concerns from residents, family members or staff regarding staffing concerns. This deficiency was cited as past non-compliance.

Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to notify the physician for a need to alter treatment for one of 36 residents in the survey sample, Resident #313. The facility failed to notify the physician that Resident #313 had not received physician ordered IV (intravenous) antibiotics for 5 days, and failed to notify the physician that the IV antibiotic medication was not available for administration, which resulted in the identification of Immediate Jeopardy (Level 4-Isolated) on 01/25/2022 at 4:25 PM. Findings include: Resident #313 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was the admission assessment, which was in progress and not complete for Resident #313. An admission nursing assessment dated [DATE] at 7:15 PM documented, .arrival date & time: 01/20/22 7:15 PM from hospital .Reason For Admission: IV antibiotic administration .diagnoses/condition .infection .IV meds/fluids .antibiotics .alert and oriented to situation, able to make needs known . Resident #313's current CCP (comprehensive care plan) documented, .Resident is on antibiotic therapy .administer the full course of antibiotic as prescribed by physician .resident has infection .Administer antibiotics .per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/25/22 at approximately 12:50 PM, during the initial tour of the facility, Resident #313 was observed in her room in bed. A central venous access device was observed in the resident's right upper chest area. Resident #313 was asked how she was doing. Resident #313 began to cry and stated that she was upset and felt as though she was getting worse instead of better. Resident #313 went on to explain that she had a fracture and infection in her spine and that she had been in the hospital receiving IV antibiotics (prior to admission to the facility) and was supposed to be receiving them here as well. Resident #313 stated that she had not received any IV antibiotics since she had arrived here. Resident #313 was asked when she was admitted to this facility. The resident stated that she came late Thursday evening (January 20, 2022). Resident #313 was asked if she had reported to anyone that she had not received the medication. The resident stated, Everyday, and further stated that the physician had come in to see her (she thought on Friday, 01/21/22) and that he had ordered the medication for her, but she still had not received it. Resident #313 stated that the nurses have kept telling her that the IV antibiotics were coming and that she wasn't sure what was going on. Resident #313 again stated that she was upset, she wanted to get better and was in fear of actually getting worse due to not having the antibiotic medication. Resident #313 stated that she thought she was supposed to have the IV medication therapy for about 4 to 6 weeks. On 01/25/22 at approximately 1:30 PM, Resident #313's clinical record was reviewed. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Order Status: Active .Order Date: 01/20/22 .Start Date: 01/20/22 . The MARs (medication administration records) were reviewed for January 2022. The MARs documented, .[MEDICATION(S)] Solution Reconstituted 1 GM Use 1000 mg intravenously every 24 hours for discitis .Start Date: 01/20/22 (2:30 PM) . Each day from 01/21/22 through 01/25/22 staff initials were documented with the time and the number 19 in each box for the IV medication. The number 19, on the legend (chart codes) indicated, 19=Other/See Nurse Notes. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #313's nursing notes documented each day that the medication was on order. No nursing or progress notes were found to indicate the physician had been notified that the medication was on order, not available for administration, or that Resident #313 had not been receiving the medication as ordered. On 01/25/22 at 2:15 PM, Resident #313's physician was interviewed and was asked if he had been notified by staff that Resident #313 had not received the physician ordered IV antibiotic in the last five days. The physician stated, No, I got something from (name of pharmacy) today that they (pharmacy) were sending a 5 day supply because it's not covered, but I didn't know (she had not received it). The physician was asked if he was aware that the IV antibiotic for Resident #313 was not available for administration and on order per the nursing notes. The physician stated, No. The physician stated that Resident #313 was getting the medication for discitis and he thought she was to receive it for 6 weeks. The physician was asked about the potential implications of Resident #313 not receiving the IV antibiotic medications as ordered. The physician stated, .the infection may not be controlled, whether the infection will spread out of the disc or not, I don't know .It could result in hospitalization , prolonged treatment, prolonged stay (in the nursing home) .I don't think it would result in [CONDITION(S)], but could increase her pain level and cause further deterioration of the disc. The physician was made aware of serious concerns regarding Resident #313 not receiving the IV antibiotics as ordered, and that the facility staff had not notified him that the medication was not administered and was not available for administration. The physician stated that the staff are usually good about contacting him. The physician was made aware of the serious concerns and the potential for harm to Resident #313. The physician stated, Unfortunately, I agree with you. The physician stated that staff usually let him know when a medication isn't administered or available and stated, I'm not sure where the breakdown occurred. The physician stated that he had received a note from the pharmacy this morning that the medication wasn't covered by insurance and that they sent a 5 day supply. The physician stated that he had spoken with RN (registered nurse) #3 [UM3 (unit 3 manager)] this morning about that, but the nurse did not mention to him that the medication had not been administered or that the medication wasn't available. On 01/25/22 at 3:05 PM, the physician was interviewed again. The physician stated that he just went to the unit at 3:00 PM to check to see if the IV medication was there. The physician stated that the IV medication, [MEDICATION(S)] was in the stat box (a different IV medication from what he had originally ordered). The physician stated, That's ([MEDICATION(S)]) what I would have switched her (Resident #313) to, had they (nursing staff) made me aware the (ordered) medication was unavailable or there was a problem getting the ordered medication. The physician then stated, The [MEDICATION(S)] came in last night (01/24/22), it's in the medication room. The physician stated that he and RN #3 checked the stat box and that RN #3 found the IV antibiotic medication ([MEDICATION(S)]) that was ordered in the med room and that it had come in last night. The physician was asked why the IV [MEDICATION(S)] was not administered last night. The physician stated he wasn't sure, but RN #3 was going to check. The physician stated, I'm really disappointed, probably more than you are. On 01/25/22 at 4:25 PM, in a meeting with the survey team, the administrator and DON were notified that survey team had consulted and discussed the above information with the State Agency, and identified IJ (Immediate Jeopardy) (Level 4-Isolated) on 01/25/2022 at 4:25 PM, due to the facility's failure to notify the physician that IV antibiotics were not administered per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The survey team advised the administrator and DON to develop and present a plan of removal regarding the facility's failure to notify the physician for Resident #313. A policy was requested for physician notification regarding unavailable medications at this time. The policy Medication shortages/Unavailable Medications documented, .upon discovery that the facility has an inadequate supply of medication to administer .should immediately initiate action to obtain the medication from pharmacy .nurse should call pharmacy to determine the status of the order .if the medication is not available in the emergency medication supply .notify pharmacy and arrange for an emergency delivery, if medically necessary .if an emergency delivery is unavailable .nurse should contact the attending physician to obtain orders or directives . On 01/25/22 at 5:00 PM, RN #3 (also known as the UM3) was interviewed. UM3 was asked if she was aware that Resident #313 had not received her IV antibiotic as ordered by the physician for 5 days. UM3 stated that the physician had brought it to her attention about an hour ago that the IV medication ([MEDICATION(S)]) was not administered to Resident #313 as ordered. UM3 stated that she had not been made aware that Resident #313 had not received it until the physician told her. UM3 stated that she was not aware the medication was not available for administration. UM3 stated that the physician had come to the unit and gave her an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . UM3 stated she had been in the medication room earlier today and saw that the original medication ([MEDICATION(S)]) was in there, but didn't realize that Resident #313 had not received it. UM3 stated that after looking into it further, they had found the medication had arrived the night before (01/24/22). UM3 was asked why the medication wasn't administered last night. UM3 stated, I can't answer that. On 01/25/22 at 5:20 PM, RNA (Registered Nurse Applicant) #4 was interviewed. RNA #4 had documented on Resident #313's MAR under the IV antibiotic on 01/22/22 and 01/23/22. RNA #4 stated that she works day shift and the medication was scheduled for 2:30 PM. RNA #4 stated that on both days (01/22/22 and 01/23/22) she looked for the medication in the medication room and up front in the Q machine (a place for extra medications) and the Q machine said it wasn't available. RNA #4 stated that a pharmacy delivery guy came and she had asked him about the medication for Resident #313, and he told her it would be in the night shipment. RNA #4 stated that she did not receive the medication. RNA #4 stated that she did not pass this information on in report to the oncoming shift, she did not report it to UM3, and did not notify the physician. RNA #4 stated she did not document anything in the progress notes. RNA #4 stated that on Sunday, she went to the stock room and the medication had not come and she reached out again to the pharmacy delivery person. RNA #4 stated that she did not call the pharmacy directly, and again did not notify UM3 or the physician. RNA #4 stated that she thought the medication may be coming in on the next shipment. On 01/25/22 at approximately 5:45 PM, LPN (licensed practical nurse) #1 was interviewed. LPN #1 had documented on Resident #313's MAR under IV antibiotic on 01/21/22, 01/24/22 and 01/25/22. LPN #1 stated that she works day shift and the medication was scheduled for 2:00 to 2:30 PM. LPN #1 stated that on Friday (01/21/22) that she realized they didn't have it in stock and she went to the computer and ordered it. LPN #1 stated that she did not report to UM3 or the physician that the medication was not in stock. LPN #1 stated that she did not pass this information on in report to the next shift. LPN #1 stated, On Monday (01/24/22) the same thing, I realized we didn't have it. I called the pharmacy and they said IV meds don't come through (the computer) and has to be faxed, I don't know who I talked to, so I faxed it. When I spoke to the woman (at the pharmacy) she said as soon as we get it (fax) we'll send it out. LPN #1 stated that she assumed over the weekend Resident #313 didn't get the medication because the facility didn't have it. LPN #1 stated that she did not report to UM3 or the physician that the resident had not received the medication or that the medication was not available to administer, and she didn't pass it on in report, .because it was a day shift thing. LPN #1 stated, I didn't even realize it was an antibiotic to be honest. On 01/26/22 at 3:41 PM, the administrator and DON presented the following plan for IJ removal: 1) Resident missed 4 doses of IV Antibiotic and nurses did not notify MD. Medication administered on 01/25/22 at 1530 and MD was notified. Nurses who did not notify MD received 1:1 (one to one) education regarding MD notification on 01/25/22. 2) Audit of missed IV medications to be completed by Thursday 01/27/22 by 5:00PM to ensure MD was notified of missing medication to ensure no other residents affected. 3) LPN/RN staff to be educated by Thursday 01/27/22 by 5:00PM on prompt notification of MD when a medication has been missed or has not been administered. LPN/RN staff out on vacation, leave, or out with illness, will be educated immediately upon return, prior to the beginning of their shift. Education on prompt notification of physician will be added to new hire education. 4) DON/designee, to complete MD notification audit 5 times weekly for 8 weeks. Analysis of the audits will be submitted to QAPI monthly x 3 months for review and recommendations. The survey team accepted the plan of removal for the immediate jeopardy status on 01/26/22 at 4:00 PM. Resident #313 received [MEDICATION(S)] 1000 mg IV per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/27/22 between 7:30 AM and 12:00 noon, interviews were conducted with nurses on each nursing unit regarding education for notification of the physician when a resident does not receive medications as ordered and notification of the physician when medications are not available for administration. Telephone interviews were also conducted by the survey team of nurses off duty to ensure education was provided. The administrator and DON presented education in-service records for the education provided, along with sign in sheets and an audit form /tool to ensure that all nursing staff off duty would be educated upon return to work. On 01/27/22 at approximately 9:30 AM, Resident #313 was interviewed and stated, Thank you, I'm much better now that I'm getting my antibiotics. The survey team abated the IJ on 01/27/22 at 12:46 PM, reducing the scope and severity level of the remaining deficient practice to level 2, isolated. No further information and/or documentation was presented prior to the exit conference on 01/28/22.

Based on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #313 was not administered IV (intravenous) antibiotic medication as ordered by the physician, which resulted in the identification of Immediate Jeopardy (Level 4-Isolated) on 01/25/2022 at 4:25 PM. The facility also failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 135 and 149 were not administered the [MEDICATION(S)] vaccine as ordered by the physician. Resident #88 was administered [MEDICATION(S)] without food when the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #102's fluid restrictions were not documented as ordered by the physician. Findings include: 1. Resident #313 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current MDS (minimum data set) was the admission assessment, which was in progress and not complete for Resident #313. An admission nursing assessment dated [DATE] at 7:15 PM documented, .arrival date & time: 01/20/22 7:15 PM from hospital .Reason For Admission: IV antibiotic administration .diagnoses/condition .infection .IV meds/fluids .antibiotics .alert and oriented to situation, able to make needs known . Resident #313's current CCP (comprehensive care plan) documented, .Resident is on antibiotic therapy .administer the full course of antibiotic as prescribed by physician .resident has infection .Administer antibiotics .per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/25/22 at approximately 12:50 PM, during the initial tour of the facility, Resident #313 was observed in her room in bed. A central venous access device was observed in the resident's right upper chest area. Resident #313 was asked how she was doing. Resident #313 began to cry and stated that she was upset and felt as though she was getting worse instead of better. Resident #313 went on to explain that she had a fracture and infection in her spine and that she had been in the hospital receiving IV antibiotics (prior to admission to the facility) and was supposed to be receiving them here as well. Resident #313 stated that she had not received any IV antibiotics since she had arrived here. Resident #313 was asked when she was admitted to this facility. The resident stated that she came late Thursday evening (January 20, 2022). Resident #313 was asked if she had reported to anyone that she had not received the medication. The resident stated, Everyday, and further stated that the physician had come in to see her (she thought on Friday, 01/21/22) and that he had ordered the medication for her, but she still had not received it. Resident #313 stated that the nurses have kept telling her that the IV antibiotics were coming and that she wasn't sure what was going on. Resident #313 again stated that she was upset, she wanted to get better and was in fear of actually getting worse due to not having the antibiotic medication. Resident #313 stated that she thought she was supposed to have the IV medication therapy for about 4 to 6 weeks. On 01/25/22 at approximately 1:30 PM, Resident #313's clinical record was reviewed. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Order Status: Active .Order Date: 01/20/22 .Start Date: 01/20/22 . The MARs (medication administration records) were reviewed for January 2022. The MARs documented, .[MEDICATION(S)] Solution Reconstituted 1 GM Use 1000 mg intravenously every 24 hours for discitis .Start Date: 01/20/22 (2:30 PM) . Each day from 01/21/22 through 01/25/22 staff initials were documented with the time and the number 19 in each box for the IV medication. The number 19, on the legend (chart codes) indicated, 19=Other/See Nurse Notes. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #313's nursing notes documented each day that the medication was on order. No nursing or progress notes were found to indicate the physician had been notified that the medication was on order, not available for administration, or that Resident #313 had not been receiving the medication as ordered. On 01/25/22 at 2:15 PM, Resident #313's physician was interviewed and was asked if he had been notified by staff that Resident #313 had not received the physician ordered IV antibiotic in the last five days. The physician stated, No, I got something from (name of pharmacy) today that they (pharmacy) were sending a 5 day supply because it's not covered, but I didn't know (she had not received it). The physician stated that Resident #313 was getting the medication for discitis and he thought she was to receive it for 6 weeks. The physician was asked about the potential implications of Resident #313 not receiving the IV antibiotic medications as ordered. The physician stated, .the infection may not be controlled, whether the infection will spread out of the disc or not, I don't know .It could result in hospitalization , prolonged treatment, prolonged stay (in the nursing home) .I don't think it would result in [CONDITION(S)], but could increase her pain level and cause further deterioration of the disc. The physician was made aware of serious concerns regarding Resident #313 not receiving the IV antibiotics as ordered and of the serious concerns and the potential for harm to Resident #313. The physician stated, Unfortunately, I agree with you. The physician stated that staff usually let him know when a medication isn't administered and stated, I'm not sure where the breakdown occurred. The physician stated that he had received a note from the pharmacy this morning that the medication wasn't covered by insurance and that they sent a 5 day supply. The physician stated that he had spoken with RN (registered nurse) #3 [UM3 (unit 3 manager)] this morning about that, but the nurse did not mention to him that the medication had not been administered. On 01/25/22 at 3:05 PM, the physician was again interviewed. The physician then stated, The [MEDICATION(S)] came in last night (01/24/22), it's in the medication room. The physician stated that he and RN #3 checked the stat box and that RN #3 found the IV antibiotic medication ([MEDICATION(S)]) that was ordered in the med room and that it had come in last night. The physician was asked why the IV [MEDICATION(S)] was not administered last night. The physician stated he wasn't sure, but RN #3 was going to check. The physician stated, I'm really disappointed, probably more than you are. On 01/25/22 at 4:25 PM, in a meeting with the survey team, the administrator and DON were notified that survey team had consulted and discussed the above information with the State Agency, and identified IJ (Immediate Jeopardy) (Level 4-Isolated) on 01/25/2022 at 4:25 PM, due to the facility's failure to ensure that the IV antibiotics were administered per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The survey team advised the administrator and DON to develop and present a plan of removal regarding Resident #313 not receiving IV antibiotic medication as ordered by the physician. On 01/25/22 at 5:00 PM, RN #3 (also known as the UM3) was interviewed. UM3 was asked if she was aware that Resident #313 had not received her IV antibiotic as ordered by the physician for 5 days. UM3 stated that the physician had brought it to her attention about an hour ago that the IV medication ([MEDICATION(S)]) was not administered to Resident #313 as ordered. UM3 stated that she had not been made aware that Resident #313 had not received it until the physician told her. UM3 stated that the physician had come to the unit and gave her an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . UM3 stated she had been in the medication room earlier today and saw that the original medication ([MEDICATION(S)]) was in there, but didn't realize that Resident #313 had not received it. UM3 stated that after looking into it further, they had found the medication had arrived the night before (01/24/22). UM3 was asked why the medication wasn't administered last night. UM3 stated, I can't answer that. On 01/25/22 at 5:20 PM, RNA (Registered Nurse Applicant) #4 was interviewed. RNA #4 had documented on Resident #313's MAR under the IV antibiotic on 01/22/22 and 01/23/22. RNA #4 stated that she works day shift and the medication was scheduled for 2:30 PM. RNA #4 stated that on both days (01/22/22 and 01/23/22) she looked for the medication in the medication room and up front in the Q machine (a place for extra medications) and the Q machine said it wasn't available. RNA #4 stated that a pharmacy delivery guy came and she had asked him about the medication for Resident #313, and he told her it would be in the night shipment. RNA #4 stated that she did not receive the medication. RNA #4 stated that she did not pass this information on in report to the oncoming shift, she did not report it to UM3, and did not notify the physician. RNA #4 stated she did not document anything in the progress notes. RNA #4 stated that on Sunday, she went to the stock room and the medication had not come and she reached out again to the pharmacy delivery person. RNA #4 stated that she did not call the pharmacy directly, and again did not notify UM3 or the physician. RNA #4 stated that she thought the medication may be coming in on the next shipment. On 01/25/22 at approximately 5:45 PM, LPN (licensed practical nurse) #1 was interviewed. LPN #1 had documented on Resident #313's MAR under IV antibiotic on 01/21/22, 01/24/22 and 01/25/22. LPN #1 stated that she works day shift and the medication was scheduled for 2:00 to 2:30 PM. LPN #1 stated that on Friday (01/21/22) that she realized they didn't have it in stock and she went to the computer and ordered it. LPN #1 stated that she did not report to UM3 or the physician that the medication was not in stock. LPN #1 stated that she did not pass this information on in report to the next shift. LPN #1 stated, On Monday (01/24/22) the same thing, I realized we didn't have it. I called the pharmacy and they said IV meds don't come through (the computer) and has to be faxed, I don't know who I talked to, so I faxed it. When I spoke to the woman (at the pharmacy) she said as soon as we get it (fax) we'll send it out. LPN #1 stated that she assumed over the weekend Resident #313 didn't get the medication because the facility didn't have it. LPN #1 stated that she did not report to UM3 or the physician that the resident had not received the medication or that the medication was not available to administer, and she didn't pass it on in report, .because it was a day shift thing. LPN #1 stated, I didn't even realize it was an antibiotic to be honest. On 01/26/22 at 3:41 PM, the administrator and DON presented the following plan for IJ removal: 1). Corrective Action: Resident # 7 (identified as Resident #313) received [MEDICATION(S)] 1000 mg IV as MD ordered on 1/25/22 (3:30 PM). MD (medical doctor) and RR (resident representative) made aware of missed doses of medication on 1/25/22. MD assessed resident to find there were no ill effects. 2). Staff nurses that were responsible for carrying out MD orders received 1:1 (one to one) education regarding following MD orders on 1/25/22. 3). Identification: All residents residing in the facility have the potential to be affected by this practice. 4). Changes: All nurses LPNs and RNs (registered nurses) employed by facility will be re-educated on following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5). Monitoring: DON or designee will audit all MD orders for IV medications for compliance weekly x 4 then monthly x 90 days facility wide. Audit findings will be reported to the Quality Assurance (QA) Committee for additional oversight and recommendation. The QA Committee will determine when to discontinue this practice. The survey team reviewed the plan of removal and accepted the plan of removal for the immediate jeopardy status on 01/26/22 at 4:00 PM. Resident #313 received [MEDICATION(S)] 1000 mg IV per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/27/22 between 7:30 AM and 12:00 noon, interviews were conducted with nurses on each nursing unit regarding education for following physician orders. Telephone interviews were also conducted by the survey team with nurses off duty to ensure education was provided. The administrator and DON presented education in-service records for the education provided, along with sign in sheets and an audit form /tool to ensure that all nursing staff off duty would be educated upon return to work. On 01/27/22 at approximately 9:30 AM, Resident #313 was interviewed and stated, Thank you, I'm much better now that I'm getting my antibiotics. The survey team abated the IJ on 01/27/22 at 12:46 PM, reducing the scope and severity level of the remaining deficient practice to level 2, isolated. No further information and/or documetnation was presented prior to the exit conference on 01/28/22. 2. Resident #135 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) was a quarterly review, dated 12/25/21. This MDS assessed the resident with a cognitive score of 12, indicating the resident had moderate impairment in daily decision making skills. On 01/27/22 at 2:59 PM, Resident #135's clinical record was reviewed. Resident #135 had a current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The date of the order was 10/23/21. No information was found in the resident's clinical record to indicate Resident #135 received the vaccine as ordered. On 01/27/22 at 3:45 PM, the pharmacy was called and interviewed regarding this vaccine. The pharmacist looked up Resident #135 in the system and stated that she did not see an order showing in the system for the vaccine. The pharmacist was made aware that the order was listed on the resident's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The pharmacist stated that the order may have been entered wrong by facility staff in the system and that may be why it wasn't showing for her. The pharmacist stated that there isn't a shortage of this vaccine and it's available and wasn't sure why the resident would not have received it, but stated that it was not showing as an order on her end. The pharmacist stated again, that it may have been entered wrong and if staff entered it in as other in the system, it doesn't come to the pharmacy, those orders have to actually be printed and faxed in. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/27/22 at 4:15 PM, the UM3 (unit 3 manager]) was interviewed regarding this medication being on order for Resident #135 since October and the resident not receiving the vaccine. UM3 stated that they should should be waiting on a consent. UM3 was asked if a consent had been obtained for Resident #135. The UM stated, Now that, I don't know. UM3 was asked if that should be documented, and stated that it should. On 01/27/22 at 5:45 PM, the administrator and DON were made aware of the above information and informed that Resident #135 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked if this should be documented. The DON stated that it should. The DON was asked why an order would be given prior to consent. The DON stated that she wasn't sure. The DON and administrator were asked how long it takes to obtain consent, as the order for this vaccine was over three months ago. No response was given. No further information and/or documentation was presented prior to the exit conference on 01/28/22. 3. Resident #149 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed Resident #149 with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. Resident #149's clinical record was reviewed on 01/26/22. A pharmacy recommendation dated 10/13/21 documented, (Name of Resident #149) is [AGE] years of age or older .unless clinically contraindicated, please administer [MEDICATION(S)] 0.5 ml intramuscularly when available from the pharmacy, with a second does administered in 60 days .Physician's Response: (check mark) I accept the recommendation above, please implement as written signature of physician dated 10/21/21. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The date of order was 10/23/21. No information was found in the resident's clinical record to indicate Resident #149 received the vaccine as ordered. On 01/27/22 at 3:45 PM, the pharmacy was called and interviewed regarding this vaccine. The pharmacist looked up Resident #149 in the system and stated that she did not see an order showing in the system for the vaccine. The pharmacist was made aware that the order was listed on the resident's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The pharmacist stated that the order may have been entered wrong by facility staff in the system and that may be why it wasn't showing for her. The pharmacist stated that there isn't a shortage of this vaccine and it's available and wasn't sure why the resident would not have received it, but stated that it was not showing as an order on her end. The pharmacist stated again, that it may have been entered wrong and if staff entered it in as other in the system, it doesn't come to the pharmacy, those orders have to actually be printed and faxed in. On 01/27/22 at 4:15 PM, the UM3 (unit 3 manager]) was interviewed regarding this medication being on order for Resident #149 since October and the resident not receiving the vaccine. UM3 stated that they should should be waiting on a consent. UM3 was asked if a consent had been obtained for Resident #135. The UM stated, Now that, I don't know. On 01/27/22 at 5:45 PM, the administrator and DON were made aware of the above information and informed that Resident #149 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was asked if this should be documented. The DON stated that it should. The DON was asked why an order would be given prior to consent. The DON stated that she wasn't sure. The DON and administrator were asked how long it takes to obtain consent, as the order for this vaccine was over three months ago. No response was given. A policy was requested at this time on vaccines. The policy was presented titled, Resident Vaccination Policy documented, .residents and/or their responsible party will be asked about prior to vaccinations at admission. Prior doses .and other other vaccines will be documented in the immunization portal (in computer) .All other vaccines: The provider will discuss the indication for any addition vaccines not covered above ([MEDICATION(S)]) with the resident/resident representative and such vaccines will be ordered and administered after informed consent is obtained. No further information and/or documentation was presented prior to the exit conference on 01/28/22. 4. Resident #88 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS) dated [DATE] assessed Resident #88 with moderately impaired cognitive skills. A medication pass observation was conducted on 1/26/22 at 7:41 a.m. with licensed practical nurse (LPN) #11 administering medications to Resident #88. Among the medications administered was [MEDICATION(S)] 500 mg (milligrams). Resident #88 took the medicines including the [MEDICATION(S)] orally with water but no food. LPN #11 did not prompt or offer food with the administration of the [MEDICATION(S)]. Resident #88 did not eat food until breakfast was served over an hour after the [MEDICATION(S)] administration. A breakfast tray was served to Resident #88 on 1/26/22 at approximately 8:45 a.m. On 1/26/22 at 8:49 a.m., Resident #88 was observed eating breakfast in bed. Resident #88's clinical record documented a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *TAKE WITH FOOD*. The clinical record documented the resident's blood sugar on 1/26/22 at 5:25 a.m. was 117. Resident #88's plan of care (revised 12/7/21) documented the resident had diabetes mellitus. Interventions to prevent diabetic complications included, medication as ordered by doctor . On 1/26/22 at 10:04 a.m., LPN #11 was interviewed about the [MEDICATION(S)] administered to Resident #88 without food. LPN #11 stated Resident #88 did not like her morning medications with food. LPN #11 stated, We can't hold the medicine. The Nursing 2022 Drug Handbook on page 942 describes [MEDICATION(S)] as an antidiabetic agent used as an adjunct to diet for lower glucose levels in patients with type 2 diabetes. Instructions for administration on page 942 include to, Give drug with meals . Potential adverse reactions listed on page 943 included [CONDITION(S)]. (1) This finding was reviewed with the administrator, director of nursing and nursing consultant on 1/27/22 at 5:30 p.m. (1) Woods, Anne Dabrow. Nursing 2022 Drug Handbook. Philadelphia: Wolters Kluwer, 2022. 5. Resident #102 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #102 as severely impaired for daily decision making with a score of 6 out 15. Resident #102's clinical record was reviewed on 01/27/2022. Observed on the order summary report was the following: Record fluid intake every shift for 1500 cc/day. Order Date 03/29/2021 Start Date 03/29/2021 Observed on Resident #102's care plans was the following focus area: Nutritional-Risk for wt (weight) Fluctuations/dehydration RT (related to) Diuretic use, CHF (congestive heart failure), DM (diabetes), Dementia, Fluid Restriction, CKD (chronic kidney disease), [CONDITION(S)] (hypertension) . Resident gets snacks from snack machine frequently. Date Initiated: 05/23/2015. Created on: 12/22/2020. Revision on: 06/16/2021. Goal: Resident will have stable WT (weight) this qtr. (quarter) with review ongoing. Interventions: Record fluid intake every shift for 1500 cc/day Date Initiated: 06/15/2021, Revision 10/28/2021 . On 01/27/2022 at 5:45 p.m., the licensed practical nurse (LPN) #7 and unit manager, registered nurse (RN) #7 were interviewed regarding the location of the fluid intake documentation. LPN #7 stated, The nurses documents the fluid intake on the TAR (treatment administration records). We (nursing) enter the amount we give the resident for example Med Pass, etc. and then CNAs (certified nursing assistants) enter the amount they give the resident in the computer. These amounts are totaled and then placed on the TAR each shift. RN #7 stated, He (Resident #102) does go to the vending machines and gets snacks so we do have to monitor him to make sure he is complaint with his fluid intake as well. He enjoys snacking. A review of Resident #102's treatment administration record (TAR) for the period of October 2021 through January 2022 revealed staff nursing staff failed to record fluid intake per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The above findings were discussed with the administrator, director of nursing (DON) and corporate nurse consultant during a meeting on 01/28/2022 at 11:00 a.m. The DON stated, (Resident #102) is independent and has been here a few years. I know staff monitors his intake because he likes to snack and goes to the vending machine frequently. They should be recording his fluid intake as well. No additional information was provided to the survey team prior to exit on 01/28/2022 at 1:00 p.m.

Based on staff interview, clinical record review, and observation the facility staff failed to assess for complications of a Foley catheter resulting in harm for one of 30 residents in the survey sample: Resident's #8 . Resident #8 was not assessed for skin breakdown related to a Foley catheter. Resident #8, developed an open penile wound without prior assessments or interventions for prevention resulting in harm to the resident. Findings include: Resident #8 was admitted to the facility on [DATE] with, but not limited to the following Diagnoses: [REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/25/17. Resident #8 was assessed as being moderately cognitively impaired total cognitive score of 8 out of 15. Resident #8's clinical record was reviewed on 6/7/17 and evidenced a Physician's Telephone Order dated 5/30/17 indicating for Resident #8 to schedule urology appt (appointment) for penile erosion & bleeding. This order was written by the Nurse Practitioner (NP). Further review of the medical record revealed a Physician's progress note dated 5/30/17 reading in part patient has foley (sic) catheter; meatus appears to have erosion with small amount of bleeding several dark clots noted . The following Nursing Notes were reviewed to include: 5/30/17 9 am Bleeding bright red noted around catheter @ tip of penis. Put on FNP (family nurse practitioner) list . 5/30/17 1005 Apply personal cleanser to perineum area after each brief change & prn (as needed) . 5/30/17 1235 pm New orders received from (NP named) .(1) Schedule urology appt for penile erosion and bleeding . 5/30/17 1245 pm Appoint for urology consult c (with) (doctor named) June 12 @10:15 am . The Skin Assessments dated 5/2-5/29/17 and 6/5/17 was reviewed to include the following: No new areas to skin noted. A Non-Pressure Ulcer Skin Conditions form dated 6/6/17 was presented to this Surveyor on 6/8/17 was reviewed to include the following: Date first observed 6/6/17 .Condition is: penile erosion .Size in CM (centimeters) 3.3 x 1.0 .Treatment / Changes Recommended .continue routine foley (sic) cath care daily. The current June 2017 physician's orders [REDACTED].#16 FR (french) Foley w/(with) 10 ml (milliliters) NS (normal saline) bulb to straight drainage for [MEDICAL CONDITION] .Change Foley Cath Q (every) month and prn (as needed) for dysfunction (change on the 20th) .Routine Foley Care Q-shift and prn . The last Foley catheter change was documented on 5/20/17. On 6/7/17 at approximately 10:52 a.m., This Surveyor accompanied a certified nursing assistant, who was caring for the resident and will be identified as CNA #1, into the resident's room. Resident #8 was observed lying in bed. This Surveyor asked Resident #8 for permission to observe the Foley catheter, with the resident's permission this Surveyor observed Resident #8's Foley catheter. A slit approximately two and a half inches was observed to the underside of the resident's shaft and the tubing of the Foley was observed pulled away from the meatus and hanging over onto the resident's scrotum. CNA #1 was interviewed regarding the penile slit and how long the area had been opened. CNA #1 stated, I have been out for a while due to surgery but when I came back in May it was like that. CNA #1 further stated that the Stat Lock, adhesive strap with a small white clamp in the center to hold the Foley in place, was changed because it was barely hanging on and it was not serving its purpose. When interviewed and asked if serving its purpose meant preventing the catheter from pulling, CNA #1 stated, Yes, we try to keep it alternated from leg to leg so that it, Foley tubing, does not lay in one spot. On 6/7/17 at approximately 11:00 a.m., A Care Plan (CP) updated on 5/5/17 was reviewed, the CP did not address the penile erosion or any treatment plans to heal the area. On 6/7/17 at approximately 11:02 a.m., the Unit Manager, who was a registered nurse and will be identified as RN #4 was interviewed regarding the CP being updated to reflect the open area to the resident's penis and the treatment plan. RN #4 stated, I don't know what the plan is to treat but I planned to put it, the open area to the penis, on the care plan but I have not done it yet. I planned to do it when the care plan got back to the floor. When RN #4 was interviewed and asked how long she was aware of the area to the resident's penis, RN #4 stated, Since May thirtieth. The CP was not updated as of 6/7/17. The Director of Nursing was present during the time of the interview with RN #4. Resident #8 also had a care plan for skin break down with interventions to include, pericare after each incontinent episode and prn, notify charge nurse of any changes in skin . On 6/7/17 at approximately 1:40 p.m., the administrator and the director of nursing (DON) were made aware of the observation of Resident #8's penis. The DON was interviewed and asked by the survey team and asked if she was aware of how the Resident's penis could have gotten in that condition. The DON stated, the catheter. When interviewed and asked how long the Foley catheter was in place the DON stated, I have to get back with you. The administrator and the DON were made aware that the clinical records did not contain documentation regarding skin assessments, treatments or a care plan for the wound. When asked the treatment for [REDACTED]. On 6/7/17 at approximately 3:03 p.m. the facilities Nurse Practitioner (NP), who will be identified as Other Staff (OS #1) was interviewed concerning the above finding. OS #1 verbalized that she was aware of Resident #8's condition and made a referral to the urologist. When interviewed and asked what could have caused the penile erosion, OS #1 stated, It's hard to say he has a catheter in place for [MEDICAL CONDITION]. Things happen without reason or because of no safety lock (the device that anchors the Foley in place to prevent the tubing from moving). OS #1 was asked if she had seen Resident #8, OS #1 verbalized she had seen Resident #8 on 5/31 and maybe the area to his penis was one (1) centimeters in length. OS #1 further stated, I should have measured it but I didn't but it was only about to right here, measuring with her thumb down to the first joint of her pointer finger. When interviewed and asked if she had seen Resident 8 since 5/31/17, OS #1 stated, No. On 6/7/17 at 3:30 p.m., This surveyor accompanied OS #1 and the wound nurse, who was a registered nurse and will be identified as RN #6, into the resident's room. Resident #8 was asked permission to assess his penis. This Surveyor observed as OS #1 and RN #6 assessed the resident's penis. OS #1 lifted the resident's penis and observed the Foley catheter tubing separated from the meatus and hanging partly onto the resident's scrotum. The slit was approximately two and a half inches long. OS #1 stated, He has good tissue here, pulling apart the residents penis at the slit, and here. OS #1 then stated, Oh this is new, he has erosion here pointing to the left inside of his penis. The wound nurse nor OS #1 was observed measuring the wound during the time of the assessment with this Surveyor. Resident #8's penis from behind the head of the penis to the base was completely open, there was no intact urethra. According to OS #1 there was some erosion inside the penile shaft. The split of the penis created an opening at the base of the penis where an indwelling catheter was observed to exit the body. The tissue was open to air with pink raw flesh and bloody drainage. On 6/7/17 at approximately 4:30 p.m., this Surveyor was informed that Resident #8's appointment had been changed from 6/12/17 to 6/8/17 at 10:00 a.m. On 6/8/17 at approximately 10:02 a.m., during the meeting with the administrator and the DON the administrator stated that the safety lock was reviewed and the safety lock was equipped to swivel in order to prevent the Foley tubing from sliding. The DON in turn stated, His issue was not the tubing turning his issue was the position of the tubing. We had to move it up so that the tubing wasn't pulling. A copy of the facility's policy on Foley Catheter care was requested an reviewed to include the following: Subject: Catheter /Changing and Prevention of Urinary Tract Infections .Guidance: .Secure catheters to the upper thigh or lower abdomen to avoid bladder and urethral trauma . On 6/8/17 at approximately 11:30 a.m., a copy of the consult from the Urologist was presented to this Surveyor. The report was reviewed to include the following: 6/8/17 Consultation Request .And to suggest .Penis circumcised-significant meatal erosion with purulent drainage .Consultation Report: (1) Cleanse bid (twice a day) with warm soap water or Antibacterial wash. (2) Apply [MEDICATION NAME] bid (twice a day). (3) Could consider SPC (suprapubic catheter) but given poor prognosis, met (metastatic) PrCa ([MEDICAL CONDITION])-poor surgical candidate. No further information was presented prior to exit conference on 6/8/17.

Based on observation, family interview, staff interview, facility document review and clinical record review, the facility staff failed to provide specialized rehabilitative services for two of 26 residents in the survey sample. Resident #1, diagnosed with [REDACTED]. Due to Resident #1's unmanaged aggressive behaviors, Resident #26 sustained a [MEDICAL CONDITION], was hospitalized for [REDACTED].#1. Residents #4 was not provided physician ordered speech therapy services. The findings include: 1. Resident #1 was admitted to the facility on [DATE] with a re-admission on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 as having short and long-term memory loss and moderately impaired cognitive skills for daily decision-making. This MDS assessed the resident had signs/symptoms of [MEDICAL CONDITION] that included inattention that changed in severity. This MDS assessed Resident #1 as short-tempered, easily annoyed on most days and demonstrating physical behavioral symptoms directed toward others such as hitting, kicking, pushing, scratching and grabbing. Resident #1 was observed on [DATE] at 1:55 p.m. seated in her wheelchair in the hallway near the nursing station on unit two. Three other residents were in wheelchairs across the hallway from Resident #1 near the nursing station. Resident #1 was quiet and her hands had a continuous tremor/shaking motion. Resident #1's clinical record revealed an ongoing history of aggressive behaviors that included hitting, kicking, grabbing, pushing, scratching and spitting at staff, other residents, visitors and self-injurious behaviors. Nursing notes from [DATE] through [DATE] documented 28 incidents of Resident #1 hitting, kicking, spitting and grabbing staff members and residents, and self injurious behavior, in addition to refusing care and medications. On [DATE] Resident #1 demonstrated aggressive agitation when in the dining room. When taken from the dining room to her room by a certified nurses' aide (CNA #6) Resident #1 pushed another resident (#26) when passing her in the hallway. Resident #26 fell and fractured her hip as a result of being pushed by Resident #1, required surgical treatment for [REDACTED]. From [DATE] through [DATE] nursing notes documented 23 additional incidents of Resident #1's ongoing aggressive behaviors that included hitting, grabbing, scratching, biting and striking out. [DATE] through [DATE] documented five incidents of aggressive, unmanaged behaviors. Aggressive behaviors were directed at staff, other residents and a visitor and the resident sometimes caused self inflicted skin tears/scratches. Nursing notes documented the following regarding Resident #1's aggressive behaviors. [DATE] at 7:15 a.m. - "Resident in bed, combative. Strikes out @ recorder & spits when spoken to. Unable to...assess at this time." [DATE] at 6:00 p.m. - "...Striking out @ recorder. Unable to...assess @ this time." [DATE] at 8:45 a.m. - "Crying at times..." [DATE] at 12:20 p.m. - "When toileted per CNA she scratched her L (left) arm & dug her nails in. Squeezing both arms & gritting her teeth. Combative toward staff..." [DATE] at 9:30 a.m. - "When recorder attempted to look @ arm to draw blood, She dug her nails into recorder's arm & was striking out. When recorder turned away she started pinching & scratching her own arms. Unable to redirect...Refused meds..." [DATE] at 11:30 a.m. - "Reached out and pinched a resident for saying 'hello'..." [DATE] at 10:00 a.m. - "...fighting - hitting - spitting scratching - unable to get VS (vital signs)" [DATE] at 11:35 p.m. - "...resident hitting at recorder..." [DATE] at 12:30 a.m. - "Attempted to obtain vital signs (without) success. Attempting to hit recorder & spit at me." [DATE] at 7:00 a.m. - "...grabbing @ recorder..." [DATE] at 5:15 p.m. - "Resident hitting @ recorder. Unable to obtain VS..." [DATE] at 9:00 a.m. - "Pt (patient) awake...hitting, kicking, spitting, scratching..." [DATE] at 11:40 p.m. - "...resident hitting at recorder..." [DATE] at 2:00 a.m. - "Resident lying in bed looking at recorder & began hitting at me." [DATE] at 10:45 a.m. - "Resident scratching & hitting herself. B/a (bandaid) applied...resident ripped b/a off threw it in the floor." [DATE] at 9:45 p.m. - "...skin tear to hand...CNA stated that resident grabbed gown out of his hands (and) later is when he noted skin tear. Resident making scrubbing motion (with) gown." [DATE] at 12:45 a.m. - "Returned to facility from ER (emergency room )...has 3 sutures to index finger on right hand...placed in wc (wheelchair) @ desk due to increase agitation..XXX[DATE] at 8:40 p.m. - "Unable to (change) dsg (dressing) to index finger...d/t (due to) agitation...resident will strike at staff..." [DATE] at 9:40 p.m. - "...Hitting and spitting @ recorder & CNA..." [DATE] at 10:30 p.m. - "Resident refused dsg change, meds. Resident caught hold of phone cord & refused to let go." [DATE] at 6:35 a.m. - "...resident has been combative and fighting and would not allow anyone to change her. Resident was given snacks and drink but this did not change her combativeness." [DATE] at 7:40 a.m. - "Resident in bathtub attempting to pull sutures out of finger..." [DATE] at 10:10 a.m. - Resident was scratching, hitting & kicking @ staff when they were bathing & dressing her...She bit her R (right) index finger & had it bleeding. When recorder asked if she could see it she hit @ her. She was also trying to spit @ staff. Attempted to redirect (without) success." [DATE] at 5:10 p.m. - "...Cont. (continued with) the swinging @ recorder (and) CNA..." [DATE] at 11:15 p.m. - "...Swinging @ recorder while vitals being obtained..." [DATE] at 7:00 a.m. - "...swinging arms @ recorder..XXX[DATE] at 8:00 a.m. - "...Scratching & hitting @ staff..." [DATE] at 11:20 a.m. - "...Resident will hit & scratch staff..." On [DATE] a facility reported incident form documented Resident #1 was "not very cooperative during meal time...hit at the CNA several times...CNA reported that she transported (Resident #1) in wheelchair from the dining room and while pushing her down the hall as they passed, (Resident #26) was standing beside another resident...(Resident #1) pushed (Resident #26) causing her to lose her balance and fall...The CNA stated (Resident #1) 'just did it'..." After the pushing and harming Resident #26 on [DATE] Resident #1 was sent to the emergency room for assessment/treatment of [REDACTED]. The hospital discharge note dated [DATE] listed the resident had "acute behavioral exacerbation - resolved" with instructions for the resident to return to the nursing home. After the emergency room evaluation, nursing notes documented Resident #1 continued with aggressive, unsafe behaviors as follows. [DATE] at 8:00 p.m. - "...skin tear...Res (resident) has been observed grabbing arm and hitting @staff..." [DATE] at 10:53 p.m. - "Resident hitting at and spitting at recorder. Refused to let recorder take vitals." [DATE] at 10:55 a.m. - "Hitting, kicking & spitting @ recorder..." [DATE] at 11:55 p.m. - "...starting striking @ recorder..." (sic) [DATE] at 6:45 p.m. - "Unable to start IV d/t (due to) resident's combativeness..." [DATE] at 9:10 a.m. - "...Combative, hitting recorder while trying to draw blood. Bruising noted on R (right) arm." [DATE] at 8:30 p.m. - "...Resident striking out @ staff. Struck L (left) arm out and hit on w/c (wheelchair) reopened area to L elbow..." [DATE] at 8:15 p.m. - "...Resident also striking out @ staff as well as other residents. Res. was placed in room, however continued to stand (and) attempt to walk...placed in front of nurses station...to try to prevent her from grabbing, striking out or hitting staff or Residents." [DATE] at 6:00 a.m. - "Resident has been fight & hitting @ staff throughout shift...scratched recorder on L hand pulled recorder's hair. Kicking @ recorder and staff..." [DATE] at 10:00 a.m. - "...constantly standing unassisted when staff attempt re-directing, verbal cueing she becomes combative...will strike out at resident or visitors. She will just do it out of nowhere...very combative at this time." [DATE] at 8:20 a.m. - "Resident hitting & scratching recorder's arm..." [DATE] at 1:50 p.m. - "...when the resident refused meds she was hitting & kicking at the staff...failed to get the pulses for her [MEDICATION NAME]." [DATE] at 7:00 a.m. - "Hitting, scratching & kicking during ADL's..." [DATE] at 5:40 p.m. - "Hitting fighting scratching & spitting cont. (continues)..." [DATE] at 11:15 p.m. - "Kicking and hitting @ recorder." [DATE] at 6:40 a.m. - "...changing resident (and) she becomes combative (and) obtains a skin tear...Resident noted pulling cover over her head..." [DATE] at 6:45 a.m. - "...S/T (skin tear)...to fourth digit...continues to swing arms & legs @ staff attemped (sic) to spit @ staff..." [DATE] at 1:40 p.m. - "...was attempting to put on band-aid...she hit the recorder on the top of her hand grabbed me by the arm and I obtained scratches to the arm attempted verbal cueing..." [DATE] at 10:00 a.m. - "Pt hitting, kicking slapping pinching (and) throwing med (physician) on call notified no new order..." [DATE] at 9:00 a.m. - "Trying to scratch recorder (and) CNA during ADL's. Refused to eat..." [DATE] at 8:10 a.m. - Hitting & trying to scratch @ staff..." [DATE] at 7:00 a.m. - "...attempting to hit recorder..." [DATE] at 11:00 a.m. - "...Refused meds...pt hitting, kicking, spitting and grab meds (and) threw them...FNP (family nurse practitioner) witnessed pt - nno (no new orders)..XXX[DATE] at 8:00 a.m. - "Hitting staff...taken to nurses station one on one done, redirection. Continues to hit @ staff..." [DATE] at 9:30 a.m. - "...resident continues to hit @ son (and) staff." [DATE] at 8:40 p.m. - "Resident hitting at, spiting (spitting) at, kicking at, and trying to bite staff when staff trying to perform ADL's..." [DATE] at 9:40 a.m. - "Resident hitting & kicking @ CNA during bath. Scratched CNA while putting on her clothes. Unable to redirect..." [DATE] at 5:25 p.m. - "Unable to obtain VS...d/t (due to) resident hitting @ recorder." There was no effective behavior modification plan developed or implemented to manage Resident #1's behaviors and special needs related to her mental illness. The clinical record documented the resident had not been seen by a psychiatrist since 2008 and was not provided any ongoing treatment by a mental health professional despite ongoing aggressive behaviors. Resident #1's care plan (reference date [DATE]) listed the resident had [MEDICAL CONDITION]. Interventions for management of the condition included medications as ordered, attempt to form a therapeutic relationship with resident, keep same routines, FNP (family nurse practitioner) and pharmacist adjusted behavior medication, monitor for psychomotor disturbances, allow privacy when these episodes occur, promote a sense of acceptance and self worth, encourage relationships with other residents, encourage exercise program, monitor mental status, medications and behaviors, encourage participation in meetings, groups and activities, with [MEDICAL CONDITION] maintain safety, verbal response may not match mood, teach her how to prevent them from occurring, family education, encourage restful sleep, use direct communication, reassure resident she is safe, when danger or violence is imminent, protect resident and others. The care plan documented the resident demonstrated combative hitting, kicking, spitting that was "not always easily altered." Interventions for behaviors included comfort, reassure and support during episodes, show to room as needed, keep familiar objects in room, reorient, encourage family and staff visits, offer snacks, encourage activity, take back to unit if moods/behaviors increase, notify nurse of behaviors. Resident #1's care plan prior to the incident with Resident #26 had similar interventions listed for [MEDICAL CONDITION] episodes and aggressive behaviors. The care plan with [DATE] origin date listed the resident had acute [MEDICAL CONDITION] episodes. Interventions included the same as those listed above in the [DATE] care plan in addition to walking away from the resident and avoiding eye contact. The record documented nursing staff periodically sent notification to the physician about the resident's aggressive behaviors and inability to perform assessments and provide care/services due to her behaviors. Scanned electronic transmissions to the physician documented the following. [DATE] - "...Unable to obtain VS or U/a (urinalysis)...very combative, kicking, and spitting. Refused all meds & food today. Yells out when asked anything." Under physician's orders [REDACTED]." [DATE] - "Unable to draw blood for Chem 7 d/t (due to) resident fighting. Refused meals, threw her tray in the floor. Combative, kicking, hitting & spitting." Physician response was agreement to attempt labs tomorrow. [DATE] - "Resident scratching & digging her nails into staff as well as herself. Refused meds & refused to let recorder draw blood...reattempted later today & she continued to fight..." Physician response was "noted." [DATE] - "Resident refused to walk with Restorative Nursing. She bits (bites), pinch, kicks and spits..." Physician ordered to discontinue restorative services. [DATE] - "...has been refusing meds...staying up on ,[DATE] shift about 4 nights out of the last 7 I have worked until 4 am...is hitting, spitting, and throwing any object that she can get in reach." Physician response was "ask (FNP) to evaluate on Friday." [DATE] - "Res. striking out at staff while preparing her for bed...right arm struck out and hit w/c and re-opened right elbow." [DATE] - "resident fell while walking without assistance...skin tear to right elbow..." Physician approved treatment to skin tear. [DATE] - "Resident became combative during ADL's and obtained 1.5 cm x 0.5 cm skin tear to right posterior hand..." Physician approved treatment to skin tear. [DATE] - "...s/t (skin tear) to....fourth digit with dark purplish color...Continues to swing arm & legs at staff, attempted to spit as staff..." Physician approved treatment for [REDACTED]. [DATE] - "resident noted to have skin tears to bilateral lower arms..." Physician approved treatment for [REDACTED]. Resident #1 was routinely seen by her primary care physician and a family nurse practitioner with no interventions for behaviors initiated other than changes to her psychiatric medication regimen. There was no effective behavior modification plan for Resident #1. The record documented the resident received the medications for treatment of [REDACTED]. Physician/FNP progress notes documented the following assessments/treatment plans for Resident #1. [DATE] - "...Resident has been very agitated hitting at staff. Refusing medications...Acute [MEDICAL CONDITION] to treat UTI." [DATE] - "...She is having no acute problems going on right now...continue therapy." [DATE] - "...She did suffer a laceration to her right index finger. She has approximately 3 [MEDICAL CONDITION] stable...Continue present therapy and medications..." [DATE] - "...she has had an episode where she pushed another resident down, with that resident sustaining a [MEDICAL CONDITION]. She was referred to...psychiatric care and evaluation following that incident...Otherwise she has had no acute medical [MEDICAL CONDITION] present therapy..." [DATE] - "I was going to say goodbye to her and she grabbed my arm, scratched all the way down from my elbow to my wrist. She has been having a lot of incidents recently...Urinary tract infection... [MEDICATION NAME] ten days..." [DATE] - "...was sitting in the chair, constantly trying to get up...fell down, hitting her chin and her right elbow...Witnessed [MEDICAL CONDITION]" [DATE] - "...very uncooperative with her exam. She tries to scratch me several times...This is not out of character for the patient [MEDICAL CONDITION] medication and orders..." [DATE] - "...will continue present therapy..." [DATE] - "...She is on multiple medications for dementia and chronic [MEDICAL CONDITION]. She is on [MEDICATION NAME] Sprinkles, [MEDICATION NAME], and [MEDICATION NAME] Gel, and these seem to manage her behavior fairly well...Chronic [MEDICAL CONDITION] with dementia and agitation...Continue with medications and orders..." Social worker (SW) notes documented on [DATE] attempts were made to have Resident #1 admitted to a geriatric psychiatric facility but no bed was available. The note documented an attempt to admit the resident to another behavioral inpatient facility but it was recorded the "resident was too violent for their population..." The note documented the resident was sent to the emergency room and returned "the same evening with no new orders..." The SW note stated, "There are no Psychiatrists in Halifax Co. that can visit nursing facilities and the Community Services Board refuses to help out with this situation..." The only PASRR (pre-admission screening and resident review) for Resident #1 was completed on [DATE] at the time of the resident's original admission to the facility. The PASRR documented the resident had serious mental illness and required no intense specialized services at that time. There were no other assessments by any mental health agencies to assess/identify Resident #1's special needs related to her serious mental illness and aggressive, unsafe behaviors. Interviews with staff members caring for Resident #1 on a routine basis stated the resident had ongoing aggressive behaviors that were not easily directed and evidenced the care plan interventions were not effective to manage the resident's behaviors. On [DATE] at 4:10 p.m. the registered nurse unit manager (RN #1) was interviewed about Resident #1's ongoing aggressive behaviors. RN #1 stated the resident was not followed by a psychiatrist as they did not have one in the area. RN #1 stated the resident had been treated several years ago by a psychiatrist but he left and had not been replaced. RN #1 stated Resident #1's behaviors had been ongoing and had been directed at staff, others and the resident sometimes scratched herself. RN #1 stated Resident #1 was difficult to re-direct and many times staff would leave her alone and attempt care at a later time. On [DATE] at 9:30 a.m. the certified nurses' aide (CNA #5) that routinely cared for Resident #1 was interviewed. CNA #5 stated the resident frequently would hit, kick, spit and scratch. CNA #5 stated, "I don't know what sets it (behaviors) off. I never know." CNA #5 stated sometimes Resident #1 was "real nice" and then would just start hitting. CNA #5 stated, "She (Resident #1) has hit me, scratched me. I just leave her alone. She's like that with her family too." CNA #5 stated Resident #1 did not have a set routine and was unpredictable with her behaviors. On [DATE] at 8:35 a.m. the licensed practical nurse (LPN #1) routinely caring for Resident #1 was interviewed. LPN #1 stated sometime when you just spoke to the resident she (Resident #1) would "claw or grab" your clothing. LPN #1 stated, "I'll tell her to turn loose. Sometimes she do and sometimes she don't." LPN #1 stated when the resident was aggressive she would "leave her alone and reapproach later." LPN #1 stated she had seen the resident reach out and grab at other residents if they came near her and that Resident #1 sometimes clawed at herself. LPN #1 stated Resident #1 had pinched another resident and pushed a resident down and stated, "You have to watch her very closely when around others." On [DATE] at 8:40 a.m. CNA #7 that also routinely cared for Resident #1 was interviewed. CNA #7 stated Resident #1 had scratched her on the arms when trying to give care. CNA #7 stated, "If someone gets close to her she will reach out to hit them." CNA #7 stated she had seen Resident #1 hit a visitor walking by her. CNA #7 stated when the resident was agitated she would leave her alone and come back another time. On [DATE] at 9:45 a.m., CNA #6 that was with Resident #1 when she pushed Resident #26 was interviewed by telephone. CNA #6 stated regarding the incident on [DATE] that Resident #1 became agitated while in the dining room eating dinner. CNA #6 stated she was rolling Resident #1 in her wheelchair back to her room. Resident #26 was standing in the hallway. CNA #6 stated when they passed by Resident #26, Resident #1 "all of a sudden took one hand and just pushed" Resident #26 and "she (Resident #26) hit the floor hard." CNA #6 stated, "It just happened all of a sudden...You just never know with her (Resident #1)." On [DATE] at 10:15 a.m. the facility's social worker (SW) was interviewed about Resident #1's ongoing, aggressive behaviors and was asked about any psychiatric services/treatment for [REDACTED]. The SW stated, "They said it was ok for her to come back." The SW stated, "We don't have a psychiatrist that we are affiliated with." When asked about any type of behavior management plan to address the resident's unsafe, aggressive, ongoing behaviors, the SW stated interventions for behaviors were in the resident's care plan. As for any special psychiatric/mental health treatment the SW stated, "We would usually do that for behaviors that are non-redirectable...When I work with her she usually wants something." On [DATE] at 11:00 a.m. the director of nursing (DON) was interviewed about Resident #1's ongoing aggressive behaviors and the incident on [DATE] that resulted in Resident #26 sustaining a [MEDICAL CONDITION]. The DON stated Resident #1 was "spontaneous, unpredictable." Regarding any type of mental health services to treat the resident's mental illness and ongoing behaviors, the DON stated they did not have a psychiatrist. The DON stated inpatient psychiatric placement was unsuccessful as there were no beds available. The DON stated the resident was sent out to the emergency room following the incident of [DATE] but returned with no new orders. The DON stated the community services board "didn't do anything" and said the resident was not a candidate for their services. These findings were reviewed with the administrator, director of nursing and unit managers on [DATE] at 4:15 p.m. and on [DATE] at 11:05 a.m. During the review on [DATE] at 11:05 a.m. the administrator stated they were in the process of recruiting/ hiring a psychiatrist. The administrator stated Resident #1 had behavior interventions in her care plan and that all efforts to seek outside help had not been successful. The administrator stated concerning specialized mental health services for Resident #1, "We've exhausted all our options." Resident #26 that was pushed by Resident #1 was admitted to the facility on [DATE] and died in the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] (prior to the fall on [DATE]) assessed Resident #26 as having memory problems and severely impaired cognitive skills for decision-making. This MDS assessed the resident required no physical assistance for ambulating in her room or on her living unit and required set up help only for transfers, eating, dressing and bed mobility. The MDS assessment dated [DATE] documented a significant decline in the resident's functional status after being pushed by Resident #1 and sustaining a [MEDICAL CONDITION]. This MDS documented after the fall/fracture hip Resident #26 was totally dependent upon staff for transfers and required the extensive assistance of one person for bed mobility, dressing, eating and did not ambulate in her room. Resident #26's nursing discharge summary stated, "...walked in the hall periodically (and) had a fall on [DATE] resulting in L hip fx (fracture). She returned on [DATE] (after) having L hip arthroplasty... Family requested hospice d/t (due to) her continuous declining condition. She expired on [DATE]." 2. Resident #4 was admitted to the facility with physician orders [REDACTED]. Resident #4 was admitted to speech therapy services on [DATE] and was discharged on [DATE] because the speech therapist left the facility. At the time of the survey Resident #4 had not had speech therapy for 14 days. Resident #4 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: [MEDICAL CONDITION] (stroke) with [MEDICAL CONDITION], hypertension, dysphagia with a recent PEG (percutaneous endoscopic gastrostomy), [MEDICAL CONDITION] and [MEDICAL CONDITION]. The admission MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assessed Resident #4 as having a cognitive summary score of 05 indicating severe cognitive impairment. At approximately 3:15 p.m. on [DATE], Resident #4 was observed lying in her bed with the head of the bed slightly elevated. A tube feeding pump was at the bedside and was infusing [MEDICATION NAME] 1.2 at 60cc per hour into her PEG as ordered by the physician. On [DATE] at approximately 3:30 p.m., an interview was conducted with a family member (not the responsible party) of Resident #4. During the interview the family member voiced concerns regarding the lack of speech therapy at the facility. Per the family member the speech therapist had left and no one had been in to resume the therapy. The family member stated that while Resident #4 had been at the hospital she was beginning to take "about half a teaspoon" of water by mouth and swallowing it without choking. The family member stated, "I know that's not much but it is a start." The family member also stated that one of Resident#4's favorite things to do had been to cook and eat. Resident #4 had been living at home alone up until the time of the stroke in November. The clinical record was reviewed following the interview. Observed within the clinical record was a physician's orders [REDACTED].[MEDICAL CONDITION] rehab." On the admission POS (physician order [REDACTED]." An order was also observed in the faxed order section of the clinical record that was dated [DATE], which stated: "Speech Therapy 5X (times) week for 90 days. Medical dxs(diagnoses): [MEDICAL CONDITION]. Treatment dxs: exspressive [MEDICAL CONDITION]. ST (speech therapy) to evaluate and treat. Clarification order: ST to evaluate and treat as stated above to focus on OM (oral motor) ex (exercise), therapeutic trial feedings, symbolic lang (language), voice treatment and pt (patient)/caregiver education and training." This order was signed by the speech therapist and the physician. The next faxed order in the clinical record was dated [DATE] and stated: "Please DC (discontinue) ST services, per change in therapist. Pt appropriate for continued services." This order was also signed by the speech therapist and the physician. The care plan dated [DATE] included the problem: "...Potential alteration in Nutrition/hydration requiring feeding tube r/t s/p [MEDICAL CONDITION], impaired swallowing (name of res) is at risk for aspiration due to feeding tube." Interventions included: "...provide ongoing dietary consultation...Provide speech therapy as ordered..." Another problem documented: "Support System: has a strong support system. His/Her family is very active in his/her care." Interventions included: "Staff will notify the family of any changes in the plan of care and/or the condition." Another problem documented: "[MEDICAL CONDITION]." Interventions included: "Notify MD/family of any concerns with condition need for eval/consults, rehab." The interim care plan dated ,[DATE] included under the problem nutritional status/diet/fluid maintenance: "Obtain orders swallowing evaluation as needed." At approximately 8:30 a.m. on [DATE], the Department Manager for the Therapy Department (other staff #2) was interviewed. She was asked what was being done to provide speech therapy to residents at the facility. She stated that the therapist left and she had been unable to find a replacement. "I am working very hard to find a new speech therapist." She stated that the PRN (as needed therapist) that fills in had also been unable to come in and provide services. It was pointed out to Other Staff #2 that Resident #4 had orders for "aggressive [MEDICAL CONDITION]" and that the order included "speech." Resident #4 had not received speech therapy since [DATE] which was 14 days ago. During an end of the day meeting on [DATE] at approximately 4:20 p.m., the DON (director of nursing) and the administrator were notified of the above findings. The administrator stated that "the area is very limited and they were doing everything they could to get a speech therapist ...(name of other staff #2) even went on facebook trying to recruit a friend." Other staff #2 was also in the meeting and she stated that she thought she was going to find someone sooner than what they had. Other staff #2 was asked by the team if she had received notice from the speech therapist that she was leaving and she stated, "Yes, but she thought she was going to stay and she didn't." On [DATE] at approximately 8:15 a.m., other staff #2 came to this surveyor and stated that she had contacted their PRN speech therapist following the end of day meeting on [DATE] and she had come in to do an evaluation for Resident #4. A new order was observed in the clinical record which stated: "ST clarification: ST treat for dysphagia 3x/wk X 4wks." Also observed in the therapy section was the "Dysphagia Plan of Treatment" that was completed on [DATE]. Clinical Impressions listed were: "Pt given trial of nectar thick liquid ...pt had timely swallow on nectar thick, no coughing/choking noted. No changes in respiration noted. NPO (nothing by mouth) nectar thick trials with SLP (speech therapist) only." On [DATE] at approximately 10:00 a.m., the responsible party was in the facility for a meeting with the facility staff. This surveyor spoke with him following the meeting. He stated that he had not been notified by the facility that Resident #4 was not receiving speech therapy. His wife stated tha

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to safely position a resident during incontinence care and provide a physician ordered fall mat for one of 4 residents in the survey sample. Resident #4, a quadriplegic totally dependent upon staff for bed mobility, fell from her bed during incontinence care without a physician ordered fall mat in place resulting in fractures to both of the resident's hips and her right shoulder. The findings include: Resident #4, a [AGE] year old female, was admitted to the facility on [DATE] with a re-admission on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #4 as having independent cognitive skills for daily decision-making. This MDS assessed Resident #4 as weighing 200 pounds (lbs.) and being totally dependent upon one person for bed mobility and transfers. Section G0400 of this MDS assessed Resident #4 as having impaired range of motion on both sides of her upper and lower extremities. The Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing & Allied Health on page 1489 defines quadriplegia as, "paralysis of four limbs; motor and/or sensory function in the cervical spinal segments is impaired or lost due to damage to that part of the spinal cord, resulting in impaired function in the upper limbs, lower limbs, trunk, and pelvic organs." (1) Resident #4 fell from her bed while CNA #2 was providing incontinence care. When CNA #2 was positioning a clean brief under the resident's buttocks with the resident on her right side, Resident #4 fell off the unattended side of her raised bed resulting in fractures to both of her hips and her right shoulder. Resident #4's closed clinical record documented a nursing note dated [DATE] at 12:00 a.m. stating, "resident rolled out of bed onto floor hitting R (right) shoulder c/o (complained of) pain when moved, bruising noted to R arm @ this time, MD called order given to send to ER for eval & tx (evaluation and treatment)..." A facility reported incident form (FRI) dated [DATE] documented Resident #4 fell from her bed while being provided incontinence care by a CNA #2. The FRI documented, "Resident (#4) fell from her bed when the CNA was changing her. She was sent immediately to the emergency room . She returned to the facility @ 6:00 a.m. 6:50 a.m. She was unresponsive and was coded. She went back to the hospital (and) expired @ 0800 (8:00 a.m.)." The facility's follow up letter dated [DATE] documented the following concerning their investigation of the events surrounding Resident #4's fall on [DATE]. The FRI documented CNA #3 was providing care to Resident #4's roommate when CNA #2 came into the room and asked CNA #3 if she needed help with Resident #4. CNA #3 told CNA #2 to wait until she finished with the roommate. The report stated, "...the ,[DATE] shift CNA (#2) started on (Resident #4) alone before she (CNA #3) finished with the resident she was cleaning; this was around 12:00 midnight. The CNA (#3) reported that she heard the ,[DATE] shift CNA call out to her to come over; when she went over to the bed (Resident #4) was out of the bed on the floor with her face down and her right hand on the bed panel..." The report documented, "The ,[DATE] CNA reported that she turned (Resident #4) onto her right side and took the dirty diaper off and was getting ready to put the clean brief under her when the resident fell off of the right side of the bed..." This report documented the resident's bed was at waist height to the CNA providing care. The report documented the CNA's turned the resident onto her back and notified the charge nurse. There was no documentation about the presence of a physician ordered fall mat at the time of the fall. The hospital emergency room (ER) report dated [DATE] stated the resident was diagnosed with [REDACTED]. The ER report dated [DATE] stated, "Pt (patient) fell approx. 3 feet out of bed, c/o pain in the following areas: right arm, right shoulder, right hand, and left leg...History comes from patient...Able to give good history. The patient was being moved in bed and fell out of bed//does not ambulate It is estimated that the patient fell approximately 3 feet...No history to suggest head injury..." X-ray results revealed the resident had bilateral hip fractures and a fracture to her right shoulder as a result of her fall. X-ray reports dated [DATE] stated, "Bilateral acute-appearing subcapital femoral neck fractures displaced with minimal impaction...Fracture of the anatomic neck of the right humerus..." The resident was discharged back to the nursing home with a sling on her right arm and orders to follow up with an orthopedist. An assessment addendum to the ER report dated [DATE] stated, "Pt unable to move all extremities. Pt is a quadriplegic with minimal arm movement and no voluntary movement of the lower extremities. Foot drop noted to feet bilaterally." Resident #4's clinical record documented the resident was a high fall risk. A fall risk assessment dated [DATE] documented the resident was a fall risk due to her inability to walk, bed/chair confinement, incontinence and use of narcotic medications. Resident #4's clinical record documented a current physician's orders [REDACTED]." The resident's plan of care (revised [DATE]) did not document specific interventions or the number of staff required to provide safe turning/positioning in bed during incontinence care. The care plan made no mention of using the physician ordered "E-Z" fall protective mat. The plan of care documented the resident was at risk for falls due to quadriplegia and stated the resident required "total assistance with all ADLs (activities of daily living) daily." A goal listed for Resident #4 was for the resident to "...be free of serious injury." Interventions documented to prevent falls/serious injury included, "Monitor effectiveness of pain management...Keep needed objects on the unaffected side...Therapeutic mattress...Try to approach from the unaffected side if possible...Assist with transfers." Interventions to meet ADL needs included, "Oral care daily...dress, bath, rom to extremities, Transfer to recliner chair with lift or two people...reposition with wedges..." Interventions related to providing incontinence care included, "Position change 4 times QS (each shift) and prn, positioning devices as needed...pericare...keep pressure off of bony prominences..." On [DATE] at 9:00 a.m. the facility's director of nursing (DON) and administrator were interviewed about Resident #4's fall that resulted in multiple fractures. The DON stated Resident #4 "could hold a cup" but had limited use of upper extremities and no voluntary movement of her lower extremities. When asked how one person could safely turn/reposition a quadriplegic weighing 200 lbs, the DON stated CNA #2 "usually handles her (Resident #4) alone." The DON stated that if the resident's legs slipped the resident usually would tell the CNA so they could reposition them to prevent a fall. The DON stated the CNA's would position the resident's hands on the grab rail to help hold the resident in place when they turned her. Concerning the resident's fall on [DATE], the DON stated the fall occurred when CNA #2 was positioning a clean brief under the resident from the back side and Resident #4 fell from the unattended side of the bed. On [DATE] at 9:40 a.m. the registered nurse unit manager (RN #3) responsible for MDS assessments and care plans for Resident #4 was interviewed about Resident #4's fall while one staff person assisted the resident. RN #3 stated the MDS assessment that the resident required one person for assistance was based data input by the CNA's caring for the resident and her assessment of the resident's condition. When asked how the determination that an obese, totally dependent quadriplegic resident could be turned/repositioned safely by one person, RN #3 stated, "She (Resident #4) was already on the unit when I came in November (2010). That's what they said they had been doing with her (one person assistance)." When asked if Resident #4 was capable of holding herself in bed, RN #3 stated, "I can't answer that." On [DATE] at 10:20 a.m. CNA #2 that was assisting Resident #4 at the time of the fall was interviewed by telephone. CNA #2 stated she went into Resident #4's room around midnight to see if the resident needed changing (incontinence care). CNA #2 stated she removed personal items from the resident's bed, let the head of the bed down and raised the bed level up "to about waist height." CNA #2 stated she got supplies and asked the resident to hold onto the grab rail and turned the resident onto her right side. Standing on the side of the bed facing the resident's back side, CNA #2 stated she cleaned the resident and removed the soiled brief. CNA #2 stated when she was pushing the clean brief under the resident's buttocks, the resident rolled off the opposite side of the bed onto the floor. CNA #2 stated, "She (Resident #4) would usually let me know (if she was slipping)...for some reason she didn't tell me." CNA #2 stated she then told CNA #3 who was in the same room with another resident and then got the charge nurse. CNA #2 stated the resident fell "on her right side," was face down on the floor and was complaining of her right shoulder hurting. When asked about the presence of the resident's physician ordered protective floor mat, CNA #2 stated, "She doesn't have a floor mat." When asked if the mat was moved to provide care, CNA #2 stated, "She doesn't have a mat at all." CNA #2 stated Resident #4 was "difficult to move about" in bed because she was obese and could not move her legs. On [DATE] at 2:35 p.m. the licensed practical nurse (LPN #3) in charge on the unit at the time of Resident#4's fall was interviewed by telephone. LPN #3 stated she was administering medications and a CNA told her Resident #4 was in the floor. LPN #3 stated she went to Resident #4's room and observed the resident in the floor beside her bed on her back. LPN #3 stated she assessed the resident's vital signs and asked the resident what had happened and about any pain. LPN #3 stated Resident #4 told her she fell out the bed while CNA #2 was providing incontinence care. LPN #3 stated the resident was alert, oriented and had no obvious cuts or scrapes but did complain of shoulder and leg pain. LPN #3 stated the resident's bed was raised "at about waist height" at the time of the fall. LPN #3 stated she called the physician, 911 and the resident was taken about 12:30 a.m. by the emergency squad to the hospital emergency room . The clinical record documented the resident returned to the facility on [DATE] at 6:00 a.m. with her right arm in a sling with orders to follow up with an orthopedist concerning her fractures. Nursing notes documented the resident was found unresponsive on [DATE] at 6:58 a.m. in cardiac arrest. Cardiopulmonary resuscitation was started and the resident was sent to the emergency room . The resident died at the hospital on [DATE] at approximately 8:00 a.m. These findings were reviewed with the administrator and director of nursing on [DATE] at 4:15 p.m. and on [DATE] at 9:00 a.m. and 10:45 a.m. This was a complaint deficiency. (1) O ' Toole, Marie T. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing and Allied Health. Philadelphia, Pennsylvania: Elsevier, 2003.

Based on observation, staff interview and clinical record review, the facility staff failed to provide a floor mat for injury prevention for one of 16 residents in the survey sample. Resident #109, with a history of falls from her bed, was observed in bed without a protective floor mat in place as required in her plan of care. The findings include: Resident #109 was admitted to the facility on [DATE] with re-admission on 4/6/11. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #109 with short and long-term memory problems and moderately impaired cognitive skills for daily decision-making. This MDS assessed Resident #109 as requiring the extensive assistance of two people for bed mobility and transfers. On 7/27/11 at 9:45 a.m. Resident #109 was observed in bed with no protective floor mat in place. The resident's bed was against the wall on one side with a bed table across the bed near the foot. Resident #109 was observed again on 7/27/11 at 10:45 a.m. and 11:00 a.m. in bed without a protective floor mat beside her bed. Resident #109's clinical record documented the resident had experienced three falls from her bed since her re-admission to the facility on [DATE]. Notes documented the resident was found in the floor by her bed on 4/29/11 and twice on 6/5/11. Resident #109's plan of care revised 7/11/11 documented the resident was as risk for falls. Care plan interventions to prevent injury from falls included "E Z mat at bedside while in bed." Accompanied by the certified nurses' aide (CNA #1) caring for the resident, Resident #109 was observed in bed without a protective floor mat on 7/27/11 at 11:00 a.m. CNA #1 was interviewed at this time about the resident's floor mat. CNA #1 stated she referenced the quick reference care plans for information about safety devices to use with the resident. CNA #1 stated she was a "floater," routinely working on different units as needed and referred to the quick plans for care information by resident. CNA #1 searched under the resident's bed and beside/behind the resident's headboard and did not locate a mat. CNA #1 stated, "She don't have one (mat)." CNA #1 stated, "They had one (mat) for her before. I don't know what happened to it." On 7/27/11 at 11:10 a.m. the registered nurse unit manager (RN #1) was interviewed about Resident #109's protective floor mat. RN #1 stated, "As of yesterday, she had one (mat). I don't know what happened." On 7/27/11 at 11:15 a.m. the licensed practical nurse (LPN #1) caring for Resident #109 was interviewed about a protective floor mat for Resident #109. LPN #1 stated, "I've seen it (mat) in the past. I'm not sure what happened." Resident #109's quick reference care plan referenced by the certified nurses' aide listed use of a bed alarm, chair alarm and low bed but did not document the resident's need for a protective floor mat. These findings were reviewed with the administrator and director of nursing on 7/27/11 at 1:55 p.m. During a follow up meeting with the administrator, director of nursing and unit managers on 7/27/11 at 3:55 p.m. registered nurse unit manager (RN #1) stated the mat was left off of Resident #109's quick reference care plan.