Every finding on record at The Chesapeake

Based on observations, staff interview, resident interviews and facility documentation, the facility staff failed to ensure staffing information was posted on one of one unit in a prominent place and readily accessible to all residents, staff and visitors. The findings included:During the initial tour of the facility on 12/2/2025, there was no observation of the daily posting of the nurse staffing information on the nursing unit. On the second day of survey (12/3/2025), no nurse staffing information was observed on the unit. On 12/3/2025 during a medication pass and pour observation, an interview was conducted with an alert resident who stated he did not know how to determine how many staff members were working.On 12/3/2025 at approximately 12:40 p.m. during lunch time, a visitor was interviewed about the nurse staffing. The visitor stated she did not know where that information was located. On 12/3/2025 at 1:00 p.m., a group interview was conducted by another surveyor with five alert and oriented individuals. The surveyor reported that each resident stated that they did not know where to find information about the nurse staffing each day.On 12/3/2025 at approximately 2:15 p.m., an interview was conducted with the Administrator who stated that the nurse staffing information was posted on the unit. The Administrator walked with the surveyor to the nursing station. The Administrator pointed to a sheet of paper that was leaning against the wall near a binder. The Administrator explained that the paper had the name of the facility, the shift, nursing positions and the census number. The writing font was very small and did not clearly state that the number in the center of each shift represented the census.During the end of day debriefing on 12/3/2025, the Administrator and Director of Nursing were informed of the findings that the nurse staffing information was not readily accessible to all residents, staff and visitors. The writing on the form was very small and difficult to see where placed on the counter, There was no indication of the location of the form for those who were not familiar. No further information was provided.

Based on observation, resident interview, and staff interview, the facility's staff failed to offer and provide snacks at bedtime. The findings included:There were no observations during this survey from 12/02/2025-12/04/2025 of snacks being offered or provided to residents. On 12/03/2025, during the resident group meeting/interview, five Residents (#2, #11, #21, #31, #43) stated that they did not receive nor are they offered snacks mid-day or bedtime regularly. The residents said that it is rare to receive snacks at bedtime. The residents also stated that when they do get snacks, it is in connection with a planned activity. An interview was conducted with the Dietary Manager (DM) on 12/03/25. The DM stated snacks are available to all units and residents, but is unsure about the distribution. On 12/04/2025, an interview was conducted with the Administrator, who stated they have snacks available but agreed that snacks are not offered consistently. On 12/04/25, at approximately 5:00 PM, the above findings were shared with the Administrator, Director of Nursing, and Assistant Director of Nursing. No additional information was provided before survey exit.

Based on observations and interviews, the facility staff failed to ensure the survey results book was readily accessible to residents, family members and legal representatives of residents. The findings included:On 12/02/25 at approximately 2:00 PM., during the facility tour, in the main hall leading to the Health Center Unit a sign was observed on the bulletin board that read Survey Book is available upon request in the main office. On 12/03/25, an interview was conducted with the Administrator concerning the survey book accessibility. The administrator stated that they initially had the survey book available to everyone without needing to request access, but it was moved to the office during construction. On 12/03/25, during the end-of-day meeting, the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were made aware of the findings, and no further information was provided.

Based on observation, resident interview, staff interview, and facility documentation, the facility's staff failed to ensure residents were aware of their right to contact the Ombudsman to advocate for them and of their right to file a complaint with the state certification agency. The findings included:On 12/03/25, during the group resident interview, none of the five residents (#2, #11, #21, #31, #43), that attended were aware of what or who the Ombudsman was or how to contact them. Also, none of the five residents in attendance were aware that they could make a complaint with the state agency or where they could find the information to do so. An interview was conducted with the facility's Activities Director (AD) and the Administrator on 12/03/25, at approximately 4:00 PM. The Administrator states that Resident Rights are addressed on admission and discussed in Resident Council Meetings and in the Resident Handbook. An interview was conducted with the admissions coordinator (AC) on 12/04/25 at approximately 11:30 AM. The AC stated it was a collaborative effort by all facility staff and leadership to inform residents where to find information on contacting the Ombudsman and/or the state agency, but this is addressed on admission and at Resident Meetings. On 12/04/25, during the end-of-day meeting, the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were made aware of the findings, and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide respiratory care consistent with professional standards of practice for 3 Residents (#19, #1 and #42) in a survey sample of 24 Residents. The findings included:1. The facility staff failed to ensure oxygen nasal canula and concentrator tubing were changed according to the physician's order for Resident #19. Resident #19 was admitted to the facility originally on 06/22/2022 and most recently readmitted on [DATE]. On 12/02/2025 at 01:15 PM, an observation was made of Resident #19's oxygen nasal canula and concentrator tubing dated 11/23/2025; the humidification bottle attached to the oxygen concentrator was not dated. A review of the clinical record revealed that the orders for oxygen read: Clean oxygen concentrator and filter, change tubing weekly (every (Q) 7 days). The MAR (Medication Administration Record) was signed off as changed on 11/16/2025 and 11/23/25. On 12/2/25, an interview was conducted with the Assistant Director of Nursing (ADON), who was asked when the oxygen tubing gets changed. She stated that it is done once a week, on Sunday. When asked about the tubing on Resident #19's oxygen nasal canula and concentrator, she stated that it must have been missed and that they have continued to train on the importance of this. On 12/03/25, an interview with the Director of Nursing (DON) was conducted, and she was asked about the expectation that nursing staff change oxygen and concentrator tubing. She stated that she expected that it would be changed according to policy, which is weekly. When asked if that was done in this case, she noted that it was not. On 12/03/25, during the end-of-day meeting, the Administrator, DON, and ADON were made aware of the findings, and no further information was provided. 2. Resident #1. The facility staff failed to ensure the oxygen concentrator tubing and the humidification bottle attached to the oxygen concentrator were changed according to the physician's order for Resident #1. Resident #1 was originally admitted to the facility on [DATE]. The resident's diagnoses included acute and chronic respiratory failure with hypoxia, unsteadiness on feet, pulmonary fibrosis, and heart failure. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 8/22/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated that Resident #1's cognitive abilities for daily decision-making were intact. On 12/2/25 at 1:55 PM, during an observation tour, it was observed that the oxygen concentrator tubing and the humidification bottle attached to the oxygen concentrator for Resident #1 were dated 11/23/25. On 12/2/25 at 2:05 PM an interview was conducted with the Director of Nursing (DON). The DON stated that the date on the oxygen tubing to the concentrator and the humidification bottle attached to the oxygen concentrator for Resident #1 were dated 11/23/25. The DON also stated that the oxygen tubing to the concentrator and the humidification bottle attached to the oxygen concentrator are changed every Sunday and these should have been changed on 11/30/25. A review of the Medication Administration Record (MAR) revealed the following - Oxygen: Mask, Tubing, and Humidifier Change on Sunday – Rinse filters on oxygen concentrator when in use every night shift every Sun. Start Date: 09/03/2025 On 12/4/25 at approximately 5:00 p.m., a final interview was conducted with the Administrator, Director of Nursing, and Assistant Director of Nursing. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information. 3.The facility staff failed to follow the physician orders for the oxygen flow rate, monitor the flow rate and failed to label and date the oxygen tubing for Resident #42. Resident #42 was admitted to the facility originally on 10/09/25, and most recently readmitted on [DATE]. The current diagnoses included; Displaced Intertrochanteric fracture of the left Femur. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/14/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #42's cognitive abilities for daily decision making were intact. A review of the Medication Administration Record (MAR) revealed the following: Oxygen at 2L via Nasal Cannula (NC) every shift for Oxygen therapy beginning 11/08/2025. Oxygen Mask, Tubing and Humidifier Change on Sunday beginning 11/09/2025. The person-centered care plan dated 11/11/25 revealed that Resident #42 was receiving oxygen therapy relating to oxygen shortness of breath (SOB) and hypoxia. The resident's goal was to have no signs or symptoms of poor oxygen absorption, and an intervention was to have oxygen settings at 2 liters via Nasal Cannula as needed. On 12/02/2025 at approximately 2:20 pm., during the initial tour Resident #42 was observed sitting up in her wheelchair receiving oxygen. An observation of the flow rate revealed the resident was receiving 3.5 liters of oxygen via nasal canula, and the resident's oxygen tubing was observed not dated or labeled. The resident said that staff had come in earlier to change her tubing and to increase her oxygen and now she feels comfortable. Shortly thereafter, the Infection Preventionist (IP) entered the room saying to the resident that she was in to change her oxygen tubing. The resident said they came in earlier and changed it. The IP was asked if it was acceptable to not have the oxygen tubing labeled or dated. The IP said it's not acceptable. On 12/04/2025 at approximately 10:11 am, a brief interview was conducted with Resident #42 concerning her oxygen needs. Resident #2 said that she's feeling better this morning. A visual inspection was made of the resident's oxygen flow rate. The flow rate was set at 3.5 liters. On 12/04/2025 at approximately 10:18 am, an interview was conducted with Licensed Practical Nurse (LPN) #2. LPN #2 was asked to verify the resident's oxygen flow rate. Upon visual inspection LPN #2 said it reads 3.5, let me check her orders. LPN #2 returned saying the orders read that the resident should be getting 2.0 liters of oxygen. LPN #2 was observed entering the resident's room, speaking to the resident, observed walking over to the resident's oxygen machine to adjust the flow rate. The Policy revised 12/2025 read: Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and or nasal catheter. Procedure: Verify there is a medical provider's order for this procedure. The order should specify oxygen source, delivery system, flow rate, and if oxygen should be issued continuously or as needed. Documentation: After completing the oxygen set-up or adjustment the following information should be recorded: The date and time procedure was performed. On 12/03/25 at approximately 5:55 pm., during the end of day meeting the Administrator, DON, and Assistant Director of Nursing (ADON) were made aware of the above findings, no further information was provided. On 12/04/25 at approximately 3:45 pm., during pre-exit, the above oxygen flow rate findings were shared with the Administrator, DON, and Assistant Director of Nursing (ADON). No further information was provided.

Based on observation, resident interview, staff interview, and facility documentation, the facility's staff failed to ensure residents were aware of how to file a grievance or complaint. The findings included:On 12/03/25, during the group resident interview, none of the five residents (#2, #11, #21, #31, #43), that attended, were aware of the availability, or how to file a grievance or complaint. An interview was conducted with the facility's Activities Director (AD) and the Administrator on 12/03/25, at approximately 4:00 PM. The Administrator stated that Resident Rights, including how to file a grievance or complaint, are addressed on admission and discussed in Resident Council Meetings and in the Resident Handbook. An interview was conducted with the admissions coordinator (AC) on 12/04/25 at approximately 11:30 AM. The AC stated it was a collaborative effort of all facility staff and leadership to inform residents on where to find information regarding their rights and that it is addressed on admission and at Resident Meetings. The facility's policy titled Resident's Rights, was received and reviewed On 12/04/25 during the end of day meeting the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were made aware of the findings, and no further information was provided.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to follow physician orders for oxygen administration for one (1) of 24 residents in the survey sample, Resident #42.The findings include: The facility staff failed to follow the physician's orders regarding the oxygen flow rate and to monitor it for Resident #42. Resident #42 was admitted to the facility originally on 10/09/25 and most recently readmitted on [DATE]. The current diagnoses included a displaced Intertrochanteric fracture of the left Femur. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/14/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #42's cognitive abilities for daily decision making were intact.A review of the Medication Administration Record (MAR) revealed the following: Oxygen at 2L via Nasal Cannula (NC) every shift for Oxygen therapy beginning 11/08/2025. Oxygen Mask, Tubing, and Humidifier Change on Sunday, beginning 11/09/2025.The person-centered care plan dated 11/11/25 revealed that Resident #42 was receiving oxygen therapy relating to oxygen shortness of breath (SOB) and hypoxia. The resident's goal was to have no signs or symptoms of poor oxygen absorption, and an intervention was to have oxygen settings at 2 liters via Nasal Cannula as needed. On 12/02/2025 at approximately 2:20 pm., during the initial tour, Resident #42 was observed sitting up in her wheelchair receiving oxygen. An observation of the flow rate revealed the resident was receiving 3.5 liters of oxygen via nasal canula. The resident said that staff had increased her oxygen and that she now feels comfortable. On 12/04/2025 at approximately 10:11 am, a brief interview was conducted with Resident #42 concerning her oxygen needs. Resident #2 said that she's feeling better this morning. A visual inspection of the resident's oxygen flow rate was performed. The flow rate was set at 3.5 liters instead of the physician's order of 2.0 liters of oxygen.On 12/04/2025 at approximately 10:18 am, a brief interview was conducted with Licensed Practical Nurse (LPN) #2. LPN #2 was asked to verify the resident's oxygen flow rate. Upon visual inspection, LPN #2 said it read 3.5 liters. LPN #2 left to check the resident's orders. LPN #2 returned, stating the orders indicated the resident should receive 2.0 liters of oxygen via nasal cannula. LPN #2 was observed entering the resident's room, speaking to the resident, then observed walking over to the resident's oxygen machine to adjust the flow rate. The Policy revised 12/2025 read: Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and or nasal catheter. Procedure: Verify there is a medical provider's order for this procedure. The order should specify oxygen source, delivery system, flow rate, and if oxygen should be issued continuously or as needed. Documentation: After completing the oxygen set-up or adjustment the following information should be recorded: The date and time procedure was performed.On 12/03/25 at approximately 5:55 pm., during the end-of-day meeting, the Administrator, DON, and Assistant Director of Nursing (ADON) were made aware of the above findings; no further information was provided. On 12/04/25 at approximately 3:45 pm., during pre-exit, the above oxygen flow rate findings were shared with the Administrator, DON, and Assistant Director of Nursing (ADON). No further information was provided.

Based on staff interviews and clinical record review, the facility staff failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for three (3) of 24 residents (Residents #14, #2, and #18) in the survey sample.Findings include: 1. 1. For Resident #14, the facility staff failed to update her comprehensive care plan to reflect her speaking more Italian and her use of an elbow extension splint. Resident #14 was admitted on [DATE] with diagnosis including but not limited to non-traumatic intracerebral hemorrhage, major depressive disorder, hypertensive chronic kidney disease, contracture, iron deficiency anemia, pain, unspecified, vascular dementia, neuromuscular dysfunction of the bladder and cerebrovascular disease. Her most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/28/25 Section C0500 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 03 out of a possible 15 indicating her cognitive abilities are severely impaired. Section GG 0170 coded her for bathing, dressing, sitting to standing, sitting to lying and chair/bed to chair transfer as substantial/maximal assistance.On 12/3/25, Resident #14 was observed in the activity room coloring. An interview was conducted with the Activity Program Assistant (OTHER STAFF #2), who shared that Resident #14 had begun to speak more in Italian due to her cognitive decline. A review of her comprehensive care plan revealed that the care plan focus: The resident has a communication problem r/t cognitive loss//dementia. Date Initiated: 12/02/2025 failed to address how to communicate with Resident #14 when she begins to speak in Italian.On 12/3/25 a review of physician orders revealed that Resident #14 had an order for Elbow Extension Splint, every day Resident should wear elbow extension splint on the left elbow for contracture management; should be worn daily for 2-4 hours; assess skin and monitor splint placement for comfort and to maintain skin integrity for elbow contracture.Resident #14 was observed with an elbow extension splint on 12/2/25, 12/3/25 and 12/4/25. An interview was conducted with the COTA (OTHER #3) regarding Resident #14's splint, and according to the COTA (OTHER STAFF #3) Resident #14 on therapy caseload and Occupational Therapy (OT) is working with her on elbow extension and the nursing staff applies the splint 2-4 hours a day and the time can vary. The Director of Therapy (ADM#5) verified that OT was working with Resident #14 on her left upper extremity strength to facilitate her functional activities and to help improve her range of motion and coordination to help to increase her independence with activities of daily living.2. 2. For Resident #2, the facility failed to update her comprehensive care plan related to new order for Resident is Comfort Care- NO weights, labs, IV's, x-rays (unless suspected fracture), DO Not send to hospital dated 11/4/25 and to monitor intake and output for Congestive Heart Failure.Resident #2 was admitted on [DATE] with diagnosis including but not limited to bed confinement status, anxiety, history of pulmonary embolism, major depressive disorder, iron deficiency anemia, atrial fibrillation with use of anticoagulants, chronic obstructive pulmonary disease, heart failure, type 2 diabetes mellitus with chronic kidney disease and Alzheimer's disease. Her most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of Section C0500 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 11 out of a possible 15 indicating moderate impairment in cognition (she experiences difficulties with daily functioning and memory support). Section GG 0170 coded her for bathing, dressing, sitting to standing, sitting to lying and chair/bed to chair transfer as dependent.During review of Resident #2's physician orders, an order for Resident is Comfort Care- NO weights, labs, IV's, x-rays (unless suspected fracture), DO Not send to hospital was written on 11/4/25 and an order to discontinue incentive spirometry on 12/2/25.A review of her care plan revealed (6) six care plan focuses related to laboratory monitoring ( monitor laboratory results) did not reflect NO labs per the Comfort Care order dated 11/4/25Care plans focus for: The Resident has COPD (Chronic Obstructive Pulmonary Disease) had an intervention to Encourage incentive spirometry prophylaxis related to COPD with recurrent exacerbation, 10 breaths every hour while awake dated 10/13/25 - order to discontinue incentive spirometry was written on 12/2/25, the intervention remained on the care planCare plan focus the resident has congestive heart failure with an intervention to monitor intake and output without evidence of monitoring the resident's intake and output.3. 3. For Resident #18, the resident's care plan was not updated to reflect code status after being admitted to Hospice services on 11/24/25, and had not been updated after infections resolved.Resident #18 was admitted to the facility on [DATE] with diagnoses to include but not limited to rhabdomyolysis (a rare muscle injury where severely damaged or injured skeletal muscles rapidly breakdown), displaced fracture of the first cervical vertebra, pulmonary hypertension, history of pneumonia, depression, heart failure, cognitive communication deficit and osteoporosis. Her most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/7/25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating her cognitive abilities are intact. Section GG 0170 coded her a dependent on staff for bathing and dressing and sitting to standing and requiring partial/maximum assistance with sitting to lying and chair/bed to chair transfer.A review of Resident #18's physician's orders revealed an order Resident admitted to Amedisys Hospice on 11/24/25 with terminal diagnosis of Alzheimer's Disease and an order DNR (Do Not Resuscitate) dated 11/13/25. A review of Resident #18's care plan revealed the focus of Advanced Directives General: FULL CODE dated 11/10/25.Further review of her care plan revealed: The resident has a urinary tract infection initiated 11/23/25 revised 12/1/25 - no evidence of resident having a urinary tract infection 11/23/25 The resident has pneumonia initiated 11/10/25 revised 12/1/25. Per Infection Control Tracking log pneumonia resolved 11/15/25. Resident is on Enhanced Barrier Precautions for right leg skin abrasions initiated 11/10/25 - no current order for Enhanced Barrier Precautions and during observations 12/2/25, 12/3/25 and 12/4/24 no evidence of signage on door for Enhanced Barrier Precautions or PPE (personal protective equipment) at her door.On 12/4/25 an interview was conducted with the Director of Nursing on her expectations for revising and updating care plans and she responded, Residents care plans should be updated when their condition changes. According to the Director of Nursing, the Assistant Director of Nursing (ADM#7) is responsible for writing and updating all resident care plans. On 12/425 an interview was conducted with the Assistant Director of Nursing (ADM #7) on what her responsibilities were in reviewing and updating/revising care plans and she responded, I make sure that every resident has a baseline care plan within 24 to 48 hours after they are admitted here and then I write the care plans after completion of the MDS (Minimum Data Set Assessment) and then update them when needed.During the interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), care plans for 3 residents were reviewed (Residents #14, #2, and #18) and according to the DON and the ADON the care plans had not been updated to reflect the current condition of the residents. Per the Assistant Director of Nursing, she stated, Yes, I see that those have not been updated.According to the Assistant Director of Nursing, she is responsible for developing and updating care plans based on Resident Assessment Instrument Manual (RAI) guidelines and regulations. The RAI mandates care plan updates whenever a resident's condition changes to reflect the resident's status.According to the Assistant Director of Nursing (ADM#7), the facility staff follow the guidelines for care planning as outlined in the RAI Manual (Resident Assessment Instrument) on care planning.Review of the RAI Manual (Resident Assessment Instrument), October 2023, Pages 4-8 As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care.On 12/4/25, during the end-of-day exit meeting, the concerns were reviewed with the Administrator, Director of Nursing, and the Assistant Director of Nursing, and no further information was provided.

Based on staff interviews and clinical record review, the facility staff failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for one (1) of 24 residents (Resident #18) in the survey sample. The findings included: On 12/3/25 during a clinical record review, it was discovered that Resident #18 did not have a baseline care plan. The first care plan was created on 11/10/25, seven (7) days after admission.Resident #18 was admitted to the facility on [DATE] with diagnoses to include but not limited to rhabdomyolysis (a rare muscle injury where severely damaged or injured skeletal muscles rapidly breakdown), displaced fracture of the first cervical vertebra, pulmonary hypertension, history of pneumonia, depression, heart failure, cognitive communication deficit and osteoporosis. Her most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/7/25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating her cognitive abilities are intact. Section GG 0170 coded her a dependent on staff for bathing and dressing and sitting to standing and requiring partial/maximum assistance with sitting to lying and chair/bed to chair transfer.On 12/4/25 an interview was conducted with the Director of Nursing on her expectations for completing a baseline care plan and she responded, every resident is to have a baseline care plan written within 24 to 48 hours after they are admitted . According to the Director of Nursing, the Assistant Director of Nursing (ADM#7) is responsible for writing and updating all resident care plans. On 12/425 an interview was conducted with the Assistant Director of Nursing (ADM #7) on what her responsibilities were in developing and revising care plans and she responded, I make sure that every resident has a baseline care plan within 24 to 48 hours after they are admitted here and then write the care plans after completion of the MDS (Minimum Data Set Assessment) and then update them when needed. A request was made for a copy of the baseline care plan for 3 residents in the survey sample. She was unable to locate a baseline care plan for Resident #18. She replied, I must have missed that one.According to her, she is responsible in developing and updating care plans based on the Resident Assessment Instrument Manual (RAI) guidelines and regulations. The regulation on pertaining to baseline care plans states A baseline care plan is to be developed and implemented for every resident within 48 hours of admission.On 12/4/25, during the end of day exit meeting the concerns were reviewed with the Administrator, Director of Nursing and the Assistant Director of Nursing and no further information was provided.

Based on clinical record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of her personal and medical record. Personal privacy includes accommodation, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups. The resident has a right to secure confidential personal and medical records. Findings include:The facility failed to ensure privacy and confidentiality of the medical record for 1 resident in survey sample of 24 residents. Resident #49.On 12/2/25, during a clinical record review for Resident #18, a progress note revealed an entry containing the name of another resident, Resident #49. 11/29/2025 21:56 NOTE TEXT: While working at admin desk M.A stated resident (#18) was seated on opposite side of the counter talking with Resident #49 (name redacted). M.A noticed a motion out of corner her eye with the W/C tipping forward. Resident #18 (name redacted) was reaching out towards Resident #49 (name redacted) to pull her closer to her. M.A reached out to Resident #18 (name redacted) and caught her before she landed on floor. Her hands were holding on to the wheelchair, and her legs were stretched in front of her and her bottom was still in the wheelchair. Resident was returned to W/C and was positioned next to M.A within arm's reach.Resident #49 was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia with anxiety, osteoporosis, hypertension, malignant neoplasm of the breast, cardiomegaly and hypertensive chronic kidney disease. Resident #49's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/6/2025 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 07 out of a possible 15 indicating severe cognitive impairment. Section GG 0170coded the resident as requiring supervision or touching assistance for lying to sitting, sitting to standing, chair/bed to chair transfer and toileting. Section GG 0120 coded her as using a walker and or a wheelchair for mobility.Resident #18 was admitted to the facility on [DATE] with diagnoses to include but not limited to rhabdomyolysis (a rare muscle injury where severely damaged or injured skeletal muscles rapidly breakdown), displaced fracture of the first cervical vertebra, pulmonary hypertension, history of pneumonia, depression, heart failure, cognitive communication deficit and osteoporosis. Her most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/7/25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating her cognitive abilities are intact. Section GG 0170 coded her a dependent on staff for bathing and dressing and sitting to standing and requiring partial/maximum assistance with sitting to lying and chair/bed to chair transfer.On 12/3/25 at approximately 10:30 AM, the progress note dated 11/29/25 observed in Resident #18's electronic medical record was shared with the Director of Nursing. During the interview the Director of Nursing was asked whether naming another resident in a resident's medical record was an acceptable standard of practice. She replied, No, that is a violation of her right to privacy and confidentiality.According to Lippincott Manual of Nursing for Standards of Practice for Documentation: Under no circumstances should another patient's name be entered into a different patient's medical chart. This is a violation of professional standards, a breach of patient confidentiality (U.S. federal law HIPPA- Health Insurance Portability and Accountability Act), and a major patient safety risk. Professional documentation in a medical record adheres to strict privacy and accuracy standards. Patient-specific records - every entry in a medical record must pertain solely to the individual patient whose chart it is. Confidentiality (HIPPA) - a patient's name, when linked with any health information, is considered Protected Health Information (PHI). Disclosing this information to unauthorized individuals, including other patients, is a serious HIPPA violation, unless specific conditions for disclosure are met (e.g. for treatment among the care team, or with written patient authorization). Lippincott Manual of Nursing for Standards of Practice: Practice Series: Documentation 2007, 1st edition.On 12/4/25, during the end-of-day exit meeting, the Administrator, Director of Nursing, and the Assistant Director of Nursing were made aware of the findings, and no further information was provided.

Based on observation, staff interview, clinical record review, and review of facility documents, the facility staff failed to cover the catheter bag for 1 of 24 residents (Resident #48), in the survey sample. The findings included:Resident #48 was originally admitted to the facility 8/29/23. The current diagnoses included; urinary tract infection, multiple sclerosis, type 2 diabetes mellitus without complications, major depressive disorder, and muscle weakness. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/10/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #48's cognitive abilities for daily decision making were intact.On 12/2/25 at 3:30 PM during an observation tour it was observed that the catheter bag for Resident #48 was not covered with a privacy bag. On 12/2/25 at 3:35 PM a second observation tour was conducted with the Director of Nursing (DON). The DON observed Resident #48's catheter bag uncovered and stated, there should be a cover over the residents catheter bag. The DON also stated that the reason for this is for the residents privacy and dignity. On 12/4/25 at approximately 5:00 p.m., a final interview was conducted with the Administrator, Director of Nursing, and Assistant Director of Nursing. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observations of the kitchen, interviews, and facility document review, the facility staff failed to maintain an effective infection prevention and control program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections among facility residents.Findings included: On 12/2/25 at 11:40 AM, during an initial tour of the main kitchen, the Assistant Administrator of Culinary Services (ADM# 6) was observed in the main kitchen area without a hairnet, and another employee with a blue uniform top was observed walking through the kitchen without a hairnet. According to the Director of Culinary (ADM# 8) the female observed walking through the kitchen was a server from the Independent Living community. When asked what his expectation was for donning hairnets in the kitchen area, he stated, Everyone should wear hairnets, but she is a server from the independent living area and doesn't work in the health care center, I don't know her nameOn 12/2/25, while exiting the kitchen area, a white bed blanket and a white sheet were observed on the top of a dirty linen bin next to an open basket cart. An interview was conducted with the Chef (Other # 4), and he said, Oh, those are clean and are supposed to be in the clean basket here. As he said that, he was observed taking the white blanket and white sheet from the top of the dirty linen bin and tossing it into the clean open cart. An interview was conducted with the Director of Culinary Services (ADM #8) on what his expectations of maintaining a clean/dirty concept and he responded stating that the laundry staff must have put the blanket and sheet on top of the bin and that they were clean When asked again if he felt this was acceptable in maintaining a clean/dirty concept he stated, Well, I guess it doesn't, we will have to speak with the laundry folks, but this is linens used to wipe up spills on floors and such.On 12/2/25, during the end-of-day meeting with the Administrator and Director of Nursing, they were made aware of the findings. According to the Administrator, she did not feel this was an acceptable practice of good infection control practices. A copy of the facility's infection prevention and control policy was requested. The Director of Nursing provided a copy of the policies.A review of the facility's infection prevention and control policy revealed:Page 1 of 19 Infection control requirement definition: The facility (name redacted) has established and is maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.Page 2 0f 19 - Infection prevention and control program includes (but not limited to) the following elements - wearing gloves and other personal protective equipment (PPE) OHSA considers head coverings like hairnets as personal protective equipment (PPE) that employees must wear especially in food prep or healthcare settings as it is crucial for preventing contamination (like hair falling into food).On 12/4/25, during the end-of-day exit meeting, the following was reviewed with the Administrator, Director of Nursing, and the Assistant Director of Nursing, and no further information was provided.

Based on observation, family interview, staff interviews, and clinical record review, the facility staff failed to ensure the most appropriate pressure reducing bed surface was afforded to a vulnerable immobile resident with a history of Moisture Associated Skin Damage (MASD) to avoid further progression of the area to a stage III pressure ulcer and deterioration to a stage IV for 1 of 25 residents (Resident #15), in the survey sample. The findings included: Resident #15 was originally admitted to the facility 9/10/20, was discharged from the facility 9/23/20, return anticipated and returned to the facility 9/26/20. Resident #15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MD'S) assessment with an assessment reference date (AR) of 12/17/20 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short-term memory problems as well as severely impaired daily decision-making abilities. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with transfers, extensive assistance of one person with bed mobility, eating, personal hygiene, bathing, dressing, and tilting. In section H (Bladder and Bowel), the resident was coded as incontinent of bladder and continent of bowel. Section M of the MDS assessment revealed the resident had a potential for skin breakdown but the assessment was coded for no skin impairments. The 10/19/20 the Braden scale for predicting pressure sore risk score was 13. The tool stated if the Resident's score was 12 or less; consider the resident at risk for pressure ulcer development. (The 1/2021 Braden assessment was omitted). The next Braden scale predictor was completed 3/23/21. The score was 14. The Braden assessment revealed the resident was with very limited ability to respond meaningfully to pressure related discomfort, the residents skin is often to exposed to moisture, the resident is bedfast, has very limited ability to control and change body position, rarely eats a complete meal, requires moderate to maximum assistance with moving to prevent skin friction and shearing. A care plan problem dated 9/26/20 read actual skin breakdown related to delicate skin, immobility, [CONDITION(S)], diabetes, incontinence, behaviors with refusal of care and history of skin breakdown (There is no indication what the problem was at that time for there were no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included; skin risk assessment; Braden scale upon admission, significant change, quarterly and as needed. The interventions included; pressure relieving device in wheel chair. Pressure relief mattress to bed. Lotion skin with care, avoid friction over bony prominences. Check care during ADL care daily. Protective skin barrier after incontinence. Diabetic shoes. Check every two hours for incontinence and change as indicated. A Social Worker's (SW) note dated 2/1/21 read the resident would become a permanent health care resident based on her level of care needs effective 2/1/22. The SW spoke with the sister/Power of Attorney (POA) who agreed to vacate the assisted living (AL) apartment and have the resident remain in the health care unit (HCU). Review of Resident #15's clinical record revealed on 2/9/21 the resident was without any existing skin conditions. On 2/15/21, Resident #15 was observed with excoriation and denuded skin to the sacrum. A new order was obtained for [MEDICATION(S)] 0.025%, [MEDICATION(S)] 2%, [MEDICATION(S)] 20%; apply to sacrum every shift for moisture associated skin damage (MASD). This treatment ended 3/8/21. A care plan problem dated 2/15/21 read; acquired moisture associated skin damage (MASD) to the sacrum, appears as denuded skin. The goal read; Area will resolve within the next 30 days. The interventions included; weekly skin checks and document the results. Treatment as ordered. Monitor for infection, redness, swelling drainage foul smell, decline in function, reduced mobility. This area was documented as resolved 4/12/21. On 2/22/21, an email from the Director of Social Work stated the Director of Nursing (DON) had given permission to swap out the HCU hospital bed for the bed the resident owned in AL. Another email dated 2/24/21 was sent to the facility's staff stating a need to coordinate moving the resident's personal bed with all the belongings on it and her recliner from [NAME] to HCU so the room could be flipped. During an interview with the Certifiecd Wound Care Associate (CWCA) on 1/6/22 at approximately 3:05 p.m., she stated the bed the resident had in AL was not a good choice for Resident #15 because it lacked the pressure reducing components she required, especially with the MASD they were treating. The CWCA was not exactly sure of the date the resident's personal bed was placed in her room but she stated it was a Friday and by Monday the midline buttock (gluteal cleft) Stage III pressure ulcer had developed. The CWCA also stated she would have issued the resident a pressure-reducing mattress overlay because the facility owned an abundance of them and they are readily available. The CWCA stated at the time the resident was observed with MASD, the resident was utilizing a standard pressure-relieving mattress to the bed and she felt it was appropriate for the resident since she required staff to provide turning and positioning and she was incontinent of her bowels and bladder coupled with multiple other co-morbidities. During the phone interview with the complainant on 1/6/22 at approximately 9:30 a.m., the complainant stated she requested Resident #15's personal bed be moved to the HCU but at that time no one explained to her that the bed wasn't appropriate for the resident with her inability to turn and reposition herself. She stated once she was educated she allowed the facility to utilize the recommended bed. An interview was conducted with the DON on 1/6/22 at approximately 5:20 p.m. to determine if she spoke with the POA to educate her why use of the resident's AL bed was not in the resident's best interest especially since she had skin impairment. The DON stated the POA declined to continue with use of the HCU bed, but not that she gave the POA beneficial reasons for the resident to use the HCU bed. The clinical record revealed a wound care note dated 3/5/21 at 14:23, which read; midline buttock (gluteal cleft) presents with a full thickness open area with 100% granulation tissue. No drainage and the skin surrounding the open area is intact. The skin evaluation form dated 3/5/21 described the midline buttock (gluteal cleft) as measuring 3.0 centimeters (cm) by width 2.0 centimeters and depth of 0.8 centimeters. The wound was classified as a healing stage III pressure ulcer. The treatment ordered read; Clean the midline buttock (gluteal cleft) with normal saline, pat dry, apply Solosite wound gel, apply gauze and cover it with a foam dressing daily and as needed. (This treatment ended 3/15/21). On 3/7/21, a nurse's note read; air mattress overlay functioning, which was a nursing judgement and did not require a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/15/21 the midline buttock (gluteal cleft) presented wound had deteriorated. It presented with 60% granulation tissue and 40% yellow slough and measured length 4.0 centimeters by width 1.0 centimeters by 0.3 centimeters. There was no drainage. The sacrum was with denuded skin. The treatment order dated 3/16/21 read; cleanse the midline buttock (gluteal cleft) with normal saline, pat dry, apply Santyl to the wound bed, apply Triad to the periwound and cover with a foam dressing daily and as needed. A care plan dated 3/29/21 read; Pressure Ulcer present Gluteal Cleft stage III, related to bed change. The goal read; Pressure ulcer will be without signs/symptoms of infection through the next review. The interventions read; nurse to measure and monitor wound status, progression or deterioration every week. Notify MD and family of changes. Treatment as ordered. Dietary consult to consider nutrition, hydration healing factors. Supplements as ordered. Frequent turning and repositioning to off-load throughout each shift. Pressure relieving device in wheel chair (gel cushion), Pressure reducing mattress (AP+). Float heels in bed. The 4/22/21 skin evaluation revealed the midline buttock (gluteal cleft) presented with 100% granulation tissue but measured; length 3.9 cm by width 3.0 cm by depth 0.6 cm. The treatment was changed to cleanse the midline buttock (gluteal cleft) with normal saline, pat dry, and apply Santyl to the wound bed pack lightly with [MEDICATION(S)] II plain cut to the size of the wound. Apply Triad to the periwound. Cover it with a foam dressing, change daily and as needed. The wound remained classified as a healing stage III. On 6/21/21 Resident #15's pressure ulcer again presented with deterioration after it had shown improvement 4/26/21 through 6/18/21. The 6/21/21 skin evaluation revealed the midline buttock (gluteal cleft) presented with 70% granulation tissue and 30% slough with exposed muscle. A note stated there was a small amount of drainage. The wound measured; length 4.0 cm by width 3.0 cm by depth 1.5 cm. The note stated to continue with the same treatment ordered 6/18/21. The treatment read; to cleanse the midline buttock (gluteal cleft) with normal saline, pat dry, apply Medi-honey calcium alginate - honey; cut to the size of the wound. Pack lightly fluffed dry 4x4 gauze and cover. Then apply skin prep to the peri-wound and cover with foam dressing, change every three days and as needed. The wound was upgraded to a stage IV. The clinical record revealed an order dated 6/18/21, which read; a low air loss/alternating air mattress to the bed to assist with healing of the sacrum wound. The facility's policy titled; Wound Care Protocol with a revision date of 9/9/21 read on page 6; for a stage II pressure ulcer apply an air pro mattress (a mattress with air cells that expand and contract on an alternating basis to continually reduce pressure) to the bed. Based on the facility's policy information Resident #15 was not advanced to and placed on the air pro mattress on 3/5/21 and instead placed on a mattress overlay (a water, gel, air, or foam device applied on top of a mattress to prevent pressure ulcers) on 3/7/21. The 6/28/21 skin evaluation indicated further deterioration of the midline buttock (gluteal cleft) pressure ulcer. It presented with 70 % granulation tissue and 30% yellow slough with exposed muscle. There was a small amount of drainage and an odor. The wound measured; length 4.0 cm by width 3.0 cm by depth 1.5 cm. The note stated to continue with the same treatment ordered 6/18/21. The treatment read; to cleanse the midline buttock (gluteal cleft) with normal saline, pat dry, apply Medi-honey calcium alginate - honey; cut to the size of the wound. Pack lightly fluffed dry 4x4 gauze and cover. Then apply skin prep to the peri-wound and cover with foam dressing, change every three days and as needed. The wound was upgraded to a stage IV. On 7/5/21 the skin evaluation revealed with further deterioration of the midline buttock (gluteal cleft) pressure ulcer. It presented with 60% granulation tissue and 40% yellow slough with exposed muscle. There was serosanguinous drainage and no odor. Undermining was observed at 9 o'clock 2.2 cm, 12 o'clock 3.5 cm, and at 6 o'clock 0.8 cm. The wound measured; length 4.4 cm by width 2.0 cm by depth 2.0 cm. The note stated new treatment orders were received. The treatment read; to cleanse the midline buttock (gluteal cleft) with normal saline, pat dry, apply Santyl to the wound bed pack lightly with [MEDICATION(S)] II plain cut to the size of the wound. Then apply z-guard and skin prep to skin where the foam dressing will be placed, cover with foam dressing, change every day and as needed. The wound was upgraded to a stage IV. On 7/9/21 at the POA's request the resident was transferred to a local emergency department where she was admitted and diagnosed with [CONDITION(S)] of the wound. The resident returned to the facility 7/13/21. On 7/28/21, the resident began wound evaluations/treatment at a local wound care clinic and continues the service. On 1/5/22 at approximately 12:45 p.m., just before the resident was transferred to the wound care clinic, an observation of wound care was made. The wound measured by sight at approximately length 4.0 centimeters by width 1.0 centimeters. The depth couldn't be estimated but at eleven o'clock, dark tissue was observed and the wound bed contained dark red tissue. There was no drainage and no odor. The resident tolerated the procedure without moaning, hitting or indications of discomfort. During the survey week 1/4/22 through 1/6/22 observations were made of the staff turning and repositioning the resident with no resistance of care was observed but there was some indications of discomfort (grimacing, moaning). An interview was also conducted with Licensed Practical Nurse (LPN) #2. LPN #2 stated Resident #15 is compliant with medication administration and wound care, staff feeds the resident and her intake is usually approximately 75% of most meals. LPN #2 stated she speaks calmly to the resident during care to prevent her from pushing and crying out. She also stated wedges and pillows are used to position the resident for pressure reduction to the pressure sore. An interview was conducted with the primary day shift Certified Nursing Assistant (CNA) #3 on 1/61/21 at approximately 12:07 p.m. CNA #3 stated the resident doesn't resist care but does cry out when turn and repositioned especially over lumps of linens and she often experiences discomfort of the left foot when it is moved. CNA #3 stated the resident is only positioned on her back for meals and for approximately 20 minutes after the meal otherwise she is turned from side to side and a wedge is placed at her back and pillows between her legs. CNA #3 stated if the resident goes out for an appointment she goes by stretcher and she only sits in a low back wheel chair if she's going to the beauty shop. CNA #3 further stated the resident is fed all meals and has a good appetite. On 1/6/22 at approximately 6:38 p.m., the above findings were shared with the Administrator, Director of Nursing and Wound Care Nurse. An opportunity was offered to the facility's staff to present additional information but they declined. The information below was obtained on 1/19/22 at (https://www.ncbi.nlm.nih.gov/books/NBK 0/). Pressure-relieving mattresses and support surfaces can lower the risk of pressure ulcers. There are now many different products that can be used in hospitals, nursing homes or at home. Most of them offer especially soft surfaces or alternating pressure. Special foam mattresses can be used to provide a soft surface, for example. These distribute the pressure over a larger surface area, reducing the pressure on especially vulnerable parts of the body. One drawback of very soft mattresses is that they can make it more difficult for people to move themselves. If they sink into the mattress, it can be harder for them to prop themselves up and change positions. This is a problem especially for weaker people who would actually still be able to change their position on their own. Therefore, it makes sense to check what kind of mattress is most suitable. Special mattresses known as alternating pressure mattresses are also commonly used and can help to prevent pressure ulcers. These mattresses have several chambers that are automatically filled with different amounts of air. The air pressure usually changes several times an hour to relieve pressure on different parts of the body. Alternating pressure mattresses are most often used for patients who have an especially high risk of developing pressure ulcers - such as patients in intensive care who are on a ventilator and can't move on their own. The information below was obtained on 1/18/22 from https://www.woundsource.com/patientcondition/moisture-associated-skin-damage-masd# Moisture-associated skin damage (MASD) is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or [MEDICATION(S)]. The information below was obtained on 1/18/22 from https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/webinars/webinar6_pu_woundassesst.pdf * A stage III Pressure Ulcer: Definition · Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Some slough may be present. ·May include undermining and tunneling Description The depth of a stage III pressure ulcer varies by anatomical location. - The bridge of the nose, ear, occiput, and malleolus do not have adipose subcutaneous tissue and stage III ulcers can be shallow. - In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. *Bone/tendon is not visible or directlypalpable A Stage IV Pressure Ulcer: Definition o Full thickness tissue loss with exposed bone, tendon, or muscle - Slough or eschar may be present. o Often include undermining and tunneling Description o The depth of a stage IV pressure ulcer varies by anatomical location. - The bridge of the nose, ear, occiput, and malleolus do not have adipose subcutaneous tissue and stage IV ulcers can be shallow. o Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making [CONDITION(S)] or osteitis likely to occur. o Exposed bone/tendon is visible or directly palpable. An Unstageable Pressure ulcer: Definition o Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Description o Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined but it will be either a Stage III or IV. o Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. *Tunneling. Tracts extending out from the wound. COMPLAINT DEFICIENCY

Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure that 1 of 25 residents (Resident #30) in the survey sample received a complete and accurate assessment Minimum Data Set (MDS). The findings included: The facility staff failed to ensure the significant change MDS with an Assessment Reference Date (ARD) of 12/02/21 under Section M (skin conditions) for the number of stage III pressure ulcers that were present upon admission/reentry into the facility was accurate for Resident #30. Resident #30 was originally admitted to the nursing facility on 03/07/04 with a readmitted [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30's Minimum Data Set (MDS-an assessment protocol) significant change MDS with an ARD of 12/02/21 coded a 08 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The comprehensive care plan with a revision date of 11/29/21documented Resident #30 has a stage three sacral pressure. The goal set for the resident by the staff is there will have no further open areas caused by pressure or friction. Some of the interventions to manage goal include turn every 2 hours, prompt incontinence care, encourage resident to allow staff to turn and reposition with the use of pillows and/or wedge, air pro mattress to bed; check placement and function every shift (effective 11/13/19). Review of Resident #30's skin evaluation form dated 11/22/21 revealed the following: facility acquired open area with darker area presented with 95% granulation tissue and 5% slough measuring 1 cm x 1 cm with light serous drainage. Review of Resident #30's significant change MDS with an ARD date of 12/02/21 was coded under section M (skin conditions) the resident presented with a stage III pressure ulcer when admitted /reentry into the facility. An interview was conducted with MDS Coordinator on 01/05/22 @ 12:35 p.m. The MDS Coordinator was asked to review Resident #30's significant change MDS with an ARD date of 12/02/21 for the accuracy of section M (skin conditions) for being admitted with a stage III sacral pressure ulcer or if the pressure ulcer was facility acquired. On the same day at approximately 2:15 p.m., the MDS Coordinator stated, The MDS is not accurate, the resident's stage III pressure ulcer was facility acquired. A debriefing was conducted with the Administrator, Director of Nursing (DON) and Staff Development Coordinator/Quality Assurance (QA) on 01/06/22 at approximately 6:38 p.m. The facility did not present any further information about the findings. CMS's RAI Version 3.0 Manual - Chapter 1: Resident assessment Instrument (RAI). -An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to send a copy of one resident's care plan (Resident #23) after being transferred to the hospital for 1 of 25 residents in the survey sample. The findings included: The facility staff failed to send Resident #23's care plan to include their goals when discharged and admitted to the hospital on 11/16/21. Resident #23 was originally admitted to the nursing facility on 10/02/19 and readmitted to the facility on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23's Minimum Data Set (MDS-an assessment protocol) an admission assessment with an Assessment Reference Date (ARD) of 11/23/21 coded a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. Review of Resident #23's admission MDS assessment with an ARD of 11/23/21, under Section G (Functional Status) was coded requiring extensive assistance of two with transfer and bed mobility, extensive assistance of one with dressing, hygiene and toilet use, limited assistance of one with bathing and supervision with one assist with eating for Activities of Daily Living (ADL) care. The Discharge MDS assessments was dated for 11/16/21 - discharge return anticipated. Resident #23 was readmitted to the nursing facility on 11/17/21. Review of Resident #23's clinical record revealed the following documentation entered on 11/16/21 at approximately 10:05 p.m., Resident #23 will be leaving for his surgery later this morning and will return to the facility until able to secure a safe discharge plan. He did not note any negative moods but acknowledged he is moving more slowly due to the right shoulder fracture. The clinical note did not provide evidence that the resident's care plan was sent when discharged to the hospital on 11/16/21. An interview was conducted with the Administrator on 01/05/22 at approximately 1:01 p.m., who stated, We were not able to find documentation in Resident #23's clinical record that the care plan was sent with him when discharged and admitted to the hospital on 11/16/21. A debriefing was conducted with the Administrator, Director of Nursing (DON) and Staff Development Coordinator/Quality Assurance (QA) on 01/06/22 at approximately 6:38 p.m. The Director of Nursing stated, The purpose of sending the resident's care plan when a resident is being discharged and admitted to the hospital is to continue with their plan of care.

Based on staff interviews, facility documentation review and clinical record review, it was determined that the facility staff failed to notify a state agency of misappropriation of stolen property in a timely manner for one of 25 residents in the survey sample, Resident #4. The findings include: Resident #4 was originally admitted to the nursing facility on 02/09/2017. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #4's Minimum Data Set an Annual assessment with an Assessment Reference Date (ARD) of 10/11/21 coded Resident #4 a 9 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS),This indicated Resident #4 cognitive abilities for daily decision making were moderately impaired. The facility staff failed to provide personal care to include showers for Resident #4 in the survey sample who was unable to independently carry out Activities of Daily Living (ADL's). In addition, the MDS coded Resident #4 requiring physical help of one person with bathing. Requiring extensive assistance of one person with bed mobility, transfers, dressing, toilet use and personal hygiene. The care plan dated 2/09/17 reads: Resident requires assistance with ADL's (Activities of Daily Living) related to increased weakness, increased falls, decreased mobility. Increased discomfort, and impaired gait. Resident will receive assistance with all ADL's as evidenced by good grooming, neat and clean appearance, and be free of body odors daily through next review. Intervention: Bathing: Shower/bed bath. Staff to complete bathing care as needed. Resident requires: Minimum assistance with one person assistance. The FRI (Facility Reported Incident) Initial Report Date: 10/15/21. Incident Date: 10/11/21. Notification to Responsible Party: 10/11/21. Notification to Physician: 10/11/21. Notification to Law Enforcement: 10/15/21. Notification to Office of Licensure and Certification (OLC): 10/19/21. Incident Type: Resident Property. Incident description reads: On the evening of 10/11/21, CNA (Certified Nursing Assistant) notified supervisor of resident missing engagement ring. Resident usually has engagement ring on chain that is gold in color around. Investigation initiated and ongoing. Resident representative notified. Medical provider notified. Police report submitted. Employee Action Taken: See Final Investigation. A review of the final investigation reveal that Resident's routine caregiver notified the evening supervisor that she found the resident's necklace on the nightstand and the diamond ring was missing. Investigations were initiated. The resident stated that the girl came in and took off my necklace, left and then came back. She could not recall the day, time or name of the individual. She was unable to provide a description. The resident's representative, Medical Director and a police report was filed as well as resident's room was searched. Review of the facility FRI's (facility reported incidents) revealed that a FRI was not submitted to the OLC (Office of Licensure and Certification) in a timely manner. (According to the documentation the incident occurred on 10/11/21 (Monday), but was reported to VDH/OLC on 10/19/21 (Tuesday) (Excluding Saturday and Sunday) was six days reporting to VDH/OLC.) On 01/05/22 at 2:09 PM, during the initial tour an interview was conducted with Resident #4. She was asked if she had any missing property. She stated, Someone stole my diamond ring a few months ago. On 1/06/22 at approximately 11:00 AM., an interview was conducted with the DON (Director of Nursing) concerning missing property for Resident #4. She confirmed that resident #4 reported that she was missing jewelry and an investigation was made. On 1/06/22 an interview was conducted with the Administrator at approximately 6:30 PM., concerning Resident #4's FRI/Facility Reported Incident. She stated that an investigation was made as well as a police report filed. The case is still ongoing pending the police report. When asked if she notified OLC within the required 5 days of reporting the incident she stated, I forwarded the incident to Virginia Department of Health on 10/19/21. On 1/06/22 an interview was conducted with Resident's niece at 5:25 PM., concerning the incident above. She stated, My aunt had her 3 carat wedding ring stolen. She had the ring for over forty-five years. She started wearing her ring and her late husband's ring around her neck for a few years because her ring had gotten too big on her fingers. RN (Registered Nurse) #1, said that a CNA (Certified Nursing Assistant) said that she saw the necklace on the night stand. A report was filled out by RN #1. I called the administrator and she stated that she was never told about the incident. I called the police detective and they never called me back. The administrator said that she will talk to the workers concerning the stolen ring. Received a copy of Handbook for the Health Care Center from the administrator on 1/06/22: Highlighted in the Handbook was the Lost and Found section. It reads: The Chesapeake is not responsible for replacing lost or misplaced items by Resident to include dentures, hearings aids and other valuables. Residents are asked to maintain valuables off site and to lock money in the secure box in their accommodation. A review of the abuse training documents show that in-services were conducted with staff members on 10/20/21 concerning Misappropriation of Property. The Policy: Abuse dated: 5/21/21 Reads: Misappropriation: Of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Investigation: The designated staff will immediately review and investigate all allegations or observations of abuse. The result of all investigations are to be communicated to the administrator or his or her designated representative and to other officials in accordance with state law, including to the State Survey Agency, within 5 working days of the incident and if the allege violation is verified appropriate correction action must be taken. A pre-exit interview was conducted on 1/06/2022 at approximately 6:40 PM. The above findings were shared with the Administrator, Director of Nursing and Licensed Practical Nurse of Staff Development and Quality Assurance. No concerns were voiced at this time.

Based on clinical record review, staff interview and facility documentation review, the facility staff failed to ensure 1 of 25 residents (Resident #46) in the survey sample was given the opportunity to formulate an Advance Directive. The findings included: Resident #46 was admitted to the nursing facility on 11/04/20. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #46's Minimum Data Set (MDS-an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 12/27/21 coded a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no impaired cognitive skills for daily decision-making. Review of Resident #46's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of Resident #46's clinical record did not show evidence of an Advance Directive. On 01/06/22 at approximately 1:47 p.m., an interview was conducted with the Social Worker, who stated, The process for obtaining the resident's Advance Directive is discuss during the admission process. He stated, Somehow getting the information related to Resident #46's Advance Directive was just overlooked. A debriefing was conducted with the Administrator, Director of Nursing (DON) and Staff Development Coordinator/Quality Assurance on 01/06/22 at approximately 6:38 p.m. The facility did not present any further information about the findings. The facility's policy titled Advance Directives with a review/revised date (01/10/17) included but not limited to: Policy: The resident has the right to request, refuse, and/or discontinue treatment to participate in or refuse to participate in experimental research, and to formulate an advanced directive. -Prior to or upon admission to a license area or program of the (name of facility), the resident shall be provided orally and in writing, information concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directive by the social worker or designee. Definitions: -[CONDITION(S)] is the most common type of arrhythmia. An arrhythmia is a problem with the rate or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm (www.Nhlbl.nih.gov).

Based on review of nurse staffing and staff interviews, the facility staff failed to have a Registered Nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week. The findings included: Review of RN coverage from October 1, 2019 through January 12, 2020 revealed there was no RN for at least 8 consecutive hours on 10/19/19. On 1/14/20 at 1:30 p.m., during an interview with the Assistant Director of Nursing (ADON), she verified they were absent an RN on 10/19/19 for at least 8 hours within a 24 hour timeframe. On 1/14/20 at 5:30 p.m., an interview was conducted with the Director of Nursing (DON). She stated the facility did not have a staffing policy related to RN coverage within a 24 hour period, but she was aware of the requirement. On 1/14/20 at 5:45 p.m., the aforementioned issue was reviewed with the Administrator and no further information was provided prior to survey exit on 1/15/20.

Based on observation and staff interview, the facility staff failed to ensure garbage and refuse were disposed of properly. The findings included: During the outside garbage and refuse observation at 12:45 P.M. on 01/14/20 the following were observed in the outside area: one discarded wheelchair, one discarded merry walker PCV pipe frame, 14 pallets, one bed side dresser, one cabinet, and copious amounts of card board boxes, paper, trash and debris. The area around the grease disposal container was noted to have copious amounts of spillage on the concrete flooring with trash and debris. During an interview with the Dietary Manger on 01/14/20 at 1:05 P.M. she stated, it was the Maintenance Department responsibility to maintain the refuse and garbage area. She would have them to clean the area immediately.

Based on observations and staff interviews, the facility staff failed to handle, prepare and store food in a manner to prevent food borne illness potentially affecting most residents in the facility. The findings included: During the initial kitchen inspection at 11:30 A.M. on 01/13/20 a male staff member was observed in the kitchen and dish washing area without a beard guard. On 01/14/20 at 11:15 A.M. a male staff member was observed in the kitchen and dish washing area without a beard guard. On 01/15/20 at 9:45 A.M. a male staff member was observed in the kitchen and dish washing area without a beard guard. During an interview on 01/13/20 at 12:30 P.M. with the Dietary Manager she stated, all staff in the kitchen are aware that hair nets and beard guards must be worn at all times.