Every finding on record at The Virginia Home

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to prevent accidents that resulted in fractured bones for two of 31 residents in the survey sample, Residents #43 and #71. This was cited at harm past non-compliance. The findings include: 1. For Resident #43 (R43), the facility staff failed to transfer the resident with a Hoyer mechanical lift, per the resident's plan of care. This resulted in a fall and R43 sustained a fractured clavicle. R43's comprehensive care plan dated 7/31/17 documented, (R43) requires assistance with ADL (activities of daily living) tasks r/t (related to) Dx (diagnoses): Cerebral Palsy, Spasticity and Mood Disorder. Approaches/Tasks: FULL MECHANICAL LIFT-Hoyer Lift for all transfers. R43's kardex dated 1/28/23 documented, Transferred using full mechanical lift (Hoyer). A review of R43's clinical record revealed a nurse's note dated 1/28/23 that documented, CNA (Certified Nursing Assistant) reported res (resident) fell to to [sic] floor during transfer. res was yelling before bed, CNA says she didn't [sic] feel comfortable with hoyer transfer so she did stand and pivot transfer from w/c (wheelchair) to bed. her shoe on right foot not on all the way, res slipped and fell on top [sic] of CNA on the floor. CNA rolled her to her back to get help. assessed and transferred by hoyer to the bed x3 [times three staff]. c/o (complained of) pain to left shoulder, no signs of injury. ice applied and tylenol given. res said she did not hit her head. mother notified. vitals normal. X-ray results dated 1/30/23 documented an acute distal clavicle fracture. A facility synopsis of events dated 2/3/23 documented, On Saturday January 28, 2023, (R43) sustained a clavicle fracture after being transferred from her wheelchair to the bed . (CNA #1) C.N.A. was interviewed on 2/3/23 by (ASM [administrative staff member] #2), DON (Director of Nursing) in regard to fall related transfer on 1/28/23 with (R43). She asked (CNA #1) if she knew what the documented transfer method was for (R43). (CNA #1) stated that it was a Hoyer transfer with two staff members. (ASM #2) asked her why she tried to execute a stand pivot transfer instead of following the care plan. (CNA #1) said she felt more comfortable doing it that way because of her behaviors. The resident was noted to have been yelling during this shift 3PM to 11PM. (CNA #1) explained the fall incident by saying she [sic] that she stood the resident up from her power wheelchair and her right shoe came off. The change in balance then precipitated the fall .Unfortunately, humans [sic] error caused this incident by diverting from the care plan for transferring the resident. CNA #1 was not available for interview during the survey. On 7/18/23 at 3:53 p.m., an interview was conducted with CNA #2. CNA #2 stated the CNAs are made aware of how a resident should be transferred via a sign on the back of the resident's room door, the resident's care plan, and in the computer system when documenting transfers. CNA #2 stated it is important to follow a resident's care plan for transfers for safety reasons. On 7/18/23 at 4:33 p.m., ASM (administrative staff member) #1 (the executive vice president) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Mechanical Lifts and Transfers documented, Residents who need assistance to transfer to bed or chair will have their Care Plan reflect the proper method .Full body mechanical lifts are to be used with a two person transfer only . A facility plan of correction dated 2/1/23 documented, Staff member transferred the resident using stand pivot instead of 2 person Hoyer lift. Resident slipped and fell on top of C.N.A. Resident was transferred to bed via Hoyer lift and 3 staff assist. 1. Resident complained of left shoulder pain after fall, assessment was completed by Charge nurse with no signs of injury noted. (R43) received Tylenol and ice was applied for complaint of pain. 1/29 resident again complained of pain. MD (Medical Doctor) notified, and X-Ray was ordered. 1/30 X-Ray showed left distal clavicle fracture. MD and mother were notified. Referral to (name of orthopedic company). 1/31 resident was seen by MD at (name of orthopedic company), ice and rest ordered. 2. All residents that are transferred incorrectly are at risk of injury. 3. Staff member that did the incorrect transfer was interviewed and stated that she knew the resident was a 2 person Hoyer transfer and she did a stand pivot instead. Staff member was terminated for not following correct procedure. Staff Development Coordinator to educate all nursing staff on the Mechanical lift Policy. 4. The Nursing Supervisor/Manager on each shift will monitor weekly for 4 weeks staff compliance. 5. Dates of Completion: 4/4/23. Credible evidence for this plan of correction was verified during the survey. Past non-compliance. 2. For Resident #71 (R71), the facility staff failed to properly transfer the resident with a sit to stand lift by utilizing the leg strap. This resulted in a fall and R71 sustained a fractured right ankle. R71's comprehensive care plan dated 7/26/17 documented, (R71) is at risk for falls r/t (related to) altered mobility, disease process and use of psychotropics. Approaches/Tasks: Transfers-Use sit to stand lift for all transfers . R71's kardex report dated 2/20/23 documented, Transfer using the sit to stand lift only. The care plan and kardex failed to document specific instructions for using a sit to stand lift. A nurse's note dated 2/20/23 documented, Assigned cna (certified nursing assistant) was transferring resident from shower chair using a seat [sic] to stand lift, Res. (Resident) fell on her knees landing on right leg. c/o (Complained of) pain to right leg, upper and lower leg X-ray ordered. A note signed by the orthopedist on 2/21/23 documented a non-displaced right ankle fracture. A facility synopsis of events dated 3/1/23 documented, On Monday February 20, 2023, (R71) sustained a ground level fall while being transferred in her room from shower chair to her wheelchair. Initial reports of right leg pain and x-ray were negative. The following day, however, the resident complained of right ankle pain and exhibited swelling in the right ankle. Additional x-rays revealed a fracture in the right ankle .At the time of the fall, (R71) separated her feet of [sic] the foot plates of the sit-to-stand lift and from there tilted forward and slid to the ground from her position in the shower chair. (CNA #2) confirmed there was no lower leg strap used during the transfer which was her omission. Logically, the use of the strap may have prevented this fall .Unfortunately, as the C.N.A. mentioned in our discussion, she lost her focus and did not use the lower leg strap to help stabilize the resident during the transfer. This incident was caused by human error and by diverting from the care plan for transferring the resident . On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/27/23, R71 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. On 7/18/23 at 8:33 a.m., an interview was conducted with R71. The resident stated she has not refused leg straps while being transferred with the sit to stand lift. On 7/18/23 at 3:53 p.m., an interview was conducted with CNA #2. CNA #2 stated she did not use the leg strap while transferring R71 on 2/20/23 and the resident slid and fell . CNA #2 stated not using the leg strap was her mistake and the CNAs are supposed to make sure they use leg straps with sit to stand lift transfers. On 7/18/23 at 4:33 p.m., ASM (administrative staff member) #1 (the executive vice president) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Sit to Stand Mechanical Lift documented, Residents who need assistance to transfer to bed or chair will have their Care Plan reflect the proper method .Raise the resident's leg and feed the strap under and up between the legs. Ensure the sling is not twisted or creased under the thigh. Repeat this procedure with the other leg . A facility plan of correction dated 2/23/23 documented, Staff member transferred the resident using sit to stand lift. Resident moved her feet off platform and fell to her knees. C.N.A. did not attach straps to her legs before being transferred. Resident was transferred to bed via Hoyer lift and 3 staff assist. 1. Resident complained of right knee pain. Knee was noted to be swollen with bruising. MD (Medical Doctor) was notified and Xray's were ordered. Results showed no fracture of knee or tibia/fibula. Resident then complained of right ankle pain. Sent to (name of orthopedic company) 2/21/23 and was diagnosed with fracture of the right BiMalleolar, and was placed in a walking boot. 2. All residents that are transferred incorrectly using a sit to stand lift are at risk of injury. 3. Staff member that did the incorrect transfer was interviewed and stated that the resident will not let her put leg straps on when using the sit to stand lift. Staff member was put on a 3 day suspension and will have training when she returns. The staff development coordinator will in-service the nursing staff on the proper transfer using the sit to stand lift. Residents that use the sit to stand for transfer will also be instructed on the proper technique for using the sit to stand lift and there will be no deviations. 4. The Nursing Supervisor/Manager will monitor for 4 weeks staff compliance. 5. Dates of Completion: 4/7/23. Credible evidence for this plan of correction was verified during the survey and no further deficiencies regarding safety and accidents were cited. Past non-compliance.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to protect three of 31 residents in the survey sample from abuse (Residents #60, #50 and #35), which resulted in harm cited at past non-compliance. The findings include: 1. The facility failed to protect Resident #60 from sexual abuse from CNA (certified nursing assistant) #5. A review of the facility synopsis of event dated 4/10/23 revealed Incident Type: allegation of abuse/mistreatment. Resident #60 reported an incident to the nursing supervisor. He stated that while getting his brief changed two days ago, his CNA (certified nursing assistant) mouth touched his penis for two seconds. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/6/23, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene and independent for eating / locomotion. A review of the comprehensive care plan dated 4/12/23 revealed, PROBLEMS: Resident has a history of trauma. He reports he was sexually abused. APPROACHES/TASKS: Nursing will continue to offer counseling and will coordinate counseling services, if accepted by resident. Resident-specific ways to comfort resident if a trigger occurs: Allow resident to express feelings and validate them. Refer to SW (social worker) or chaplain for support. Resident-specific ways to decrease triggers: Resident requests to have female CNA's (certified nursing assistants). Staff to speak calmly and tell him what they want to do beforehand (changing clothes, all activities of daily living). Staff will ensure safety of resident by ensuring physical setting is safe and interpersonal interactions promote a sense of safety. Staff will promote collaboration and mutuality with resident by partnering with him and sharing power and decision-making. Staff will promote trustworthiness and transparency by maintaining transparency and building and maintaining trust with resident. Staff will uphold resident's empowerment and choice by supporting shared decision-making, choice, and goal setting. Staff will honor resident's self-advocacy skills. A review of the physician's progress note dated 4/10/23 at 3:33 PM, revealed, Seen for recent incident regarding abuse. Resident mentioned the same story about the aide having an inappropriate contact with him; he refused to allow me to examine him as he said there were no injuries and he was in no pain. I asked again and he was very clear that he did not wish to be examined. He was upset at the incident and was agreeable to follow-up and get some therapy/counseling on the next behavioral health visit. A review of Resident #60's Trauma assessment dated [DATE], revealed, Is there a history of trauma, briefly describe the event: Resident reported on April 7th the 3-11 shift that his assigned CNA was changing him on the bed. CNA was reported to put his mouth briefly on resident's penis. Resident asked him to stop and he did. Self-Reporting Scale 0-10 (0= does not impact me at all 10= this impacts me a great deal). Using a Self-Reporting Scale, how much does this trauma impact your daily life: Resident said 10. What coping skills do you use to deal with thoughts of the traumatic event? Resident is unable to articulate an answer to this. Would you like the opportunity to meet with a counselor/therapist to discuss traumatic events that may continue to impact your life? Resident told me no - that he would talk with staff as needed. He told physician that he would. Is there anything you would like your social worker to know? Want to be able to talk with someone. Wants to sit outside. Wants to talk with his father and stepmother. Work with a female CNA only. A review of the director of nursing (DON) note dated 4/10/23 at 9:29 AM, revealed, Meeting with resident, social worker and myself. Resident is reporting an incident that happened on Friday night with his assigned CNA. Resident stated that when the aid was providing peri care his aide momentarily put his mouth on his penis. Resident stated he told him to stop and he did, closed his brief and left the room. Resident said that it was the first time having the CNA and he has not had him since. A review of the 4/11/23 3:22 PM care coordination note, revealed, Resident came to see me today. He talked a little about the incident that occurred on 4/7. Resident asked to call his parents - we called his stepmother and they talked for about 10 minutes. Resident's mood was calm, he said it was his 1st time coming to the first floor today. He went to recreational therapy and pt (physical therapy). He did not appear upset or frightened. A review of the 4/17/23 11:00 AM care coordination note, revealed, Checked on resident this morning. He said he enjoyed participating in the Walk-in-Roll event on Saturday the 15th. He declined to come to the 1st floor to socialize. He said he didn't feel like it. He had his tv on and was playing a computer game. A review of the 4/17/23 psychological services progress note, revealed, Patient readily discussed the recent incident of sexual abuse by a staff person, relating preoccupation about the incident and anxiety about his future safety and worry about interpersonal relationships. He related about how he had been a resident for a long time and previously felt safe there. Help patient to develop plan for coping with anxiety and build ways to improve self-esteem. A review of the hepatitis and STI (sexually transmitted infections) lab profile obtained 4/19/23, revealed Hepatitis B, HCV (hepatitis C virus), RPR (rapid plasma regain) and HIV (human immunodeficiency virus) all non-reactive. A review of the social services note dated 4/20/23 at 3:56 PM, revealed, Resident came to writer's office, requested to speak with writer in his room. Writer provided active listening and therapeutic support. Helped resident to recall several strategies he uses to self-soothe, validated feelings. Resident expressed gratitude for counseling support, staff support. A review of the 4/24/23 psychological services progress note, revealed, Patient has had individual therapy to improve anxiety and depression. The incident of sexual abuse is now also a focus of treatment due to increased symptoms. A review of the social services note dated 4/26/23 at 10:49 AM, revealed, Resident came to see SW (social worker) today for supportive listening. He said he was feeling fine. A review of the social services note dated 5/3/23 at 2:44 PM, revealed, SW spoke with resident. He was smiling and reported he was in a good mood. A review of the social services note dated 5/4/23 at 3:29 PM, revealed, Today, resident came to SW and asked to call his stepmother. We called her and resident said he was feeling sad from thinking about the traumatic event that occurred. Resident said he wanted to talk with the chaplain. SW took resident to see the chaplain and they have talked. Resident has come to see SW several times and said he was doing okay. His father/stepmother will come to visit this week (May 6 or 7). A review of the social services note dated 5/16/23 at 10:51 AM, revealed, Resident came to see SW yesterday the 15th and today the 16th. He is in a calm mood and said he feels better. Resident saw his father the previous weekend and said they had a nice visit. A review of the social services note dated 6/5/23 at 2:21 PM, revealed, Resident came to see me. He wanted to call his brother and they had a nice talk. Resident said he had some problems sleeping over the weekend. He said he didn't know what was wrong. He said he slept well last night. A review of the social services note dated 6/12/23 at 5:04 PM, revealed, Writer checked in with resident in his room, he asked when the court case would occur. Informed resident that I did not have concrete information but that it would take some time. Resident expressed satisfaction with that answer, then began discussing his latest music project and his visit with his dad. A review of the social services note dated 6/23/23 at 3:56 PM, revealed, Writer checked in with resident in his room, he states he is feeling good. Talked about his haunted house ideas, making new friends, and the TV show he was watching. A review of the social services note dated 7/10/23 at 1:30 PM, revealed, Quarterly assessment note for 7/6/23. Resident scored 14 on the BIMS - unable to tell me the current day of week. He scored 00 on the resident Mood Interview - no mood concerns noted. Resident likes to come to the first floor for certain programs. He likes to watch tv and play video games. His mood has been good. His father comes to visit 1 -2 times a month and he enjoys these visits very much. He has no discharge plans. He has a legal guardian. Quarter goal to assist as requested. A review of CNA (certified nursing assistant) #5's employee record, revealed the following. CNA #5 was hired on 1/9/23. Reference checks were obtained and were positive in describing CNA #5. The Virginia State Police Criminal background check was obtained on 12/20/22 and found 'no identifiable records. His nurse aid certification was obtained on 12/19/22 from the Virginia Department of Health Professions (DHP) License Lookup site. Certification was current and additional public information was listed as 'no'. According to the facility's timeline of this incident, On 3/23/23, a senior investigator from the Virginia DHP requested information on CNA #5. After this request ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing reviewed CNA #5's performance record. There were no other resident complaints, and the charge nurses and other staff did not observe any problems with CNA #5. Based on all available information, ASM #1 and ASM #2 determined that CNA #5 was doing his job well and giving good care to residents. A review of the Virginia DHP license lookup site on 7/18/23 revealed, CNA #5's nurse aide certification was suspended 6/27/23 due to The Board of Nursing (BON) concluding that CNA #5 is a substantial danger to public health and safety. In review of the BON actions, it references, he sexually assaulted four residents in his care. One resident was located in another facility in another location and the three residents located at this facility. An interview was conducted on 7/18/23 at 2:00 PM with Resident #60. When asked if he could describe the events related to the sexual abuse, Resident #60 stated, From what I can remember, he was changing me and he bent down and he touched his mouth to my penis. Police talked to me and filed a report. It was a Friday (4/7/23), Good Friday and I had just come back from services and it happened. Resident #60 stated, Ever since then, I am not the same, I have been talking with the staff working here. He (CNA #5) is not here. I have talked with the police and detective a couple of times. It was a bad situation. I felt bad. I told him to stop. It was not good for me. When asked how he felt now, Resident #60 stated, Better now. I feel safe here and felt safe before. An interview was conducted on 7/18/23 at 3:00 PM with ASM #2, the director of nursing. When asked to describe the events regarding 4/10/23 sexual abuse allegation for Resident #60, ASM #2 stated, As soon as we knew about it, we started the investigation. We suspended the CNA while we investigated. We assessed and interviewed all male residents beginning on 4/10/23. We called the police, informed VDH-OLC (Virginia Department of Health-Office Licensure Certification). On 4/11/23 during the investigation we discovered (Resident #35) had also been sexually abused. Virginia DHP (Department of Health Professions) was informed of the two residents alleging sexual abuse and our investigation. On 4/13/23 DHP investigators arrived at facility. (Resident #50) also stated that CNA #5 had sexually abused him multiple times. An interview was conducted on 7/18/23 at 3:15 PM with RN (registered nurse) #1. When asked to describe the events regarding 4/10/23 sexual abuse allegation for Resident #60, RN #1 stated, It was reported to me by a CNA on Monday morning. (Resident #60) said something to the CNA and she got me to hear the issue. He told me the CNA (#5) was taking care of him and mouth touched his penis and CNA #5 lifted his head up. RN #1 stated that (Resident #60) did not want him to take care of him anymore. I reported it to the DON and I met with the COO/CEO (chief operating officer/chief executive officer). I called the residents family. The physician was notified and saw the resident. An interview was conducted on 7/18/23 at 3:20 PM with LPN (licensed practical nurse) #9. When asked to describe the events regarding 4/10/23 sexual abuse allegation for Resident #60, LPN #9 stated, This was not known to me till later. I did not know that it happened. When asked if he had observed CNA #5 during the shift, LPN #9 stated, Yes, I never had any complaints till this situation happened. He was eager to be here and eager to help. Offered aid to other CNA's. None of the residents reported to us real time. An interview was conducted on 7/19/23 at 10:30 AM with CNA #4. When asked to describe the events regarding 4/10/23 sexual abuse allegation for Resident #60, CNA #4 stated, The resident told me that a male CNA had sexually assaulted him a couple of days earlier, that he touched the resident's penis with his mouth. I informed the nursing supervisor immediately. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the interim administrator was made aware of the above concern on 7/19/23 at 9:05 AM. According to the facility's policy Abuse Prohibition which reveals in part, All residents at the facility will be treated with dignity and respect for their individuality. Abusive or neglectful acts towards residents by employees, visitors, relatives or others, in any form, will not be tolerated. Abuse can consist of any sexual contact. Administrator will direct investigation which shall include at a minimum: interviews with abused resident, the alleged abuser, staff person discovering incident, witnesses and others who may have necessary information. Investigation may also require physical/medical exam of the allegedly abused resident by nursing and/or medical staff. The facility developed and implemented a plan of correction, which contained the following 5 points: 1. The employee involved in the incident is no longer employed by the facility. Resident 1 (Resident #60) and Resident 2 (Resident #35) were assessed by the physician. Resident 3 (Resident #50) refused the assessment. Residents 1, 2 and 3 were assessed for psychosocial distress and care plans were revised as necessary. Residents have been referred to a psychologist for evaluation and treatment. 2. All current residents were interviewed by Social Services as they may have been affected. Interviews completed of all residents on 4/13/23. Any new allegations of abuse verbalized will be reported according to the facility abuse policy and the potential threat removed immediately while an investigation is in process. 3. Social Services/designee will be responsible for monitoring residents for abuse/psychological distress and ensuring any allegations verbalized will be reported according to the facility abuse policy. The Director of Social Services/designee has inserviced staff regarding abuse and the facility abuse policy including requirements/removing a potential threat immediately while an investigation is in process. Staff inservicing was completed on 4/21/23. 4. Social Services will meet weekly with residents affected and provide assistance as needed for a period of two months. 5. The Director of Social Services/designee will meet with the residents on the second Tuesday of each month to review resident rights and abuse. Any allegations of abuse will be investigated immediately as per the facility abuse policy. Education and training will be provided to staff on an ongoing basis. The Director of Social Services/designee will identify and report any trends and/or patterns to the quality assurance committee on at least a quarterly basis. 6. Completion date 5/9/23. The credible evidence including the Plan of Correction, education, in-service sign in sheets, audits and Quality Council minutes were reviewed and found to be in order. Random interviews were conducted with staff on varying shifts regarding abuse education and training and failed to reveal any concerns. Review of current residents failed to identify any concerns. Past non-compliance. 2. The facility failed to protect Resident #50 from sexual abuse from CNA (certified nursing assistant) #5. A review of the facility synopsis of event dated 4/14/23 revealed Incident Type: allegation of abuse/mistreatment. Resident #50 reported an incident to the social worker, that while being cared for his CNA (certified nursing assistant) mouth touched him inappropriately. The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 5/18/23, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility: total dependence for transfer, dressing, eating, hygiene, bathing and locomotion. A review of the comprehensive care plan dated 4/14/23 revealed, PROBLEMS: Resident has a history of trauma. He reports a former caregiver was sexually inappropriate with him. APPROACHES/TASKS: Nursing will continue to offer counseling and will coordinate counseling services, if accepted by resident. Resident-specific ways to comfort resident if a trigger occurs: He reports he enjoys going to a local park/garden. Encourage him to speak with a trusted staff member. Resident-specific ways to decrease triggers: Resident stated none. Staff will ensure safety of resident by ensuring physical setting is safe and interpersonal interactions promote a sense of safety. Staff will promote collaboration and mutuality with resident by partnering with him and sharing power and decision-making. Staff will promote trustworthiness and transparency by maintaining transparency and building and maintaining trust with resident. Staff will uphold resident's empowerment and choice by supporting shared decision making, choice, and goal setting. Staff will honor resident's self-advocacy skills. A review of the social services note dated 4/13/23 at 12:58 PM, revealed, Today, resident came to my office and asked to call his mother. He had reported that while being taken care of by a staff person, he was touched inappropriately. His mother, DON (director of nursing), Medical director and CEO (chief executive officer) were notified. The police and health department were also notified. A review of the physician progress note dated 4/13/23 at 1:55 PM, revealed, Seen primarily for recert (recertification) but also to discuss the recent assault allegations. Resident was going out and mentioned that he would discuss it tomorrow. He appeared well. I mentioned possibly doing some testing as well. Will follow up in am. Orders renewed. A review of Resident #50's Trauma assessment dated [DATE], revealed, Is there a history of trauma, briefly describe the event: Resident expressed an allegation of sexual misconduct against a staff person on 3-11 shift. Self-Reporting Scale 0-10 (0= does not impact me at all 10= this impacts me a great deal). Using a Self-Reporting Scale, how much does this trauma impact your daily life: Resident said 0. What coping skills do you use to deal with thoughts of the traumatic event? He said, I go to (Name of Park) to get my mind off of it. Would you like the opportunity to meet with a counselor/therapist to discuss traumatic events that may continue to impact your life? He declined counseling services. Is there anything you would like your social worker to know? Want to be able to talk with someone. Wants to sit outside. Wants to talk with his father and stepmother. Work with a female CNA only. A review of the hepatitis and STI (sexually transmitted infections) lab profile obtained 4/14/23, revealed Hepatitis B, HCV (hepatitis C virus), RPR (rapid plasma regain) and HIV (human immunodeficiency virus), chlamydia and gonococcus all non-reactive. A review of the social services note dated 4/17/23 at 11:07 AM, revealed, Resident came to see me this morning .His family came to visit over the weekend, and he enjoyed their support. A review of the social services note dated 4/24/23 at 11:01 AM, 5/2/23 at 11:20 AM, and 5/16/23 at 10:54 AM revealed no voiced concerns. A review of the social services note dated 5/24/23 at 2:14 PM, revealed, Annual assessment note for 5/18/23. Resident scored 12 on the BIMS - unable to tell me the current year. Resident scored 00 on the resident Mood Interview - no mood concerns voiced. Resident experienced a traumatic event that included a staff person. Resident has not expressed any negative consequences from the event. He gets up daily in his w/c (wheelchair) and likes to ride to the park or to sit outside. Resident has a circle of peers he likes to talk with. Resident has a cell phone to call his family. His parents are supportive and visit often. We reviewed his advanced directives and he said he is satisfied with his current plans. He said he understands that he can make changes when he wants. We reviewed his discharge plans. He said he understands that he has the right to request to move at any time. Quarter goal to assist as requested. A review of the social services note dated 6/14/23 at 4:33 PM, revealed, SW met with resident in his room for weekly check-in. He states he feels fine and safe knowing alleged assailant is not allowed in the building . A review of the social services note dated 6/22/23 at 2:22 PM, revealed, SW met with resident in his room. SW asked how he's been feeling and he stated, great! He states he would like to speak with the detective in his case but doesn't have his name or number. He states the detective texted his number to the resident. Resident gave permission for SW to look through his recent texts, but SW did not find a text from detective. SW left message for administrator requesting information. A review of the social services note dated 7/10/23 at 11:46 AM, revealed, Resident asked to talk with me about a personal matter. We discussed his concern and he was satisfied with our talk. He said he is doing well and sleeping fine. An interview was conducted on 7/18/23 at 3:00 PM with ASM #2, the director of nursing. When asked to describe the events regarding the sexual abuse allegation for Resident #50, ASM #2 stated, On 4/13/23 DHP (department of health professions) investigators arrived at facility. (Resident #50) stated that (CNA #5) had sexually abused him multiple times on that day. He had not previously disclosed to us that he had been assaulted. An interview was conducted on 7/18/23 at 3:15 PM with RN (registered nurse) #1. When asked to describe the events regarding 4/13/23 sexual abuse allegation for Resident #50, RN #1 stated, this resident stated that CNA #5 had performed oral sex on him multiple times and had ejaculated in his room. He stated that CNA #5 had also watched pornographic content with him in his room. An interview was conducted on 7/18/23 at 3:20 PM with LPN (licensed practical nurse) #9. When asked to describe the events regarding the sexual abuse allegation for Resident #50, LPN #9 stated, This was not known to me till later. I did not know that it happened. When asked if he had observed (CNA #5) during the shift, LPN #9 stated, Yes, I never had any complaints till this situation happened. He was eager to be here and eager to help. Offered aid to other CNA's. None of the residents reported to us real time. An interview was conducted on 7/19/23 at 7:40 AM with Resident #50. When asked if he could describe the events related to the sexual abuse, Resident #50 stated, he (CNA #5) was changing me and he bent down and he touched his mouth to my penis. I told him to stop that I did not like it. He wanted to know if I was sure he did not want any of this and showed me his penis. There was another time when the CNA ejaculated in my room. I did not report this when they first asked. There were several of us he did this to. Police talked to me and filed a report. He (CNA) is not here. I have talked with the detective. It did not make me feel good or safe. I did not feel good. I told him to stop. When asked how he was feeling now, Resident #50 stated, it is all good now, there are no issues. He is not working here anymore. When asked if this had occurred more than once, Resident #50 stated, no. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the interim administrator was made aware of the above concern on 7/19/23 at 9:05 AM. According to the facility's policy Resident Rights and Abuse Prohibition which reveals, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility developed and implemented a plan of correction, which contained the following 5 points: 1. The employee involved in the incident is no longer employed by the facility. Resident 1 (Resident #60) and Resident 2 (Resident #35) were assessed by the physician. Resident 3 (Resident #50) refused the assessment. Residents 1, 2 and 3 were assessed for psychosocial distress and care plans were revised as necessary. Residents have been referred to a psychologist for evaluation and treatment. 2. All current residents were interviewed by Social Services as they may have been affected. Interviews completed of all residents on 4/13/23. Any new allegations of abuse verbalized will be reported according to the facility abuse policy and the potential threat removed immediately while an investigation is in process. 3. Social Services/designee will be responsible for monitoring residents for abuse/psychological distress and ensuring any allegations verbalized will be reported according to the facility abuse policy. The Director of Social Services/designee has inserviced staff regarding abuse and the facility abuse policy including requirements/removing a potential threat immediately while an investigation is in process. Staff inservicing was completed on 4/21/23. 4. Social Services will meet weekly with residents affected and provide assistance as needed for a period of two months. 5. The Director of Social Services/designee will meet with the residents on the second Tuesday of each month to review resident rights and abuse. Any allegations of abuse will be investigated immediately as per the facility abuse policy. Education and training will be provided to staff on an ongoing basis. The Director of Social Services/designee will identify and report any trends and/or patterns to the quality assurance committee on at least a quarterly basis. 6. Completion date 5/9/23. The credible evidence including the Plan of Correction, education, in-service sign in sheets, audits and Quality Council minutes were reviewed and found to be in order. Random interviews were conducted with staff on varying shifts regarding abuse education and training and failed to reveal any concerns. Review of current residents failed to identify any concerns. Past non-compliance. No further information was provided prior to exit. 27660 3. For Resident #35 (R35), the facility staff failed to protect the resident from sexual abuse from a staff member CNA (certified nursing assistant) #5. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/25/2023, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score indicating the resident moderately impaired for making daily decisions. In Section G - Functional Status, R35 was coded as requiring extensive assistance of one or more staff members for all of his activities of daily living except locomotion as the resident was independent after set up assistance was provided. The facility synopsis of event dated, 4/14/2023, documented in part, Additional/Update Information Related to the Reported Incident: In the discovery process for the allegation made by (R60), 2 additional residents, (R50) and (R35) made complaints against (CNA - certified nursing assistant #5). Staffing assignments confirmed that he was caring for the resident who made the allegations .Outcome of Investigation: Allegations were verified by evidence collected including victim interviews and assignment of staffing schedules with the incident timeline .Steps taken to investigate the allegation: Alleged victim's account were consistent in interview with facility staff, Department of Health Professions investigator and law enforcement. No evidence of psychosocial distress or harm as expressed by the resident or noticed by care team or direct care staff Conclusion: Allegations were verified by evidence collected which included interviews with all three victims by facility staff, Department of Health Professionals investigators and law enforcement in which their accounts remained consistent and the alignment of staff schedules with the time in which the incidents occurred .As a result of a verified finding of abuse, such as physical, sexual, or mental abuse, identify counseling or other interventions planned and implemented to assist the resident. (R60), (R35). and (R50) will receive continued monitoring to determine if there are any physical or mental changes or negative outcomes of the abuse. They will all receive trauma informed care assessments to determine if further counseling is needed. If counseling is needed, it will be arranged by the resident's care team. Each resident's care plan will be modified to include the incident . (Name of a physician) examined (R35) and (R50). (R60) refused a physical exam. (Name of physician) ordered STD (sexually transmitted disease) testing. (R60) refused the blood draw required for the test. Results for (R35) and (R50) are pending. The progress note dated, 4/11/2023 at 1:39 p.m. documented, Resident came to SW (social worker) office. SW invited DON (director of nursing) to meet with resident and she joined meeting. The progress note dated, 4/11/2023 at 1:40 p.m., documented, Meeting with social worker, (R35) and myself. Resident stated that last Tuesday a staff member was playing with his (expletive - penis) He also stated that the staff member unzipped his pants and asked him if he would like some of it. (R35) said he told him no. Investigation will be done. (Name of doctor) notified. The physician note dated, 4/11/2023 at 2:11 p.m. documented in part, CC (chief complaint) - seen for allegations regarding a staff member .Plan: seen for recent incident regarding abuse. STD panel ordered as a precaution, unsure of level of exposure. deferred exam, (R35) mentioned no injuries. Encouraged to discuss with SW for support and if needed can get additional therapy and counseling. The progress note dated, 4/12/202 [TRUNCATED]

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to completely develop a policy for the monthly drug regimen reviews with times frames for the different steps in the process, including identifying an irregularity that requires urgent actions to protect the resident for five residents reviewed for medications, (Residents #18, #38, #43, #83 and #109), in the survey sample of 31 residents. The findings include: The facility, Consultant Pharmacist policy failed to include any documentation regarding the timeframe that a pharmacy recommendation is required to be provided to the physician and acted upon by the physician. The policy did not meet regulatory requirements of specifying those time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. During the unnecessary medication review and drug regimen review, the following resident records were reviewed: Resident #18's clinical record was reviewed for unnecessary medications. There were no identified concerns with the use of anticoagulation the resident was receiving. Resident #38's clinical record was reviewed for unnecessary medications. There were no identified concerns with the use of anticoagulation the resident was receiving. Resident #43's clinical record was reviewed for unnecessary medications. There were no identified concerns with the use of antidepressant the resident was receiving. Resident #83's clinical record was reviewed for unnecessary medications. There were no identified concerns with the use of psychotropics the resident was receiving. Resident #108's clinical record was reviewed for unnecessary medications. There were no identified concerns with the use insulin the resident was receiving. A review of the facility policy regarding medication regimen reviews and pharmacy recommendations was conducted. The policy, Consultant Pharmacist documented in part, The clinical pharmacist recommends that the facility regularly reviews and analyzes data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements within 30 days of receipt. On 07/18/23 at 1:15 PM, an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that the facility's pharmacy medication review policy, was what they had and the pharmacy did not have a separate policy. ASM #2 provided a revised policy, however it did not meet guidelines. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the interim administrator was made aware of the above concern on 7/19/23 at 9:05 AM. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to ensure one of 31 residents in the survey sample was free from an unnecessary medication; Resident #38. The findings include: For Resident #38 (R38), the facility staff failed to monitor the resident for side effects (bleeding) from the anticoagulant (blood thinning) medication Eliquis (1). A review of R38's clinical record revealed a physician's order dated 11/3/20 for Eliquis five milligrams by mouth two times a day for pulmonary embolism. A review of R38's MARs (medication administration records) for May 2023 through July 2023 revealed the resident was administered Eliquis five milligrams two times each day. Further review of R38's clinical record (including the MARs and nurses' notes for May 2023 through July 2023) failed to reveal the resident was monitored for side effects (bleeding) from Eliquis. On 7/19/23 at 9:03 a.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated residents that are administered anticoagulants should be monitored for bleeding every shift. RN #2 stated the nurses utilize an anticoagulant monitoring form, but the form was not in place for R38. On 7/19/23 at 9:11 a.m., ASM (administrative staff member) #1 (the executive vice president) and ASM #2 (the director of nursing) were made aware of the above concern. The facility did not have a policy regarding anticoagulant medication monitoring. Reference: (1) ELIQUIS is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF) .Bleeding Risk: ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding. This information was obtained from the website: https://www.eliquis.com/eliquis/hcp/wellcareform?cid=sem_2167331&ovl=isi&gclid=64c052d127001aa9ec1836cd1510884c&gclsrc=3p.ds&

Based on resident interview, staff interview, clinical record review, and review of facility's documentation, it was determined that the facility failed to promote and enhance each resident's right to a dignified and respected existence for three of 31 residents in the survey sample, Resident #60, #50 and #35. The findings included: 1. For Resident #60, the facility staff failed to ensure the resident was treated with dignity and respect. The resident had been sexually abused by a staff member. Resident #60 was admitted to the facility on [DATE]. A review of the facility synopsis of event dated 4/10/23 revealed Incident Type: allegation of abuse/mistreatment. (Resident #60) reported an incident to the nursing supervisor. He stated that while getting his brief changed two days ago, his CNA (certified nursing assistant) mouth touched his penis for two seconds. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/6/23, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene and independent for eating / locomotion. A review of the comprehensive care plan dated 4/12/23 revealed, PROBLEMS: Resident has a history of trauma. He reports he was sexually abused. APPROACHES/TASKS: Nursing will continue to offer counseling and will coordinate counseling services, if accepted by resident. Resident-specific ways to comfort resident if a trigger occurs: Allow resident to express feelings and validate them. Refer to SW (social worker) or chaplain for support. Resident-specific ways to decrease triggers: Resident requests to have female CNA's (certified nursing assistants). Staff to speak calmly and tell him what they want to do beforehand (changing clothes, all activities of daily living). Staff will ensure safety of resident by ensuring physical setting is safe and interpersonal interactions promote a sense of safety. Staff will promote collaboration and mutuality with resident by partnering with him and sharing power and decision-making. Staff will promote trustworthiness and transparency by maintaining transparency and building and maintaining trust with resident. Staff will uphold resident's empowerment and choice by supporting shared decision-making, choice, and goal setting. Staff will honor resident's self-advocacy skills. A review of the physician's progress note dated 4/10/23 at 3:33 PM, revealed, Seen for recent incident regarding abuse. Resident mentioned the same story about the aide having an inappropriate contact with him; he refused to allow me to examine him as he said there were no injuries and he was in no pain. I asked again and he was very clear that he did not wish to be examined. He was upset at the incident and was agreeable to follow-up and get some therapy/counseling on the next behavioral health visit. A review of Resident #60's Trauma assessment dated [DATE], revealed, Is there a history of trauma, briefly describe the event: Resident reported on April 7th the 3-11 shift that his assigned CNA was changing him on the bed. CNA was reported to put his mouth briefly on resident's penis. Resident asked him to stop and he did. Self-Reporting Scale 0-10 (0= does not impact me at all 10= this impacts me a great deal). Using a Self-Reporting Scale, how much does this trauma impact your daily life: Resident said 10. What coping skills do you use to deal with thoughts of the traumatic event? Resident is unable to articulate an answer to this. Would you like the opportunity to meet with a counselor/therapist to discuss traumatic events that may continue to impact your life? Resident told me no - that he would talk with staff as needed. He told physician that he would. Is there anything you would like your social worker to know? Want to be able to talk with someone. Wants to sit outside. Wants to talk with his father and stepmother. Work with a female CNA only. A review of the 4/11/23 3:22 PM care coordination note, revealed, Resident came to see me today. He talked a little about the incident that occurred on 4/7. Resident asked to call his parents - we called his step-mother and they talked for about 10 minutes. Resident's mood was calm, he said it was his 1st time coming to the first floor today. He went to recreational therapy and pt (physical therapy). He did not appear upset or frightened. A review of the 4/17/23 11:00 AM care coordination note, revealed, Checked on resident this morning. He said he enjoyed participating in the Walk-in-Roll event on Saturday the 15th. He declined to come to the 1st floor to socialize. He said he didn't feel like it. He had his tv on and was playing a computer game. A review of the 4/17/23 psychological services progress note, revealed, Patient readily discussed the recent incident of sexual abuse by a staff person, relating preoccupation about the incident and anxiety about his future safety and worry about interpersonal relationships. He related about how he had been a resident for a long time and previously felt safe there. Help patient to develop plan for coping with anxiety and build ways to improve self-esteem. A review of the social services note dated 4/20/23 at 3:56 PM, revealed, Resident came to writer's office, requested to speak with writer in his room. Writer provided active listening and therapeutic support. Helped resident to recall several strategies he uses to self-soothe, validated feelings. Resident expressed gratitude for counseling support, staff support. A review of the social services note dated 4/26/23 at 10:49 AM, revealed, Resident came to see SW (social worker) today for supportive listening. He said he was feeling fine. A review of the social services note dated 5/4/23 at 3:29 PM, revealed, Today, resident came to SW and asked to call his step-mother. We called her and resident said he was feeling sad from thinking about the traumatic event that occurred. Resident said he wanted to talk with the chaplain. SW took resident to see the chaplain and they have talked. Resident has come to see SW several times and said he was doing okay. His father/step-mother will come to visit this week (May 6 or 7). An interview was conducted on 7/18/23 at 2:00 PM with Resident #60. When asked if he could describe the events related to the sexual abuse, Resident #60 stated, from what I can remember, he was changing me and he bent down and he touched his mouth to my penis. Police talked to me and filed a report. It was a Friday on Good Friday and I had just come back from services and it happened. Ever since then, I am not the same, I have been talking with the staff working here. He (CNA #5) is not here. I have talked with the police and detective a couple of times. It was a bad situation. I felt bad. I told him to stop. It was not good for me. When asked how he felt now, Resident #60 stated, better now. I feel safe here and felt safe before. An interview was conducted on 7/18/23 at 2:45 PM with LPN (licensed practical nurse) #7. When asked about the resident being treated with respect and dignity, LPN #7 stated, no, his rights to being treated with dignity and respect were not being honored. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the interim administrator was made aware of the above concern on 7/19/23 at 9:05 AM. According to the facility's policy Resident Rights and Abuse Prohibition which reveals, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. No further information was provided prior to exit. 2. For Resident #50, the facility staff failed to ensure the resident was treated with dignity and respect. The resident had been sexually abused by a staff member. Resident #50 was admitted to the facility on [DATE]. A review of the facility synopsis of event dated 4/14/23 revealed Incident Type: allegation of abuse/mistreatment. (Resident #50) reported an incident to the social worker, that while being cared for his CNA (certified nursing assistant) mouth touched him inappropriately. The most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 5/18/23, coded the resident as scoring a 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility: total dependence for transfer, dressing, eating, hygiene, bathing and locomotion. A review of the comprehensive care plan dated 4/14/23 revealed, PROBLEMS: Resident has a history of trauma. He reports a former caregiver was sexually inappropriate with him. APPROACHES/TASKS: Nursing will continue to offer counseling and will coordinate counseling services, if accepted by resident. Resident-specific ways to comfort resident if a trigger occurs: He reports he enjoys going to a local park/garden. Encourage him to speak with a trusted staff member. Resident-specific ways to decrease triggers: Resident stated none. Staff will ensure safety of resident by ensuring physical setting is safe and interpersonal interactions promote a sense of safety. Staff will promote collaboration and mutuality with resident by partnering with him and sharing power and decision-making. Staff will promote trustworthiness and transparency by maintaining transparency and building and maintaining trust with resident. Staff will uphold resident's empowerment and choice by supporting shared decision making, choice, and goal setting. Staff will honor resident's self-advocacy skills. A review of the social services note dated 4/13/23 at 12:58 PM, revealed, Today, resident came to my office and asked to call his mother. He had reported that while being taken care of by a staff person, he was touched inappropriately. His mother, DON (director of nursing), Medical director and CEO (chief executive officer) were notified. The police and health department were also notified. A review of Resident #50's Trauma assessment dated [DATE], revealed, Is there a history of trauma, briefly describe the event: Resident expressed an allegation of sexual misconduct against a staff person on 3-11 shift. Self-Reporting Scale 0-10 (0= does not impact me at all 10= this impacts me a great deal). Using a Self-Reporting Scale, how much does this trauma impact your daily life: Resident said 0. What coping skills do you use to deal with thoughts of the traumatic event? He said I go to [Name of Park] to get my mind off of it. Would you like the opportunity to meet with a counselor/therapist to discuss traumatic events that may continue to impact your life? He declined counseling services. Is there anything you would like your social worker to know? Want to be able to talk with someone. Wants to sit outside. Wants to talk with his father and stepmother. Work with a female CNA only. A review of the social services note dated 4/17/23 at 11:07 AM, revealed, Resident came to see me this morning .His family came to visit over the weekend, and he enjoyed their support. A review of the social services note dated 4/24/23 at 11:01 AM, revealed, Resident came to my office to socialize. No concerns voiced. A review of the social services note dated 5/2/23 at 11:20 AM, revealed, Resident came to see me. He said he is doing fine and planning to [go] out to the park. An interview was conducted on 7/19/23 at 7:40 AM with Resident #50. When asked if he could describe the events related to the sexual abuse, Resident #50 stated, He [CNA #5] was changing me and he bent down and he touched his mouth to my penis. I told him to stop that I did not like it. He wanted to know if I was sure he did not want any of this and showed me his penis. Resident #50 stated, There was another time when the CNA ejaculated in my room. I did not report this when they first asked. There were several of us he did this to. Police talked to me and filed a report. He (CNA) is not here. I have talked with the detective. It did not make me feel good or safe. I did not feel good. I told him to stop. When asked how he was feeling now, Resident #50 stated, It is all good now, there are no issues. He is not working here anymore. An interview was conducted on 4/18/23 at 2:45 PM with LPN (licensed practical nurse) #7. When asked about the resident being treated with respect and dignity, LPN #7 stated, no, his rights to being treated with dignity and respect were not being honored. ASM #1, the administrator, ASM #2, the director of nursing and ASM #3, the interim administrator was made aware of the above concern on 7/19/23 at 9:05 AM. According to the facility's policy Resident Rights and Abuse Prohibition which reveals, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. No further information was provided prior to exit. 27660 3. For Resident #35 (R35), the facility staff failed to treat the resident in a dignified manner. The resident had been sexually abused by a staff member. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 5/25/2023, the resident scored a 12 out of 15 on the BIMS (brief interview for mental status) score indicating the resident moderately impaired for making daily decisions. In Section G - Functional Status, R35 was coded as requiring extensive assistance of one or more staff members for all of his activities of daily living except locomotion as the resident was independent after set up assistance was provided. Resident has a motorized wheelchair. An interview was conducted with R35 on 7/19/2023 at 9:17 a.m. accompanied by OSM (other staff member) #1, the social worker, to help in translating. R35 was asked what happened, R35 stated, He (expletive) me. He pulled my pants down and asked if I wanted some. Ewe. He put something in my mouth. Ewe. I don't know why he did this to me. I asked him to get out of my room or I would knock him out, on his face on purpose. OSM #1 clarified that sometimes we hit people accidentally, but he would have hit him on purpose. When asked how it made him feel, R35 stated, Bad. R35 was asked what he put in his mouth, R35 stated, His (expletive - penis). When asked if the CNA touched his private area, R35 stated yes, the CNA put his hands on his penis. R35 was asked when and where this happened, OSM #1 stated that through the interviews with R35, throughout the investigation, it occurred in R35's room after CNA #5 had given R35 a shower. R35 stated, That's why he's [CNA #5] not here anymore. The facility synopsis of event dated, 4/14/2023, documented in part, Additional/Update Information Related to the Reported Incident: In the discovery process for the allegation made by (R60), 2 additional residents, (R50) and (R35) made complaints against [CNA - certified nursing assistant #5]. Staffing assignments confirmed that he was caring for the resident who made the allegations .Outcome of Investigation: Allegations were verified by evidence collected including victim interviews and assignment of staffing schedules with the incident timeline .Steps taken to investigate the allegation: Alleged victim's account were consistent in interview with facility staff, Department of Health Professions investigator and law enforcement. No evidence of psychosocial distress or harm as expressed by the resident or noticed by care team or direct care staff Conclusion: Allegations were verified by evidence collected which included interviews with all three victims by facility staff, Department of Health Professionals investigators and law enforcement in which their accounts remained consistent and the alignment of staff schedules with the time in which the incidents occurred .As a result of a verified finding of abuse, such as physical, sexual, or mental abuse, identify counseling or other interventions planned and implemented to assist the resident. (R60), (R35). and (R50) will receive continued monitoring to determine if there are any physical or mental changes or negative outcomes of the abuse. They will all receive trauma informed care assessments to determine if further counseling is needed. If counseling is needed, it will be arranged by the resident's care team. Each resident's care plan will be modified to include the incident . (Name of a physician) examined (R35) and (R50). (R60) refused a physical exam. (Name of physician) ordered STD (sexually transmitted disease) testing. (R60) refused the blood draw required for the test. Results for (R35) and (R50) are pending. The progress note dated, 4/11/2023 at 1:39 p.m. documented, Resident came to SW (social worker) office. SW invited DON (director of nursing) to meet with resident and she joined meeting. The progress note dated, 4/11/2023 at 1:40 p.m., documented, Meeting with social worker, (R35) and myself. Resident stated that last Tuesday a staff member was playing with his (expletive - penis) He also stated that the staff member unzipped his pants and asked him if he would like some of it. (R35) said he told him no. Investigation will be done. (Name of doctor) notified. The physician note dated, 4/11/2023 at 2:11 p.m. documented in part, CC (chief complaint) - seen for allegations regarding a staff member .Plan: seen for recent incident regarding abuse. STD panel ordered as a precaution, unsure of level of exposure. deferred exam, (R35) mentioned no injuries. Encouraged to discuss with SW for support and if needed can get additional therapy and counseling. The progress note dated, 4/12/2023 at 11:38 a.m., documented, LATE ENTRY: SW completed trauma assessment with resident. Resident indicated he experienced a traumatic event. He reports he was sexually abused by a caregiver. He reports he is glad this caregiver is no longer in his life. He states the trauma doesn't affect him daily, but talking with his SW helps . He states he is open to counseling and is comforted by talking to someone. He was not able to identify any triggers. SW notified nursing and MD (medical doctor) that resident would like to participate in counseling. The Trauma assessment dated , 4/12/2023 at 11:29 a.m. documented in part, Trauma History: 1. Is there a history of trauma, briefly describe traumatic event. Resident reports he was sexually abused by a CNA. Self-Reporting Scale 0-10, 0 = does not impact me at all, 10 = this impacts me a great deal. 2. Using a Self-Reporting Scale, how much does this trauma impact your daily life. 1 (one). History of Therapeutic Interventions. 3. Have you received therapeutic interventions for this trauma? If so, what service were received, where and when? No. Traumatic Event. 4. If the traumatic event does not impact you daily, how often do these memories cause you to feel distressed: Weekly, Monthly, Little or Never. N/A (not applicable). Coping Skills Identified. 5. What coping skills do you use to deal with thoughts of the traumatic event? Talking to my social worker. Counseling. 6.Would you like the opportunity to meet with a counselor/therapist to discuss traumatic events that may continue to impact your life? Yes. Triggers and Coping. 7. Please identify what makes you remember the traumatic event and how you like to be comforted when you have these memories. Nothing triggers memories of the event. I would like to be comforted by talking to me. Social Worker. 8 Is there anything you would like your social worker to know? No. The comprehensive care plan dated, 4/13/2023, documented, (R35) has a history of trauma. He reports he was sexually abused by a caregiver. The Interventions documented, Nursing will continue to offer counseling and will coordinate counseling services, if accepted by resident. Resident-specific ways to comfort resident if a trigger occurs: 1) Talk to him. Resident specific way to decrease triggers: 1) Ask before providing personal care. Staff will ensure safety of resident buy ensuring physical setting is safe and interpersonal interactions promote a sense of safety. Staff will promote collaboration and mutuality with resident by partnering with him and sharing power and decision-making. Staff will promote trustworthiness and transparency by maintaining transparency and building and maintaining trust with resident. Staff will uphold resident' empowerment and choice by supporting shared decision-making, choice and goal setting. Staff will honor resident's self-advocacy skills. An interview was conducted with CNA #6 on 7/18/2023 at 2:46 p.m. When asked if a resident tells them that a staff member touched them in a manner the resident did not like, sexually, what steps do you take, CNA #6 stated she would go tell the charge nurse or supervisor. CNA #6 was asked if a resident told you a staff member inappropriately touched them, in a sexual manner, is that abuse? CNA #6 stated, yes. When asked if that is treating a resident with dignity, CNA #6 stated, no. ASM #1, the executive vice president, was made aware of the above concern for the resident not being treated with dignity on 7/19/2023 at 10:15 a.m. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to implement the comprehensive care plan for one of 31 residents in the survey sample, Resident #38. The findings include: For Resident #38 (R38), the facility staff failed to implement the resident's comprehensive care plan for anticoagulant medication monitoring. R38's comprehensive care plan dated 7/31/20 documented, (R38) is on anticoagulant therapy .Monitor for side effects and effectiveness Q (every)-SHIFT . A review of R38's clinical record revealed a physician's order dated 11/3/20 for Eliquis (1) five milligrams by mouth two times a day for pulmonary embolism. A review of R38's MARs (medication administration records) for May 2023 through July 2023 revealed the resident was administered Eliquis five milligrams two times each day. Further review of R38's clinical record (including the MARs and nurses' notes for May 2023 through July 2023) failed to reveal the resident was monitored for side effects (bleeding) from Eliquis. On 7/19/23 at 9:03 a.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated residents that are administered anticoagulants should be monitored for bleeding every shift and the nurses utilize an anticoagulant monitoring form, but the form was not in place for R38. RN #2 stated the purpose of the care plan is to make sure the patient is being taken care of at their highest level of care and nurses have access to care plans to ensure they are implementing them. On 7/19/23 at 9:11 a.m., ASM (administrative staff member) #1 (the executive vice president) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Resident Care Management System failed to document specific information regarding care plan implementation. Reference: (1) ELIQUIS is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF) .Bleeding Risk: ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding. This information was obtained from the website: https://www.eliquis.com/eliquis/hcp/wellcareform?cid=sem_2167331&ovl=isi&gclid=64c052d127001aa9ec1836cd1510884c&gclsrc=3p.ds&

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for two of 31 residents in the survey sample, Residents #6 and #34. The findings include: 1. For Resident #6 (R6), the facility staff failed to review and revise the care plan after the resident returned from the hospital with kidney stones. The hospital discharge summary dated, 4/24/2023, documented in part, Discharge Diagnoses/Plan: Complicated UTI (urinary tract infection) in the setting of right-sided obstructive ureteral stone with hydronephrosis treated with cystoscopy and stent and IV (intravenous) antibiotics. Completed total of 14 days of antibiotics, discharged on oral ciprofloxacin to cover both Citrobacter and Enterococcus. Patient will need outpatient follow-up with urology for definitive stone management. The hospital discharge summary dated, 5/19/2023, documented in part, Discharge Diagnosis/Plan: Sepsis due to urinary tract infection and bacteremia. Nephrolithiasis: Patient with right proximal stone, s/p (status post) stent placement on 4/21/2023. Urology evaluating, timing for stone treatment to be determined. Needs outpatient follow-up. The physician orders dated, 7/17/2023, documented, Res (resident) has a schedule Urology Procedure appt (appointment) on July 24, 2023, at 6:00 a.m. with (name of urologist) at (initials of hospital with address) Outpatient Registration. Nothing to eat or drink after (12:01 a.m.) in prep for urology procedure. Review of the comprehensive care plan revised on 8/28/2019, documented, Problem: (R6) has a history of bowel and bladder incontinence with urosepsis r/t (related to) TBI (traumatic brain injury). The Interventions documented, Apply moisture barrier to skin as ordered. Check and change toileting schedule. Resident will at time decline to return to the unit to be change. Maintain hydration, encourage/assist with fluid intake. Monitor and document BMs (bowel movements), offer PRN (as needed) interventions if no BM > (greater than) 3 days. Administer meds (medications) as ordered. Monitor for sings of UTI. Monitor skin per protocol. Monitor/document for s/sx (signs and symptoms) UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. On toileting plan of check and change. Staff prompt him to use the toilet and assist as needed. Apply Tena Protective cream after each in continent episode. There was no documentation in the comprehensive care plan related to the resident's ureteral stones and upcoming urological procedures. An interview was conducted with LPN (licensed practical nurse) #10 on 7/18/2023 at 12:59 p.m. When asked the purpose of the care plan, LPN #10 stated, it's to have guidelines to the resident's care, such as what lift to use, how they use the bathroom, their diet, and behaviors. LPN #10 was asked who updates the care plans, LPN #10 stated they go over them quarterly, she stated she does some nursing updates. When asked if a resident has kidney stones and is scheduled for urological surgery and has been in the hospital twice for this concern, should that be addressed on the care plan, LPN #10 stated, if it's an issue, it should be care planned and have interventions in place. R6's diagnoses and care plan reviewed with LPN #10. LPN #10 stated, (R6) used to drink a lot of sodas so we are now giving him flavored water, has cups with his name on them. LPN #10 stated they try to make sure he has a cup of water on his wheelchair with his long straw. When asked if these interventions should be on his care plan, LPN #10 stated, yes. LPN #1 was asked then who updates the care plans, LPN #10 stated, she only adds minor things to the care plan, but didn't know who updates them. LPN #10 made a call to the DON (director of nursing) who told her, RN (registered nurse) #2 does the updates to the care plan. An interview was conducted with RN #2, the MDS (minimum data set) nurse on 7/18/2023 at 1:08 p.m. When asked who updates the care plan, RN #2 stated she typically does but anyone can update them. The care plans are accessible by everyone on the IDT (interdisciplinary team). The interventions that LPN #10 spoke of were discussed with RN #2. When asked if they should be on the care plan, RN #2 stated, yes, they should be. RN #2 was asked if the resident has a stent, history of stones, sepsis twice and having a urological procedure the end of July, shouldn't something related to this be on the active care plan, RN #2 stated, she had it on the care plan under UTI, but she resolved (deleted) that care plan. The facility policy, Resident Care Management System documented in part, 10. All members of the Interdisciplinary Care Plan Team must reassess and revise a resident's care plan throughout the quarter anytime there is a change with their care. ASM (administrative staff member) #1, the executive vice president, and ASM #2, the director of nursing, were made aware of the above concern on 7/18/2023 at 4:15 p.m. No further information was provided prior to exit. 42183 2. For Resident #34, the facility failed to revise the comprehensive care plan to include bed rails. Resident #34 was observed in bed with upper bilateral side rails on 7/17/23 at 3:05 PM and on 7/18/23 at 8:10 AM. Resident #34 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: multiple sclerosis and dementia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/6/23, coded the resident as scoring a 09 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. A review of the Section G-functional status coded the resident as requiring total dependence for bed mobility, transfer, locomotion, dressing, eating, hygiene and bathing. A review of the comprehensive care plan dated 6/4/19 revealed, PROBLEMS: Resident is at risk for falls related to altered mobility, disease process, and use of psychotropics. APPROACHES/TASKS: Has special bed. No side rails. A review of the bed rail assessments for 1/7/22 and 1/4/23 revealed, Are bed rails indicated-YES. Two bed rails are indicated-self positioning. An interview was conducted on 7/18/23 at 1:30 PM with LPN (licensed practical nurse) #8. When asked the purpose of the care plan, LPN #8 stated, to provide direction for the care and interventions for the resident. When asked if bed rails should be included on the care plan, LPN #8 stated, yes, they should. When asked if the care plan revealed no side rails and the resident had bilateral upper side rails, had the care plan been revised; LPN #8 stated, no, it was not correct to what the resident had, it has not been revised. On 7/18/23 at approximately 4:40 PM, ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing was made aware of the findings. A review of the facility's Resident Care Plan policy revised 11/17, reveals, All members of the Interdisciplinary Care Plan Team must reassess and revise a resident's care plan throughout the quarter anytime there is a change with their care. No further information was provided prior to exit.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to store a resident's nebulizer mask in a sanitary manner for one of 31 residents in the survey sample, Resident #93. The findings include: For Resident # 93 (R93) the facility staff failed to cover the nebulizer mask when it was not in use. R93 was admitted to the facility with diagnoses that included but was not limited to wheezing. Resident #93's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/06/2023, coded Resident #93 as scoring a 15 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact for making daily decisions. On 07/17/23 at approximately 3:17 p.m., an observation of R93's room revealed a nebulizer mask on R93's desk uncovered. On 07/18/23 at approximately 8:21 a.m. and 12:35 p.m., observations of R93's room revealed a nebulizer mask on R93's desk uncovered. The physician's order for Resident # 93 documented in part, Albuterol Solution 0.5 - 2.5 (3) MG/3ML inhale orally every 12 hours as needed for dyspnea (1). Order Date: 10/25/2021. Start Date: 10/26/2021. On 07/18/2023 at approximately 12:45 p.m. an observation of R93's room and interview were conducted with LPN (licensed practical nurse) #3. When asked to describe the procedure for storing a nebulizer mask when it was not in use, she stated that it should be placed in a plastic bag to keep it clean. After LPN #3 observed R93's nebulizer mask uncovered lying on top of the desk in R93's room she stated that it should be covered. The facility's policy Respiratory Equipment Care it documented in part BREATHING TREATMENT EQUIPMENT - NEBULIZER. After each treatment: Remove the mouthpiece on mask and medication cup. Rinse under strong stream of hot tap water, shake off excess water and air dry. When completely dry, reassemble and store mouthpiece in zip-lock bag. On 07/18/2023 at approximately 4:30 p.m., ASM (administrative staff member) #1, executive vice-president, and ASM #2, director of clinical services, were made aware of the above findings. No further information was provided prior to exit. Reference: (1) Shortness of breath - known medically as dyspnea - is often described as an intense tightening in the chest, air hunger, difficulty breathing, breathlessness or a feeling of suffocation. https://www.mayoclinic.org/symptoms/shortness-of-breath/basics/definition/sym-20050890

Based on observation, staff interview, and facility document review it was determined facility staff failed to store and prepare food in a sanitary manner. The facility staff failed to ensure a table-top and floor mixer that were ready for use, were cleaned and free from food debris. The facility staff failed to maintain a 30 inch fan blowing on clean dishes and cups, located in the clean dish area of the kitchen, clean and free of dust. The facility staff failed to ensure a gallon container of apple cider dressing with an open date of [DATE] was available for use. The findings include: On [DATE] at approximately 11:20 a.m., an observation of the facility's kitchen was conducted with OSM [other staff member] # 1, nutritional service director, with the following concerns: 1. Observation of the table-top mixer located in the facility's kitchen was conducted with OSM # 1. Observation of the table-top mixer revealed the bowl and whisk were cover with plastic wrap. When asked if the mixer was cleaned and ready for use OSM # 1 stated yes. After OSM # 1 removed the plastic from the mixer, an observation of the mixer revealed food debris splattered on the bowl guard, bowl guard frame and spindle. When asked if the mixer was clean OSM # 1 stated no. Observation of the floor standing mixer revealed the bowl and whisk were cover with plastic wrap. When asked if the mixer was cleaned and ready for use OSM # 1 stated yes. After OSM # 1 removed the plastic from the mixer, an observation of the mixer revealed food debris splattered on the neck of mixer, on the spindle, and on support bracket for the mixing bowl. When asked if the mixer was clean OSM # 1 stated no. On [DATE] at approximately 1:37 p.m. an interview was conducted with OSM # 1 regarding the procedure for cleaning the table-top mixer and the floor standing mixer. OSM # 1 stated that the mixer are disassembled after use, parts are placed in the dish machine, and debris is scraped off the surface of the mixers, washed and rinsed. The facility's policy Cleaning Instructions: Mixers documented, Procedures: 1. Disconnect the electric power. 2. Remove all attachments and guards. 3. Scrap solid food into the trash from the attachments, body, drive arm and base of the mixer. 4. Rinse the attachments and guards with warm water and place in the dish sink. Clean, rinse, sanitize and place on the dish rack to air dry. 5. Clean the outer surface of the mixer with a clean cloth that has been moistened with hot, soapy water. Follow with hot water rinse. Do not immerse or dump water on the motor casing of the mixer. Use the white handle brush if needed to get into the crevices of the mixer. 6. Allow to air dry. 7. Reassemble the guard and mixing bowl. 2. On [DATE] at approximately 1:29 p.m., an observation of the dish washing room revealed a stainless steel three shelf cart with four plastic drying racks, two on the top shelf, one on the middle shelf and one on the bottom shelf, filled with clean fruit cups, glasses, soup/cereal bowls and desert containers. Observation of a 30 inch fan revealed it was in front of the cart blowing air across all of the racks containing clean fruit cups, glasses, soup/cereal bowls and desert containers. Kitchen staff would remove the racks of dishes that were dry, place them on another cart, away from the fan, and place another rack on the cart in front of the fan. During the period of observation, six racks of clean dishware was observed being placed in front of the fan. On [DATE] at 8:55 a.m., an observation of the facility's dishwashing room revealed a 30 inch fan blowing on four trays and three dish racks containing clean food trays, fruit cups, glasses, soup/cereal bowls and desert containers. On [DATE] at approximately 9:00 a.m. an interview was conducted with OSM # 1 regarding the observations of the fan blowing on the clean dishware. OSM # 1 was asked to turn the fan off, and observation of the fan after being turned off revealed grey dust coating the three fan blades, and the front and rear fan cages of the fan. When asked to describe the condition of the fan OSM # 1 stated, It's dirty. OSM # 1 further stated, The fan should not be blowing on the dishes. When asked why the fan shouldn't be blowing on the clean dishes OSM # 1 stated, Dirt could be blown on the dishes. The facility's policy Dish-machine: Drying Dishes documented in part, 4. Dishes will be air dried on the dish racks, not dried with towels or fan. 3. On [DATE] at approximately 11:20 a.m., an observation of the walk-in produce refrigerator with OSM # 1 reveal a gallon container of apple cider dressing with approximately one-fifth remaining in the container. Observation of the container revealed an open date of [DATE] documented on the container and failed to evidence a use-by-date. When asked how long the dressing could remain available for use after being opened, OSM # 1 stated that they did not know and would check with the manufacturer. On [DATE] at approximately 10:30 a.m., OSM # 1 provided a copy of an email from [Name of Food Service Company] in regard to the apple cider dressing documented in part, Opened product, store under proper refrigeration and in our original container, will remain for 14 days . On [DATE] at 9:07 a.m., an interview was conducted with OSM # 1 regarding the procedure to prevent expired food items being available for use. OSM # 1 stated that they have supervisors that check items that are expired, for dates and rotate stock. OSM # 1 further stated, It's my responsibility to follow behind them. When asked if they had a policy regarding the procedure for ensuring expired food item were not available for use, OSM # 1 stated that they did not have a policy. On [DATE] at approximately 4:15 p.m., ASM [administrative staff member] #1, executive vice president/chief operation officer, and ASM # 3, director of nursing was made aware of the findings. No further information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide the required written notification of a hospital transfer to the resident representative RR) upon a transfer to the hospital for four of 32 residents in the survey sample; Residents #45, #44, #31, and #116. The facility staff failed to provide written notification to the Resident #45's resident representative (RR) of hospital transfers on 12/13/19 and 1/1/20. The facility staff failed to provide written notification to the resident representative (RR) of Resident #44's hospital transfer on 1/31/20. The facility staff failed to evidence that written notification of transfer was provided to the resident or resident's representative for a facility-initiated transfer on 12/11/2019 for resident #31 and failed to provide Resident # 116 and Resident # 116's representative written notification of a facility-initiated transfer on 11/27/19 for Resident #116. The findings include: 1. Resident #45 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/12/19 coded the resident as being mildly impaired in ability to make daily life decisions, scoring a 12 out of a possible 15 on the BIMS (Brief Interview for Mental Status exam). The resident was coded as requiring total care for all areas of activities of daily living. A review of the clinical record revealed the following nurses notes documenting the resident was transferred to the hospital on [DATE]. 12/13/19 at 7:07 AM: Writer in to assess resident @ (at) 7:05am. Resident slow to respond when I spoke to him. Presented ashy/pale skin color, temp 100.9 .Vomiting dark brown emesis during assessment. Asked if he would like to (go to) hospital and resident replied okay. 12/13/19 at 7:45 AM: Called POA (power of attorney) (brother's name) at 7:43 am x 3. Each time got his voice mailbox that is full. Called (name of aunt) for an alternate number for (brother) but no one answered the call. Will attempt call to POA at a later time. Further review of nurse's notes failed to reveal any documentation of written notification provided to the resident representative. A review of the hospital transfer form dated 12/13/19 did not document that a written notification was provided to the RR. Further review of the clinical record revealed the following nurses notes that documented Resident #45 was transferred to the hospital on [DATE] as follows: 1/1/20 at 1:08 AM: Resident vomited large amounts x 2. Left side abdomen firm distended. [MEDICATION NAME] ineffective .Resident has audible congestion, skin pale with grey color. History of bowel obstruction .Spoke with (name of doctor) at 1:05 am Send to hospital ER (emergency room ) 1/1/20 at 2:20 AM: Call placed to resident's brother/POA, (name of brother) at 0145 (1:45 AM). No answer. Voicemail left for him to please call (the facility). 1/1/20 at 6:46 AM: At this time call placed to residents brother again - no answer left message to call (facility) - will alert oncoming supervisor. Further review of nurse's notes failed to reveal any documentation of written notification provided to the resident representative. A review of the hospital transfer form dated 1/1/20 did not document that a written notification was provided to the RR. On 2/20/20 at 4:45 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. ASM #2 stated, We don't have written notification. We were cited on that (regulation) last year and we did a plan of correction (POC) and we didn't have it written in the plan and they (the state agency) accepted it. I don't remember it being in the citation last year or we would have included it in the plan of correction. A review of the previous POC with ASM #2 revealed that the facility was in fact cited for this concern and neglected to include this in their POC. When asked if the facility should have been aware of this as it was a regulation and they were previously cited for this concern, ASM #2 stated she was not aware of this requirement. A review of the facility policy, Transfer of Residents to Hospitals did not include criteria for notifying the Resident Representative in writing of the hospital transfer. No further information was provided. References: (1) Tylenol is used to relieve mild to moderate pain and reduce fever. Information obtained from https://medlineplus.gov/druginfo/meds/a 4.html (2) Clysis is the introduction of large amounts of fluid into the body usually by [MEDICATION NAME] injection to replace that lost (as from hemorrhage or in dysentery or burns), to provide nutrients, or to maintain blood pressure. Information obtained from https://www.merriam-webster.com/medical/clysis (3) [MEDICATION NAME] is used to prevent and control nausea and vomiting. Information obtained from https://medlineplus.gov/druginfo/meds/a 4.html 2. Resident #44 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/12/19 coded the resident as being severely impaired in ability to make daily life decisions. The resident was coded as requiring total care for all areas of activities of daily living. A review of the clinical record revealed the following nurses notes documenting the resident was transferred to the hospital: 1/31/20 at 9:39 AM: Residents mother (name) arrived here at (facility) just as they were loading him into the ambulance. Writer explained to her that they were taking (Resident #44) to (name of hospital) for possible TIA (mini stroke). She thanked us for sending him out and proceeded to get into the ambulance with (Resident #44)1/31/20 at 10:57 AM: Resident went semi-unresponsive during breakfast at 8:50 a.m. His color was pale and gray. BP (blood pressure) at 67/42. 911 called and the resident was transported to the hospital. Further review of nurse's notes failed to reveal any documentation of written notification provided to the resident representative regarding the the reasons for the trnaser on 1/31/2020. A review of the hospital transfer form dated 1/31/20 did not document that a written notification was provided to the RR. On 2/20/20 at 4:45 PM, an interview was conducted with ASM #2 (Administrative Staff Member) the Director of Nursing. ASM #2 stated, We don't have written notification. We were cited on that (regulation) last year and we did a plan of correction (POC) and we didn't have it written in the plan and they (the state agency) accepted it. I don't remember it being in the citation last year or we would have included it in the plan of correction. A review of the previous POC with ASM #2 revealed that the facility was in fact cited for this concern and neglected to include this in their POC. When asked if the facility should have been aware of this as it was a regulation and they were previously cited for this concern, ASM #2 stated she was not aware of this requirement. A review of the facility policy, Transfer of Residents to Hospitals did not include criteria for notifying the Resident Representative in writing of the hospital transfer. No further information was provided. 3. Resident #31was admitted to the facility on [DATE] with a readmission on 12/18/2019 with [DIAGNOSES REDACTED]. Resident #31's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/05/19, coded Resident #31 in as scoring a 12 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 12- being moderately impaired for making daily decisions. The facility transfer form dated 12/11/19 at 11:15 a.m. for Resident #31 documented medication and treatment administration records, care plan, current orders, labs (laboratory tests) and facesheet being sent to the hospital with the resident at the time of transfer. The document failed to evidence written notification with the reason for the transfer being provided to the resident or the representative. Further review of Resident #31's clinical record failed to evidence that written notification of transfer was provided to the resident or representative for the facility initiated transfer on 12/11/19. On 2/20/20 at approximately 1:30 p.m., a request was made via a list provided to ASM (administrative staff member) #2, the director of nursing for evidence that written notification of discharge was provided to the resident or representative and the ombudsman for the facility initiated transfer on 12/11/2019 for Resident #31. On 2/20/20 at approximately 3:15 p.m., ASM #2 provided a copy of the transfer form dated 12/11/19 for Resident #31 which documented verbal notification of the responsible party for the transfer and a copy of the fax transmittal documenting notification of the ombudsman for the transfer on 12/11/19. On 2/20/20 at 4:45 p.m., an interview was conducted with ASM #2 (Administrative Staff Member), the director of nursing. When asked if a written notification of the reason for transfer is sent to the resident or representative, ASM #2 stated that they do not send written notification of transfer to the resident or responsible party. ASM #2 stated that the facility was cited previously for not sending the notification and they thought that they were in compliance with all requirements for this regulation. ASM #2 stated that she was not aware that they should be sending written notification that they have only been providing verbal notification to the responsible party. ASM #2 stated that she did not have any evidence of written notification of transfer to the responsible party for Resident #31 for the facility initiated transfer on 12/11/2019. A review of the facility policy, Discharge to Hospital and Hold Days, Issued: 7/1982, Revised: 12/18 documented in part, . 2. Every resident sent to a hospital will receive a letter from the President/CEO (chief executive officer) of (Name of Facility). This is required by State and Federal regulations. This letter defines the conditions in the Policy Statement. The facility policy, Involuntary Transfer, Issued: 07/1981, Revised: 09/2017 documented in part, Procedure: . 2. The Administrator, Physician, Director of Nursing, or Social Services would contact resident, his/her family/representative, and the Ombudsman regarding the discharge. The reason for discharge would be explained in a manner that is understood. On 2/20/20 at approximately 3:40 p.m., ASM (administrative staff member) #1, the president/CEO and ASM #2, the director of nursing were made aware of the above concern. No further information was presented prior to exit. References: 1. [MEDICAL CONDITION] A group of disorders that affect a person's ability to move and to maintain balance and posture. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/cerebralpalsy.html. 2. Hypertension High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 4. Resident # 116 was admitted to the facility with [DIAGNOSES REDACTED]. Resident # 116's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/30/2020, coded Resident # 116 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. The facility's Progress Notes for Resident # 116 dated 11/27/2019 documented in part, 15:40 (3:40 p.m.) 911 team at bedside for emergency transfer to (Name of Hospital) ER (emergency room ) dept (department) for evaluation / treatment of [REDACTED]. Review of the clinical record and the EHR (electronic health record) for Resident # 116 failed to evidence that a written notification of the reason for transfer was provided to the resident and resident's representative for Resident # 116's facility-initiated transfer to the hospital on [DATE]. On 02/20/20 at 4:44 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked about the written notification of discharge to the Resident # 116 and Resident # 116's representative ASM # 2 stated that they did not have a written notification to the Resident # 116 and Resident # 116's representative. ASM # 2 further stated that they were not aware that the written notification need to be sent. On 02/20/2020 at 4:44 p.m. ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) A nervous system disease that affects your brain and spinal cord. It damages the myelin sheath, the material that surrounds and protects your nerve cells. This damage slows down or blocks messages between your brain and your body, leading to the symptoms of MS. This information was obtained from the website: https://medlineplus.gov/[MEDICAL CONDITION].html. (2) A mental condition that causes both a loss of contact with reality ([MEDICAL CONDITION]) and mood problems (depression or mania). This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 0.htm.

Based on observation, staff interview, and facility document review, it was determined that facility staff failed to ensure the secure storage of controlled medications and failed ensure prefilled syringes were labeled with an expiration date, not expired and not available for use in two of two medication rooms observed, (the third and fifth floor medications rooms). A black metal box, one containing a 30 ml (milliliter) bottle of [MEDICATION NAME] was observed inside the third floor medication room refrigerator and two 30 ml (milliliter) bottles of [MEDICATION NAME] and twenty, 1 ml syringes of [MEDICATION NAME] were observed inside the fifth floor medication room refrigerator. The black metal boxes were not secured and could easily be removed. In the fifth floor medication room [ROOM NUMBER] ml (milliliter) syringes filled with sterile water without an expiration date were available for use. The findings include: On [DATE] at 2:50 p.m., an observation of the facility's medication room on the third floor was conducted with LPN (licensed practical nurse) # 1. When asked to enter the medication room LPN # 1 unlocked the door to the room and entered with this surveyor. Upon entering the medication room a small refrigerator was observed under the counter on the left side of the room. Observation of the refrigerator revealed a small pad lock located on the upper left corner. LPN # 1 unlock the refrigerator and opened the door. Observation of the inside of the refrigerator revealed a black metal box sitting on the middle shelf. When asked about the box LPN # 1 stated that it contained the narcotics for the residents and that the box was locked. LPN # 1 was asked to open the box. LPN # 1 removed the box from the refrigerator, placed it on the counter, unlocked the box using a key and opened it. Observation of the contents inside the box revealed one sealed, full, 30 mL (milliliter) bottle of [MEDICATION NAME] (1). On [DATE] at 3:00 p.m., an observation of the facility's medication room on the fifth floor was conducted with LPN (licensed practical nurse) # 2. When asked to enter the medication room LPN # 2 unlocked the door to the room and entered with this surveyor. Upon entering the medication room a small refrigerator was observed under the counter on the left side of the room. Observation of the refrigerator revealed a small pad lock located on the upper left corner. LPN # 2 unlock the refrigerator and opened the door. Observation of the inside of the refrigerator revealed a black metal box sitting on the middle shelf. When asked about the box LPN # 2 stated that it contained the narcotics for the residents and that the box was locked. LPN # 2 was asked to open the box. LPN # 2 removed the box from the refrigerator, placed it on the counter, unlocked the box using a key and opened it. Observation of the contents inside the box revealed two sealed, full, 30 mL bottles of [MEDICATION NAME] and 20, one mL syringes of [MEDICATION NAME]. Further observation of the fifth floor medication room revealed five - 30ML syringes laying in a drawer containing catheters. Observation of the syringes revealed they were filled with a clear liquid and did not have an expiration date. Further observation of the fifth floor medication room revealed five, 30 mL (milliliter) syringes filled with sterile water laying in a drawer that contained packages of catheters. Observations of the syringes failed to evidence an expiration date. When asked to identify the expiration date on the five syringes, LPN # 2 stated she was unable to locate a date. When asked what the syringes were used for and where they came from, LPN # 2 stated that they were probably taken out of the catheterization tray kits and should have been discarded since they were not used. The label on the facility's Universal Catheterization Tray kits documented in part, 30 mL Pre-filled Syringe of Sterile Water. On [DATE] at 10:09 a.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked how they secure medications in the medication room that are classified as narcotics ASM # 2 stated, There are three locks to secure them. The lock on the metal box inside the refrigerator that contains the controlled medications, a lock on the refrigerator and the medication room door is locked. When asked about securing the box inside the refrigerator containing the narcotics, ASM # 2 stated, They should be secured inside the refrigerator. When informed of the above observations, ASM # 2 asked which medications rooms did not have secured narcotic boxes. When asked about the 30 mL syringes found in the fifth floor medication room, ASM # 2 stated that they should have been discarded. On [DATE] at 4:44 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked what standard of practice the nursing staff follow ASM # 2 stated, We follow Mosby, Lippincott and our policies and procedures. The facility's policy Controlled Substances documented in part, D. CVONTROLLED MEDICATION STAORAGE. 1. All Schedule II controlled medication shall be secured in a double-locked cabinet, drawer or other secured enclosure. 2. The key(s) to such enclosure shall be in possession of the charge nurse or other designated nurse. 3. The key shall not be given to a private duty nurse or any other person who is not authorized to administer medications. On [DATE] at 4:44 p.m. ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) Used to relieve anxiety. [MEDICATION NAME] is in a class of medications called benzodiazepines. It works by slowing activity in the brain to allow for relaxation. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 3.html.

Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to meet mandatory training requirements for eight of 10 CNA (certified nursing assistant) educational records reviewed, (CNA #6, #1, #2, #3, #4, #8 , #9 and #10). The findings include: On 2/19/20, educational records of 10 CNA (Certified Nursing Assistants) were reviewed. The following concerns were identified: - CNA #6, for the anniversary year of 10/30/18 to 10/30/19, did not have all the required 12 hours of annual training. CNA #6, had 9 hours and did not have the required annual training for abuse. - CNA #1, for the anniversary year of 2/16/19 to 2/16/20, did not have the required annual abuse training. - CNA #2, for the anniversary year of 7/7/18 to 7/7/19, did not have all the required 12 hours of annual training. CNA #2, had 6 hours and did not have the required annual training for abuse and dementia care. - CNA #3, for the anniversary year of 5/10/18 to 5/10/19, did not have all the required 12 hours of annual training. CNA #3, had 4.75 hours and did not have the required annual training for abuse. - CNA #4, for the anniversary year of 6/8/18 to 6/8/19, did not have all the required 12 hours of annual training and only had 11.25 hours. - CNA #8, for the anniversary year of 2/25/18 to 2/25/19, did not have all the required 12 hours of annual training. CNA #8, had 5.25 hours and did not have the required annual training for dementia care. - CNA #9, for the anniversary year of 5/9/18 to 5/9/19, did not have all the required 12 hours of annual training. CNA #9 had 7.25 hours and did not have the required annual training for abuse. - CNA #10, for the anniversary year of 6/11/18 to 6/11/19, did not have all the required 12 hours of annual training and had 7.75 hours of training. On 2/20/20 at approximately 2:00 PM, ASM #2 (Administrative Staff Member, the Director of Nursing) stated that she did not have anything further regarding these training requirements. On 2/20/20 at 2:26 PM an interview was conducted with RN #1 (Registered Nurse) Staff Development. RN #2 stated the CNA's are required to have a minimum of 12 hours of annual training and are required to have abuse and dementia care annually. She stated the way the the electronic educational system was set up, all the annual trainings were assigned prior to the anniversary date and some staff may have completed them early. She stated that the facility met with the electronic education system company about reorganizing how the education was assigned, and is now being done month by month. She stated that before, not only were there staff doing it early, but some procrastinators were late doing theirs, and as a result educations were not showing up in the correct anniversary year time frame. A review of the facility policy In-Service Education Program documented, Mandatory annual training - At least one training program shall be held each year for all employees in each of the following topics: .Abuse, neglect, or misappropriation of resident property; Abuse prevention strategies including, but not limited to identifying, correcting, intervening, and reporting requirements in situations where abuse, neglect, or misappropriation of resident property is likely to occur; Dementia - How to care for residents with dementia E. To be compliant with Federal and State certifying regulations for Certified Nurse Assistants in Long Term Care will ensure that each full time Certified Nurse Assistant (CNA) receives the required 12 hours of continuing education annually. On 2/20/20 at 3:40 PM in a meeting with ASM #1 (the President) and ASM #2 were made aware of the findings. No further information was provided.

Based on observation, resident interview, staff interview, and clinical record review, and facility document review it was determined that facility staff failed to maintain the dignity for one of 32 residents in the survey sample, Residents # 5. The facility staff posted pictures of Resident #5 with positioning instructions and the residents name on the wall above the resident's bed. The postings could be viewed by visitors or staff not involved in the residents care and Resident #5 stated she did not like the postings on the wall. The findings include: Resident # 5 was admitted to the facility with [DIAGNOSES REDACTED]. Resident # 5's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 11/14/2019, coded Resident # 5 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 5 was coded as requiring extensive assistance of one staff member for activities of daily living. On 02/20/20 at 8:26 a.m., an observation of Resident # 5 was conducted. At this time the resident extended an invitation to enter the room. Resident #5 was observed lying in bed. Observation of the bed revealed it was positioned kitty-corner in the left far corner of the room as you face the resident from the entry door. From standing at the foot of Resident # 5's bed, observation of the wall to the right of Resident # 5's head, rvealed two - eight and a half by eleven sheets of paper hanging in a column on the wall. One of the sheets documented the title, (Name of Resident # 5) Positioning partial SIDELYING. Under the title was a photograph of Resident # 5 lying on her right side with her left hip and buttocks exposed demonstrating the position of the wedge on Resident # 5's sacral region. The other sheet documented the title, (Name of Resident # 5) Positioning full SIDELYING. Under the title was a photograph of Resident # 5 lying on her right side with her left hip and buttocks exposed demonstrating the position of the wedge on Resident # 5's sacral region. Observation of the wall to the left of Resident # 5's head revealed the same two documents as described above. On 02/20/20 at approximately 8:26 a.m., an interview was conducted with Resident # 5. When asked about the positioning pictures posted on the wall, Resident # 5 stated, I don't like it and I wish it could be placed somewhere else. People can see it, but they probably don't say anything. When asked if she felt the posting violated her dignity, Resident #5 stated, Yes. On 02/20/20 02:25 p.m., an interview was conducted OSM (other staff member) # 1, occupational therapist. When asked about the positioning pictures of Resident# 5 posted on the wall in the resident's room, OSM # 1 stated that they had taken them and put them up in the resident's room. OSM # 1 further stated that the pictures were put up for the staff and were explicit for the staff to follow and make sure the positioning wedge is correctly placed. When asked if the picture violated Resident # 5's dignity by having them hung on the walls where other staff members who are not involved in patient care and visitors could see the postings, OSM #1 stated yes. On 02/20/20 at approximately 3:44 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. After reviewing the positioning sheets for Resident # 5 that were posted above the resident's bed, ASM # 2 was asked if the photographs violated Resident # 5's dignity. ASM # 2 stated, I do the wound care for Resident # 5 and she had never expressed any concerns. It was my understanding that she (Resident # 5) was okay with it. On 02/20/20 at 4:44 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked what standard of practice the nursing staff follow ASM # 2 stated, We follow Mosby, Lippincott and our policies and procedures. The facility's Resident's Rights documented in part, (a.) Residents rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. On 02/20/2020 at 4:44 p.m. ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit. References: (1) A group of disorders that affect a person's ability to move and to maintain balance and posture. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/cerebralpalsy.html.

Based on observation, resident interview, staff interview, and clinical record review, and facility document review it was determined that facility staff failed to maintain privacy for one of 32 residents in the survey sample, Residents # 5. The facility staff posted positioning instructions with pictures of Resident #5 and the residents name on the residents wall beside the resident's bed. The posted care instructions and pictures of the resident could be easily viewed by visitors or staff not involved in the residents care. The findings include: Resident # 5 was admitted to the facility with [DIAGNOSES REDACTED]. Resident # 5's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 11/14/2019, coded Resident # 5 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15 - being cognitively intact for making daily decisions. Resident # 5 was coded as requiring extensive assistance of one staff member for activities of daily living. On 02/20/20 at 8:26 a.m., an observation of Resident # 5's room was conducted. At this time the resident extended an invitation to enter the room. Upon entering the resident's room, Resident # 5 was observed lying in bed awake. Observation of the bed revealed it was positioned kitty-corner in the left far corner of the room as you face the resident from the entry door. From standing at the foot of Resident # 5's bed, observation of the wall to the right of Resident # 5's head, revealed two - eight and a half by eleven sheets of paper hanging in a column on the wall. One of the sheets documented the title, (Name of Resident # 5) Positioning partial SIDELYING. Under the title was a photograph of Resident # 5 lying on her right side with her left hip and buttocks exposed demonstrating the position of the wedge on Resident # 5's sacral region. The other sheet documented the title, (Name of Resident # 5) Positioning full SIDELYING. Under the title was a photograph of Resident # 5 lying on her right side with her left hip and buttocks exposed demonstrating the position of the wedge on Resident # 5's sacral region. Observation of the wall to the left of Resident # 5's head revealed the same two documents as described above. On 02/20/20 at approximately 8:26 a.m., an interview was conducted with Resident # 5. When asked about the positioning pictures posted on the wall Resident # 5 stated, I don't like it and I wish it could be placed somewhere else. People can see it but they probably don't say anything. When asked if she felt the signs violated her privacy Resident #5 stated, Yes. On 02/20/20 02:25 p.m., an interview was conducted OSM (other staff member) # 1, occupational therapist. When asked about the positioning pictures of Resident# 5 posted on the wall in the resident's room, OSM # 1 stated that they had taken them and put them up in the resident's room. OSM # 1 further stated that the pictures were put up for the staff and were explicit for the staff to follow and make sure the positioning wedge is correctly placed. When asked if the picture violated Resident # 5's privacy by having them hung on the walls where other staff members who are not involved in patient care and visitors could see them, OSM #1 stated yes. On 02/20/20 at approximately 3:44 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. After reviewing the positioning sheets for Resident # 5 that were posted above the resident's bed, ASM # 2 was asked the photographs violated Resident # 5's privacy. ASM # 2 stated, I do the wound care for Resident # 5 and she had never expressed any concerns. It was my understanding that she (Resident # 5) was okay with it. On 02/20/20 at 4:44 p.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked what standard of practice the nursing staff follow ASM # 2 stated, We follow Mosby, Lippincott and our policies and procedures. The facility policy titled, Resident's Rights documented in part, (h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (3) The resident has a right to secure and confidential personal and medical records. On 02/20/2020 at 4:44 p.m. ASM (administrative staff member) # 1, administrator, ASM # 2, director of nursing, were made aware of the above findings. No further information was provided prior to exit.

Based on observation, staff interview, and facility documentation review, facility staff failed to prepare and serve food items in a safe and sanitary manner. Cold food items were being held above safe temperature prior to food service. The Findings Included: On 11/27/2018 at 11:30 a.m., a tour of the kitchen was conducted with Other Staff Member (OSM) #2, the Food Services Manager. Following the kitchen tour, observation of the tray line was conducted with OSM #1, a Dietary Aide. OSM #1 checked the temperatures of each food item. The cold plate meal, which consisted of Seafood Salad and assorted fruit, was temped twice, in the deepest part of the scoop of seafood salad. The observed temperatures were 48.6F and 47.3F. Upon seeing the temperatures, OSM #1 stated I don't know why it is not cold enough, it should be cooler. When asked what temperature the food should be, OSM #1 replied It should be 40 or below for cold plates. A review of the facility policy entitled Administrative Policy #730.6 Food Temperatures revealed the following: Policy: The temperatures of all food items will be taken and properly recorder prior to the service of each meal. Procedure: . 2. All cold food items must be stored and served at a temperature of 41 F or below. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 11/28/2018. No further information was provided.

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide a dignified dining experience in the 5th floor activity/dining area during lunch on 11/27/18 for four of 33 residents in the survey sample, Residents #70, #67, #58, and #83. 1. The facility staff stood over Residents #70, #67, #58, and #83, while feeding them in the 5th floor activity/dining area. 2. Resident #70 was not served her tray at the same time her tablemate's were. She was not served until approximately 10 minutes after her table mates were eating. The findings include: 1. The facility staff stood over Residents #70, #67, #58, and #83, while feeding them in the 5th floor activity/dining area. Resident #70 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an annual assessment with an ARD (Assessment Reference Date) of 10/11/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive assistance for eating. Resident #67 was admitted on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 10/11/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive assistance for eating. Resident #58 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 10/4/18. The resident was coded as being cognitively intact in ability to make daily life decisions. The resident was coded as requiring total care for eating. Resident #83 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 10/18/18. The resident was coded as severely cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for eating. On 11/27/18 at 12:41 p.m., (when trays arrived to the unit), lunch was observed on the 5th floor activity/dining room. The following was observed: · On 11/27/18 at 12:46 p.m., CNA #1 (Certified Nursing Assistant) stood over Resident #58 to feed him. She did not sit down next to him to feed him until 12:48 p.m., approximately 2 minutes after she started feeding him while standing up over him. · On 11/27/18 at 12:49 p.m., CNA #2 was standing over Resident #83 while feeding her. · On 11/27/18 at 12:51 p.m., Resident #70 was served her tray, approximately 10 minutes after her tablemate's. CNA #2 stood over Resident #70 while feeding her. · On 11/27/18 at 12:53 p.m., CNA #2 who was standing over Resident #70 feeding her, went to the other side of the table to assist Resident #67 with feeding. She handed Resident #67 his fork, then went back to Resident #70, and proceeded to stand over Resident #70 to feed her again. At 1:03 p.m., 1:04 p.m., and a second time at 1:04 p.m., she repeated the process of going between Resident #70 and Resident #67, feeding each, back and forth. On 11/27/18 at 2:50 p.m., in an interview with CNA #1, she stated that staff should not feed residents while standing over them. CNA#1 stated staff should feed only one resident at a time and residents at a table should all be served at the same time; so that no one has to wait while watching, others at the table eat. CNA #1 stated all the staff knows all this and what was observed during dining should not have occurred. A review of the facility policy Feeding a Resident documented, 5. Be seated yourself if this is possible 8. Give the resident choices and make the mealtime as pleasant as possible . The policy did not state that staff should not stand over a resident to feed them. A review of the facility policy, The Person Centered Dining Approach documented, Person centered care and hospitality services, including dining, will be a vital part of everyday living. The person centered dining approach will focus on each individual's needs related to food, nutrition, and dining 4. All individuals will be treated with the utmost courtesy, respect and dignity. Each person will be treated as a guest On 11/29/18 at 8:56 a.m., ASM #2 (Vice President/Chief Operating Officer) was made aware of the findings. No further information was provided by the end of the survey. 2. Resident #70 was not served her tray at the same time her tablemates were. She was not served until approximately 10 minutes after her table mates were eating. Resident #70 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set) was an annual assessment with an ARD (Assessment Reference Date) of 10/11/18. The resident was coded as cognitively intact in ability to make daily life decisions. The resident was coded as requiring extensive assistance for eating. On 11/27/18 at 12:41 p.m. (when trays arrived to the unit), lunch was observed on the 5th floor activity/dining room. The following was observed: · On 11/27/18 at 12:47 p.m., Resident #70 asked about her tray. She was sitting at a table with three other residents. The other three residents were already eating their meal, as they were served immediately when the trays arrived to the room at approximately 12:41 p.m., CNA #1 (Certified Nursing Assistant) informed Resident #70 that she will get it (her meal) when someone is ready to feed her. A couple minutes later, another resident who was also at the same table as Resident #70, then asked about Resident #70's tray. CNA #1 stated that she (Resident #70) will get it (her meal) when it is time for her (Resident #70) to eat. · On 11/27/18 at 12:51 p.m., Resident #70 was served her tray, approximately 10 minutes after her table mates. On 11/27/18 at 2:50 p.m., in an interview with CNA #1, she stated that residents at a table should all be served at the same time and no one should have to wait while watching others at the table eat. CNA #1 stated all the staff knows all this and what was observed during dining should not have occurred. A review of the facility policy Feeding a Resident documented, 8. Give the resident choices and make the mealtime as pleasant as possible . The policy did not state that each resident at a given table should be served at the same time. A review of the facility policy, The Person Centered Dining Approach documented, Person centered care and hospitality services, including dining, will be a vital part of everyday living. The person centered dining approach will focus on each individual's needs related to food, nutrition, and dining 4. All individuals will be treated with the utmost courtesy, respect and dignity. Each person will be treated as a guest The policy did not state that each resident at a given table should be served at the same time. On 11/29/18 at 8:56 a.m., ASM #2 (Vice President/Chief Operating Officer) was made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to provide written notification to the resident and/or resident representative, and ombudsman for facility initiated transfers to the hospital for two of 33 residents in the survey sample: Residents #105 and 36. 1. The facility staff failed to provide written documentation to the resident and/or resident representative and notify the ombudsman upon a facility initiated transfer to the hospital on [DATE] for Resident #105. 2. The facility staff failed to provide Resident #36 or the resident's representative (RP) and the ombudsman with written documentation of a facility initiated transfer dated 10/19/18. The findings include: 1. The facility staff failed to provide written documentation to the resident and/or resident representative and notify the ombudsman upon a facility initiated transfer to the hospital on [DATE] for Resident #105. Resident #105 was admitted to the facility on [DATE], with a most recent readmission of 8/27/18, with [DIAGNOSES REDACTED]. This damage slows down or blocks messages between the brain and the body) (1), [MEDICAL CONDITIONS] bladder (lack of bladder control due to a brain, spinal cord, or nerve condition) (2), dementia, high blood pressure, diabetes, and low back pain. Resident #105 was admitted to the facility on [DATE], with a most recent readmission of 8/27/18, with [DIAGNOSES REDACTED]. This damage slows down or blocks messages between the brain and the body. (1)), [MEDICAL CONDITIONS] bladder (lack of bladder control due to a brain, spinal cord, or nerve condition. (2)), dementia, high blood pressure, diabetes, and low back pain. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/01/18, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she has moderate cognitive impairment for daily decision making. The nurse's note dated 8/24/18 at 2:36 p.m. documented in part, Resident was seen by the MD (medical doctor) today for excessive drowsiness .We will continue to monitor and follow up as needed. The nurse's note dated 8/24/18 at 6:59 p.m. documented in part, Resident has been sleeping very soundly since the start of this shift. Currently unable to awaken her. Her current VS (vital signs) are stable. Will not respond to verbal or physical stimulus. Will notify MD and plan to transfer to (hospital's name) ER (emergency room ) dept (department) for medical evaluation. The physician's orders [REDACTED]. An interview was conducted with LPN (licensed practical nurse) #5 on 11/28/18. When asked if the nurses play any role in notifying the ombudsman of resident transfers to the hospital, LPN #5 stated, No, we don't have a role in that. Maybe the DON (director of nursing) or the ADON (assistant director of nursing) does that. An interview was conducted with ASM (administrative staff member) #3, the director of nursing, on 11/28/18 at 2:42 p.m. ASM #3 was asked if the resident and/or the resident representative are provided anything in writing as to why they were being sent out when residents' are transferred to the hospital, ASM #3 stated, We call them. I don't believe we give them anything. When asked if she plays a role in notifying the ombudsman regarding a transfer to the hospital, ASM #3 stated, I don't think they do. When asked who would do it, ASM #3 stated, 'Maybe the social worker does. An interview was conducted with ASM #2, the vice president, chief operating officer, on 11/28/18 at 2:59 p.m. When asked if the facility notifies the ombudsman when a resident is transferred to the hospital, ASM #2 stated, I don't believe so. An interview was conducted with RN (registered nurse) #2, on 11/28/18 at 3:35 p.m. When asked if the facility notifies the ombudsman of a facility initiated transfer to the hospital, RN #2 stated the facility has a policy that all beds are held for the resident, so we don't need to notify the ombudsman. She further stated, In the beginning, we contacted the ombudsman and they told us it wasn't necessary for us to notify them because we take everyone back. ASM #1, the president/CEO (chief operating officer), ASM #2, and ASM #3 were made aware of the above findings on 11/28/18 at 4:16 p.m. No further information was provided prior to exit. 1) This information was obtained from the National Institutes of Health at https://medlineplus.gov/[MEDICAL CONDITION].html 2) This information was obtained from the National Institutes of Health at https://medlineplus.gov/ency/article/ 4.htm 3) This information was obtained from the National Institutes of Health at https://medlineplus.gov/ency/article/ 5.htm 2. The facility staff failed to provide Resident #36 or the resident's representative (RP) and the ombudsman with written documentation of a facility initiated transfer dated 10/19/18. Resident #36 was admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 9/6/18 coded the resident as having a score of 15 of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. Review of Resident #36's clinical record revealed that he had been sent to the hospital on [DATE]. A nursing note dated 10/19/18 at 9:00 a.m. documented, Resident was assessed for c/o (complaint of) nausea and vomiting. It was noted that resident vomited about 50-100 ml (milliliters) of coffee ground material his abdomen was very distended (swollen) and he c/o abdominal pain. The M.D. (medical doctor) who was in the facility assessed the resident and ordered him to the ER (emergency room ) for evaluation. The residents brother, POA (power of attorney) and emergency contact was notified of the residents illness and pending transfer out to the ER. The clinical record failed to evidence documentation that Resident #36, the RP or the Ombudsman were given written notice regarding the facility initiated transfer dated 10/19/18. On 11/28/18 at approximately 2:40 p.m., LPN (licensed practical nurse) #2. LPN #2 was asked if Resident #36 and/or the resident representative was provided anything in writing documenting why Resident #36 was transferred, to the hospital on [DATE], LPN #2 replied, Nothing, to my knowledge. An interview was conducted with ASM (administrative staff member) #3, the director of nursing, on 11/28/18 at 2:42 p.m. ASM #3 was asked if the resident and/or the resident representative are provided anything in writing as to why they were being sent out when residents' are transferred to the hospital, ASM #3 stated, We call them. I don't believe we give them anything. When asked if she plays a role in notifying the ombudsman regarding a transfer to the hospital, ASM #3 stated, I don't think they do. When asked who would do it, ASM #3 stated, 'Maybe the social worker does. An interview was conducted with ASM #2, the vice president, chief operating officer, on 11/28/18 at 2:59 p.m. When asked if the facility notifies the ombudsman when a resident is transferred to the hospital, ASM #2 stated, I don't believe so. An interview was conducted with RN (registered nurse) #2, on 11/28/18 at 3:35 p.m. When asked if the facility notifies the ombudsman of a facility initiated transfer to the hospital, RN #2 stated the facility has a policy that all beds are held for the resident, so we don't need to notify the ombudsman. She further stated, In the beginning, we contacted the ombudsman and they told us it wasn't necessary for us to notify them because we take everyone back. On 11/28/18 at approximately 5:30 p.m., ASM #1, the President and ASM #2, the Vice President and ASM #3, the Director of Nursing were made aware of the findings. No further information was provided prior to exit. 1. Ulcerative [MEDICAL CONDITION] (UC) is a disease that causes inflammation and sores, called ulcers, in the lining of the rectum and colon. It is one of a group of diseases called [MEDICAL CONDITION] bowel disease. UC can happen at any age, but it usually starts between the ages of 15 and 30. It tends to run in families. The most common symptoms are pain in the abdomen and blood or pus in diarrhea. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=ulcerative+[MEDICAL CONDITION]. 2. [MEDICAL CONDITION] or paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. 3. Cholesterol is a fat (also called a lipid) that your body needs to work properly. Too much bad cholesterol can increase your chance of getting [MEDICAL CONDITION], stroke, and other problems. The medical term for high blood cholesterol is lipid disorder, [MEDICAL CONDITION], or [MEDICAL CONDITION]. This information was obtained from the website: https://medlineplus.gov/ency/article/ 3.htm.

Based on resident interview, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for one of 33 residents in the survey sample, Resident #113. The facility staff failed to document non-pharmacological interventions that were offered to Resident #113 prior to administering as needed pain medication on multiple dates in (MONTH) (YEAR) and (MONTH) (YEAR). The findings include: Resident #113 was admitted to the facility on [DATE]. Resident #113's [DIAGNOSES REDACTED]. Resident #113's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 11/8/18, coded the resident as being cognitively intact. Section J coded Resident #113 as reporting a pain score of eight on a scale from zero to ten during the past five days. Review of Resident #113's clinical record revealed a physician's orders [REDACTED]. Review of Resident #113's (MONTH) (YEAR) and (MONTH) (YEAR) MARs (medication administration records) revealed the resident was administered as needed [MEDICATION NAME] on the following dates (including but not limited to): 10/1/18 10/4/18 10/15/18 10/22/18 10/23/18 10/25/18 11/1/18 11/6/18 11/9/18 Further review of Resident #113's clinical record (including (MONTH) (YEAR)/November (YEAR) MARs and nurses' notes) failed to reveal non-pharmacological interventions were offered to Resident #113 prior to the administration of as needed [MEDICATION NAME] on the above dates. (Note: non-pharmacological interventions were documented as provided per physician's orders [REDACTED]. Resident #113's comprehensive care plan dated 7/28/17 documented, (Name of Resident #113) has chronic pain r/t (related to) headache and musculoskeletal pain right hip .Offer non-pharmacological interventions per MD (Medical Doctor) orders prior to the administration of PRN (as needed) medications. On 11/28/18 at 2:31 p.m., an interview was conducted with LPN (licensed practical nurse) #4 (a nurse who administered as needed [MEDICATION NAME] to Resident #113 on many of the above dates). LPN #4 was asked what should be done prior to administering as needed pain medication. LPN #4 stated, Try to do an alternative. Put them in a quiet environment or depending on what it is. Find out the root of the problem. When asked if nurses should document the attempted non-pharmacological interventions, LPN #4 stated, We have a thing on the MAR indicated [REDACTED]. LPN #4 stated she offers non-pharmacological interventions such as repositioning prior to administering as needed [MEDICATION NAME] to Resident #113. When shown some of the above dates where there was no documentation of the attempted interventions, LPN #4 stated, My mistake. There are times that I'll forget (to document). I write it on my paper then I forget to go back and document. On 11/28/18 at 2:55 p.m., an interview was conducted with Resident #113. The resident confirmed staff attempts non-pharmacological interventions prior to the administration of as needed [MEDICATION NAME]. On 11/28/18 at 4:24 p.m., ASM (administrative staff member) #1 (the president/chief executive officer), ASM #2 (the vice president/chief operating officer) and ASM #3 (the director of nursing) were made aware of the above concern. The facility policy titled, Pain Management documented, (Name of facility) will routinely assess the pain of all residents upon admission and regularly thereafter. Pain will be managed by non-pharmacological and pharmacological interventions. Refer to physician orders [REDACTED]. No further information was presented prior to exit. (1) [MEDICATION NAME] is used to relieve pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 9.html

Based on observation, staff interview, facility document review, and clinical record review, it was determined the facility staff failed to provide respiratory care and services consistent with professional standards of practice for one of 33 residents in the survey sample, Resident #66. The facility staff failed to store Resident #66's nebulizer mask in a sanitary manner. On multiple occasions during the survey, Resident #66's nebulizer mask was observed on her bedside table, without any cover and not in use by the resident. The findings include: Resident #66 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 10/11/18 coded the resident as having a score of 14 out of 15 on the BIMS (brief interview for mental status) indicating the resident was cognitively intact to make daily decisions. The physician order [REDACTED]. Review of the MAR (medication administration record) dated (MONTH) (YEAR), for Resident #66 documented [MEDICATION NAME] 0.2 mg/ml (milligrams per milliliter) solution. 2.5 ml inhale orally via nebulizer two times a day for asthma was documented as being given. On 11/27/18 at approximately 11:20 a.m., an observation was made of Resident #66. Resident #66's nebulizer mask was observed on her bedside table, without any cover and not in use by the resident. On 11/27/18 at approximately 2:08 p.m., a second observation was made of Resident #66. Resident #66's nebulizer mask was observed on her bedside table, without any cover and not in use by the resident. On 11/27/18 at approximately 3:24 p.m., a third observation was made of Resident #66. Resident #66's nebulizer mask was observed on her bedside table, without any cover and not in use by the resident. On 11/28/18 at approximately 1:12 p.m., an interview was conducted with LPN (licensed practical nurse) #3, Charge Nurse. When asked how Resident #66's nebulizer mask should be stored when not in use, LPN #3 replied, They are supposed to be covered with a towel or placed in a bag. On 11/28/18 at approximately 2:39 p.m., an interview was conducted with CNA (certified nursing assistant) #3. When asked how a nebulizer mask is supposed to be stored when not in use, CNA #3 replied, We cover them with a towel. When asked why nebulizer masks are supposed to be covered, CNA #3 To keep it clean. According to facility policy titled Respiratory Equipment Care with a revision date (MONTH) (YEAR), documented Keep nebulizer equipment covered with clean towel when not in use. On 11/28/18 at approximately 5:30 p.m., ASM (administrative staff member) #1, the President and ASM #2, the Vice President and ASM #3, the Director of Nursing were made aware of the findings. No further information was provided prior to exit. 1. A group of disorders that affect a person's ability to move and to maintain balance and posture. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/cerebralpalsy.html. 2. A disease that causes the airways of the lungs to swell and narrow. It leads to wheezing, shortness of breath, chest tightness, and coughing. This information was obtained from the website: https://medlineplus.gov/ency/article/ 1.htm. 3. Wheezing is a high-pitched [MEDICATION NAME] sound during breathing. It occurs when air moves through narrowed breathing tubes in the lungs. This information was obtained from the website: https://medlineplus.gov/ency/article/ 0.htm 4. [MEDICATION NAME] oral inhalation is used to prevent wheezing, shortness of breath, coughing, and chest tightness in people with [MEDICAL CONDITION] ([MEDICAL CONDITION]; a group of diseases that affect the lungs and airways) such as chronic [MEDICAL CONDITION] (swelling of the air passages that lead to the lungs) and [MEDICAL CONDITION] (damage to the air sacs in the lungs). [MEDICATION NAME] is in a class of medications called [MEDICATION NAME][MEDICATION NAME]. It works by relaxing and opening the air passages to the lungs to make breathing easier. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a 1.html.

Based on staff interview, clinical record review and facility document review, it was determined that the facility staff failed to evidence that all required documentation was provided to the receiving facility upon transfer to the hospital for three of 33 residents in the survey sample; Residents #105, 36, and 71. 1. The facility staff failed to evidence documentation of the documents sent to the hospital for a facility initiated transfer for 8/24/18 for Resident #105. 2. The facility staff failed to evidence documentation that Resident #36's comprehensive care plan goals were provided to the receiving provider for a facility initiated transfer on 10/19/18. 3. The facility staff failed to evidence documentation of the documents sent to the hospital for Resident # 71's facility initiated transfer on 11/17/18. The findings include: 1. The facility staff failed to evidence documentation of the documents sent to the hospital for a facility initiated transfer for 8/24/18 for Resident #105. Resident #105 was admitted to the facility on [DATE], with a most recent readmission of 8/27/18, with [DIAGNOSES REDACTED]. This damage slows down or blocks messages between the brain and the body. (1)), [MEDICAL CONDITIONS] bladder (lack of bladder control due to a brain, spinal cord, or nerve condition. (2)), dementia, high blood pressure, diabetes, and low back pain. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 11/01/18, coded the resident as scoring a 12 on the BIMS (brief interview for mental status) score, indicating she has moderate cognitive impairment for daily decision making. The nurse's note dated 8/24/18 at 2:36 p.m. documented in part, Resident was seen by the MD (medical doctor) today for excessive drowsiness .We will continue to monitor and follow up as needed. The nurse's note dated 8/24/18 at 6:59 p.m. documented in part, Resident has been sleeping very soundly since the start of this shift. Currently unable to awaken her. Her current VS (vital signs) are stable. Will not respond to verbal or physical stimulus. Will notify MD and plan to transfer to (hospital's name) ER (emergency room ) dept (department) for medical evaluation. The physician's orders [REDACTED]. Review of the clinical record failed to evidence what resident information, including clinical information, was included/provided to the receiving facility for the resident's transfer. An interview was conducted with LPN (licensed practical nurse) #3 on 11/28/18 at 2:24 p.m., regarding what information is sent with residents transferred to the hospital. LPN #3 stated we send their orders but really, the supervisor does that. I stay with the resident until the rescue squad calls. The supervisor does all the paperwork. An interview was conducted with LPN #5, the supervisor, on 11/28/18 at 2:34 p.m., regarding what paper work is sent to the hospital when a resident is transferred to the hospital. LPN #5 stated, the facility send a Transfer Form and any attachments required, physician orders, labs (laboratory test results), the care plan, history and physical, nurses notes and face sheet. LPN #5 provided this writer with a copy of the Transfer Form. The Transfer Form, documented in part, Residents' name, language spoken, code status, reason for transfer and actions taken prior to transfer. The Transfer Form, documented the doctor's name and contact information, their vital signs (blood pressure, pulse, respiration), baseline mental status, the resident representatives name and contact information, attachments of the care plan, MAR (medication administration record), TAR (treatment administration record), Doctor's orders, recent pertinent labs, face sheet, x-rays, copy of the DDNR (durable do not resuscitate order) advance directive. It further documented if the resident was at risk for falls, skin breakdown, [MEDICAL CONDITION], communicable disease, aspiration, high and low blood sugars and harm to self or others. The form also documented special conditions, wounds, immunization records, feeding assistance required, and if the resident had any infections. When asked if the facility keeps a copy of the form evidencing what information was sent to the hospital LPN #5 stated, No, we don't keep a copy. An interview was conducted with administrative staff member (ASM) #3, the director of nursing on 11/28/18 at 3:30 p.m. When asked if the facility keeps a copy of the form that goes to the hospital upon a transfer evidencing what information was provided to the hospital, ASM #3 stated, the facility does not keep a copy of the form. ASM #1, the president/CEO (chief operating officer), ASM #2, the vice-president/COO (chief operations officer), and ASM #3, the director of nursing, were made aware of the above findings on 11/28/18 at 4:16 p.m. A review of the facility's policy, Transfer of Residents to Hospitals, documents in part, 1. Transfer to Hospital: 1. The physician gives the order to send resident to the hospital to the supervisor. 2. The nursing office secretary arranges transportation .if an emergency 911 is called. 4. The supervisor completes transfer form and copies necessary information from chart (including the comprehensive care plan). 7. The next of kin or legal guardian is notified by the nursing supervisor. No further information was provided prior to exit. 1) This information was obtained from the National Institutes of Health at https://medlineplus.gov/[MEDICAL CONDITION].html 2) This information was obtained from the National Institutes of Health at https://medlineplus.gov/ency/article/ 4.htm 3) This information was obtained from the National Institutes of Health at https://medlineplus.gov/ency/article/ 5.htm 2. The facility staff failed to evidence documentation that Resident #36's comprehensive care plan goals were provided to the receiving provider for a facility initiated transfer on 10/19/18. Resident #36 was admitted to the facility on [DATE] with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a quarterly assessment, with an ARD (assessment reference date) of 9/6/18 coded the resident as having a score of 15 of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact to make daily decisions. Review of Resident #36's clinical record revealed that he had been sent to the hospital on [DATE]. A nursing note dated 10/19/18 at 9:00 a.m. documented, Resident was assessed for c/o (complaint of) nausea and vomiting. It was noted that resident vomited about 50-100 ml (milliliters) of coffee ground material his abdomen was very distended (swollen) and he c/o (complained of) abdominal pain. The M.D. (medical doctor) who was in the facility assessed the resident and ordered him to the ER (emergency room ) for evaluation. The residents brother, POA (power of attorney) and emergency contact was notified of the residents illness and pending transfer out to the ER. There was no evidence in the clinical record that Resident #36's comprehensive care plan goals were sent to the receiving provider for this facility- initiated transfer dated 10/19/18. On 11/28/18 at approximately 2:24 p.m., an interview was conducted with LPN (licensed practical nurse) #3. When asked what documentation is provided to the receiving provider for a facility initiated hospital transfer, LPN #3 stated, We send their orders but really the supervisor does that. I stay with the resident until the rescue squad calls. The supervisor does all the paperwork. On 11/28/18 at approximately 2:34 p.m., an interview was conducted with LPN #5, the Supervisor. When asked what documentation is provided to the receiving provider for a facility initiated hospital transfer, LPN #5 stated, We send a 'Transfer Form' and any attachments required: physician orders, labs (laboratory test results), the care plan, history and physical, nurses notes and face sheet. When asked if the facility had evidence, the receiving provider received a Transfer Form for Resident #36's facility initiated hospital transfer dated 10/19/18, LPN #5 replied, No, we don't keep a copy. On 11/28/18 at approximately 2:36 p.m., LPN #5 provided a copy of the facility document titled Transfer Form. The Transfer Form, documented in part, Residents' name, language spoken, code status, reason for transfer and actions taken prior to transfer. The Transfer Form, documented the doctor's name and contact information, their vital signs (blood pressure, pulse, respiration), baseline mental status, the resident representatives name and contact information, attachments of the care plan, MAR (medication administration record), TAR (treatment administration record), Doctor's orders, Recent pertinent labs, face sheet, x-rays, copy of the DNR (durable do not resuscitate order) advance directive. It further documented if the resident was at risk for falls, skin breakdown, [MEDICAL CONDITION], communicable disease, aspiration, high or low blood sugars and harm to self or others. The form also documented special conditions, wounds, immunization records, feeding assistance required, and if the resident had any infections. On 11/28/18 at approximately 3:30 p.m., an interview was conducted with administrative staff member (ASM) #3, the Director of Nursing. When asked if the facility keeps a copy of the form that goes to the hospital upon a transfer, ASM #3 stated, The facility does not keep a copy of the form. On 11/28/18 at approximately 5:30 p.m., ASM #1, the president/CEO (chief operating officer), and ASM #2, the vice-president/COO (chief operations officer), were made aware of the findings. No further information was provided prior to exit. 1. Ulcerative [MEDICAL CONDITION] (UC) is a disease that causes inflammation and sores, called ulcers, in the lining of the rectum and colon. It is one of a group of diseases called [MEDICAL CONDITION] bowel disease. UC can happen at any age, but it usually starts between the ages of 15 and 30. It tends to run in families. The most common symptoms are pain in the abdomen and blood or pus in diarrhea. This information was obtained from the website: https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=ulcerative+[MEDICAL CONDITION]. 2. [MEDICAL CONDITION] or paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. 3. Cholesterol is a fat (also called a lipid) that your body needs to work properly. Too much bad cholesterol can increase your chance of getting [MEDICAL CONDITION], stroke, and other problems. The medical term for high blood cholesterol is lipid disorder, [MEDICAL CONDITION], or [MEDICAL CONDITION]. This information was obtained from the website: https://medlineplus.gov/ency/article/ 3.htm 3. The facility staff failed to evidence documentation of the documents sent to the hospital for Resident # 71's facility initiated transfer on 11/17/18. Resident #71 was admitted to the facility 7/18/16 with a recent readmission on 11/14/18 with diagnoses, that included but were not limited to: [MEDICAL CONDITION] (loss or deficiency of muscle control due to permanent, nonprogressive brain damage occurring before or at the time of birth. (1)), [MEDICAL CONDITION] (Characterized by [MEDICAL CONDITION] changes in the joints, pain, stiffness and swelling can develop after exercise. (2)). high blood pressure, depression, chronic pain, and anxiety disorder. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 10/11/18 coded the resident as scoring a 15 on the BIMS (brief interview for mental status) score, indicating she was capable of making daily cognitive decisions. The resident was coded as requiring extensive assistance for all of her activities of daily living. The nurse's note dated, 11/27/18 at 6:42 a.m. documented, Was notified by nurse assigned resident having respiratory problems, and O2 (oxygen) was applied at 2L via N/C (nasal cannula). MD (medical doctor) was notified and N.O (new order) to send out to ER (emergency room ) to treat and evaluate. The physician order [REDACTED]. An interview was conducted with LPN (licensed practical nurse) #3 on 11/28/18 at 2:24 p.m., regarding what information is sent with residents transferred to the hospital. LPN #3 stated we send their orders but really, the supervisor does that. I stay with the resident until the rescue squad calls. The supervisor does all the paperwork. An interview was conducted with LPN #5, the supervisor, on 11/28/18 at 2:34 p.m., regarding what paper work is sent to the hospital when a resident is transferred to the hospital. LPN #5 stated, the facility send a Transfer Form and any attachments required, physician orders, labs (laboratory test results), the care plan, history and physical, nurses notes and face sheet. LPN #5 provided this writer with a copy of the Transfer Form. The Transfer Form, documented in part, Residents' name, language spoken, code status, reason for transfer and actions taken prior to transfer. The Transfer Form, documented the doctor's name and contact information, their vital signs (blood pressure, pulse, respiration), baseline mental status, the resident representatives name and contact information, attachments of the care plan, MAR (medication administration record), TAR (treatment administration record), Doctor's orders, recent pertinent labs, face sheet, x-rays, copy of the DDNR (durable do not resuscitate order) advance directive. It further documented if the resident was at risk for falls, skin breakdown, [MEDICAL CONDITION], communicable disease, aspiration, high and low blood sugars and harm to self or others. The form also documented special conditions, wounds, immunization records, feeding assistance required, and if the resident had any infections. When asked if the facility keeps a copy of the form evidencing what information was sent to the hospital LPN #5 stated, No, we don't keep a copy. An interview was conducted with administrative staff member (ASM) #3, the director of nursing on 11/28/18 at 3:30 p.m. When asked if the facility keeps a copy of the form that goes to the hospital upon a transfer, ASM #3 stated, the facility does not keep a copy of the form. Administrative staff member (ASM) #1, the president, chief executive officer, ASM #2, the vice president, chief operating officer and ASM #3, the director of nursing, were made aware of the above findings on 11/28/18 at 4:20 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 422. (2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 114.