Every finding on record at Walter Reed Post Acute

Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a leg strap was available to secure to a resident's leg to prevent the Foley (brand) catheter from dislodging or being pulled and the facility staff failed to date resident's Foley bag and Foley catheter for 1 of 45 residents (Resident #29), in the survey sample. The findings included: Resident #29 was originally admitted to the facility 02/22/2016 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; retention of urine. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/17/24 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. In sectionH(Bladder and Bowel) the resident was coded as having an indwelling catheter. The care plan dated 6/26/24 read that Resident #29 requires the use of an indwelling catheter. The goal for the resident was that urine elimination needs will be met through the use of the catheter through the next review. The intervention for the resident was to change catheter and bag per order to maintain patency and minimize infection. A review of the Physicians Order dated 11/26/22 read: ensure catheter is secured to the leg with appropriate device two times daily, days, evenings and as needed. A review of the Physicians Order dated 11/26/22 read: Gravity/leg drainage bag to be changed every two weeks and as needed. On 08/21/24 at approximately 3:01 PM., an observation was made of Resident #29 lying in her [NAME] (recliner) chair in the TV room. The resident's Foley bag was observed with no label affixed. On 8/21/24 at approximately 3:05 PM., an interview was conducted with Licensed Practical Nurse (LPN) #1 concerning the resident's Foley bag. LPN #1 said that she wasn't sure if the resident's Foley bag was dated but will take the resident to her room and check. Upon visual inspection, the foley bag had no label, the foley catheter observed laying on the side of the resident's left upper thigh unsecured. LPN #1 said that there should be a date and a strap to keep the foley in place. On 8/21/24 at approximately 3:30 PM., an interview was conducted with the Director of Nursing (DON) concerning the above issue. The DON said there should have been a strap to hold the catherter tubing in place. On 8/21/24 at approximately 3:50 PM., an interview was conducted with Certified Nursing Assistant #1. CNA #1 said that while showering the resident this morning, she noticed that the resident's leg strap was missing, but forgot to report it to the nurse. CNA #1 also said that the strap is important because it keeps the Foley cathere tubing from getting pulled. The importance of fixation and securing devices in supporting indwelling catheters: Health-care professionals follow recognized national guidelines to assess clinical reasons for the insertion of urinary catheters. However, the use of fixation and securing devices is an area that is often neglected. Health-care professionals sometimes employ a 'do-it-yourself' approach, using adhesive tape or Velcro strapping devices, neither of which are appropriate. If urinary catheters are not secured appropriately, they can lead to severe trauma of a patient's urethra, potential damage to bladder neck, infection and inflammation, pain and irritation, possible bypassing, accidental dislodging of a catheter and a cleaving (condition whereby the catheter splits the penile or labial tissues). This article identifies reasons for using securing/fixation devices and explains the advantages and disadvantages of the different types of devices in relation to individual patients. https://pubmed.ncbi.nlm.nih.gov/24335791/ On 8/22/24 at approximately 10:00 AM., the above findings were shared with the Administrator and Director of Nursing and Corporate Consultant. There were no further concerns voiced prior to the survey's exit.

Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to assist the resident to obtain vision services for 1 of 45 residents (Resident #85), in the survey sample. The findings included: Resident #85 was originally admitted to the facility 11/16/23 after an acute care hospital stay. The current diagnoses included Macular Degeneration. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/5/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #85 cognitive abilities for daily decision making were intact. In sections B.1000 the resident's vision was coded as two which represented moderately impaired, limited vision, and not able to see newspaper headlines but can identify objects and section B.1200 was coded zero, identified the resident did not utilize corrective lenses. The current care plan dated 8/13/2024 was initiated on 11/16/23 had a problem which read B1000.2 Vision: (name of resident) ability to see in adequate light was moderately impaired. The goal read, will maintain current level of function/activity without injury through the next review. The interventions included schedule eye exam for evaluation/management of vision and use large print for any item (the resident name) must read (signs, labels, menu). This care plan has not been revised since initiation for vision. An interview was conducted with Resident #85 on 08/20/24 at approximately 4:35 PM. The resident stated that she was unable to see my face, but she could see the outline of my body. The resident also stated that she could no longer view the television screen or read books which is a hobby. Resident #85 stated that she had not seen an eye doctor since admission to the facility and staff is aware of her low vision. On 8/20/24 an interview was conducted with Licensed Practical Nurse (LPN) #2 at approximately 4:50 PM. LPN #2 stated that she was aware of Resident #85's visual impairments but not aware of her limitations which included the inability to see faces and view the television. LPN #2 Further stated that she ensures that frequently used items are kept within reach. An interview was held with one of the facility's Social Workers (SW) on 8/21/24 at approximately 5:25 PM. The SW stated that Resident #85 was not on her primary case load, but based on her chart review she does not see where the resident had a vision appointment since admission. The SW confirmed this with the Administrator to be accurate. The SW further stated she would add Resident #85 to the list to be seen next month by SVS. The facility's policy titled person-centered baseline and comprehensive care plan, last reviewed on 11/14/22 indicated, the facility will review and revise residents care plans on a quarterly basis and as needed. The facility was unable to provide a policy on resident's vision care services but did provide an agreement from 2007 with Senior Vision Services (SVS). This agreement indicated SVS will provide primary vision care for the facility residents by request. On 8/22/24 at approximately 10:00 AM, the above findings were shared with the Administrator and Director of Nursing. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on observation and interviews, the facility failed to ensure food items were stored and served under sanitary conditions in that the facility failed to ensure dietary staff cleansed food preparation areas with an appropriate strength sanitizer, failed to change gloves and perform hand hygiene before touching clean dishes and before serving food. This deficient practice had the potential to affect all the residents in the facility. Findings included: Observation on 05/18/21 at 9:19 AM, Dietary Aide (DA)27 cleansed the counter surfaces in the kitchen with a solution in a red bucket labeled Sanitizer solution. DA27 tested the solution in the buckets described above and reported the solution recorded zero Part Per Million (PPM) according to the Bleach test strips. During an interview on 05/21/21 at 2:25 PM, the Dietary Manager (DM) stated that dietary staff completed a log which recorded the PPM of the sanitizing solution. She said it was the individual staff's responsibility to ensure the solution was changed out as needed to ensure it maintained its recommended concentration. The DM stated that the sanitizing solution needed to be at a minimum of 200 PPM to be considered potent enough to perform its sanitizing function. Observation on 05/18/21 at 08:57 AM, DA26 intermittently adjusted her mask with her gloved hands while she transferred the clean plates from the clean dish machine racks to where the clean plates were shelved ready to use. On 05/21 at 9:10 AM, DA 26 stated that she did not know that there was the potential to cross-contaminate the dishes, when she was adjusting her mask and not performing glove changes and hand hygiene. On 05/18/21 at 9:19 AM, DA 27 was observed cleaning the food preparation surfaces in the kitchen with a cloth rag and a solution which was in a red bucket. DA27 was observed to doff the pair of gloves, adjusted her face mask and immediately proceeded to the serving area where DA27 plated the dessert on the dessert plates. DA27 failed to perform hand hygiene after completing the cleaning task and after doffing her gloves. DA27 did not apply gloves before dishing out the dessert on the dessert dishes. On 5/20/21 at 3:59 PM, DA24 was observed in the kitchen opening a package of mixed vegetable, emptied the vegetables into a tray, and then proceeded to disposed of the plastic package in the trash can that was underneath the cook's prep sink. The DA24 pulled out the trash can with her gloved hands, disposed of the plastic container described above and then rubbed her hands against her shirt. She returned to the vegetable tray without changing out her gloves and performing hand hygiene. On 05/21/21 at 2:25 PM, the DM stated that dietary staff were trained to wash their hands when they were visibly soiled, between completing different tasks, before and after wearing gloves She stated that dietary staff should not be touching body part or adjusting mask without hand hygiene.

Based on observation, interview, and record review, the facility failed to notify the physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of R65's quarterly Minimum Data Set (MDS) assessment found under the MDS tab of the Electronic Medical Record (EMR) with an assessment reference date (ARD) of 03/19/21, revealed a Brief Interview Mental Status (BIMS) score of 15 which indicated cognitively intact. The MDS did not indicate any pressure ulcers. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the Assistant Director of Nursing and observation of R65's sacrum on 05/20/21 at 3:00 PM, the Assistant Director of Nursing (ADON) stated that she had no knowledge of an open area to R65's sacrum area. The observation revealed that R65's sacrum had an open area that measured 7 centimeters (cm) in length and 5.1 cm wide, no depth. Review of R65's clinical record revealed that there was no documentation that the resident's physician had been notified of the new open area. During the interview on 05/20/21 at 3:00 PM, the ADON confirmed that there was no documentation in R65's clinical record that R65's physician was notified of the open area. During a phone interview on 5/21/21 at 10:50 AM, Licenses Practical Nurse (LPN)129 stated that on 5/18/21 that LPN115 told her that R65 had an open area on her sacrum. LPN129 further stated that the ADON stated that she would come and take a look at it but in the meantime, place a Triad and border foam dressing on the open area. In an interview on 05/21/21 at 02:04 PM, LPN15 stated that when she returned to work from being off over the weekend, she heard from another licensed nurse about R65's open area to the sacrum. LPN115 stated that the resident told her about the area on May 17th. LPN115 stated that she reported it directly to the ADON who stated that she would assess the area. LPN115 stated that she applied an Alleyvn (absorbent foam dressing) while waiting for the ADON to get an order. She further stated that she did not know if the ADON obtained an order.

Based on interview, record review, and facility policy review, the facility failed to ensure that one of five sampled residents reviewed for unnecessary medications was free from the use of a [CONDITION(S)] medications (Resident (R) 61). R61 was restarted on [MEDICATION(S)] (medication used to treat certain mental/mood conditions and may be used with other medication to treat depression) at the Hospital and was readmitted to the facility without clinical justification for the drug's use and continued drug use. Findings include: Review of R61's undated Face Sheet, located in the resident's electronic medical record (EMR), under the face sheet tab, revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R61's Diagnoses, located in the resident's EMR under the admissions tab, revealed the resident's diagnoses included unspecified [CONDITION(S)], unspecified dementia without behaviors, panic disorder, anxiety disorder, and major depressive disorder. Review of the Hospital History and Physical report, dated 03/16/21, provided by the Director of Nurses (DON), revealed R61 had [CONDITION(S)] related to a urinary tract infection and there was no evidence R61 had psychotic symptoms or behaviors at the hospital. The Hospital History and Physical report revealed R61's discharge medications included [MEDICATION(S)] 7.5 milligrams (mg) at bedtime. Review of R61's Physician's Order, dated 03/19/21 revealed, [MEDICATION(S)] 7.5 mg tablet by mouth, to be given every night at for [CONDITION(S)]. During an interview with the DON on 05/21/21 at 11:05 AM, the DON stated R61 did not receive [CONDITION(S)] medication after the [MEDICATION(S)] was discontinued in 2018 until after she returned from the hospital on 03/19/21. Review of R61's change in status Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/24/21 and found under the MDS tab in the resident's EMR, revealed R61 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had no cognitive impairment. The MDS also revealed the resident did not have any behaviors and received antipsychotic medication six of seven days during the last seven days. Review of the facility Medication Regimen Review (MRR) Consultation Report, completed by the Pharmacist dated 03/27/21 revealed R61, .may need the following evaluated. The hospital appears to have unintentionally changed several of her medications based on an incorrect home medication list on their History and Physical form. The MMR revealed, there were some medications R61 had not used since her hospital admission in 2018 that included [MEDICATION(S)] 7.5 mg at bedtime, that was discontinued at the Hospital in 2018 related to an elevated QTc greater than 500 (in electrocardiography, the duration of the interval adjusted for the patient's heart rate. Prolonged QTc greater than 500 is associated with an increased risk of [CONDITION(S)] (abnormality in heart rhythm), stroke, and sudden death). The MMR revealed the need to .consider clarifying if her previous orders should resume, and these unintentional changes should be corrected. The MMR dated 03/27/21 revealed the Nurse Practitioner (NP) agreed to all of the Pharmacy recommendations, except for the [MEDICATION(S)], which was not to be discontinued. Further review of the MMR revealed the NP documented to keep the [MEDICATION(S)]-discussed with the nursing staff, all other changes made. The MMR revealed no rational as to why R61 needed the [MEDICATION(S)]. Review of the NP Progress Note, dated 03/30/21 located under the notes tab of the resident's EMR, revealed R61 was .seen today for review of MMR recommendations .QT interval was prolonged (>500) while in the hospital, will discontinue [MEDICATION(S)]. Review of R61's Medication Administration Record (MAR), located in the administration tab in the EMR dated March 2021, revealed R61 received [MEDICATION(S)] 7.5 mg every night from 03/19/21 through 04/29/21. Review of R61's Physician's Order, dated 04/30/21, revealed the resident's [MEDICATION(S)] was discontinued on 04/30/21. During interviews with Social Worker 117 on 05/19/21 at 12:33 PM, Licensed Practical Nurse (LPN) 117 on 05/20/20 at 9:00 AM, Certified Nursing Assistant (CNA) 57 on 05/20/21 2:19 PM, and CNA 59 on 05/20/21 at 2:55 PM, they stated R61 was pleasant, alert, oriented, and had no behaviors toward herself, other residents, and staff. LPN117 stated R61 had no signs of [CONDITION(S)] during interactions with her. During an interview on 05/21/21 at 11:05 AM, the DON stated that R61 did not receive any [CONDITION(S)] medication after the [MEDICATION(S)] was discontinued in 2018 until 03/19/21. The DON stated on 03/16/21, R61 was admitted to the hospital and treated for urosepsis. On 03/19/21, R61 was transferred back to the facility, with the hospital discharge medication list that included [MEDICATION(S)] 7.5 mg at bedtime. The DON stated R61 had no behavioral symptoms prior to or after her hospitalization in March 2021 that required antipsychotic medication. During the same interview, the DON stated that on 03/27/21, the Pharmacist's MRR recommendation included reviewing the [MEDICATION(S)] for discontinuation related to her elevated QTc. The DON stated on 03/30/21, the NP documented in R61's clinical record not to discontinue the [MEDICATION(S)] on the MMR. The DON stated that on the same day the NP assessed R61 and dictated her progress note to discontinue the [MEDICATION(S)] related to a past elevated QTc at the hospital. The DON stated that the facility did not receive the faxed NP Progress Note until 04/05/21 and that she did not know why nursing staff did not discontinue the [MEDICATION(S)] on 04/05/21. The DON stated that on 04/30/21, the NP was in the facility for R61's follow-up evaluation and wrote the order in R61's clinical record to discontinue the [MEDICATION(S)]. The DON confirmed that R61 should not have received [MEDICATION(S)] from 04/05/21 until 04/30/21. Review of the facility's policy titled, Behavior Management revised on 07/10/16 revealed, .The facility must evaluate the use of the antipsychotic medication within two weeks of admission and consider whether or not the medication can be reduced or discontinued .

Based on observations, record review and interviews, the facility failed to accommodate the need of one (Resident (R) 20 of two residents reviewed for accommodation of needs. Specifically, the facility failed to ensure R20, who had contractures of both hands, was provided with a call bell system that R20 could use to signal for assistance and that the call bell was within reach when in bed. Findings include: Review of R20's Face sheet in the Electronic Medical Record (EMR) under the Admission tab revealed R20 was admitted on [DATE]. Review of R20's EMR physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R20's EMR quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/04/21 showed a Brief Interview for Mental Status (BIMS) screening that was not completed with the resident. The resident had functional limitation in range of motion in the upper and lower extremities. The resident required one person assist with bed mobility and transfer. Observation on 5/18/21 at 9:25 AM, R20 was in bed and the call bell was on the floor behind the headboard of the bed and not within the resident's reach. Observation on 5/18/21 at approximately 2:47 PM, the resident was in bed and the call bell was on the floor not within the resident's reach. On 05/20/21 08:32 AM, Certified Nurse Aide (CNA)74 observed the call bell on the floor and not within the resident's reach. She acknowledged that the resident was unable to use the type of call bell. CNA74 stated that the resident sometimes had seizures and that the call bell should be within the resident's reach. On 05/20/21 at 09:47 AM, CNA11 stated that the call bell was to be clipped to the resident's bedsheet and that staff were to make sure it was within the resident's reach. During an observation and interview on 05/20/21 at 10:27 AM, the Director of Nursing (DON) and the facility's Vice President of Nursing (VPNRS) observed the resident in bed. The DON stated that R20 was unable to use the cylindrical, push button styled call light because she has contractures of both of her hands. The DON stated that the resident was unable to call or alert staff for care or concerns that required immediate attention. Review of the facility's policy titled Call Bell dated 01/07/12 indicated, .Call bells should be place within reach before leaving the resident's room .

Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to notify 1 of 3 sampled residents (Resident #1) physician of a change of condition in a timely manner. The Findings included: For Resident#1, the facility staff failed to notify the physician of a fall in a timely manner. Resident #1 was an [AGE] year old. Resident #1 was her own responsible party. Resident #1's [DIAGNOSES REDACTED]. The Annual Minimum Data Set, with an Assessment Date of 5/14/19 was reviewed. Resident #1 had a Brief Interview of Mental Status Score of 13, indicating that independence in daily decision making ability. Resident #1 was coded as requiring a wheelchair for mobility. On 2/20/20 a review was conducted of Resident #1's clinical record, revealing a Fall Risk Care Plan that was in place prior to her fall. An excerpt read, Has a potential to fall-High Risk-History of falls, Incontinence, [MEDICAL CONDITION]. Z cushion with dycem in place. Assist to turn and reposition at frequent intervals. Frequently remind to request staff assistance when needed. Notify the MD of any change in status. Monitor the effectiveness of medications. Monitor and encourage good nutritional intake . According to the investigation, on 9/16/19, Resident #1, stated that while she was alone in her room, she dropped a tissue on the floor. She did not ask staff for assistance. She bent over and tried to pick up the tissue and slid out of her wheelchair. One and a half years prior to the fall, on 3/16/18, Resident had a fall, without injury. An excerpt from her statement on 3/16/18 read, I was trying to get a pillow off of the chair. The fall on 9/16/19 occurred during the evening shift change. The nurse's note stated that Resident #1 was assessed, vitals obtained, range of motion preformed, and resident denied pain. The nurse documented the assessment as a late entry on 9/17/19, the next day. The physician was not informed until 9/17/19. He ordered a x-ray, and confirmed that her leg was fractured. Resident #1 was then sent out to the hospital, where she was treated and discharged . Resident #1 did not return to the facility. The nurse (Employee C) was disciplined in writing by the facility for not notifying the physician in a timely manner. On 2/20/20 at 1:00 P.M. the Director of Nursing (Employee B) was interviewed. She stated that the nurse was disciplined for not notifying the physician immediately after the fall. The DON submitted a plan and stated that the deficiency was a past non-compliance issue. She stated that as of 11/4/19 the facility had educated their staff and was in compliance. There were no other physician notification issues since 11/4/19 identified during the survey. No further information was received.

Based on observation, interview, and clinical record review the facility failed to provide [MEDICAL TREATMENT] services for 1 Resident (Resident #135) in a survey sample of 42 Residents resulting in harm. For Resident #135 the facility failed to ensure transportation to and from [MEDICAL TREATMENT] appointments which resulted in two back-to-back missed appointments. The missed appointments on 03/01/2018 (Thursday) and 03/03/2018 (Saturday) resulted in a new prescription for [MEDICATION NAME] (a medication for anxiety) due to a panic attack. This resulted in harm. For the missed appointments on 04/28/2018 (Saturday) and 05/01/2018 (Tuesday), the resident was hospitalized . This also resulted in harm. These four missed appointments result in a pattern. Resident # 135 a [AGE] year old female was admitted on [DATE] with [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) with an Assessment Reference Date of 6/18/2018 coded resident as having a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. On 8/21/2018 at 8:15 A.M. during initial tour Resident #135 was interviewed. She expressed concern over missing appointments for [MEDICAL TREATMENT]. She was tearful in explaining her situation and expressed desire to find a new facility. She stated she was afraid that the facility would be mean to me if I complain. A review of clinical records was conducted and a physician progress notes [REDACTED]. History of present illness --Crying, breathing rapidly, talking rapidly, stating I am having a panic attack. -States she is having a panic attack and in fear of losing her life b/c (because) she has not been to [MEDICAL TREATMENT]; missed her last two appointments (3/1/2018 and 3/3/2018) d/t (due to) transportation issues. The progress note further states Resident #135 was prescribed [MEDICATION NAME] 0.5 milligrams PO (by mouth) Every 8 hours PRN (as needed) for Anxiety. On 8/22/2018 at 3:50 PM an interview as conducted with the Director at [MEDICAL TREATMENT] Center who stated that Resident #135 is scheduled for [MEDICAL TREATMENT] Tuesday, Thursday, and Saturday. The missed dates were as follows: 03/01/2018 (Thursday) 03/03/2018 (Saturday) 03/24/2018 (Saturday) 03/31/2018 (Saturday) 04/28/2018 (Saturday) 05/01/2018 (Tuesday) 08/07/2018 (Tuesday) During the interview, the [MEDICAL TREATMENT] clinic director stated The danger with missing [MEDICAL TREATMENT] is fluid overload and elevated Potassium Levels which can cause cardiac issues. She stated I know at one hospital admission she had a Potassium level of 6 or 8. The Director of [MEDICAL TREATMENT] submitted attendance record showing the missed dates and the treatment record showing the patient weight before and after [MEDICAL TREATMENT] indicating how much fluid was removed during [MEDICAL TREATMENT]. On 5/1/2018 Resident #135 requested to be sent to the hospital after missing another two consecutive [MEDICAL TREATMENT] on 4/28/18 and 5/1/18. Lab values were reviewed in the 5/1/18 hospital discharge summary. Lab values in the discharge summary read: Potassium - 5.9 H (normal value 3.5-5.1) Creatinine - 10.80 H (normal value 0.5-1.4) Blood Urea Nitrogen - 80 H (normal value 7-20) BUN/Creatinine - 7.4 L Included in the discharge summary was a note from the attending emergency room physician. The note read I discussed your labs with (Nephrologist name) and he wants to make sure you undergo [MEDICAL TREATMENT] tomorrow. On 8/22/2018 at 3:15 p.m., an interview was conducted with LPN B. LPN B stated If transportation doesn't show up we call the transport company, then we notify [MEDICAL TREATMENT] or the doctor, the responsible party and the house doctor. On 8/22/2018 at 3:22 p.m., an interview with the Administrator, the DON, and Corporate Nurses was conducted. The Administrator stated We have the usual ongoing problems with (name of transportation provider), they will dump a call for one that pays more which means Residents won't get picked up. We usually try to call another company. In addition, the DON stated if they miss an appointment with [MEDICAL TREATMENT] we contact the [MEDICAL TREATMENT] center and try to reschedule, we notify the physician and the responsible party and if family can take them they do, she also stated we have taken some people in the facility van when their transportation didn't show up. On 8/22/18 at 4:40 PM an interview with the Social Worker A she stated that the facility gets the orders for [MEDICAL TREATMENT] on admission. We contact the (transportation provider) and they set up continuous pick up and drop off based on the Resident's [MEDICAL TREATMENT] days and times. Usually we have her (Resident #135) ready an hour before pick up. They (transportation) then tell us what time they will be picking her up from facility and what time they will pick her up from [MEDICAL TREATMENT] to return to the facility. She further stated when the transportation doesn't show up we usually find out when [MEDICAL TREATMENT] calls us and says she didn't show up. Then we call transportation and try to schedule another time but we cannot get transportation arranged in 24 hours. Social Worker A stated that Resident #135 was a stretcher transport and had to go by ambulance.

Based on observation, staff interview and facility documentation review the facility staff failed to store and serve food in accordance with professional standards for food service safety. Facility staff failed to use correct handwashing procedures, hold food at appropriate temperature, and reheat food to appropriate temperature. The findings included: An initial tour of the kitchen began on 8/21/18 at 7:30 a.m. At 7:32 a.m. Diet Staff A was observed to wet hands, use soap and turn faucet off with paper towel in approximately 5 seconds. Diet Staff B was observed to wet hands, did not use soap and did not turn off faucet with a paper towel. Diet Staff C was observed to was hands for approximately 3 seconds. On 8/22/18 at 11:45 a.m. food was observed on the steam table in preparation for lunch tray line. The Corporate Dietitian took the temperatures of the food with a digital thermometer. The sweet potato tots were measured at 128 degrees Fahrenheit. They were sent back to the oven to be reheated. Dietary Staff D also took the temperatures of the food on the steam table. The broccoli measured 128 degrees Fahrenheit. It was sent back to the oven to be reheated. At 12:15 p.m., the reheated sweet potato tots were removed from the oven and measured 150 degrees Fahrenheit. The broccoli was removed from the oven and measured 144.9 degrees Fahrenheit. Both items were placed on the steam table for service. The food was not reheated to 165 degrees Fahrenheit. Diet Staff E was observed to load the trays onto the cart during the entire meal service. During the observation, Diet Staff E was not observed to wash his hands using appropriate handwashing technique. On two occasions, Diet Staff E was observed to use soap with out water, wiping the soap from his hands with a paper towel. The tray line began at 12:30 p.m. and concluded at 1:51 p.m. After all of the trays were prepared to be delivered to the units, Diet Staff D was asked to prepare a regular diet test tray for the survey team to be included on the last cart which was for the Abingdon Unit. Temperatures were taken at 1:55 p.m. by the Corporate Dietitian of the foods on the test tray using a digital thermometer as follows: chicken tenders= 126.5 degrees F broccoli= 102.3 degrees F mashed potatoes= 113 degrees F The food was not held on the steam table at 135 degrees or above during meal service. The cart was delivered to the Abingdon Unit. After all trays were delivered to the residents, the test tray was removed from the cart and food temperatures were re-measured at 2:06 p.m. by the Corporate Dietitian using the same digital thermometer as follows: chicken tenders= 110 degrees F broccoli= 100 degrees F mashed potatoes= 108 degrees F The survey team tasted the food from the test tray. The food was not hot. On 8/23/18 at 10:00 a.m., the kitchen observations were reviewed with the Corporate Dietitian, Facility Dietitian, Dietary Manager and Diet Staff D. The facility staff were notified of the multiple instances of inappropriate handwashing technique. The facility staff were asked to explain proper handwashing technique. The Dietary Manager stated that handwashing should be done in the length of time it takes to sing the Happy Birthday song. It was reviewed that food was not held on the steam table at 135 degrees or above and it was reviewed that foods were not reheated to proper temperature. The facility staff were asked to what temperature food should be re-heated. The Corporate Dietitian stated 165 degrees. Handwashing instructions were hung above the handwashing sink. The instructions read, How? Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. Lather your ands by rubbing them together with the soap. Be sure to lather the backs of your hands, between your fingers and under your nails. Scrub your hands for at least 20 seconds. Need a timer? Hum the 'Happy Birthday' song from beginning to end twice. Rinse hands well under clean, running water. Dry hands using a clean towel or air dry them. On 8/23/18 at 11:17 a.m. the Director of Nursing (DON) was interviewed about infection control procedures as she functioned as the infection control nurse. When asked if she monitored the handwashing technique of the dietary staff, the DON stated that she does not monitor the dietary staff. She stated she was unsure who monitored the dietary staff for proper handwashing procedures. The Administrator and Director of Nursing were notified of the kitchen issues at the end of day meeting on 8/23/18.

Based on observation and resident interview the facility failed to ensure food was served at a palatable temperature. Facility staff failed to ensure food was served hot. The findings included: On 8/21/18 after the initial tour of the facility, the breakfast meal observation was conducted at 8:00 a.m. Residents #15, and #66 were observed and interviewed. Both Residents were in their rooms and both had pancakes and bacon on Styrofoam plates. Both Residents complained of cold food, and neither of them ate the meal. They stated that this had happened a lot lately, and getting the food reheated was almost impossible, as the staff was busy handing out trays, and feeding other Residents. Resident #15 requested just feel this, no one wants cold bacon and pancakes, I am not eating this, and requested the surveyor touch the pancakes and bacon. Both were cool to the touch. On 8/22/18 at 11 a.m., 12 out of 12 cognitively intact residents complained of the food being cold the majority of the time during the group meeting. While complaints about the food were issued from residents on all the units, a majority of the complaints were from residents living on the Abingdon Unit. On 8/22/18, the lunch tray line was observed. The tray line began at 12:30 p.m. and concluded at 1:51 p.m. After all of the trays were prepared to be delivered to the units, Diet Staff D was asked to prepare a regular diet test tray for the survey team to be included on the last cart which was for the Abingdon Unit. Temperatures were taken at 1:55 p.m. by the Corporate Dietitian of the foods on the test tray using a digital thermometer as follows: chicken tenders= 126.5 degrees F broccoli= 102.3 degrees F mashed potatoes= 113 degrees F The food was not held on the steam table at 135 degrees or above during meal service. The cart was delivered to the Abingdon Unit. After all trays were delivered to the residents, the test tray was removed from the cart and food temperatures were re-measured at 2:06 p.m. by the Corporate Dietitian using the same thermometer as follows: chicken tenders= 110 degrees F broccoli= 100 degrees F mashed potatoes= 108 degrees F The food on the test tray did not leave the kitchen at the required hot holding temperature of 135 degrees Fahrenheit or above. The food was even colder by the time it was served on the unit. The survey team tasted the food from the test tray. The food was not hot. The Administrator and Director of Nursing were notified of the food temperature issues at the end of day meeting on 8/23/18.

Based on observations, staff interview, clinical record review, and facility policy review, the facility staff failed to provide care and service associated with Activities of Daily Living by not serving food in a scoop plate for one Resident (Resident # 101) in a survey sample of 42 residents. The findings include: Resident # 101 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident # 101's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/02/2018 was coded as a quarterly assessment. Resident #101 was coded with a Brief Interview of Mental Status (BIMS) score of 8 out of possible 15 indicating moderate cognitive impairment. Functional status for eating is coded as needing set-up help only. On 08/22/18 at 6:45 pm, Resident #101 was observed in his bed. The head of bed of the bed was elevated and resident was feeding himself. The main meal was on a plate and a mixed fruit cup was in a small plastic container. The resident was unable to pick up fruit with the spoon. The resident put the spoon down and ate the fruit with his hand. The tray menu included instructions that stated yellow scoop plate. The resident's clinical record review of physician's orders [REDACTED]. An occupational therapy note dated 05/22/2018 stated .include scoop plate in order to maximize independence with self-feeding routine. The resident's care plan had an active intervention that stated scoop plate to assist with meals. 08/23/18 at approximately 11:00 am, an interview was conducted with certified nursing assistant (CNA) A. CNA A was asked if resident had special instructions on his tray card and CNA A stated that resident needs to have the yellow scoop plate for self-feeding. On 08/23/18 at 3:40 pm, an interview with Admin C was conducted. Admin C stated the dishwasher was down on 08/22/2018 and there was not an alternative plan in place. Admin C also stated that the facility Assistant Director of Nursing (ADON) went in to check on the resident during the evening meal on 08/22/2018 and observed him eating the fruit with his hand and making it work without his scoop plate. On 08/23/2018, the DON and the Administrator were notified of the finding and they offered no further information.

Based on observations, family interview, staff interview, and clinical record review, the facility staff failed to provide hydration care and services for one resident (Resident # 94) in a survey sample of 42 residents. The facility staff failed to provide Resident #94 with water. The findings include: Resident # 94 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident # 94's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/2018 was coded as a quarterly assessment. Resident #94 was coded with a Brief Interview of Mental Status (BIMS) score of 5 out of possible 15 indicating severe cognitive impairment. Functional status of eating and drinking is coded for a one-person physical assist and supervision, oversight, encouragement, or cueing. On 08/21/18 at 1:30 pm, in a telephone interview with resident's daughter, the daughter stated she used to visit her parent 1-2 times a week and never saw a water pitcher in her parent's room. She stated she shared her concerns with facility staff. She has only visited her parent a few times in the past 4 weeks but still has not seen a water pitcher in the room. On 08/21/18 at 2:30 pm, Resident #94 was in his room seated in his wheelchair. A water pitcher was not seen on any table surfaces in the Resident's room. On 08/22/18 at 9:00 am, Resident # 94 was observed in his room and again, a water pitcher was not seen on any table surfaces in the Resident's room. On 08/22/18 at approximately 10:30 AM, certified nursing assistant (CNA) A stated water pitchers are usually delivered toward the end of night shift (11pm-7am). When told it was observed there was not a water pitcher in resident's room, CNA A stated sometimes the Resident's roommate (also with a [DIAGNOSES REDACTED]. On 08/22/18 at approximately 11:30 am, the licensed practical nurse (LPN) D stated she just brought ice water to the resident's room. On 08/23/18, Record review indicates resident is on a regular diet with no added salt, low concentration sweets, and large portions. On 08/23/2018, the Director of Nursing and Administrator were notified of findings.

Based on staff interview and clinical record review the facility staff failed to ensure medications were available for administration for 1 resident (Resident #244) of 42 residents in the survey sample. For Resident #244 the facility staff failed to ensure [MEDICATION NAME] (for anxiety) was available for administration. The findings included: Resident #244, an [AGE] year old, was admitted on [DATE]. [DIAGNOSES REDACTED]. A Minimum Data Set assessment had not been completed since the resident was new to the facility. Resident #244 was observed to have cognitive impairment and required extensive assistance with activities of daily living. Resident #244 was at the facility for a respite stay from 8/17/18- 8/22/18. Resident #244 had a physician order [REDACTED]. According to the (MONTH) Medication Administration Record [REDACTED]. The notes on the MAR indicated [REDACTED] 8/17/18 no [MEDICATION NAME] on cart 8/18/18 Not Administered 8/19/18 Medication is not on the cart and has not been sent to the facility from the pharmacy 8/20/18 not available 8/21/18 Not Administered On 8/23/18 in the afternoon, the Corporate Nurse provided the packing slip for Resident #244's [MEDICATION NAME]. The medication was delivered on 8/22/18, after the resident had been discharged . The Corporate Nurse stated that the medication had not been filled timely because the facility was waiting for a hard script from hospice. The facility policy titled Medication Shortages and Unavailable Medications was reviewed. The policy read, When medication orders are unavailable or were not received, the licensed nurse will initiate action in cooperation with the physician and the pharmacy. The procedure read, Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from the Pharmacy.

Based on observation, interview and clinical record review the facility failed to ensure 1 Resident (Resident #24) was free from unnecessary [MEDICAL CONDITION] medication in a survey sample of 42 Residents. For Resident # 24 the facility failed to ensure Resident was free from unnecessary [MEDICAL CONDITION] medication. The findings include: Resident # 24 an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her last (MDS) Minimum Data Set (a screening tool) was coded as having a (BIMS) Brief Interview of Mental Status score of 0, indicating Resident has severe cognitive impairment. On 8/21/18 at 7:30 AM during initial tour Resident #24 was noted to be still in bed asleep. On 8/22/18 at 11:30 AM Resident #24 was in wheel chair in the day room / common area did not appear to interact with other Residents and mumbled something unintelligible when spoken to. On 8/22/18 a review of clinical record was conducted and found that Resident #24 had orders for the following medications listed along with the Diagnosis: [REDACTED]. ICD-10:F99 - Mental Disorder Not Otherwise Specified. R46.89 - Other symptoms and signs involving appearance and behavior F41.9 Anxiety disorder Unspecified F03.91 Dementia with behavioral disturbance The manufacturer instructions state: WARNING! INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED [MEDICAL CONDITION]; and SUICIDAL THOUGHTS AND BEHAVIORS Increased Mortality in Elderly Patients with Dementia-Related [MEDICAL CONDITION] Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death (see WARNINGS AND PRECAUTIONS). [MEDICATION NAME] is NOT approved for the treatment of [REDACTED]. According to the FDA: [MEDICATION NAME] may cause serious side effects, including: 1. Risk of death in the elderly with dementia. Medicines like [MEDICATION NAME] can increase the risk of death in elderly people who have memory loss (dementia). [MEDICATION NAME] is not for treating [MEDICAL CONDITION] in the elderly with dementia. 2. Risk of suicidal thoughts or actions (antidepressant medicines, depression and other serious mental illnesses, and suicidal thoughts or actions). In addition, the resident also has an order for [REDACTED].>[MEDICATION NAME] 125 mg capsule (a [MEDICAL CONDITION] medication) delayed release sprinkle 1 cap in the AM 8-10 AM med pass and 2 caps give at4 PM med pass daily. ICD-10:F99 - Mental Disorder Not Otherwise Specified , Alzheimer Dementia with combative behavior. According to the manufacturer: [MEDICATION NAME]® Sprinkle Capsules ([MEDICATION NAME] sodium delayed release capsules), for oral use, is a prescription medicine used alone or with other medicines to treat: Manic episodes associated with [MEDICAL CONDITION] disorder Alone or with other medicines to treat: Complex partial [MEDICAL CONDITION] in adults and children [AGE] years of age and older Simple and complex absence [MEDICAL CONDITION], with or without other [MEDICAL CONDITION] types Prevention migraine headaches On 8/22/18, a request was made to the Director of Nursing (DON) for any psychiatric notes or consults for this resident regarding medications. On 8/23/18, an interview with Corporate nurse and DON was conducted and the DON Stated the facility Dr. gave us the [DIAGNOSES REDACTED]. She further stated she was aware of the black box warnings about elderly / dementia patients taking anti-psychotics such as [MEDICATION NAME]. Administration were made aware on 8/23/18 and no further information was provided

Based on staff interview and clinical record review the facility staff failed to ensure 2 resident (Resident #244 and #9) of 42 residents in the survey sample were free from significant medication errors. 1. For Resident #244 the facility staff failed to administer [MEDICATION NAME] (for anxiety) for five days. 2. For Resident #9, the facility failed to administer prn (as needed) [MEDICATION NAME] per physician order [REDACTED]. The findings included: 1. For Resident #244 the facility staff failed to administer [MEDICATION NAME] (for anxiety) for five days. Resident #244, an [AGE] year old, was admitted on [DATE]. [DIAGNOSES REDACTED]. A Minimum Data Set assessment had not been completed since the resident was new to the facility. Resident #244 was observed to have cognitive impairment and required extensive assistance with activities of daily living. Resident #244 was at the facility for a respite stay from 8/17/18- 8/22/18. Resident #244 had a physician order [REDACTED]. According to the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The notes on the MAR indicated [REDACTED] 8/17/18 no [MEDICATION NAME] on cart 8/18/18 Not Administered 8/19/18 Medication is not on the cart and has not been sent to the facility from the pharmacy 8/20/18 not available 8/21/18 Not Administered On 8/23/18 in the afternoon, the Corporate Nurse provided the packing slip for Resident #244's [MEDICATION NAME]. The medication was delivered on 8/22/18, after the resident had been discharged . The Corporate Nurse stated that the medication had not been filled timely because the facility was waiting for a hard script from hospice. 2. For Resident #9, the facility failed to administer prn (as needed) [MEDICATION NAME] (for swelling) per physician order. Resident #9, a [AGE] year old, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #9's most recent Minimum Data Set assessment was a significant change assessment with an assessment reference date of 7/25/18. He was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment and required limited assistance with activities of daily living. Resident #9 had a physician order [REDACTED]. (pounds) A Nutritional assessment dated [DATE] read Wts (weights) being monitored 3 times weekly. Resident #9's weights were reviewed. According to the weights, the [MEDICATION NAME] should have been administered as follows: 7/20/18= 316 pounds 7/23/18= 319.5 pounds. The medication should have been administered on 7/23/18 for a 3.5 pound weight gain. 8/10/18= 314.5 pounds 8/13/18= 317.4 pounds. The medication should have been administered on 8/13/18 for a 2.9 pound weight gain. 8/15/18= 317.4 pounds 8/17/18= 322.0 pounds. The medication should have been administered on 8/17/18 for a 4.6 pound weight gain. According to the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records (MAR), the [MEDICATION NAME] was not administered per physician order [REDACTED]. The Administrator and Director of Nursing (DON) were notified of the issue on 8/23/18 at 12:30 p.m. On 8/23/18 at 3:45 p.m., the DON stated that the prn [MEDICATION NAME] had not been given and should have been administered.

Based on observation and staff interview the facility staff failed to ensure meals were served according to the published menu. The food served for lunch on 8/22/18 did not reflect the foods listed on the published lunch menu. The findings included: On 8/22/18 at 11 a.m., 12 out of 12 cognitively intact residents complained that the facility hardly ever served what was listed on the menu board in the lobby. They stated they wished they could have the meals as listed on the menu. They stated they have very little to be excited about but they would like to enjoy their food. They gave an example of one day when chocolate pie was listed. They stated they were excited to be able to have pie but they were served jello instead because the kitchen ran out of the pie. Two residents in the group meeting asked why the dietary staff did not seem to know how to prepare enough meals for the number of residents in the facility. They stated there should be enough food to serve to residents. One resident stated during one meal four residents seated at the table together all received different food. While complaints about the food were issued from residents on all the units, a majority of the complaints were from residents living on the Abingdon Unit. The menu for the date of 8/22/18 was provided by the facility dietitian. The lunch menu for a regular diet read, chicken tenders, baked sweet potato, broccoli, dinner roll, pudding, beverage. A white board was posted outside of the dining room. The lunch meal for 8/22/18 was hand written on the board. The white board read: chicken tenders, baked sweet potato, broccoli, dinner roll, chocolate pudding. On 8/22/18 at 11:45 a.m., food was observed on the steam table in preparation for lunch tray line. The following foods were on the steam table and used to prepare a regular diet tray at the beginning of meal service: sweet potato tots, chicken tenders, broccoli. The tray line began at 12:30 p.m. and concluded at 1:51 p.m. During the trayline observation, the broccoli ran out and additional broccoli was prepared for service. The sweet potato tots ran out and were replaced with mashed potatoes. A regular test tray was prepared for the survey team to be included on the last cart which was for the Abingdon Unit. The food on the test tray included chicken tenders, broccoli, mashed potatoes and vanilla pudding. Two of the four foods on the test tray were different from what was on the menu and the white board: mashed potatoes instead of baked sweet potato and vanilla pudding instead of chocolate pudding. Baked sweet potato, as listed on the menu, was never on the tray line for meal service. Meal trays containing these different foods were sent to the Abingdon Unit where a majority of the complaints were issued by the group interview residents. On 8/23/18 at 10:00 a.m., the menu issues were reviewed with the Corporate Dietitian, Facility Dietitian, Dietary Manager and Diet Staff D. The facility staff were notified that the residents expressed concern about not getting the food listed no the published menu. The Dietary Manager stated that she ordered food according to the census. She stated if the census increased from the time she placed the food order then they would run out of food during the tray line. When asked if she was limited to the amount of food she could purchase, the Diet Manager stated no, she just tried to order per the census. The Administrator and Director of Nursing were notified of the menu issues at the end of day meeting on 8/23/18.

Based on resident interview, staff interview, facility documentation and clinical record review Administration failed to use its resources to ensure the [MEDICAL TREATMENT] residents attain and maintain the highest practicable physical and psychosocial wellbeing. For Resident #135 the facility failed to ensure highest practicable wellbeing for [MEDICAL TREATMENT] patients by not utilizing its resources to transport [MEDICAL TREATMENT] patients to appointments. Resident # 135 a [AGE] year old female was admitted on [DATE] with [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) with an Assessment Reference Date of 6/18/2018 coded resident as having a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. On 8/21/2018 at 8:15 A.M. during initial tour Resident #135 was interviewed. She expressed concern over missing appointments for [MEDICAL TREATMENT]. She was tearful in explaining her situation and expressed desire to find a new facility. She stated she was afraid that the facility would be mean to me if I complain. A review of clinical records was conducted and a physician progress notes [REDACTED]. History of present illness --Crying, breathing rapidly, talking rapidly, stating I am having a panic attack. -States she is having a panic attack and in fear of losing her life b/c (because) she has not been to [MEDICAL TREATMENT]; missed her last two appointments (3/1/2018 and 3/3/2018) d/t (due to) transportation issues. The progress note further states Resident #135 was prescribed [MEDICATION NAME] 0.5 milligrams PO (by mouth) Every 8 hours PRN (as needed) for Anxiety. On 8/22/2018 at 3:50 PM an interview as conducted with the Director at [MEDICAL TREATMENT] Center who stated that Resident #135 is scheduled for [MEDICAL TREATMENT] Tuesday, Thursday, and Saturday, and she has missed eight appointments with [MEDICAL TREATMENT]. The missed dates are as follows: 03/01/2018 (Thursday) 03/03/2018 (Saturday) 03/24/2018 (Saturday) 03/31/2018 (Saturday) 04/28/2018 (Saturday) 05/01/2018 (Tuesday) 08/02/2018 (Thursday) 08/07/2018 (Tuesday) 08/11/2018 (Saturday) During the interview, the [MEDICAL TREATMENT] clinic director stated The danger with missing [MEDICAL TREATMENT] is fluid overload and elevated Potassium Levels which can cause cardiac issues. She stated I know at one hospital admission she had a Potassium level of 6 or 8. The Director of [MEDICAL TREATMENT] submitted attendance record showing the missed dates and the treatment record showing the patient weight before and after [MEDICAL TREATMENT] indicating how much fluid was removed during [MEDICAL TREATMENT]. On 5/1/2018 Resident #135 requested to be sent to the hospital after missing another two consecutive [MEDICAL TREATMENT] on 4/28/18 and 5/1/18. Lab values were reviewed in the 5/1/18 hospital discharge summary. Lab values in the discharge summary read: Potassium - 5.9 H (normal value 3.5-5.1) Creatinine - 10.80 H (normal value 0.5-1.4) Blood Urea Nitrogen - 80 H (normal value 7-20) BUN/Creatinine - 7.4 L Included in the discharge summary was a note from the attending emergency room physician. The note read I discussed your labs with (Nephrologist name) and he wants to make sure you undergo [MEDICAL TREATMENT] tomorrow. On 8/22/2018 at 3:15 p.m., an interview was conducted with LPN B. LPN B stated If transportation doesn't show up we call the transport company, then we notify [MEDICAL TREATMENT] or the doctor, the responsible party and the house doctor. On 8/22/2018 at 3:22 p.m., an interview with the Administrator, the DON, and Corporate Nurses was conducted. The Administrator stated We have the usual ongoing problems with (name of transportation provider), they will dump a call for one that pays more which means Residents won't get picked up. We usually try to call another company. In addition, the DON stated if they miss an appointment with [MEDICAL TREATMENT] we contact the [MEDICAL TREATMENT] center and try to reschedule, we notify the physician and the responsible party and if family can take them they do, she also stated we have taken some people in the facility van when their transportation didn't show up. On 8/22/18 at 4:40 PM an interview with the Social Worker A she stated that the facility gets the orders for [MEDICAL TREATMENT] on admission. We contact the (transportation provider) and they set up continuous pick up and drop off based on the Resident's [MEDICAL TREATMENT] days and times. Usually we have her (Resident #135) ready an hour before pick up. They (transportation) then tell us what time they will be picking her up from facility and what time they will pick her up from [MEDICAL TREATMENT] to return to the facility. She further stated when the transportation doesn't show up we usually find out when [MEDICAL TREATMENT] calls us and says she didn't show up. Then we call transportation and try to schedule another time but we cannot get transportation arranged in 24 hours. Social Worker A stated that Resident #135 was a stretcher transport and had to go by ambulance. When asked about the four missing appointments in (MONTH) before the fall (at the facility ) that rendered her non weight bearing thus requiring a stretcher, she stated we have no way to transport her if they don't show up. Administration was interviewed and aware of concerns no further information was provided.

Based on observation and staff interview the facility staff failed to implement an effective infection control program. The ice scoop was stored in the ice machine on the(NAME)unit. The findings included: On 8/22/18 at 11:15 a.m. the ice scoop was observed stored inside the ice machine on the(NAME)Unit. The ice machine had a storage compartment inside the machine for the ice scoop. There was also a bin with an ice scoop on top of the ice machine. On 8/23/18 at 11:17 a.m., an interview was held with the Infection Control Nurse who was also the Director of Nursing (DON). The DON was informed that the ice scoop was stored inside the ice machine. The DON stated that the ice scoop should not be stored inside the ice machine. The DON and this surveyor together observed the ice scoop in the machine. The 6th Edition of the ServSafe Manager training book addressed the storage of the ice scoop. Chapter 6, page 6.5, section titled Ice read, Containers and scoops: Use clean and sanitized containers and ice scoops to transfer ice from an ice machine to other containers. Store ice scoops outside of the ice machine in a clean, protected location, as shown in the photo at left. The photo showed a scoop holder affixed to the outside of the ice machine. During the lunch observation in the main kitchen on 8/22/18, Diet Staff D stated that she and the Dietary Manager just obtained their ServSafe food safety certification. No further information was provided.

Based on observations, staff interview, clinical record review, and facility policy review, the facility staff failed to meet professional standards by failing to secure a prescription for a controlled substance for one Resident (Resident # 101) in a survey sample of 42 residents. The findings include: Resident # 101 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident # 101's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/02/2018 was coded as a quarterly assessment. Resident # 101 was coded with a Brief Interview of Mental Status (BIMS) score of 8 out of possible 15 indicating moderate cognitive impairment. On 08/23/2018 at approximately 08:55 am, an original handwritten prescription for [MEDICATION NAME], an opioid [MEDICATION NAME], was observed in Resident's chart. It was an active prescription for [MEDICATION NAME] dated 08/21/18. 08/23/18 at approximately 09:00 am an interview was conducted with licensed practical nurse (LPN) B. When asked LPN B about the process for filling prescriptions of controlled substances, LPN B stated that the physician hands the script to the nurse, the nurse will then scan it to the pharmacy, put the original script in the pharmacy folder, and place a copy in the chart. When asked how to tell if a script has been scanned, LPN B stated there will be a checkmark in the upper right-hand corner of the original script. When asked if Resident # 101's prescription had been filled, LPN B stated it didn't look like the prescription was scanned to pharmacy and stated I will scan it now. In a review of facility policies, the procedure for securing original prescriptions of controlled substances was not addressed. On 08/23/2018, the Director of Nursing and the Administrator were notified of the findings.

Based on observation and staff interview, the facility staff failed to ensure shower areas on the Abington (two shower rooms), Botetourt and the Memory care unit were clean and homelike. The shower rooms had black, discolored tiles and grout, and broken baseboards in the shower rooms for the Abington,(NAME)and the Memory Care units. The findings included: On 6/15/17 at 9:30 AM, the shower room on the(NAME)unit was observed. The shower area near the entrance had stained, discolored and broken tiles, with black buildup in the grout. The two shower rooms on the Abington area were checked. Again, broken tiles and stained tiles were present. Some of the tiles had been replaced. On the Memory Care Unit, the shower room also had broken and stained tiles in the shower area. Dark discoloration was present in the grout. On 6/15/17 at 10:55 AM, the maintenance director was interviewed. He stated, The 12 month plan is to remove and replace tiles, bleach, place a concrete board 24 inches from the floor. On 6/15/17 at approximately 11:00 AM, the Administrator was notified of above findings. He stated, We have been planning to fix the shower room, but other things came up.

Based on observation, staff interview, and clinical record review the facility staff failed for one resident (Resident #9)of 27 residents in the survey sample to manage intrusive and aggressive behaviors creating an unsafe environment on the Memory Care unit resulting in Immediate Jeopardy and substandard quality of care. The Administration was informed on 8/27/15 at 10:50 a.m. of the immediate jeopardy situation. After the removal of the immediate jeopardy on 8/27/15 at 2:42 p.m., the scope and severity level of the deficiency was lowered to a level 2 isolated. Resident #9 was observed attempting to move Resident #21 by lifting her tray table, touching her chest and attempting to lift Resident #21 by the arm pits. The survey team called the floor nurse over to intervene. Eight days earlier, Resident #9 pulled Resident #21 over in her wheelchair to the floor. The findings included: Resident #9, a [AGE] year old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED].) <<http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/EmotionalBehavioralChallenges/Pseudobulbar-Affect-PBA_UCM_ 7_Article.jsp>> Resident #9's most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 7/8/15. She was coded with a Brief Interview of Mental Status score of 9 indicating moderate cognitive impairment. She was coded to have physical and verbal behaviors. She was coded to ambulate independently and to wander. Resident #21, a [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #21's most recent Minimum Data Set assessment with an Assessment Reference Date of 7/1/2015 was coded as a quarterly assessment. A Brief Interview of Mental Status was unable to be completed, and she was coded as having moderate cognitive impairment by a staff assessment. Resident #21 was coded as needing the assistance of one staff member for activities of daily living. On 8/27/15 at approximately 9:00 a.m., Resident #9 was observed by two surveyors to approach Resident #21. The residents were at the end of the hall near the nursing station. The dining room was located at the other end of the hallway. Two Certified Nursing Assistants (CNAs) were in the dining room feeding residents. A third CNA was working somewhere on the unit. Licensed Practical Nurse C (LPN C) was working at the medication cart on the end of the hall in front of the dining room. The Unit Manager was not on the unit. She supervised two units. All other residents were in the dining room or in their own rooms. Resident #9 (independently ambulating) approached Resident #21 (self propelling in wheel chair) from the Resident #21's left side. Resident #9 attempted to lift the half lap tray that was attached to the left arm of Resident #21's wheel chair. Resident #9 touched Resident #21's chest and then reached to grab her under the arm pits. At this time, LPN C (working on the medication cart at the end of the hall) was called by the surveyor to intervene. LPN C escorted Resident #9 down to the dining area and had her sit down. LPN C prepared her a cup of coffee. Resident #9 began to cry and refused the coffee. Resident #9's nursing notes were reviewed from July 2015 to present. Almost daily, nursing staff documented intrusive and aggressive behaviors for Resident #9. The following nursing notes were documented in the clinical record: 7/1/15, 11:56 a.m. walking up and down hallways, pulling on other residents 7/2/15, 12:02 p.m. resident continues to try and assist other residents. cries with any attempts at redirection 7/2/15, 10:36 p.m. Resident repeatedly grabs and pulls on other residents and becomes tearful with redirection. Redirection is successful for a short amount of time. 7/3/15, 2:36 p.m. Resident grabbing at others, aggressive with staff x 1 7/3/15, 8:24 p.m. continues grabbing at others, attempts to push other residents while in their wheel chairs, when redirected she either becomes combative or tearful. 7/4/15, 2:43 p.m. Resident wanders and intrusive towards others at times. 7/5/15, 2:28 p.m. Grabbing at others at times, redirected each time with effect. 7/7/15, 2:36 p.m. Resident wandering, crying at times. Grabbing other residents at times. Redirected, given snack, activities without much effect. 7/7/15, 9:18 p.m. resident continues to grab at others, she is tearful at times redirection has no effect. 7/8/15, 2:59 p.m. Resident wandering, grabbing others. Redirected each time. 7/8/15, 9:14 p.m. resident continues to grab at others, when redirection attempted resident becomes tearful. 7/9/15, 2:46 p.m. Wandering, grabbing other residents. Going into others rooms and unmaking beds. Redirected numerous times. 7/10/15, 2:38 p.m. Resident wandering, grabbing at others at times. Redirected each time. 7/10/15, 9:38 p.m. Resident has been intrusive this shift, grabbing and pulling on other residents, and pushing residents' wheelchairs. Redirection successful for a short amount of time. 7/11/15, 2:54 p.m. crying at times, very intrusive, pulling on other residents, pushing their wheelchairs, redirection not effective. very agitated. 7/11/15, 11:12 p.m. Resident wandering and intrusive this shift. Resident was grabbing other residents, grabbing and pushing on their wheelchairs, and pulling at their clothes. Redirection not successful. 7/12/15, 2:40 p.m. resident cries when redirected. continuously pulling on other residents, pushing their wheel chairs and getting them upset. redirection only works for short periods. 7/12/15, 9:40 p.m. Resident increasingly difficult to redirect throughout the shift. Resident pulling and grabbing onto other residents and staff, residents' wheelchairs and carts. Resident becomes tearful and agitated when redirection. 7/13/15, 2:39 p.m. Resident wandering, grabbing at others, cussing with redirection. 7/13/15, 9:52 p.m. Resident noted to be grabbing at others, bending down and trying to pick up something on the floor that the nurses can not see. 7/15/15, 9:37 p.m. resident cursed at staff x2 this pm. 7/20/15, 1:20 p.m. resident more intrusive than usual, pulling on residents in their w/c taking blankets off residents. attempting to take things off med cart. crying with all attempts at redirection, gets angry and refuses to stop what she is doing. 7/20/15, 8:09 p.m. resident found on floor in unit hallway. Fall was not witnessed. 7/21/15, 9:48 p.m. resident has been grabbing on others, when redirection attempted she becomes tearful or defiant. 7/27/15, 2:47 p.m. Grabbing at other residents at times, redirected after each with effect. 7/27/15, 8:07 p.m. earlier in shift she was grabbing others, when redirection attempted she became tearful. 7/29/15, 2:11 p.m. grabbing other residents wheel chairs and their arms. combative and cursing with attempts at redirection. crying most of shift. snack, toileting or activities not effective. 7/30/15, 3:08 p.m. resident was in a altercation with another resident causing injuries to the other resident. 7/30/15, 10:08 p.m. Resident continues to be intrusive, grabbing and pulling other residents. Tearful when redirected. Resident was taken to room and went to bed, no further problems noted. 7/31/15, 2:50 p.m. Resident wandering, grabbing others, no aggressive behaviors this shift. Crying noted x1. 7/31/15, 8:15 p.m. resident continues to grab others and attempts to push/ pull others that are in their wheel chairs. 8/1/15, 2:26 p.m. Resident wandering, grabbing others at times. No aggressive behaviors this shift. 8/1/15, 8:53 p.m. resident continues to grab others, when redirected she becomes tearful. 8/2/15, 2:39 p.m. Resident wandering, grabbing at other residents. Resident hitting at staff during redirection. 8/3/15, 2:34 p.m. resident angry with nurse when she moved coffee cart to take to kitchen, slapped nurse repeatedly saying that's mine I tell you that's mine. nurse moved out of residents way and coffee cart was taken to kitchen resident walked off. 8/4/14, 3:05 p.m. Wandering, grabbing others, hitting at staff when redirected. 8/4/15, 8:44 p.m. resident has been tearful and grabbing others earlier this shift. one on one and snack given with no effect. resident also toileted with no no effect. 8/5/15, 2:29 p.m. Resident cussing at staff this shift, redirected with some effect. 8/5/15, 8/56 p.m. noted with increased tearfulness and pulling on others, when redirection attempted resident becomes more tearful. 8/6/15, 2:35 p.m. Resident grabbing others, aggressive with staff when redirected. 8/6/15, 8:54 p.m. resident grabbing others, increased tearfulness noted also. when she is redirected increased agitation is noted. 8/7/15, 2:48 p.m. Resident wandering, grabbing others. Aggressive with redirection. 8/8/15, 11:44 a.m. resident agitated, crying, hitting staff, pulling on other residents doesn't understand redirection. 8/8/15, 10:04 p.m. Resident pulling on residents, pushing residents in wheelchairs. Redirection unsuccessful, resident becomes tearful. 8/9/15, 2:48 p.m. resident continues to grab and pull on other residents. attempts at redirection makes her angry and then she hits whoever is attempting to redirect her. 8/9/15, 5:37 p.m. Resident grabbing and pulling on residents this shift. When redirected by staff, becomes aggressive and begins hitting staff. 8/10/15, 2:02 p.m. Resident continues to exhibit intrusive behaviors. Becomes tearful and sad during staff intervention or redirection. No aggressive behaviors noted this shift. 8/10/15, 2:56 p.m. Resident wandering, grabbing others, aggressive and hitting staff. 8/10/15, 9:29 p.m. attempting to push/pull; others while in their wheelchair, redirection increases agitation/tearfulness. refuses to participate in activities today. did accept snacks and liquids. 8/11/15, 2:41 p.m. Resident wandering, grabbing others. Resistant to adls (activities of daily living) this am. 8/11/15, 7:41 p.m. resident continues to wander and grab others, she becomes combative when redirection is attempted. 8/12/15, 3:41 p.m. Very intrusive all shift. Resident continues to grab, push, and pull at staff and other residents. 8/12/15, 8:20 p.m. combative with staff and pulling-grabbing others. when redirection attempted resident became tearful and more combative. resident was given a snack which she threw on the floor. 8/13/15, 2:07 p.m. Resident has been extremely aggressive and combative with staff and other residents. Attempts to redirect and distract have been unsuccessful. 8/14/15, 1:04 p.m. Resident continues to exhibit intrusive behaviors, continues to grab and pull at others. Resident became aggressive towards staff during one-on-one redirection. 8/14/15, 2:32 p.m. Resident wandering and grabbing others. Resident cussing and hitting staff when redirected. Attempted to kick cna (certified nursing assistant) during shower. 8/14/15, 3:26 p.m. Provider make aware of frequent behaviors. New orders received. 8/14/15, 8:38 p.m. resident has been intrusive, grabbing others while they are walking or propelling self in wheelchair. becomes very tearful when any type of redirection attempted. 8/15/15, 2:52 p.m. Resident wandering, grabbing others, tearful at times. redirection and one on one increase tearfulness. 8/16/15, 2:09 p.m. resident continues to wander, but is easily redirected. 8/16/15, 2:42 p.m. Wandering, grabbing others, redirection not effective. 8/17/15, 3:25 p.m. Resident attempting to swipe at staff when staff attempted ADL care this AM. Resident was redirected with effect Resident wandered throughout unit this shift and attempting to hold hands of other residents while they were ambulating/propelling themselves in wheelchair. Numerous attempt at redirection made with success at times of occurrences. 8/18/15, 3:03 p.m. Resident wandering, grabbing others, redirected each time. Aggressive x1 with staff. 8/19/15, 1:28 p.m. Resident pulled another resident (Resident #21) over in w/c (wheelchair to floor. _____ pa (physician assistant) made aware due to repeated incidents. Resident #21 was not injured. 8/20/15, 11:06 p.m. Spoke with (psychiatrist) regarding resident's intrusive & aggressive behaviors and interventions used on 8/19/15. Recommendations include 25 mg (milligrams) Benadryl TID (three times per day) along with PO (by mouth) Haldol, and 25 mg IM (intramuscular) Benadryl PRN (as needed) to be used with PRN (as needed ) IM Haldol. Orders approved via _____, PA (physician assistant). 8/20/15, 2:49 p.m. Wandering, grabbing others x 2. 8/20/15, 9:21 p.m. resident has been tearful x2 this shift. 8/21/15, 3:21 p.m. Grabbing others x2, redirected with effect. 8/22/15. 2:46 p.m. resident crying at times. did not pick up food to eat. staff had to feed. 8/23/15, 12:57 p.m. resident pulling on other resident and their wheelchairs. attempts to redirect her resulted in her cursing and hitting whoever is doing the redirection. 8/24/15, 3:00 p.m. Resident wandering, grabbing others at times. Slight agitation during adls (activities of daily living). 8/24/15, 3:05 p.m. Resident evaluated by PA (physician assistant). New orders received 8/25/15, 3:01 p.m. Wandering, grabbing others. Redirected numerous times. 8/26/15, 11:38 a.m. resident pushing residents wheel chairs, attempts to help them out of their chairs, hitting aides and nurses when redirected constant pacing. resident was given 1 on 1 assistance, she was toileted. snack was given x2. continued with behaviors, prn (as needed) Ativan was given at 10 am. There were two incidents documented in the nursing notes where Resident #9 injured other residents. The first took place on 7/30/15. The incident on 7/30/15, 3:08 p.m. read resident was in a altercation with another resident causing injuries to the other resident. This incident involved Resident #20. As a result of the altercation, Resident #20 sustained a scratch on her chest measuring 6 inches, a hematoma (bruise) to the left hand and a bruise to the right elbow. Both residents resided on the memory care unit. The description of the injuries was documented in Resident #20's nursing notes on 7/30/15. The second incident took place on 8/19/15. The incident on 8/19/15, 1:28 p.m. read Resident pulled another resident over in w/c (wheelchair) to floor. _____ pa (physician assistant) made aware due to repeated incidents. This incident involved Resident #21. This was the same resident that Resident #9 approached and attempted to move on 8/27/15. Resident #9's care plan was reviewed. The care plan was updated after the 7/30/15 incident. It was not updated after the 8/19/15 incident. Resident #9 was care planned for her behaviors. The care plan effective date read 10/21/14- Present. The Problems read Ms._____ requires placement on Memory Care Unit due to (specify below) Exit seeking behaviors, Physical behavior symptoms, verbal behavior symptoms, disruptive behaviors, hallucinations, delusions. The Interventions created on 10/17/14 read: -Apply wander alert upon admission to unit - Encourage family to bring in personal pictures, mementos, etc. that may assist resident in maintaining orientation to room as well as serve a focal point for conversation -Attempt to identify personal activity preferences and involve resident in diversional activities on unit. -Encourage resident to have meals in dining area on unit. Monitor interaction with other residents and need for any special seating arrangements. -Monitor adjustment to unit. Identify usual routine and preferences through resident and/or family interviews. -Monitor for any targeted behaviors and attempt to identify any precipitating and/or contributing factors -Monitor need for psych consults and schedule as ordered by the physician. -Encourage resident to participate in care plan meetings. The care plan was updated on 8/3/15 to add an intervention to the problem _____ is at risk for impaired Quality of Life Alteration in mood state, Impaired social interactions as evidenced by the following behaviors yelling/screaming, verbal abuse, physical abuse, wandering, socially inappropriate. The new intervention was created on 8/3/15, effective 7/30/15. The new intervention read Monitor interactions with other residents. Redirect and separate as needed. NP (nurse practitioner) to review medication status. On 8/27/15 at 4:50 p.m. an interview was conducted with the Activities Director (Other C). Other C stated that she or her assistant would check in on the memory unit daily. She stated that Resident #9 would usually come and go from scheduled activities, never sitting through an entire activity. Other C stated that Resident #9 likes snacks, would occasionally dance, watch tv for short periods of time and occasionally go out into the courtyard. Other C stated that Resident #9 had been a care giver. She stated that they tried to give her a baby and stroller but it was ineffective. The following note was documented by Other C in the clinical record on 7/21/15, 2:05 p.m. Care plan meeting held with IDT (Interdisciplinary Team). Reviewed plan of care. _____ requires specialized unit at this time. is confused. Wanders. Was a caregiver in the past and is re-directed for trying to help peers. ____ will attend activities but needs constant direction/ instructions to stay focused. Will walk in and out of activities. is given the freedom to move about the unit at will. one on one provided for conversations. have tearful episodes, usually redirected. Goes outdoors. See cp (care plan). On 8/27/15 at 4:30 p.m., the Director Of Nursing (DON) was provided with a list of questions regarding Resident #9. In her answers, the DON wrote that Resident #9's behaviors were present upon admission and that Resident #9 had only ever lived on the Memory Care unit while at the facility. For the question How were you keeping other residents safe? the DON wrote: frequent monitoring, redirection and diversional activities. The DON provided a copy of Resident #9's Picture Me Portrait that was kept at the memory care nursing station as a reference for the nurses and certified nursing assistants (CNA) to know how to work with Resident #9. Resident #9's Picture Me Portrait was reviewed. It read ____ enjoys watching activities but when solicited will participate. She loves eye to eye communication in a gentle soft re-assuring tone. Re-assuring that everything is ok. She responds well with touch like holding hands when re-assuring her. She needs cuing and reminding consistently regarding her activities of daily living. Approach with low hands and positive words. She loves to be complimented on her smile. Was a caregiver and will try to help peers and staff. Walks on unit with peers. Resident #9's medications were reviewed. A Resident Medication Summary was provided by the Director of Nursing on 8/27/15 at 9:10 a.m. The following medications were prescribed in attempts to control her behaviors: 3/30/15- 4/27/15 Alprazolam 0.25 mg (milligrams), 1 tablet qd (every day) 4/27/15- 4/30 15 Alprazolam 1 mg, 1 tablet bid (twice per day) 5/1/15- 8/20/15 Alprazolam 0.5 mg, 1 tablet bid 5/1/15- 5/28/15 Seroquel 25 mg, 1 tablet qd bedtime 7/31/15- 8/1/15 Seroquel 25 mg, 1 tablet qd 1:00 p.m. 8/1/15- 8/3/15 Seroquel 25 mg, 1 tablet qd 1:00 p.m. 8/3/15- 8/11/15 Seroquel 25 mg, 1 tablet tid (three times per day) 8/11/15- 8/14/15 Seroquel 50 mg, 1 tablet bid 5/30/15- 6/5/15 Nudexta 20-10 mg 1 capsule, every one day for seven days 6/7/15- 6/17/15 Nudexta 20-10 mg 1 capsule, bid 6/18/15- 7/23/15 Nudexta 20-10 mg 1 capsule, qd 11/1/14- 7/30/15 Risperdone (generic Risperdal) 0.5 mg tablet, 1 tablet tid 7/31/15- 8/3/15 Risperdal 0.5 mg, 1 tablet bid 8/15/15- 8/19/15 Valproic Acid 250 mg/5 ml (5 ml), tid 8/19/15 (stat dose) Haloperidol 10's, 5mg/ml (0.5 ml), one time for one day 8/20/15- 8/24/15 Haloperidol 1 mg, 1 tablet tid 8/20/15- 8/21/15 Haloperidol 10's, 5mg/ml (0.5 ml), PRN (as needed) Current medications to control behaviors: 8/24/15- present Haloperidol 2 mg, 1 tablet tid 8/20/15- present Benadryl Allergy 25 mg, 1 tablet tid (Instructions: Administer 25 mg Benadryl TID along with PO Haldol, to prevent EPS (Extrapyramidal Effects) Although the facility implemented multiple medication changes, Resident #9's behaviors continued to increase. She continued to roam the unit, touching, grabbing and attempting to move other residents as documented in the nursing notes. Resident #9's progress notes were reviewed. A note was written by the physician assistant on 8/14/15. The note read Chief Complaint/ Nature of Presenting Problem: Increasing agitation, hitting other residents and staff members. History of Present Illness read Recently, this patient has been seen for increased agitation. She was initially started on Risperdal which was ineffective. This was switched over to Seroquel 25 mg 3 times a day which is also not effective. Nursing staff states that she continues to hit other residents as well as attempts to hit staff members. Patient has a history of dementia with behavioral disturbances. Review of Systems read Psychiatric: Increasing agitation. Wanting to hit other residents. Attempting to hit staff. The Assessment section read Dementia with behavioral disturbance, unspecified dementia type Suspect vascular dementia. Will discontinue Seroquel and start patient on Depakote 250 mg 3 times a day. A progress note was written on 8/20/15 by the physician assistant. The note read Chief Complaint/ Nature of Presenting Problem: F/U (follow up) Increased agitation/ anxiety. History of Present Illness read Patient resides on memory unit. Last week was extremely agitated causing harm to follow residents. Patient was placed on valproic acid 250 mg 3 times a day which was not controlling her symptoms. Haldol 1 mg was added 3 times a day. This seems to have helped dramatically. Per nursing, patient much more subdued not to the point of being over sedated. Getting along with fell ow residents much better today. A phone consult was placed to psychiatry who agreed with medication decisions. Psychiatrist added and Benadryl to offset any possible ill effects of Haldol. The Assessment section read Dementia with behavioral disturbance, unspecified dementia type Better with current medication. Will continue to monitor behaviors. Ativan was discontinued as regimented medication- now prn. On 8/26/15 at 2:30 p.m., LPN C was asked if she felt the Haloperidol and Benadryl were effective in controlling Resident #9's behaviors. LPN C stated that Resident #9 had hit her 2 times that day and that she didn't feel that the medications were effective. LPN C said that she thought the medications needed more time to become effective. Resident #9's psychotropic medications were reviewed with the DON on 8/27/15 at 9:10 a.m When asked why the resident was prescribed Benadryl along with the Haldol, the DON stated that the [DIAGNOSES REDACTED]. When asked if other residents were given Benadryl with their psychotropic medications, the DON stated no. The DON was asked if the psychiatrist assessed Resident #9. She stated that a consult was performed by telephone. The DON was asked to provide that last psychiatry consult note. She stated that the psychiatry consults available on Resident #9's clinical record were very old, that there was nothing current. The DON was also asked about the targeted behaviors for the Haldol administration. She stated that she needed to look up the answer. On 8/27/15 at 4:30 p.m., the DON provided answers to written questions regarding Resident #9. Included was the question What are the target behaviors for the Haldol. The DON wrote combative behavior. Targeted behaviors for Resident #9 were reviewed. For a scheduled psychotropic medication, behavior monitoring was included on the Non-PRN treatment notes record. The target behaviors that were documented as being monitored for Resident #9 were pacing and tearfulness. These were the behaviors that were monitored during July 2015 and August 2015. Documentation of monitoring for combative behavior was not included in the behavior monitoring information provided. The facility was notified of the immediate jeopardy situation on 8/27/15 at 10:50 a.m. At this time, the Vice President of Operations (ADM C) stated that the facility had contacted CSB (Community Services Board) and CSB could not assist with Resident #9. As documented in the clinical notes, the facility staff did not contact CSB until 8/25/15. This was six days after Resident #9 pulled Resident #21 over in her wheel chair and was administered stat (now) IM (intramuscular) Haldol as a result. A social services note regarding contact with CSB was documented on 8/25/15, 10:21 a.m. It read CSB (Community Services Board) contacted in reference to resident's behavior. Recommendation at this time is if resident's behaviors continue to send resident to ER (emergency room ) to evaluate and treat and CSB will evaluate at ER. Addendum Note CSB (Community Services Board) contacted in reference to resident's behavior. Recommendation at this time is if resident's behaviors increase to send resident to ER (emergency room ) to evaluate and treat and CSB will evaluate at ER. A community services board (CSB) is the point of entry into the publicly-funded system of services for mental health, intellectual disability, and substance abuse. CSBs provide pre-admission screening services 24-hours per day, 7 days per week. This information was accessed at the website www.dbhds.virginia.gov/individuals-and-families/community-services-boards <http://www.dbhds.virginia.gov/individuals-and-families/community-services-boards> <<http://www.dbhds.virginia.gov/individuals-and-families/community-services-boards>> on 8/31/15 at 4:09 p.m. Immediate Jeopardy (IJ) Identification: 8/27/15 10:10 a.m. State office (Long Term Care (LTC) Supervisor) notified 10:25 a.m. State Office (LTC Supervisors )determined IJ was present 10:27 a.m. Facility administration asked to come to conference room 10:50 a.m. Facility administration informed of IJ situation concerning Resident #9's aggressive behaviors towards residents on the Memory unit. 2:42 p.m. POC (Plan of Correction) reviewed and accepted by survey team Accepted POC: 1. The residents were immediately separated, the physician assistant was notified, and an order was received at 10:38 am to transfer to the emergency room . Resident #1881 (Resident #9) was provided with one to one direct staff supervision until her transfer to the emergency room at 11:06 am. Resident #1313 (Resident #21) was assessed and there were no injuries or negative psychosocial outcomes to this resident following this interaction. Resident #1881 will not be returning to this facility. 2. All residents on memory care unit who have previously demonstrated physically aggressive behaviors will be assessed to ensure that care plan interventions are appropriate and addressed resident specific behaviors. The facility is providing the necessary care and services to the resident on the memory care unit to address any behaviors that may pose a safety risk to other residents. The charge nurse on each shift will be responsible for monitoring resident interactions and ensuring that appropriate interventions are in place to address any behaviors demonstrated. 3. The Nursing Education and Training Coordinator has in-serviced the staff on the memory care unit regarding dealing with residents with aggressive behaviors. The in-service includes the importance of monitoring closely for resident to resident interactions and intervening as needed to ensure the safety of all residents. 4. The Charge nurse on each shift will meet with memory care unit staff on each shift daily to review care plan interventions to address resident behaviors and interactions. The Director of Nursing/ designee will make daily rounds on the memory care unit and provide specific direction to unit staff as needed. Education and training will be provided to the memory care staff on an ongoing basis. The Director of Nursing will identify any trends or patterns, identify any need for additional education and training and provide the training on an ongoing basis. She will discuss findings with the CQI (quality assurance) committee on at least quarterly. 5. The dates of completion for #1, #2 and #3 are effective 8/27/15. The dates of completion for #4 is 8/27/15 and ongoing. The administrator stated to the team on 8/27/15 at 2:04 PM that Resident #9 was sent out to the hospital and would not be allowed to come back. He stated he was going to issue a 30 day discharge notice.

Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed for one resident, Resident #6, in a survey sample of 25 residents, to accurately identify wounds, and implement interventions to prevent recurrent acquired heel wounds with eschar. For Resident #6, the facility staff failed to provide preventive care including appropriate assessment to prevent recurrent unable to stage pressure ulcers on the heels. Resident #6 developed pressure ulcers on both heels that were not identified until they were unstageable. The findings included: Resident #6, was admitted to the facility 12/278/11. [DIAGNOSES REDACTED]. Resident #6's most recent MDS (minimum data set) with an ARD (assessment reference date) of 7/16/13 was coded as a quarterly assessment. Resident #6 was coded as having short and long term memory deficits and required total assistance in making daily life decisions. The resident was unable to understand others or make self understood. Resident #6 was also coded as requiring total assistance of one or two staff members to perform activities of daily living, such as bed mobility. Resident #6 was coded as being at risk for the development of pressure ulcers and two pressure ulcers were coded on the quarterly MDS assessment as being a stage 2 and a stage 4. Resident #6 had impaired ROM (range of motion) of both upper and lower extremities. Review of the resident's wound tracking record revealed the resident had a current sacral wound, a healing stage 4. In addition, the resident had a healing stage 3 pressure ulcer on the left heel. The NPUAP (National Pressure Ulcer Advisory Panel) defines a stage III pressure ulcer as: "Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable." Guidance provided at www.NPUAP.com defined an unstageable pressure ulcer as follows: "The goal for revising the definition of unstageable ulcers was to reduce the tendency to classify an ulcer with any necrotic tissue as unstageable, when the depth of the ulcer can be seen. The new definition is "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed." Note the phrase "the base of the ulcer" is used to denote the inability to determine the depth. If necrotic tissue is present, for example, on the edge of the ulcer, but the base is bone, the ulcer should be staged as a Stage IV. Further description of Stage IV ulcers include these phrases: "Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover' and should not be removed." Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Review of the facility's wound tracking , wound clinic notes, and nurse's notes for the left heel revealed: 2/15/13: Left heel resolved 3/11/13: Left heel stage 2, measured 1.9 cm (centimeters) by 1.1 cm 4/16/13: Left heel resolved 4/24/13: Left heel, unstageable necrosis, 4.0 cm by 5.0 cm with 50 % eschar. Eschar is described as thick, adherent necrotic (dead) tissue. There were no nurse's notes or wound tracking for this wound prior to this date. Recommendation by the wound clinic was to "float heels in bed." Skin prep was to be applied daily. The left heel wound was later classified as a stage 3. On 6/12/13, the left heel was a stage 3, treated with Hydrogel once daily. On 6/19/13, the left heel continued to be treated with Hydrogel once daily. On 7/3/13, the left heel was treated with Santyl once daily. On 7/24/13, the left heel continued to be treated with Santyl once daily. 8/15/13: Left heel continued to be treated with Santyl once daily. Review of the facility's wound tracking, nurse's notes and wound clinic notes for the right heel revealed: 6/13/13: Nurse's notes by the wound care nurse: "found with black area right heel, 0.4 cm by 0.5 cm with opening of 0.3 cm by 0.3 cm." The wound tracking notes by the same nurse read: "black, with indistinct , not clearly visible wound edges." Wound clinic notes dated 6/19/13 revealed: Unstageable DTI (deep tissue injury) 4.0 cm by 3.3 cm." 7/3/13: Right heel treated with skin prep daily 7/11/13: Right heel resolved. 7/17/13: Right heel unable to stage measured 2.0 cm by 2.2 cm, red and black. 7/24/13: "Unstageable necrosis resolved." On 8/13/13 at 4:00 PM, Resident #6 was observed in the bed on her back. Both heels were elevated on a pillow, with the heels off the alternating pressure mattress. On 8/14/13 at 8:15 AM, Resident #6 was observed in the bed facing the window. No pillows were in place, and both heels were flat on the mattress. Review of the resident's care plan dated 6/27/13 revealed the following: "Float heels as tolerated." An interview with the MDS/Care plan RN (registered nurse) was conducted. RN (A) stated, "The heels for this resident should be floated at all times." An interview with the DON (director of nursing) on 8/14/13 at 4:45 PM revealed the following statement, "As tolerated means to keep the heels elevated according to the comfort of the resident; resident may take heels off the pillow." The DON went on to state that "according to Best Practice, the heels should be floated at all times." The DON also stated, "Even if her heels are not elevated, she is on a specialty mattress." Further review of the care plan indicated on 3/8/13 an " open area on the left heel, treatment as ordered. " On 4/16/13, a new order for " skin prep " to area as directed. " On 5/3/13, a new addition for an open area to left heel, with treatment as ordered. " The care plan did not address the acquired right heel wounds on 6/13/13, or 7/17/13 right heel wound. The article "Prevention of heel ulcers in an orthopedic unit", from Nursing Times .net, June 18, 2002, stated, "Although tissue breakdown is a complex multifactorial process, the focus with pressure ulcer development in the heels is on extrinsic factors such as pressure, shear and friction, with the most plausible explanation being the failure to relieve pressure. While many advances, such as pressure-relieving mattresses and beds, have greatly reduced the incidence of sacral ulcers (Blasczczyk et al, 1998). Krasner (1987) recognized that, even with pressure reduction, most support surfaces do not adequately relieve heel pressure." The NPUAP advises "Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed. Place heel suspension boots for long-term use." On 8/14/13 at 9:10 AM, Resident #6's CNA (certified nursing assistant) A entered the room. The CNA was asked to pull back the sheet. The resident's heels remained flat on the mattress. CNA (A) stated, "I don't know why she is like that, her heels should be up." On 8/14/13 at 10:15 AM, an interview was conducted with the LPN (A). When asked about the acquired left heel wound on 4/24/13, she stated, "There should have been a tracking note or a nurse's note about it when it was found." She also stated "No" when asked if wounds should be found at an unable to stage, or found with eschar. On 8/15/13 at 8:40 AM, wound care observation was conducted. The left heel had two small open areas. According to LPN (licensed practical nurse) A, the two areas were the one wound with a "bridge " of intact healed skin between the open areas. The right heel was intact with fragile appearing reddened skin. On 8/15/13 at 10:45 AM , an interview was conducted with the DON and the Director of Education. The DON discussed the acquired left heel wound discovered on 4/24/13. The DON stated, "We continued to treat the left heel with skin prep for 6 months. The nurses notified the wound physician when it worsened." The DON was asked if there was documentation to support that the nurses had identified the left heel wound prior to discovery of that wound with eschar. The DON stated, No, I know we have documentation issues." The nurse educator stated that the wound "never really healed." The nurse educator also went on to say that the nurses were treating the area every shift with skin prep, and the wound could have developed between the shifts. The DON went on to discuss the right heel wound discovered on 6/13/13. She stated, "The wound care nurse was new; she didn't realize the area was a blister." The wound tracking and nurse's note was reviewed with the DON in regards to the wound nurse had not documented anything about the appearance of a blister, but that the area was black. In addition, the previous wound nurse, RN (D) also signed the assessment on 6/13/13 as an " unstageable, black area, " with no description of a blister. The DON was questioned as to the experience and training of the new wound nurse. The DON went on to state that the nurse had no previous experience as a wound nurse, but that she had been trained by the former wound nurse and had done training on the CMS website. On 8/15/13 at about 10:45 AM, the current wound care nurse, LPN (licensed practical nurse) A was interviewed. She stated, "I followed the previous wound care nurse for 4 days as part of my training." When asked about her nurse's note dated 6/13/13 regarding the right heel wound, she stated, "It (heel wound) was a piece of blackened tissue, I knew that black was bad." She went on to state, "Now that I think about it, it may have been a blood blister. The wound doctor removed the black tissue from the wound." Review of the CNA skin checks from February to present showed a notation dated 6/13/13 of a skin problem on the right heel. No other documentation was present in the CNA skin checks regarding other heel problems. Review of the RN/LPN weekly skin checks did not document any heel issues. On 8/15/13, the nurse educator produced slides of the CMS (Centers for Medicare/Medicaid Services) Webinar "The Documentation Series, Session 3:Wound Assessment Documentation" that the wound nurse viewed as part of her education. On page 2, the slide read: "New pressure ulcer suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers." On page 16, Support Surfaces and repositioning for prevention of pressure ulcers contained the following: "Support surfaces should be combined with other interventions, such as pressure relief for the heels." The DON was questioned as to whether any sort of heel suspension boot; the DON stated, "We tried a boot, she broke down on her leg." No documentation was presented as to type of boot used or therapy screens for other types of boots attempted. On 8/14/13 at the end of the day exit, the facility Administrator and DON were notified of above findings with harm level deficiency. And again on 8/15/13.

Based on observations, staff interview, facility documentation and clinical record review, the facility staff failed to train and supervise staff for use of the harness and seat belt resulting in entrapment of one resident (Resident #9) of 31 residents in the survey sample resulting in immediate jeopardy and substandard quality of care. After removal of the immediate jeopardy, the scope and severity was lowered to a level 2, isolated. Resident #9 was not assessed for a new wheelchair and harness. The resident was found entrapped in the harness. The findings included: Resident #9 was a [AGE] year old who was originally admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #9's most recent MDS (Minimum Data Set Assessment) was a quarterly with an ARD (Assessment Reference Date) of 7/23/12. The MDS assessment coded Resident #9 as being severely impaired in daily decision making. Resident #9 was coded as requiring total assistance with transferring and all other activities of daily living such as eating and toileting. Resident #9 was also coded as having impairment of range of motion in both extremities, both upper and lower. The survey team entered the facility on 8/28/12 at 1:45 PM. On 8/29/12, clinical record review revealed the resident had an order for [REDACTED]. On 8/29/12 at 10:10 AM, Resident #9 was observed in the wheelchair with the lap belt in place, but the harness was not in place. NA (nurse's aide, not certified) A stated, "Therapy is working with his new chair, he is not using the harness." The DON (director of nursing) was questioned, and stated, "I will check." On 8/29/12 at 12:30 PM, the DON stated, "There are no therapy notes for the new chair." On 8/29/12 at 10:55 AM, Resident #9 was observed in the wheelchair with his buttocks on the edge of the chair, and the lower edge of the harness tightly around his neck, and the upper edge across the resident's mouth and nose. Resident #9 was making grabbing motions at the harness, and was making choking sounds. Staff was requested for assistance, and four staff entered the room. CNA (certified nursing assistant) B stated, "She was supposed to recline the chair, that's why he slipped down." The resident was not in a reclined position. The seat belt was in place. On 8/29/12 at 11:10 AM, Resident #9 was observed in the hallway at the nurse's station, harness and lap belt in place. Review of the Social Worker's note dated 8/16/12, revealed the following: "New chair delivered for resident, family happy. _______ (name of resident's father) stated, "Med Air needs to return to make some minor adjustments, but was pleased overall." The chair, harness and seat belt were put into place. There were no therapy notes regarding appropriateness of the new chair and equipment. On 8/29/12 at 11:30 AM, NA (A) was questioned about who placed the harness. The NA stated, "___ (name of LPN-licensed practical nurse-A) helped me. I was trained how to put on the harness." She also stated, "I did recline him back." NA (A) went on to state, "I don't know anything about the new chair." Review of NA (A)'s employee record revealed she had been working in the facility for 3 weeks. LPN (A) stated, I didn't see her recline him back, she had not finished putting on his shoes, and I left." On 8/29/12 at 11:50 AM, the Nurse Practitioner assessed the resident after the entrapment. The assessment contained the following: "Skin: fading small ecchymotic areas above right aureola chest approximately the size of 1/2 dollar. No [DIAGNOSES REDACTED] or ecchymosis around neck or under arms." On 8/29/12 at 1:00 PM, LPN (A) stated, "The harness comes over the head and snaps on the side around waist." She went on to state, "I have not been trained to apply the harness." On 8/29/12 at 1:10 PM, CNA (B) stated, "It is important to keep the chair in a reclined position." She went on to state, "I have not been trained to put on the harness." On 8/29/12, the care plan dated 8/8/12 was reviewed. The care plan did not contain information regarding how to use the harness, only that a harness and lap belt was to be used. On 8/29/12 at approximately 12:30 PM, the DON stated, "There are no therapy notes for the use of the new chair." The last assessment of use of the harness and lap belt was done in 2009. The Administrator stated, "The family requested a new chair; the manufacturer supplied the harness, which was similar." The DON stated, "There was no record of training for that type of vest" with the new NA or other staff. The facility was unable to present manufacturer's guidelines for the harness or new chair. The information provided by the facility on the harness showed a different type of harness that zipped down the front. In 2009, Resident #9 had received a new harness and seat belt due to wear and tear, and Occupational Therapy had screened the resident for use and appropriate fit. On 8/29/12 at 1:15 PM, the Administrator stated, "The chair and the harness are in the storage room." The DON stated, "He has been transferred to bed and therapy is to assess for alternate means of mobility." The harness was examined. The harness straps were bolted to the back of the chair. The top of the harness came down over the head like an apron, and two straps at the top and the bottom of the harness buckled together, similar to a car seat. On 8/29/12 at 2:00 PM, Physical Therapy assessed Resident #9 for wheelchair seating. The assessment contained the following: "Resident needs a chair that reclines or tilts to assist with trunk control...Resident at increased risk of harm in upright position...positioning needs are ongoing due to poor insight, [DIAGNOSES REDACTED], motor restlessness and seizure disorder." On 8/29/12 at 12:42 PM, the LTC (long term care) supervisor was called, and further information was requested. 8/29/12 at 1:42 PM, the LTC supervisor notified the survey team of IJ (immediate jeopardy) and substandard quality of care at 1:51 PM. The sample was extended to include residents with lap belts. No other residents had a harness type device. Additional tasks were added and performed. On 8/29/12 at 1:57 PM, the Administrator, DON and corporate staff were notified of IJ and substandard quality of care. On 8/29/12 at 4:01 PM, the facility presented the POC (plan of correction). The POC was reviewed by the survey team. On 8/29/12 at 4:17 PM, the Administrator and DON were notified the POC was not accepted. On 8/29/12 at 6:17 PM, the POC was accepted. The facility POC documented the following 5 points: 1. Resident #9 was visited and assessed by the Nurse Practitioner on 8/29/12 at 11:50 AM. Resident #9 was assessed by the Physical Therapist on 8/29/12 at 2:00 PM for the use of an alternative wheelchair and positioning devices. The Nursing Assistant assigned to provide direct care to Resident #9 on the 7-3 shift was suspended and she left the facility at 12:05 PM pending the completion of the investigation. The chest harness was discontinued on 8/29/12 at 5:25 PM. 2. The rehab department will assess all residents with seatbelts and lap trays to ensure that the devices are applied and used correctly. The Charge nurse on each shift will be responsible for ensuring that devices are correctly applied and appropriately used. The Charge nurse on each shift will also be responsible for monitoring those residents with devices to ensure that the residents demonstrate no negative outcomes. The Charge nurse on each shift will also be responsible for notifying the DON /Designee of any residents with negative outcomes. The DON/Designee will consult with the resident's attending physicians and the rehab department. 3. The inservice coordinator inserviced RN's, LPN's and CNA's on "Use of positioning devices including seat belts and lap trays." The inservice included a review of these devices, manufacturer's recommendations, and the importance of recognizing any indications that the residents may require an alternative device. The skilled care coordinator inserviced Botetourt Unit staff on the current plan of care for Resident #9. The DON met with nursing management team to review the plan of care for Resident #9 and the importance of frequent monitoring of those residents with devices to ensure proper application and use. The inservice coordinator and the rehab department will be responsible for educating staff on any new specialty equipment. 4. The DON /Designee will monitor 100% daily for 30 days of those residents using seat belts and lap trays to ensure all devices are applied correctly and are appropriate for the resident demonstrated medical symptoms. The interdisciplinary (IDT) team will review the plan of care for residents utilizing devices at least quarterly. The DON will review the findings and identify the need for any changes in the resident's plan of care and /or for additional staff training and will meet with the nursing management team weekly to review systems and identify any corrective interventions. The DON will also identify and report any patterns or trends to the CQI committee at least monthly. 5. Immediate correction is in place as of 8/29/12 at 6:17 PM. After acceptance of the POC, the scope and severity was lowered to a level 2, isolated. Surveyors observed the wheelchair and harness for Resident # 9 had been removed and placed into the storage room. Evaluations of residents with lap belts by therapy were verified as completed per the submitted plan of removal. In-servicing of staff was also verified as completed. No other residents in the facility were identified as having a wheelchair with harness and lap belt. On 8/30/12 10:15 AM, Resident #9 was observed in the hallway, seated in a reclining wheelchair, with a lap belt in place. Footrests were elevated.

Based on observation, staff interview, and clinical record review, the facility staff failed for one Resident (Resident #3) in a survey sample of 31 residents, to ensure the resident did not develop an avoidable Stage 3 pressure sore. The facility staff failed to ensure assessment and interventions to prevent the development of an avoidable pressure sore were implemented, and failed to assess after the development of a pressure sore; as result of this failure Resident #3 developed a Stage 3 pressure ulcer that was found and identified on 8/28/12. The facility staff failed to perform wound care in a manner to prevent infection for Resident #3. The findings included: Resident #3, a [AGE] year old female, was admitted to the facility on [DATE]. Resident #3's [DIAGNOSES REDACTED]. Resident #3's most recent Minimum Data Set with an Assessment Reference Date of 7/13/12 was coded as a significant change. Resident #3 was assessed as having short and long term memory deficits and as being severely impaired in making daily life decisions. Resident #3 was also coded as requiring total physical assistance with all of her activities of daily living. Resident #3 was coded as being at risk for pressure ulcers, and coded as having no unhealed pressure ulcers. Resident #3 was observed 8/29/12 at 9:00 A.M. She was lying on her back in bed with the head of the bed elevated. Resident #3 was alert and verbally responsive with encouragement. Resident #3 was confused and disoriented. Review of Resident #3's clinical record revealed a signed physician's orders [REDACTED]." Review of the skin assessment records for May, 2012 through August, 2012 revealed that skin assessments were not done on a routine basis by nurses. Resident #3 had a Braden Scale -Predicting Pressure Ulcer Risk completed on 2/1/12, and 4/27/12. Resident #3 was coded as being at High Risk for pressure sores on both dates. Resident #3 did not receive weekly skin assessments by licensed nurses. On 8/30/12 a review of facility documentation was conducted, revealing a "Nurse Skin Assessment Detail Report" dated 4/1/12 through 8/29/12. The Director of Nursing confirmed that the assessments were not done by nurses, but by the Certified Nursing Assistants whose names were listed on the documents, on all three shifts. CNA's consistently denied that Resident #3 had any skin problems, including on 8/27/12, and 8/28/12 at 3:03 P.M., and at 7:14 P.M. on the day Resident #3 was diagnosed as having a Stage 3 pressure wound. No entries were evident that identified any skin breakdown, discoloration, or bruising. On 8/29/12 a review of Resident #3's clinical record was conducted, revealing a Pressure Ulcers Initial Skin Documentation / Assessment Form dated 8/28/12 which read, "Developed after admission, Location (L) inner thumb, Stage 3, Size (CM) Length 1, Width 1, Depth 0.3, Drainage: Yes, Type Serosanguineous, Odor: No, Wound Edges Defined, not attached to wound base, Surrounding Tissue: Normal for ethnic group." On 8/29/12 at 12:15 P.M. an interview was conducted with the wound care nurse, LPN (licensed practical nurse) D. When asked why Resident #3's pressure wound was not identified, assessed, and treated prior to it becoming a Stage 3 wound, LPN D stated, "We found it yesterday. The aides were giving ADL (Activities of Daily Living) care and noticed drainage on the washcloth. I was called to assess the area. It was assessed to be a Stage 3 pressure sore. Her hand is contracted. The nurses do a Braden Scale Assessment upon admission. The aides are responsible for assessing the skin after that." LPN D then stated that Occupational Therapy will assess her contractures to see if she needs an assistive device, and that Resident #3 was on Tylenol. On 8/30/12 at 8:30 A.M. another interview was conducted with the wound care nurse (LPN D). The wound care nurse stated that she had been doing wound care for two years. She stated that she'd just found another Braden Scale Predicting Pressure Ulcer Risk dated 7/7/12 and 7/13 /12. LPN D was reminded that on the previous day, 8/29/12 she stated that the Braden scale is assessment is done by a nurse upon admission, and that CNA's are responsible for skin assessments after that. When LPN D was asked where the newfound Braden Scale Assessment came from, the Director of Nursing, who came to the interview with LPN D interrupted LPN D, and said that they'd found it in the record. LPN D stated, "I cannot answer why it wasn't seen by us yesterday. I couldn't tell you. When asked how Resident#3's skin can deteriorated from normal to a Stage 3 pressure wound, LPN D stated, "It shouldn't." Facility documentation revealed a Certified Nursing Assistant Job Description Dated 11/28/06, Revised 1/13/12 that read, "Provides direct resident care in a timely manner, maintains resident rooms and nursing unit in accordance with infection control standards, maintains accurate, complete and timely documentation of resident care, works with the interdisciplinary team to assist in achieving planned resident goals, identifies residents on nursing programs (Restorative Passive Range of Motion, etc.) and provides the necessary services." According to the job description, CNA's are not responsible for performing skin assessments. Review of the care plan revealed interventions had been put in place prior to the development of the pressure ulcer. The care plan dated 5/2/12 read, "Resident is unable to move extremities independently resulting in potential for contractures related to Cognitive Deficits, Limited Range of Motion, Limitation on both sides, Partial loss, Extensive Assist of two staff. Goal: Resident will maintain ROM (Range of Motion) in all extremities within functional limitations and have no new contractures. Approach: PT, OT (Physical Therapy, Occupational Therapy) screen as indicated 5/2/12, 5/2/12 Notify nurse of any change in participation or endurance. 5/2/12 passive ROM to Extremities 2x day for @ Least 7.5 mins. Responsible Disciplines CNA, NSG. (nursing)." 5/2/12 Resident is at risk for and or has altered skin integrity related to impaired mobility, Requires extensive assistance or is dependent for bed mobility and / or transfers, Unable to change position or shift weight when in chair, contractures-rigidity of extremities, Urinary incontinence, Bowel incontinence, Impaired circulation, Pain, Terminal condition / end stage disease process [MEDICAL CONDITION], Diabetes, Current or history of pressure ulcers. Goal: Resident will not develop a pressure ulcer through next review. Resident will not develop avoidable skin tears through next review. Resident will experience wound healing without signs of infection by next review. Approach: Complete Braden scale on admission and at least quarterly, Report and investigate any changes in skin condition (redness, bruising, changes in color, etc.), Pressure reduction device, Administer wound treatments as ordered; assess wounds at least weekly and notify physician of any decline or failure to respond to ordered treatment, assist resident with transfers to minimize friction and shearing." Physical Therapy and Occupational Therapy screening was not done in May 2012, as indicated in the care plan. Resident #3's only Physical Therapy evaluation was done on 2/9/12. It read, "Res. Eval'd (evaluated) for PT and Res not appropriate will benefit from ROM (Range of Motion) program." An Occupational Therapy evaluation was also done on 2/9/12. It read, "Pt . was seen for eval only. Pt was not appropriate for skilled OT svcs (services) due to cognition and no functional use of UES. Pt is not a candidate for UE splinting due to fixed nature of contractures. Pt's hands are open with no risk of palmar skin breakdown. Pt will benefit from Restorative Progm. UE and LE as tolerated." On 8/30/2012 at 8:30 A.M. an interview was conducted with the Director of Nursing (Administration B) in the conference room. The Director of Nursing stated, "Finding a wound at Stage 3 is typically unusual, but the resident has chronic deformities to her hands. It is painful to move her hands. I know that a wound should not first be identified when it's at a Stage 3." The Director of Nursing then stated that CNA C was the aide who worked with Resident #3 on a daily basis. An interview was immediately conducted with CNA C on 8/30/12 at 8:55 A.M. When interviewed, CNA C stated, "I have to wiggle the washcloth between her (Resident #3) fingers. The other day I washed them and noticed some oozing of a clear substance. I've never actually opened up her fingers to look at them. She says she's in pain and it hurts. I've never done any range of motion or hand exercises with her, or exercises with her fingers." On 8/30/12 at 4:30 P.M. the Director of Nursing entered the conference room and stated, "I looked and we don't have any documentation in the Care Tracker that states that the resident (Resident#3) received Restorative exercises." On 8/31/12 at 9:50 A.M., the Director of Nursing recanted her previous statement and stated that she'd just found documentation in the Care Tracker that Resident #3 received restorative exercises. CNA C's name was listed on the form as having provided Restorative passive range of motion almost every weekday from February, 2012 through August 2012. The Director of Nursing was informed that CNA C had denied ever having done the Restorative passive range of motion exercises. Resident #3's clinical record contained a Profile History Report dated 3/12/12 which lists general information for CNA's and nursing staff about Resident #3 the report did not contain the care planned intervention for Restorative Passive Range of Motion. The report read, "Mobility Aid Program: Total Lift, Meals: Tube feeder NPO (nothing by mouth), Bathing: Total Dependent Assist x 1 Person, Dressing: Total Dependent Assist x 1 Person; Resident wears skin sleeves to bilateral arms and legs, Toileting: Incontinent Bowel / Bladder Total Dependent Assist x 1Person." Resident #3 was also observed during wound care on 8/30/12 at 9:30 A.M. She was lying on her back. LPN D, the wound care nurse, was observed performing wound care. LPN E, the Skilled Care Coordinator, assisted LPN D. LPN D stated the wound was assessed as being a stage III pressure ulcer. LPN D washed her hands, and donned gloves. She placed a drape on top of the medication cart. LPN D then stirred a mixture of [MEDICATION NAME] and Cellerate inside of a small cup. She then pulled a pair of scissors out of the left pocket of her lab coat, and without cleaning the scissors; she cut open the [MEDICATION NAME] ABD pad out of its packaging, and then replaced the scissors back into her left pocket. After the old dressing was removed, the wound was observed to be beefy red, bloody, and had granulation tissue. LPN D stated that the wound previously had yellow tissue. LPN D then cleaned the wound with normal saline, and applied the [MEDICATION NAME] / Cellerate mixture, LPN D then placed the compromised [MEDICATION NAME] ABD on Resident #3's pressure wound. During the procedure, Resident #3 groaned and complained that her hand was in pain. LPN D then asked Resident #3 "Was that so bad?" Resident #3 stated, "Yes it was. I am worn out." When reminded that she'd pulled the 'blue' scissors out of her left pocket and then cut open the pad, LPN D stated, "They are purple, see. I put them back in my left pocket." On 8/31/12 an interview was conducted in the conference room with the wound care physician (Other A). Other A stated, "A '3' sounds terrible and it is, depending on where it's located. She (Resident # 3) has [MEDICAL CONDITION], Dementia and severe contractures on her hands and feet, and wounds can develop in less than a shift." Other A stated that he was aware of Resident#3's hand contractures because he'd treated her previously for another pressure wound. Other A was asked for documentation of any orders he'd written for care to be provided in order to prevent a pressure wound from developing on Resident #3's contracted hands. Other A had not written any orders regarding Resident#3's hands. In addition, he stated he had no involvement with the Stage 3 pressure wound on Resident #3's left hand until it was identified on 8/28/12. Guidance can be found on the National Pressure Ulcer Advisory Panel's website at www.npuap.org. The NPUAP (National Pressure Ulcer Advisory Panel) defines a stage III pressure ulcer as: "Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a Stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable." Slough is defined by www.medical-dictionary.medical dictionary.com as "A layer or mass of dead tissue separated from surrounding living tissue, as in a wound, a sore, or an inflammation." www.reference.medscape.com defines slough as "*Slough is white or yellow tissue that clings to the wound bed in strings or clumps." Pressure Ulcer Prevention Points: Perform head to toe skin assessment at least daily, especially check sacrum, isocheim, trochanters, heels, elbows, and the back of the head. Individualize bathing frequency." Additional guidance can be found from www.cdc.gov <http://www.cdc.gov>: "Unused supplies and medications should be maintained in clean areas separate from used supplies and equipment (e.g., glucose meters). Do not carry supplies and medications in pockets." The administrator and DON were informed on 8/20/12 at 4:00 P.M. of the failure of the facility staff to prevent the development of a pressure sore and failed to assess after the development of a pressure sore resulting in the development of a Stage 3 pressure sore for Resident #3, and failure to perform wound care in a manner to prevent infection for Resident #3.