Every finding on record at Waverly Rehabilitation and Healthcare Center

Based on staff interview and facility documentation review, the facility staff failed to ensure correct completion and acknowledgment of receipt of an insurance Advance Beneficiary Notice [ABN] of Non-Coverage, for one Resident (#1) in a survey sample of 6 Residents.The findings included.For Resident #1 the facility failed to ensure Resident #1 signed and acknowledged receipt of the notice of loss of insurance coverage and her right to appeal the decision.On 5-12-26 at approximately 2:00 PM the business office manager was given the name of the client record required for ABN notices review. She returned with Resident #1's ABN notice which was not dated, nor signed.Page 1 documented Resident #1's name and Effective Date Coverage of Your Current Skilled Nursing Facility Services Will End: 7-14-25. The document informed that a request for immediate appeal should be made as soon as possible but no later than noon on the day before the effective date. The document provided a telephone number to contact QIO Livanta LLC for appeal at [PHONE NUMBER].Additional information on page 2 optional documented: Emergency contact #1 was called on 7-11-25 at 4:32 PM on Telephone Number [number given] to inform that Resident's last covered day of skilled service will be 7-14-25. Name of emergency contact is [name given] niece. Resident's niece verbalized understanding. Notice given by [name] Social Services Director. Resident not informed due to cognitive deficit. The document was not signed by the Resident nor the emergency contact and no date was documented by the signature line.On the last page #3 titled Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) the document revealed, Beginning on 7-15-25 you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. CARE: In patient nursing facility stay. Reason Medicare May Not Pay: No longer requires skilled care on a daily basis. Estimated Cost: $281.00 per day. OPTIONS: CHECK ONLY one box. We can't choose a box for you. Option 1 - I want the care listed above. I want Medicare to be billed for an official decision on payment. Which will be sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I'm responsible for paying, I can appeal to Medicare by following the directions on MSN.Option 2 - I want the care listed above, but don't bill Medicare. I understand that I may be billed now because I am responsible for payment of the care. I cannot appeal because Medicare won't be billed.Option 3 - I don't want the care listed above. I understand that I'm not responsible for paying, and I can't appeal to see if Medicare would pay. Option 3 was checked as chosen by the facility staff.On 5-13-26 at 10:00 AM, the Social Services Director was interviewed and stated she had not mailed a copy of the document for signature to the emergency contact listed, nor had she given a copy to the Resident.On 5-13-26 at 3:00 PM during the end of day meeting when asked about the ABN notice not being filled out completely and the Resident not making a choice out of the three options, nor did anyone receive the notice, the Administrator stated it was not completed correctly and they had no further information to provide.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to investigate neglect and abuse for two Residents (Residents #3 & #4) in a survey sample of six residents. For Resident #3, the facility staff failed to conduct a thorough investigation of an allegation of abuse.The findings included.Resident #3 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Stroke, hypertension, depression, and chronic obstructive respiratory disease.The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #3 with moderate cognitive impairment, is able to be understood and understand others. The Resident required limited assistance from staff for bed mobility, transfers and ambulation, he was independent for eating, toileting, and hygiene, and was ambulatory with a walker or wheelchair.On 5-12-26 at 10:30 a.m. Resident #3's electronic clinical record was reviewed. Nursing, Social work, and physician Progress revealed no indication of any incident on 5-14-24 with Certified Nursing Assistant [CNA] students, nor the Administrator.Review of the Resident's care plan revealed a care plan entry on 5-15-24 for sexual abuse of a minor [under the age of 18 years] high school CNA student. The interventions were 1:1 with a staff member at all times for 1 day on 5-14-26, which was later changed to every 15 minute checks by staff on 5-15-26, and he was moved to a private room.The current Administrator, and the Director of Nursing [DON] who were not employed at the facility when the incident took place were interviewed individually and were asked for all documentation relating to this incident.The Social Worker was interviewed and was admitted ly present and current staff during the incident and did remember the incident and recounted it accurately according to other staff member interviews. She stated she knew of the allegation, however, had learned about it after the fact and did not witness any of it. She stated that the police were called and responded to the alleged sexual abuse incident, and Resident #3 went to court where it was decided he would not be prosecuted, rather, he would be on good behavior for 1 year. At the end of that year if no further incidents occurred, the charges would be dropped. The Resident expired before the year was completed and had been on hospice for quite a while with no further incidents.Two staff members were interviewed and agreed to the interview via cellular telephone only on grounds of anonymity who stated they were concerned about retaliation. They stated that they did remember the former Administrator yelling at Resident #3 to get back in his room and not to come out., after he attempted to walk down the hallway with students in the building immediately following the incident.A letter from the former Administrator to the Virginia Department of Health Professionals [DHP] was supplied, which revealed this complaint involving the former Administrator had been received by that agency and was investigated. The letter was a reply from the former Administrator to the DHP's request for information. The Administrator's letter denied having yelled at Resident #3 when he attempted to leave his room after the sexual abuse of the CNA student had taken place.The current Administrator stated she could find no investigation nor documents related to the incident other than the 15-minute check sheets which had been documented by staff on the days involved. Those were supplied. She further stated that the former DON had allegedly conducted the investigation and was no longer employed by the facility. The Administrator stated she contacted everyone she knew at the corporate office level and they said they had no documents relating to the incident.The Administrator was asked for a copy of the abuse policies, and they were supplied. One follows below. All residents will be kept safe and protected from any form of Verbal/physical/mental/sexual/financial abuse or neglect. Any employee that is proven to have verbally/physically/ mentally/sexually/financially abused or neglected a resident will be immediately terminated from employment at [name of company] Healthcare. The Department of Health will be notified. If the employee is licensed, the appropriate licensing agency will be notified. All employees will be oriented to [name] Healthcare's policy concerning resident abuse during their orientation.All incidents of all possible verbal/physical/ mental/sexual/financial abuse or neglect of a resident will be immediately brought to the attention of the shift supervisor and notify the Abuse Coordinator (Administrator).An investigation will consist of interviews with the resident, other residents who are in the area when the incident occurred, and staff members from all departments that were working in that particular unit/area. The results of the investigation will be reviewed with the Director of Nursing, Department Supervisor, and Administrator.If it can be proven that a specific employee did abuse a resident, he/she will be terminated immediately. The Department of Health will be notified of the incident as well as the name of the employee. If the employee is licensed, the appropriate licensing agency will be notified.If the investigation is unable to place responsibility for abuse to any particular employee, the Director of Nursing and HR Designee will in-service employees of the specific unit about the facility policy regarding abuse. Attendance records and documents will be kept on file in the HR Designee office.Employee education records were supplied and revealed education for all staff on abuse dated 6-26-24. Forty-three [43] days after the incident on 5-14-24.On 5-13-26 at 3:30 p.m. an end-of-day meeting with the Administrator, DON, and Corporate Director of Nursing was held. A request for any additional information was made. They stated none was available. They were made aware that no investigation of abuse by the former Administrator, and no follow up investigation report constituted deficient practice. 2. For Resident #4, the facility staff failed to fully investigate an allegation of abuse on 6-13-24 involving the willful attack with water by a roommate, and neglect by the the willful withholding of medication and Activities of Daily Living [ADL] care by staff on 6-14-24.Resident #4 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Anorexia, anxiety, depression, hypertension, dementia, malnutrition, and hypothyroid disease. The Resident was ordered to begin hospice on 2-7-26 and expired 2-14-26.The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #4 with severe cognitive impairment. The Resident was completely dependent on staff for all activities of daily living [ADL] care such as dressing, hygiene and bathing. The Resident was incontinent of bowel and bladder.On 5-12-26 at 10:30 a.m. Resident #4's electronic clinical record was reviewed. Nursing, Social work, and physician Progress revealed no indication of any incident on 6-14-24 with withholding of care and medication for that day. On 6-13-24 Resident #4's roommate was documented to have thrown water on Resident #4, and in her bed where she was sleeping. The Resident was cleaned by staff and moved to another room. On 6-14-24 the Resident was in the new room.Review of the Resident's care plan revealed no care plan entry for the abuse from her first roommate having thrown water on her in bed. There were entries with interventions notating her complete dependence on staff for ADL care and medication administration. The current Administrator, and the Director of Nursing [DON] who were not employed at the facility when the incidents took place were interviewed individually and asked for all documentation relating to this incident, and the allegation that Resident #4 did not receive care nor medications on 6-14-24. The DON stated she knew of the termination of the two staff members and knew it had been found that the 2 staff involved had been guilty of neglect. She further stated they could not find any records of the investigations nor the reports to the state agency.The Social Worker was interviewed and was admitted ly present and current staff during the incidents and did remember it and recounted it accurately. She stated she knew of the allegations, however, had learned about it after the fact and did not witness any of it. She stated that the Resident was moved because of her room-mate's behavior issue, and that the 2 staff members involved in the 6-14-24 incident were both terminated as it was true that Resident #4 had not received care nor medications on that day.Medication records for Resident #4 were reviewed and revealed signatures indicating medications had been administered on 6-14-24. The DON stated she could not account for the signatures, and they were from different nurses and not the nurse who was assigned that day.The current Administrator stated she could find no investigation nor documents related to the incidents. She further stated that the former DON had allegedly conducted the investigation and was no longer employed by the facility. The Administrator stated she contacted everyone she knew at the corporate office level and they said they had no documents relating to the incidents.The Administrator was asked for a copy of the abuse policies, and they were supplied. One follows below. All residents will be kept safe and protected from any form of Verbal/physical/mental/sexual/financial abuse or neglect. Any employee that is proven to have verbally/physically/ mentally/sexually/financially abused or neglected a resident will be immediately terminated from employment at [name] Healthcare. The Department of Health will be notified. If the employee is licensed, the appropriate licensing agency will be notified. All employees will be oriented to [name] Healthcare's policy concerning resident abuse during their orientation.All incidents of all possible verbal/physical/ mental/sexual/financial abuse or neglect of a resident will be immediately brought to the attention of the shift supervisor and notify the Abuse Coordinator (Administrator).An investigation will consist of interviews with the resident, other residents who are in the area when the incident occurred, and staff members from all departments that were working in that particular unit/area. The results of the investigation will be reviewed with the Director of Nursing, Department Supervisor, and Administrator.If it can be proven that a specific employee did abuse a resident, he/she will be terminated immediately. The Department of Health will be notified of the incident as well as the name of the employee. If the employee is licensed, the appropriate licensing agency will be notified.If the investigation is unable to place responsibility for abuse to any particular employee, the Director of Nursing and HR Designee will in-service employees of the specific unit about the facility policy regarding abuse. Attendance records and documents will be kept on file in the HR Designee office Employee education records were supplied and revealed education for all staff on abuse dated 6-26-24. thirteen days after the first incident on 6-13-24.On 5-13-26 at 3:30 p.m. an end-of-day meeting with the Administrator, DON, and Corporate Director of Nursing was held. A request for any additional information was made. They stated none was available. They were made aware that no investigation of abuse, and no follow up investigation report constituted deficient practice.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to report neglect and abuse for two Residents (Residents #3 & #4) in a survey sample of six residents. For Resident #3, the facility staff failed to report an allegation of verbal abuse.The findings included.Resident #3 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Stroke, hypertension, depression, and chronic obstructive respiratory disease.The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #3 with moderate cognitive impairment, is able to be understood and understand others. The Resident required limited assistance from staff for bed mobility, transfers and ambulation, he was independent for eating, toileting, and hygiene, and was ambulatory with a walker or wheelchair.On 5-12-26 at 10:30 a.m. Resident #3's electronic clinical record was reviewed. Nursing, Social work, and physician Progress revealed no indication of any incident on 5-14-24 with Certified Nursing Assistant [CNA] students, nor the Administrator.Review of the Resident's care plan revealed a care plan entry on 5-15-24 for sexual abuse of a minor [under the age of 18 years] high school CNA student. The interventions were 1:1 with a staff member at all times for 1 day on 5-14-26, which was later changed to every 15 minute checks by staff on 5-15-26, and he was moved to a private room.The current Administrator, and the Director of Nursing [DON] who were not employed at the facility when the incident took place were interviewed individually and were asked for all documentation relating to this incident.The Social Worker was interviewed and was admitted ly present and current staff during the incident and did remember the incident and recounted it accurately according to other staff member interviews. She stated she knew of the allegation, however, had learned about it after the fact and did not witness any of it. She stated that the police were called and responded to the alleged sexual abuse incident, and Resident #3 went to court where it was decided he would not be prosecuted, rather, he would be on good behavior for 1 year. At the end of that year if no further incidents occurred, the charges would be dropped. The Resident expired before the year was completed and had been on hospice for quite a while with no further incidents.Two staff members were interviewed and agreed to the interview via cellular telephone only on grounds of anonymity who stated they were concerned about retaliation. They stated that they did remember the former Administrator yelling at Resident #3 to get back in his room and not to come out., after he attempted to walk down the hallway with students in the building immediately following the incident.A letter from the former Administrator to the Virginia Department of Health Professionals [DHP] was supplied, which revealed this complaint involving the former Administrator had been received by that agency and was investigated. The letter was a reply from the former Administrator to the DHP's request for information. The Administrator's letter denied having yelled at Resident #3 when he attempted to leave his room after the sexual abuse of the CNA student had taken place.The current Administrator stated she could find no investigation nor documents related to the incident other than the 15-minute check sheets which had been documented by staff on the days involved, or any credible evidence that the allegation/incident had been reported to the state survey agency or adult protective services. Those were supplied. She further stated that the former DON had allegedly conducted the investigation and was no longer employed by the facility. The Administrator stated she contacted everyone she knew at the corporate office level and they said they had no documents relating to the incident. 2. For Resident #4, the facility staff failed to report an allegation of abuse/neglect to the state agency after the willful abuse by a roommate on 6-13-24, and the withholding of medication and Activities of Daily Living [ADL] care by staff was identified as having occurred on 6-14-24.Resident #4 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Anorexia, anxiety, depression, hypertension, dementia, malnutrition, and hypothyroid disease. The Resident was ordered to begin hospice on 2-7-26 and expired 2-14-26.The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #4 with severe cognitive impairment. The Resident was completely dependent on staff for all activities of daily living [ADL] care such as dressing, hygiene and bathing. The Resident was incontinent of bowel and bladder.On 5-12-26 at 10:30 a.m. Resident #4's electronic clinical record was reviewed. Nursing, Social work, and physician Progress revealed no indication of any incident on 6-14-24 with withholding of care and medication for that day. On 6-13-24 Resident #4's roommate was documented to have thrown water on Resident #4, and in her bed where she was sleeping. The Resident was cleaned by staff and moved to another room. On 6-14-24 the Resident was in the new room.Review of the Resident's care plan revealed no care plan entry for the abuse from her first roommate having thrown water on her in bed. There were entries with interventions notating her complete dependence on staff for ADL care and medication administration. The current Administrator, and the Director of Nursing [DON] who were not employed at the facility when the incidents took place were interviewed individually and asked for all documentation relating to this incident, and the allegation that Resident #4 did not receive care nor medications on 6-14-24. The DON stated she knew of the termination of the two staff members and knew it had been found that the 2 staff involved had been guilty of neglect. She further stated they could not find any records of the investigations nor the evidence that the incident was reported to the state agency.The Social Worker was interviewed and was admitted ly present and current staff during the incidents and did remember it and recounted it accurately. She stated she knew of the allegations, however, had learned about it after the fact and did not witness any of it. She stated that the Resident was moved because of her room-mate's behavior issue, and that the 2 staff members involved in the 6-14-24 incident were both terminated as it was true that Resident #4 had not received care nor medications on that day.Medication records for Resident #4 were reviewed and revealed signatures indicating medications had been administered on 6-14-24. The DON stated she could not account for the signatures, and they were from different nurses and not the nurse who was assigned that day.The current Administrator stated she could find no investigation nor documents related to the incidents. She further stated that the former DON had allegedly conducted the investigation and was no longer employed by the facility. The Administrator stated she contacted everyone she knew at the corporate office level and they said they had no documents relating to the incidents.The Administrator was asked for a copy of the abuse policies, and they were supplied. One follows below. All residents will be kept safe and protected from any form of Verbal/physical/mental/sexual/financial abuse or neglect. Any employee that is proven to have verbally/physically/ mentally/sexually/financially abused or neglected a resident will be immediately terminated from employment at [name] Healthcare. The Department of Health will be notified. If the employee is licensed, the appropriate licensing agency will be notified. All employees will be oriented to [name] Healthcare's policy concerning resident abuse during their orientation.All incidents of all possible verbal/physical/ mental/sexual/financial abuse or neglect of a resident will be immediately brought to the attention of the shift supervisor and notify the Abuse Coordinator (Administrator) FAILURE TO REPORT SUSPECTED ABUSE WILL BE CONSIDERED ABUSE AND GROUNDS FOR TERMINATION.On 5-13-26 at 3:30 p.m. an end-of-day meeting with the Administrator, DON, and Corporate Director of Nursing was held. A request for any additional information was made. They stated none was available. They were made aware that no report to the state agency about an allegation of abuse and neglect was made, which constituted deficient practice.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to investigate, report to the State Agency, and implement the facility abuse policies for two Residents (Residents #3 & #4) in a survey sample of six Residents. The findings included. 1. For Resident #3, the facility staff failed to investigate, report, and implement the facility abuse policies after a staff member witnessed and made an allegation of verbal abuse. Resident #3 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Stroke, hypertension, depression, and chronic obstructive respiratory disease. The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #3 with moderate cognitive impairment, is able to be understood and understand others. The Resident required limited assistance from staff for bed mobility, transfers and ambulation, he was independent for eating, toileting, and hygiene, and was ambulatory with a walker or wheelchair. On 5-12-26 at 10:30 a.m. Resident #3's electronic clinical record was reviewed. Nursing, Social work, and physician Progress revealed no indication of any incident on 5-14-24 with Certified Nursing Assistant [CNA] students, nor the Administrator.Review of the Resident's care plan revealed a care plan entry on 5-15-24 for sexual abuse of a minor [under the age of 18 years] high school CNA student. The interventions were 1:1 with a staff member at all times for 1 day on 5-14-26, which was later changed to every 15 minute checks by staff on 5-15-26, and he was moved to a private room. The current Administrator, and the Director of Nursing [DON] who were not employed at the facility when the incident took place were interviewed individually and were asked for all documentation relating to this incident. The Social Worker was interviewed and was admitted ly present and current staff during the incident and did remember the incident and recounted it accurately according to other staff member interviews. She stated she knew of the allegation, however, had learned about it after the fact and did not witness any of it. She stated that the police were called and responded to the alleged sexual abuse incident, and Resident #3 went to court where it was decided he would not be prosecuted, rather, he would be on good behavior for 1 year. At the end of that year if no further incidents occurred, the charges would be dropped. The Resident expired before the year was completed and had been on hospice for quite a while with no further incidents. Two staff members were interviewed and agreed to the interview via cellular telephone only on grounds of anonymity who stated they were concerned about retaliation. They stated that they did remember the former Administrator yelling at Resident #3 to get back in his room and not to come out., after he attempted to walk down the hallway with students in the building immediately following the incident. A letter from the former Administrator to the Virginia Department of Health Professionals [DHP] was supplied, which revealed this complaint involving the former Administrator had been received by that agency and was investigated. The letter was a reply from the former Administrator to the DHP's request for information. The Administrator's letter denied having yelled at Resident #3 when he attempted to leave his room after the sexual abuse of the CNA student had taken place. The current Administrator stated she could find no investigation nor documents related to the incident other than the 15-minute check sheets which had been documented by staff on the days involved. Those were supplied. She further stated that the former DON had allegedly conducted the investigation and was no longer employed by the facility. The Administrator stated she contacted everyone she knew at the corporate office level and they said they had no documents relating to the incident. The Administrator was asked for a copy of the abuse policies, and they were supplied. One follows below. All residents will be kept safe and protected from any form of Verbal/physical/mental/sexual/financial abuse or neglect. Any employee that is proven to have verbally/physically/ mentally/sexually/financially abused or neglected a resident will be immediately terminated from employment at [name of company] Healthcare. The Department of Health will be notified. If the employee is licensed, the appropriate licensing agency will be notified. All employees will be oriented to [name] Healthcare's policy concerning resident abuse during their orientation.All incidents of all possible verbal/physical/ mental/sexual/financial abuse or neglect of a resident will be immediately brought to the attention of the shift supervisor and notify the Abuse Coordinator (Administrator).An investigation will consist of interviews with the resident, other residents who are in the area when the incident occurred, and staff members from all departments that were working in that particular unit/area. The results of the investigation will be reviewed with the Director of Nursing, Department Supervisor, and Administrator.If it can be proven that a specific employee did abuse a resident, he/she will be terminated immediately. The Department of Health will be notified of the incident as well as the name of the employee. If the employee is licensed, the appropriate licensing agency will be notified.If the investigation is unable to place responsibility for abuse to any particular employee, the Director of Nursing and HR Designee will in-service employees of the specific unit about the facility policy regarding abuse. Attendance records and documents will be kept on file in the HR Designee office.FAILURE TO REPORT SUSPECTED ABUSE WILL BE CONSIDERED ABUSE AND GROUNDS FOR TERMINATION.Employee education records were supplied and revealed education for all staff on abuse dated 6-26-24. Forty-three [43] days after the incident on 5-14-24.On 5-13-26 at 3:30 p.m. an end-of-day meeting with the Administrator, DON, and Corporate Director of Nursing was held. A request for any additional information was made. They stated none was available. They were made aware that no investigation of abuse by the former Administrator, no report to the state agency, not implementing their abuse policies, and no follow up report constituted a deficient practice. 2. For Resident #4, the facility staff failed to prevent neglect by withholding medication and Activities of Daily Living [ADL] care on 6-14-24 and failed to implement their abuse policies after an allegation of abuse was made. Resident #4 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Anorexia, anxiety, depression, hypertension, dementia, malnutrition, and hypothyroid disease. The Resident was ordered to begin hospice on 2-7-26 and expired 2-14-26. The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #4 with severe cognitive impairment. The Resident was completely dependent on staff for all activities of daily living [ADL] care such as dressing, hygiene and bathing. The Resident was incontinent of bowel and bladder. On 5-12-26 at 10:30 a.m. Resident #4's electronic clinical record was reviewed. Nursing, Social work, and physician Progress revealed no indication of any incident on 6-14-24 with withholding of care and medication for that day. On 6-13-24 Resident #4's roommate was documented to have thrown water on Resident #4, and in her bed where she was sleeping. The Resident was cleaned by staff and moved to another room. On 6-14-24 the Resident was in the new room. Review of the Resident's care plan revealed no care plan entry for the abuse from her first roommate having thrown water on her in bed. There were entries with interventions notating her complete dependence on staff for ADL care and medication administration. The current Administrator, and the Director of Nursing [DON] who were not employed at the facility when the incidents took place were interviewed individually and asked for all documentation relating to this incident, and the allegation that Resident #4 did not receive care nor medications on 6-14-24. The DON stated she knew of the termination of the two staff members and knew it had been found that the 2 staff involved had been guilty of neglect. She further stated they could not find any records of the investigations nor the reports to the state agency. The Social Worker was interviewed and was admitted ly present and current staff during the incidents and did remember it and recounted it accurately. She stated she knew of the allegations, however, had learned about it after the fact and did not witness any of it. She stated that the Resident was moved because of her room-mate's behavior issue, and that the 2 staff members involved in the 6-14-24 incident were both terminated as it was true that Resident #4 had not received care nor medications on that day. Medication records for Resident #4 were reviewed and revealed signatures indicating medications had been administered on 6-14-24. The DON stated she could not account for the signatures, and they were from different nurses and not the nurse who was assigned that day.The current Administrator stated she could find no investigation nor documents related to the incidents. She further stated that the former DON had allegedly conducted the investigation and was no longer employed by the facility. The Administrator stated she contacted everyone she knew at the corporate office level and they said they had no documents relating to the incidents. The Administrator was asked for a copy of the abuse policies, and they were supplied. One follows below. All residents will be kept safe and protected from any form of Verbal/physical/mental/sexual/financial abuse or neglect. Any employee that is proven to have verbally/physically/ mentally/sexually/financially abused or neglected a resident will be immediately terminated from employment at [name] Healthcare. The Department of Health will be notified. If the employee is licensed, the appropriate licensing agency will be notified. All employees will be oriented to [name] Healthcare's policy concerning resident abuse during their orientation.All incidents of all possible verbal/physical/ mental/sexual/financial abuse or neglect of a resident will be immediately brought to the attention of the shift supervisor and notify the Abuse Coordinator (Administrator).An investigation will consist of interviews with the resident, other residents who are in the area when the incident occurred, and staff members from all departments that were working in that particular unit/area. The results of the investigation will be reviewed with the Director of Nursing, Department Supervisor, and Administrator.If it can be proven that a specific employee did abuse a resident, he/she will be terminated immediately. The Department of Health will be notified of the incident as well as the name of the employee. If the employee is licensed, the appropriate licensing agency will be notified.If the investigation is unable to place responsibility for abuse to any particular employee, the Director of Nursing and HR Designee will in-service employees of the specific unit about the facility policy regarding abuse. Attendance records and documents will be kept on file in the HR Designee office.FAILURE TO REPORT SUSPECTED ABUSE WILL BE CONSIDERED ABUSE AND GROUNDS FOR TERMINATION.Employee education records were supplied and revealed education for all staff on abuse dated 6-26-24. thirteen [13] days after the first incident on 6-13-24.On 5-13-26 at 3:30 p.m. an end-of-day meeting with the Administrator, DON, and Corporate Director of Nursing was held. A request for any additional information was made. They stated none was available. They were made aware that no investigation of abuse, no report to the state agency, not implementing their abuse policies, and no follow up report constituted a deficient practice.

Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to protect the resident's right to be free from abuse and neglect for two residents (Residents #3 & #4) in a survey sample of six residents. The findings included. For Resident #3, the facility staff failed to prevent verbal abuse, failed to fully investigate that abuse, failed to report it to the state agency, and failed to train staff timely on abuse after abuse occurred. Resident #3 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Stroke, hypertension, depression, and chronic obstructive respiratory disease. The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #3 with moderate cognitive impairment, is able to be understood and understand others. The Resident required limited assistance from staff for bed mobility, transfers and ambulation, he was independent for eating, toileting, and hygiene, and was ambulatory with a walker or wheelchair. On 5-12-26 at 10:30 a.m. Resident #3's electronic clinical record was reviewed. Nursing, Social work, and physician Progress revealed no indication of any incident on 5-14-24 with Certified Nursing Assistant [CNA] students, nor the Administrator.Review of the Resident's care plan revealed a care plan entry on 5-15-24 for sexual abuse of a minor [under the age of 18 years] high school CNA student. The interventions were 1:1 with a staff member at all times for 1 day on 5-14-26, which was later changed to every 15 minute checks by staff on 5-15-26, and he was moved to a private room. The current Administrator, and the Director of Nursing [DON] who were not employed at the facility when the incident took place were interviewed individually and were asked for all documentation relating to this incident. The Social Worker was interviewed and was admitted ly present and current staff during the incident and did remember the incident and recounted it accurately according to other staff member interviews. She stated she knew of the allegation, however, had learned about it after the fact and did not witness any of it. She stated that the police were called and responded to the alleged sexual abuse incident, and Resident #3 went to court where it was decided he would not be prosecuted, rather, he would be on good behavior for 1 year. At the end of that year if no further incidents occurred, the charges would be dropped. The Resident expired before the year was completed and had been on hospice for quite a while with no further incidents. Two staff members were interviewed and agreed to the interview via cellular telephone only on grounds of anonymity who stated they were concerned about retaliation. They stated that they did remember the former Administrator yelling at Resident #3 to get back in his room and not to come out., after he attempted to walk down the hallway with students in the building immediately following the incident. A letter from the former Administrator to the Virginia Department of Health Professionals [DHP] was supplied, which revealed this complaint involving the former Administrator had been received by that agency and was investigated. The letter was a reply from the former Administrator to the DHP's request for information. The Administrator's letter denied having yelled at Resident #3 when he attempted to leave his room after the sexual abuse of the CNA student had taken place. The current Administrator stated she could find no investigation nor documents related to the incident other than the 15-minute check sheets which had been documented by staff on the days involved. Those were supplied. She further stated that the former DON had allegedly conducted the investigation and was no longer employed by the facility. The Administrator stated she contacted everyone she knew at the corporate office level and they said they had no documents relating to the incident. The Administrator was asked for a copy of the abuse policies, and they were supplied. One follows below. All residents will be kept safe and protected from any form of Verbal/physical/mental/sexual/financial abuse or neglect. Any employee that is proven to have verbally/physically/ mentally/sexually/financially abused or neglected a resident will be immediately terminated from employment at [name of company] Healthcare. The Department of Health will be notified. If the employee is licensed, the appropriate licensing agency will be notified. All employees will be oriented to [name] Healthcare's policy concerning resident abuse during their orientation.All incidents of all possible verbal/physical/ mental/sexual/financial abuse or neglect of a resident will be immediately brought to the attention of the shift supervisor and notify the Abuse Coordinator (Administrator).An investigation will consist of interviews with the resident, other residents who are in the area when the incident occurred, and staff members from all departments that were working in that particular unit/area. The results of the investigation will be reviewed with the Director of Nursing, Department Supervisor, and Administrator.If it can be proven that a specific employee did abuse a resident, he/she will be terminated immediately. The Department of Health will be notified of the incident as well as the name of the employee. If the employee is licensed, the appropriate licensing agency will be notified.If the investigation is unable to place responsibility for abuse to any particular employee, the Director of Nursing and HR Designee will in-service employees of the specific unit about the facility policy regarding abuse. Attendance records and documents will be kept on file in the HR Designee office.FAILURE TO REPORT SUSPECTED ABUSE WILL BE CONSIDERED ABUSE AND GROUNDS FOR TERMINATION.Employee education records were supplied and revealed education for all staff on abuse dated 6-26-24. Forty-three [43] days after the incident on 5-14-24.On 5-13-26 at 3:30 p.m. an end-of-day meeting with the Administrator, DON, and Corporate Director of Nursing was held. A request for any additional information was made. They stated none was available. They were made aware that no investigation of abuse by the former Administrator, no report to the state agency, not implementing their abuse policies, and no follow up report constituted deficient practice. 2. For Resident #4, the facility staff failed to prevent neglect by withholding medication and Activities of Daily Living [ADL] care on 6-14-24, failed to fully investigate that neglect/abuse, failed to report it to the state agency, and failed to train staff timely on abuse/neglect after neglect occurred. Resident #4 was originally admitted to the facility on [DATE] with the diagnoses of, but not limited to, Anorexia, anxiety, depression, hypertension, dementia, malnutrition, and hypothyroid disease. The Resident was ordered to begin hospice on 2-7-26 and expired 2-14-26. The Resident's most recent Minimum Data Set (MDS) to the alleged incident coded Resident #4 with severe cognitive impairment. The Resident was completely dependent on staff for all activities of daily living [ADL] care such as dressing, hygiene and bathing. The Resident was incontinent of bowel and bladder. On 5-12-26 at 10:30 a.m. Resident #4's electronic clinical record was reviewed. Nursing, Social work, and physician Progress revealed no indication of any incident on 6-14-24 with withholding of care and medication for that day. On 6-13-24 Resident #4's roommate was documented to have thrown water on Resident #4, and in her bed where she was sleeping. The Resident was cleaned by staff and moved to another room. On 6-14-24 the Resident was in the new room. Review of the Resident's care plan revealed no care plan entry for the abuse from her first roommate having thrown water on her in bed. There were entries with interventions notating her complete dependence on staff for ADL care and medication administration. The current Administrator, and the Director of Nursing [DON] who were not employed at the facility when the incidents took place were interviewed individually and asked for all documentation relating to this incident, and the allegation that Resident #4 did not receive care nor medications on 6-14-24. The DON stated she knew of the termination of the two staff members and knew it had been found that the 2 staff involved had been guilty of neglect. She further stated they could not find any records of the investigations nor the reports to the state agency. The Social Worker was interviewed and was admitted ly present and current staff during the incidents and did remember it and recounted it accurately. She stated she knew of the allegations, however, had learned about it after the fact and did not witness any of it. She stated that the Resident was moved because of her room-mate's behavior issue, and that the 2 staff members involved in the 6-14-24 incident were both terminated as it was true that Resident #4 had not received care nor medications on that day. Medication records for Resident #4 were reviewed and revealed signatures indicating medications had been administered on 6-14-24. The DON stated she could not account for the signatures, and they were from different nurses and not the nurse who was assigned that day.The current Administrator stated she could find no investigation nor documents related to the incidents. She further stated that the former DON had allegedly conducted the investigation and was no longer employed by the facility. The Administrator stated she contacted everyone she knew at the corporate office level and they said they had no documents relating to the incidents. The Administrator was asked for a copy of the abuse policies, and they were supplied. One follows below. All residents will be kept safe and protected from any form of Verbal/physical/mental/sexual/financial abuse or neglect. Any employee that is proven to have verbally/physically/ mentally/sexually/financially abused or neglected a resident will be immediately terminated from employment at [name] Healthcare. The Department of Health will be notified. If the employee is licensed, the appropriate licensing agency will be notified. All employees will be oriented to [name] Healthcare's policy concerning resident abuse during their orientation.All incidents of all possible verbal/physical/ mental/sexual/financial abuse or neglect of a resident will be immediately brought to the attention of the shift supervisor and notify the Abuse Coordinator (Administrator).An investigation will consist of interviews with the resident, other residents who are in the area when the incident occurred, and staff members from all departments that were working in that particular unit/area. The results of the investigation will be reviewed with the Director of Nursing, Department Supervisor, and Administrator.If it can be proven that a specific employee did abuse a resident, he/she will be terminated immediately. The Department of Health will be notified of the incident as well as the name of the employee. If the employee is licensed, the appropriate licensing agency will be notified.If the investigation is unable to place responsibility for abuse to any particular employee, the Director of Nursing and HR Designee will in-service employees of the specific unit about the facility policy regarding abuse. Attendance records and documents will be kept on file in the HR Designee office.FAILURE TO REPORT SUSPECTED ABUSE WILL BE CONSIDERED ABUSE AND GROUNDS FOR TERMINATION.Employee education records were supplied and revealed education for all staff on abuse dated 6-26-24. thirteen [13] days after the first incident on 6-13-24.On 5-13-26 at 3:30 p.m. an end-of-day meeting with the Administrator, DON, and Corporate Director of Nursing was held. A request for any additional information was made. They stated none was available. They were made aware that no investigation of abuse, no report to the state agency, not implementing their abuse policies, and no follow up report constituted deficient practice.

Based on Observation, facility document review, clinical record review, staff interview, and Resident interview the facility staff failed to follow the menu and preferences of two Residents (Resident #1, and #2) in the survey sample of 3 residents. The findings included: 1. For Resident #1, the tray ticket, and menu, were not followed for the lunch meal on 4-9-24. Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as frequently incontinent of bowel and bladder. On 4-9-24 at 12:00 noon, Resident #1 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this lunch today is again not what it is supposed to be. She explained that she got lunch and that the menu said one thing and her tray had another. She went on to state that she was diabetic and almost everything on the tray was carbohydrates which she was not supposed to have & not her choice. She stated I can't eat that hard pork, and I don't like it, they know that. The pork cutlet was found on the tray untouched. The tray ticket revealing the menu was on the tray and reviewed at that time by the surveyor. The tray ticket indicated that the meal should consist of A Controlled Carbohydrate Diet (CCD), meaning that the carbohydrates in a meal must be consistently planned to avoid blood sugar spikes for those with diabetes. The tray ticket described the meal as consisting of; smothered chicken thigh, whipped sweet potatoes, lima beans, corn bread, sliced pears, and 8 ounces of iced tea. This would indicate a meal of almost all carbohydrates. The meal tray actually consisted of a pork cutlet in gravy, brussels sprouts, white potatoes with cheese on them, a hamburger bun (for a dinner roll), 8 ounces of iced tea, and no fruit. The Resident's room mate's tray ticket was reviewed as well and was identical to Resident #1's tray ticket and identical to the meal that was served for Resident #1. The meal served was not what the menu planned, nor what the Resident preferred, and there was only one 8 ounce drink on the tray. On 4-9-24 at end of day debrief the DON (director of nursing), and Administrator were notified of the above findings. the Administrator stated there should be at least 2 drinks on every tray, and the menu should be followed. No further information was provided. 2. For Resident #2, the tray ticket, and menu, were not followed for the lunch meal on 4-9-24. Resident #2 was admitted to the facility on [DATE] with diagnoses including; Stroke, vascular dementia, hypertension, diabetes, chronic kidney disease, and urinary tract infection. Resident #2's most recent MDS (minimum data set) with an ARD (assessment reference date) of 3-28-24 was coded as a new payment assessment. Resident #2 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #2 was also coded as requiring only supervision of one staff member to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as continent of bowel and bladder. On 4-9-24 at 12:00 noon, Resident #2 was observed sitting in a wheel chair at her bedside, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this lunch today is again not what it is supposed to be. She explained that she got lunch and that the menu said one thing and her tray had another. She went on to state that she was diabetic and almost everything on the tray was carbohydrates which she was not supposed to have & not her choice. The Resident and her room mate (Resident #1) agreed on this. The tray ticket revealing the menu was on the tray and reviewed at that time by the surveyor. The tray ticket indicated that the meal should consist of A Controlled Carbohydrate Diet (CCD) (NAS) no added salt, meaning that the carbohydrates in a meal must be consistently planned to avoid blood sugar spikes for those with diabetes, and because of high blood pressure no added salt was included. The tray ticket described the meal as consisting of; smothered chicken thigh, whipped sweet potatoes, lima beans, corn bread, sliced pears, and 8 ounces of iced tea. This would indicate a meal of almost all carbohydrates. The meal tray actually consisted of a pork cutlet in gravy, brussels sprouts, white potatoes with cheese on them, a hamburger bun (for a dinner roll), 8 ounces of iced tea, and no fruit. The Resident's room mate's tray ticket was reviewed as well and was identical to Resident #2's tray ticket and identical to the meal that was served for Resident #2. The meal served was not what the menu planned, nor what the Resident preferred, and there was only one 8 ounce drink on the tray. On 4-9-24 at end of day debrief the DON (director of nursing), and Administrator were notified of the above findings. the Administrator stated there should be at least 2 drinks on every tray, and the menu should be followed. No further information was provided.

Based on staff interview, Resident interview, facility documentation review, and clinical record review, the facility staff failed to prevent significant medication errors for one Resident (Residents #1) in a survey sample of 3 Residents. The findings included: For Resident #1, the facility staff failed to check finger stick blood sugar (FSBS), and failed to administer insulin for an insulin dependent Resident with Diabetes Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as frequently incontinent of bowel and bladder. On 4-9-24 at 12:00 noon, Resident #1 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this lunch today is again not what it is supposed to be. She explained that she got lunch and that the menu said one thing and her tray had another. She went on to state that she was diabetic and almost everything on the tray was carbohydrates which she was not supposed to have & not her choice. The Resident's physician orders were reviewed and reveal orders for FSBS, and insulin administration for diabetes treatment. Those orders were for the following; 1. Ordered 3-9-24 Tresiba insulin Deglu[DATE] unit/milliliter give 60 units one time per day subcutaneously hold if blood sugar less than 100. Administer at 7:30 a.m. 2. Ordered 9-28-23 Humalog insulin Lispro 100 unit/milliliter inject subcutaneously as per sliding scale before meals and at bedtime for Diabetes. Administer 4 times per day at 6:30 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. The sliding scale was as follows; 0-150 = give 0 units 151-200 = give 2 units 201-250 = give 4 units 251-300 = give 6 units 301-350 = give 8 units 351-400 = give 10 units, and call MD (doctor) if greater than 400 The Medication and Treatment Administration Record (MAR/TAR) was reviewed for April 2024, and revealed the absence of nursing signatures indicating the Insulin and FSBS blood sugar checks were not completed on 6 occasions. Those follow; Tresiba 4-2-24 at 7:30 a.m. Humalog 4-2-24 at 4:00 p.m., 4-4-24 at 11:00 a.m., and 4:00 p.m., 4-5-24 at 9:00 p.m., and 4-6-24 at 6:30 a.m. Nursing medication administration notes do not indicate why the FSBS were not completed, and why insulin was omitted. Nurses on the nursing unit were asked if insulin was administered on the dates in question and the responses were if it's not documented, it's not done. Guidance for the administration of Insulin is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov Insulin must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses and check blood sugar as ordered to decide proper dosing needed. Do not discontinue this medication without seeking a doctor's help. Stopping Insulin will increase the risk of hyperglycemic attack which can be life threatening. The nursing facility stated [NAME] as their nursing standard. [NAME] stated all medications must be administered by the physician's order. Resident #1's care plan was reviewed and revealed a care plan for diabetes that instructed to administer medications as ordered by the physician. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been omitted, nor that the doctor was made aware of the omissions. On 4-10-24 at 11:00 a.m., the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, nor that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 4-10-24 at approximately 2:00 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to prevent significant medication errors in omissions of finger stick blood sugar checks, and insulin as ordered. No further information was provided.

Based on staff interview, Resident interview, facility documentation review, and clinical record review, the facility staff failed to maintain the professional standards of medication administration in nursing practice for two Residents(Residents #1 and # 3) in a survey sample of 3 Residents. The findings included: 1. For Resident #1, the facility staff failed to check finger stick blood sugar (FSBS), and failed to administer insulin for an insulin dependent Resident with Diabetes. Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as frequently incontinent of bowel and bladder. On 4-9-24 at 12:00 noon, Resident #1 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this lunch today is again not what it is supposed to be. She explained that she got lunch and that the menu said one thing and her tray had another. She went on to state that she was diabetic and almost everything on the tray was carbohydrates which she was not supposed to have & not her choice. The Resident's physician orders were reviewed and reveal orders for FSBS, and insulin administration for diabetes treatment. Those orders were for the following; 1. Ordered 3-9-24 Tresiba insulin Deglu[DATE] unit/milliliter give 60 units one time per day subcutaneously hold if blood sugar less than 100. Administer at 7:30 a.m. 2. Ordered 9-28-23 Humalog insulin Lispro 100 unit/milliliter inject subcutaneously as per sliding scale before meals and at bedtime for Diabetes. Administer 4 times per day at 6:30 a.m., 11:00 a.m., 4:00 p.m., and 9:00 p.m. The sliding scale was as follows; 0-150 = give 0 units 151-200 = give 2 units 201-250 = give 4 units 251-300 = give 6 units 301-350 = give 8 units 351-400 = give 10 units, and call MD (doctor) if greater than 400 The Medication and Treatment Administration Record (MAR/TAR) was reviewed for April 2024, and revealed the absence of nursing signatures indicating the Insulin and FSBS blood sugar checks were not completed on 6 occasions. Those follow; Tresiba 4-2-24 at 7:30 a.m. Humalog 4-2-24 at 4:00 p.m., 4-4-24 at 11:00 a.m., and 4:00 p.m., 4-5-24 at 9:00 p.m., and 4-6-24 at 6:30 a.m. Nursing medication administration notes do not indicate why the FSBS were not completed, and why insulin was omitted. Nurses on the nursing unit were asked if insulin was administered on the dates in question and the responses were if it's not documented, it's not done. Guidance for the administration of Insulin is given by The National Institutes of Health (NIH), and is as follows; National Institutes of Health & Medline.gov Insulin must be given as per a doctor's order and on the schedule indicated. If a dose is missed the doctor must be notified. Do not miss doses and check blood sugar as ordered to decide proper dosing needed. Do not discontinue this medication without seeking a doctor's help. Stopping Insulin will increase the risk of hyperglycemic attack which can be life threatening. The nursing facility stated [NAME] as their nursing standard. [NAME] stated all medications must be administered by the physician's order. Resident #1's care plan was reviewed and revealed a care plan for diabetes that instructed to administer medications as ordered by the physician. Nursing and physician progress notes were reviewed, and revealed no notes documenting that the medication had been omitted, nor that the doctor was made aware of the omissions. On 4-10-24 at 11:00 a.m., the DON (director of nursing) and Administrator were interviewed in the conference room and stated that they had been unaware that medications had not been given, nor that the doctor and family were not notified of medications being omitted by staff. The DON was a new staff member and had recently been hired. On 4-10-24 at approximately 2:00 p.m., at the end of day debrief, the Administrator and DON were again made aware of the failure of staff to administer finger stick blood sugar checks, and insulin as ordered. No further information was provided. 49916 2. The facility staff failed to administer medications on 1/26/24 as ordered by the physician for Resident #3. Resident #3 was admitted to the facility in May of 2017 with diagnoses including but not limited to essential hypertension, and other psychoactive substance abuse. nontraumatic intracerebral hemorrhage. viral hepatitis c, dysphasia, cataract, altered mental status, convulsions, anxiety, asymptomatic human immunodeficiency virus (HIV) disease, and need for assistance with personal care. The most recent MDS (minimum data set) was a quarterly assessment with an (ARD) assessment reference date of 3/14/24 was reviewed and revealed a (BIMS) Brief Interview for Mental Status score of 14 out of a possible score of 15 which indicated no cognitive impairment. A review of the clinical record was conducted on 4/09/24-4/10/24. A review of the January 2024 Medication Administration Record (MAR) revealed a check mark that indicated all medications were administered to Resident #3. On 4/10/24, Resident #3's clinical record was reviewed and revealed physician orders and medication administration documentation as follows: -Keppra Tablet 500 MG (levetiracetam) give 1 tablet by mouth two times a day related to unspecified convulsions. -Restasis (cyclosporine) Emulsion 0.05 %, instill 1 drop in both eyes two times a day, for chronic dry eyes. On 4/10/2024, an interview was conducted with the Corporate Nurse Consultant (CNC) who stated that she would be able to access an audit report that reflected medications that were missed or administered late on 1/26/2024 on Unit 2. The CNC provided a copy of the Medication Audit Report for Unit 2. Reviewing the Medication Administration Audit Report revealed that two (2) medications scheduled for administration on 1/26/24 at 8:00 p.m. were not administered until 12:00 a.m. on 1/27/24. The two medications were Keppra and Restasis. On 4/10/24 at 11:45 AM an interview was conducted with the Director of Nursing (DON) who stated that the expectation was that medications would be administered as ordered by the physician. Review of the facility policy entitled, Administering Medications, Medications are administered in a safe and timely manner, and as prescribed and subheading Policy Interpretation and Implementation, item 4 read, Medications are administered per prescribed orders, including any required time frame. According to [NAME]'s Nursing Procedures, Seventh Edition, 2016, section entitled, Oral Drug Administration, steps in the implementation of medication administration included but were not limited to: Verify the medication is being administered at the proper time .to reduce the risk of medication errors. On 4/10/24 during the end-of-day debriefing, the Administrator and DON were informed of the above findings. The DON stated that the expectation was that medications should be administered timely, as ordered by the physician. No further information was provided

Based on Observation, Resident interview, staff interview, and facility document review, the facility staff failed to provide the appropriate size adult brief for one Resident (Resident #1) in a survey sample of 3 Residents. The findings include: For Resident #1, the facility staff applied an adult incontinence brief that was too small for the Resident causing discomfort and spilling of waste onto the Resident's bed Resident #1, was admitted to the facility on [DATE]. Diagnoses included; diabetes, cancer, hypertension, and morbid obesity. Resident #1's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-05-24 was coded as a quarterly assessment. Resident #1 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or no cognitive impairment. Resident #1 was also coded as requiring extensive to total dependence on one to two staff members to perform activities of daily living, such as hygiene, transferring, and bed mobility. The Resident was coded as frequently incontinent of bowel and bladder. On 4-9-24 at 12:00 noon, Resident #1 was observed in bed, with the head of the bed elevated, during initial tour of the facility. A Resident interview was conducted, and the Resident complained that this lunch today is again not what it is supposed to be. She explained that she got lunch and that the menu said one thing and her tray had another. She went on to state that she was diabetic and almost everything on the tray was carbohydrates which she was not supposed to have & not her choice. She went on to say that she could not sit up comfortably because her brief was too small and she kept pulling at it to rearrange every time she moved in the bed to reposition herself. She stated look at this, and pulled her bed linens back to expose herself and the brief for the surveyor to view, and it was noted that the brief side closures were cutting into the skin across her abdomen and were too tight on her leg openings, and there was a yellow urine wet spot next to the Resident's right leg opening. That just makes no sense, she stated they have bigger ones that do fit. On a wheel chair near the Resident's bed was noted a clean stack of about 10 of the same briefs that the Resident was wearing. On 4-9-24 at approximately 12:30 p.m., the supply room on Resident #1's unit was toured and no largest bariatric briefs were in the supplies in the room, however, many other sizes were there in stock. A nurse from the unit was with the surveyor and when asked stated yes we have more supplies in the big store room and if we run out we can get them from (name) employee C, the person who orders supplies and does the schedule. On 4-9-24 at 1:30 p.m., Employee C was interviewed and stated We do have those largest briefs in the store room, and if staff will let us know when they are out we will restock them. She showed the surveyor briefs of all sizes from inventory on hand and identified the brief in the Resident's room as the next to the largest available, and had the largest to compare it to for the surveyor. On 4-9-24 at 3:00 p.m., Employee C delivered supply requisition documents for several months illustrating that the largest briefs were used by 2 Residents in the facility and were ordered weekly and always on hand. The information revealed that the largest briefs were available and nursing unit staff simply did not ask for stock when it ran low. They used whatever they had on the unit for their convenience rather that restocking the appropriate size for Resident #1. On 4-9-24 at end of day debrief the DON (director of nursing), and Administrator were notified of the above findings. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for medication administration for 1 resident, Resident #1, in a survey sample of 3 residents. The findings included: For Resident #1, facility staff failed to administer, and/or document medications as administered, as ordered by the physician on 7/16/23 and 7/26/23. On 11/13/23, Resident #1's clinical record was reviewed and revealed physician orders and medication administration documentation as follows: -Depakote Extended Release, 250mg, ordered to be given once a day at 12:00 PM--missed dose on 7/16/23 and 7/26/23. -Diltiazem HCl Extended Release, 300mg, ordered to be given once a day at 9:00 AM--missed dose on 7/16/23 and 7/26/23. -Lisinopril, 5mg, ordered to be given once a day at 8:00 AM--missed dose on 7/16/23. -Plavix, 75mg, ordered to be given once a day at 8:00 AM--missed dose on 7/16/23. -Hydralazine HCl, 10mg, ordered to be given two times a day--missed the 8:00 AM dose on 7/16/23 -Meformin HCl, 1000mg, ordered to be given two times a day--missed the 8:00 AM dose on 7/16/23. -Namenda, 10mg, ordered to be given two times a day--missed the 8:00 AM dose on 7/16/23. On 11/13/23 at approximately 2:45 PM, an interview was conducted with the Facility Administrator who confirmed the findings and stated that medications are expected to be given as ordered by the physician. The Facility Administrator stated that the facility's professional nursing standards reference was [NAME]. A facility policy on medication administration was requested and received. At approximately 3:00 PM, an interview was conducted with licensed practical nurse (LPN C) who was assigned to Resident #1 on 7/16/23 and responsible for administering the medications. LPN C stated, I can't explain why I didn't chart his [Resident #1's] morning meds, it's not like me to miss this but I feel like I did give them to him, he did not have any problems that were out of the ordinary on that day, I just can't explain how I missed charting his meds, I click them off as I prepare them, I must have forgot to click the last button that records the med pass before closing out of his record, I am so sorry about all of this. Review of the facility policy entitled, Administering Medications, revised April 2019, heading Policy read, Medications are administered in a safe and timely manner, and as prescribed and subheading Policy Interpretation and Implementation, item 4 read, Medications are administered in accordance with prescriber orders, including any required time frame. According to [NAME] Nursing Procedures, Seventh Edition, 2016, section entitled, Oral Drug Administration, steps in the implementation of medication administration included but were not limited to: Verify the medication is being administered at the proper time .to reduce the risk of medication errors. On 11/13/23 at the end of day meeting, the Facility Administrator was updated on the findings. No further information was provided.

Based on document review and interview, the facility failed to ensure there was a Registered Nurse (RN) on duty for eight continuous hours per day. This failure had the potential to affect residents who needed the skills of an RN on those days. Findings include: Review of the facility provided Daily Staffing sheets for the weekends in the Centers for Medicare and Medicaid (CMS), quarter one (Q1) (October, November, and December 2022), triggered on the Payroll Based Journal [PBJ] facility reporting for no RN coverage for eight continuous hours on weekends in Q1 showed the following dates without RN coverage: 10/08/22 Saturday -- no RN coverage. 10/15/22 Saturday -- no RN coverage. 10/22/22 Saturday -- no RN coverage. 10/23/22 Sunday -- no RN coverage. During an interview on 05/10/23 at 9:45 AM the Administrator confirmed there were no RN's working on the listed dates. At end of day debriefing on 05/11/23, the Administrator and Director of Nursing were made aware of deficient practice and stated there was no further information to provide.

Based on observations, staff interviews, clinical record reviews and in the course of a complaint investigation the facility staff failed to implement infection control measures to prevent the spread of COVID-19 for 2 Residents (Resident #6, #7) in a survey sample of 12 Residents. The facility staff failed to provide signage to notify facility staff and any visitors of the identified Residents being on transmission based precautions, this lack of signage resulted in facility staff providing direct Resident care without donning proper PPE to minimize the risk of exposure and/or spread of infection, specifically COVID-19. The findings included: On 1/5/22 at approximately 12:45 PM, Surveyor C conducted tour of the facility. During this tour no signage to indicate Residents #6 and #7 were on transmission based precautions was noted, nor was any PPE (personal protective equipment) located outside of the rooms. Surveyor C proceed to make direct observations and interactions with Resident #6 and Resident #7. On 1/5/22 at approximately 3PM, Surveyor C again entered the room of Resident #7 to make additional observations. No signage was observed and no PPE (personal protective equipment) station was outside of the room. CNA B was in the room providing direct patient care to Resident #7. CNA B was observed to have on an N-95 mask (medical respirator) and eye protection. On 1/6/22 at approximately 10 AM, Surveyor C again made observations and interviewed Resident #6 in her room. There was no signage to indicate Resident #6 was on isolation and no PPE was available outside of the room. Surveyor C exited the room and notified LPN F of a request Resident #6 had. On 1/6/22 at 10 AM, LPN F was observed passing medications on the hall to Resident #7. LPN F was observed to have only an N-95 mask and eye protection on. On 1/6/22 at approximately 4:30 PM, during the course of a complaint investigation the facility staff identified and provided the survey team with physician orders for Resident #6 and Resident #7 stating they were on quarantine/TBP (transmission based precautions) due to a recent direct exposure to a COVID positive staff member. The physician orders read as follows: * Resident #6 had an order dated 12/27/21, that read, Maintain resident on enhanced droplet precautions d/t [due to] partial vaccinated status and potential exposure every shift for 14 days maintain resident on enhanced droplet precautions. * Resident #7 had an order dated 12/27/21, that read, Maintain resident on enhanced droplet precautions d/t partial vaccinated status and potential exposure every shift for 14 days maintain resident on enhanced droplet precautions. On 1/6/22 at approximately 4:35 PM, Surveyors C and D again observed the rooms of Residents #6 and #7. There was no signage on the unit doors, which were open, no signs on the Resident room entry and no PPE observed outside of the rooms. On 1/6/22 at approximately 4:40 PM, Surveyor D notified LPN C, the unit manager concerning Resident #6. LPN C then responded to Resident #6's room wearing an N-95 mask and eye protection. LPN C entered without donning any additional PPE, approached the bedside of Resident #6, interacted with the Resident and made adjustments to her bed. When LPN C exited the room she confirmed that the Residents on the hall were all on TBP. When asked why she had not donned [put on] an isolation gown and gloves, she said, That's on me. When asked how staff would know the Residents were on TBP, LPN C said, It's in the computer. LPN C confirmed that there was no signage present that would notify staff. On 1/6/22 at approximately 4:40 PM, Surveyor C & D interviewed LPN F and CNA B. Both LPN F and CNA B confirmed they had been responsible for Residents #6 and #7 for the entire shift (since 7 AM) and had been providing direct Resident care to the Residents. Both staff stated that the Residents were not on TBP (transmission based precautions) that they were aware of and no one had told them otherwise. On 1/6/22 at approximately 5 PM, the facility Administrator, VPO (Vice President of Operations) and LPN C were made aware of the concerns. The facility Administrator stated she knew signs had previously been in place and was unaware of why or when they were removed. LPN C, who is also the facility infection preventionist confirmed the facility follows CDC (Centers for Disease Control and Prevention) guidance. Review of the facility policy titled Isolation- Categories of Transmission-Based Precautions read, Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; . and is at risk of transmitting the infection to other residents .Droplet Precautions. 1. Droplet Precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that can be generated by the individual coughing, sneezing, talking, or by the performance of procedures such as suctioning Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions. The facility policy titled, COVID Guidance for [company name redacted] with a creation date of 9/14/21, was reviewed. It read, Management of Residents with Close Contract of Higher Risk exposure: Unvaccinated residents with exposure will be placed on TBP/quarantine for 14 days following the exposure, regardless of test result .HCP [healthcare personnel] will wear full PPE when providing care for the resident (gown, gloves, eye protection, N95). CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes read, Manage Residents who had Close Contact with Someone with [CONDITION(S)]-CoV-2 Infection. Unvaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should be placed in quarantine for 14 days after their exposure, even if [CONDITION(S)] testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_ 450 CDC guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic was reviewed. It read, 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Ensure everyone is aware of recommended IPC practices in the facility. -Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html No further information was provided.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to obtain lab services for 1 Resident (Residents #3) in a survey sample of 12 residents. Findings included: For Resident #3, the facility staff failed to obtain a physician ordered BMP (Basic Metabolic Profile) blood specimen. Review of the clinical record revealed a physician's progress note ordering a BMP lab on 11-6-21. However, no specimen was ever obtained. Review of facility lab policy revealed the following; 1. The physician will identify and order .lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process requisitions and arrange for tests. 3. The laboratory or other testing source, will report test results to the facility. On 1-6-21 at approximately 2:31 p.m., the Administrator was asked for the BMP results for Resident #3, and she responded We have no BMP for (name) this Resident. The Administrator and DON were notified of the staff failure to obtain a lab test ordered by a physician at the end of day meeting on 1-6-21. The Administrator stated that the expectation was that nurses would obtain labs as ordered by the physician. No further information was provided. COMPLAINT DEFICIENCY

Based on staff interviews, facility documentation review, clinical record review and in the course of a complaint investigation, the facility staff failed to administer medications due to a lack of availability, to one Resident (Resident #6) in a survey sample of 12 Residents. The findings included: On 1/5/22, Surveyor C conducted a clinical record review for Resident #6. This review revealed a physician order dated 12/24/21, that read, [MEDICATION(S)] Tablet 0.5 MG Give 1 tablet by mouth at bedtime for EPS [extrapyramidal signs/muscle stiffness and rigidity]. Review of the MAR (medication administration record) revealed that Resident #6 did not receive this medication as prescribed until 12/27/21. Review of the nursing notes revealed no entries as to why Resident #6 did not receive the medication [MEDICATION(S)] tablets for 3 days. On 1/5/22 at approximately 3PM, Surveyor C accompanied by LPN F, conducted an observation of the medication availability for Resident #6. This review revealed that Resident #6's [MEDICATION(S)] was present in the medication cart and had 21 tablets remaining. The medication card indicated a pharmacy dispense date of 12/27/21. LPN F was unable to give any details as to when this medication had been ordered. On 1/5/22 in the afternoon, an interview was conducted with LPN B. LPN B indicated that medications can be ordered several ways and the pharmacy delivers daily. On 1/5/22, during an end of day meeting, the facility staff were made aware that Resident #6 had a delay in receiving medications as ordered. On 1/6/22 at 10:55 AM, an interview was conducted with LPN D. LPN D stated when orders are received the pharmacy delivers medications within 24 hours. When asked what is the process if a medication is not available she stated, I would see if it is available in the Pyxis [emergency stock of medications], if not, I would call the provider and see if they want to hold it or give an order for something else. When asked why it is important for Residents to receive medications as ordered, LPN D said, They have conditions that need it. On 1/6/22, Employee F, the Vice President of Operations confirmed that Resident #6 had a delay in medication administration due to the unavailability of medications. Employee F went on to state that the facility had ongoing issues with the pharmacy and were in the process of changing pharmacy providers in the near future. Review of the facility policy titled, Administering Medications was reviewed. This policy read, .4. Medications are administered in accordance with prescriber orders, including any required time frame. No further information was received. Complaint related deficiency.

Based on Resident interview, staff interviews, facility documentation review, clinical record review and during the course of a complaint investigation, the facility staff failed to provide ADL assistance with regards to showering, for a Resident who was dependent upon staff to maintain personal hygiene, for one Resident (Resident #5) in a survey sample of 12 Residents. The findings included: On 1/5/22 at approximately 12:30 PM, Surveyor C conducted an interview with Resident #5. When asked if he receives showers, Resident #5 stated, Rarely. On 1/6/22, a clinical record review was conducted. This review revealed from 12/8/21 through 1/6/22, Resident #5 only received bed baths. The clinical record revealed no indication that Resident #5 had refused a shower during this time frame. On 1/6/22, the facility staff provided the survey team with additional ADL (activities of daily living) records from 11/1/21 through 1/6/22. These records were reviewed and revealed that Resident #5 had not received a shower during this time, only bed baths were provided. Review of Resident #5's care plan revealed the following entry, BATHING/SHOWERING: The resident requires max assist. There was no indication in the care plan that Resident #5 refused showers. On 1/6/22, interviews were conducted with CNA B and CNA D. Both reported that Residents are showered based upon a shower schedule. CNA's B and D stated that if Residents refused a shower it is documented in the ADL record. On 1/6/22, the shower schedule was received. This revealed that Resident #5 was scheduled to receive showers on the 3-11 PM, shift on Monday and Thursday of each week. Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting read, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). A review of the facility policy titled Bath, Shower/Tub was conducted. This policy read, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Documentation 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath 5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. On 1/6/22, the facility Administrator was made aware of the concern that Resident #5 was not provided showers. No further information was received. Complaint related deficiency.

Based on interview, clinical record review, facility record review, and in the course of an investigation, the facility staff failed to meet professional standards of quality for 3 Residents (#'s 1, 5, and 7) in a survey sample of 12 Residents. The findings include: For Resident #1 the facility staff failed to report a change in patient condition to the charge nurse, wound nurse, physician and family. Resident #1 was admitted to the facility on [DATE], with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/6/22 review of the clinical record revealed and FRI investigation revealed two LPN's employed through a staffing agency, were found to have had knowledge of maggots on Resident #1's foot prior to a nurse finding them on 7/5/21. The results of the investigation revealed the two nurse's contracts were subsequently terminated for failing to report these findings to a charge nurse, wound nurse, supervisor or physician. A review of the investigation revealed the Administrator did conduct interviews and found that two nurses were heard discussing the fact that they had seen the maggots days before. NOTE: It is important to note that the maggots were not seen in a wound. On the morning of 1/6/22 an interview was conducted with LPN C who stated that Nurses should report changes in condition to the Nurse Practitioner, or the Physician and the family and it should be documented in the 24 hour report. The nurses were unable to be reached for interview. Per the Agency for Healthcare Research and Quality [ahrq.gov] https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod1.html#:~:text=A%20change%20in%20a%20resident%27s%20condition%20may%20mean,complications%2C%20transfer%20to%20a%20hospital%2C%20or%20even%20death A change in a resident's condition may mean that he or she is at risk. Action can be taken only if changes are noticed and reported, the earlier the better. Changes that are not reported can lead to serious outcomes, including medical complications, transfer to a hospital, or even death. On 1/6/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure a resident's environment promoted their dignity for two of 18 sampled residents (Resident (R) 8 and R71). Observations revealed urinary catheter bags for two residents were fully visible to other residents and staff during the survey, resulting in the potential for residents to have an undignified living situation. Findings include: 1. Review of R8's undated Admission Record, located in the resident's electronic medical record (EMR) under the profile tab, revealed the resident was admitted to the facility on [DATE], with a subsequent readmission on 03/04/21and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R8's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/20, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident was moderately cognitively impaired. During an observation of R8, in his room laying in bed, on 03/08/21 at 1:00 PM, the catheter bag was not in a dignity bag, and was visible from the hallway and anyone passing by in the hall. Clear yellow urine was noted. It was hooked to the bed in the middle, not placed below the level of the bladder. During an observation of R8, in his room laying on his bed, on 03/09/21 at 10:00 AM, the catheter bag was not in a dignity bag, and was visible from the hallway and anyone passing by in the hall. Clear yellow urine was noted. It was hooked to the bed in the middle, not placed below bladder level. During an observation of R8, in his room laying on his bed, on 03/11/21 at 9:30 AM, the catheter bag was observed not in a dignity bag, was visible from the hallway and was placed at the level of the bladder. Clear yellow urine was noted in the tubing. 2. Review of R71's undated Admission Record, located in the resident's EMR under the profile tab, revealed the resident was admitted to the facility on [DATE], with a subsequent readmission on 03/04/21and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R71's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/21, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated the resident was severely cognitively impaired. During an observation of R71, in her room laying in bed, on 03/08/21 at 1:30 PM, the catheter bag was not in a dignity bag, was visible from the hallway and anyone passing by in the hall. Clear yellow urine was noted. It was hooked to the bed in the middle, not placed below the bladder level. During an observation of R71, in her room laying in bed, on 03/09/21 at 10:28 AM, the catheter bag was not in a dignity bag, was visible from the hallway and anyone passing by in the hall. Clear yellow urine was noted. It was hooked to the bed in the middle, not placed below bladder level. During an observation of R71, in her room laying in bed, on 03/10/21 at 9:54 AM, the catheter bag was observed not in a dignity bag, was visible from the hallway and was placed above the level of the bladder. Clear yellow urine was noted in the tubing. During an observation of R71, in her room laying in bed, on 03/10/21 at 02:41 PM, the catheter bag was observed not in a dignity bag, was visible from the hallway and was placed at the level of the bladder. Clear yellow urine was noted in the tubing. During an observation of R71, in her room laying in bed, on 03/11/21 at 9:00 AM, the catheter bag was observed not in a dignity bag, was visible from the hallway and was placed at the level of the bladder. Clear yellow urine was noted in the tubing. During an interview with Unit Manager (UM)1 on 03/11/21 at 9:15 AM, she stated the catheter should always be covered in a dignity bag and she was not sure why one was not in place. UM1 also stated the catheter bag should always be placed below the level of bladder. During an interview with the Director of Nursing (DON) on 03/11/21 at 10:00 AM, the DON stated catheter bags should .always be in a dignity bag and hooked to the bed at the level of the bladder or below. During an additional interview with the DON on 03/11/21 at 11:00 AM she stated she makes rounds each morning when she is here to check if catheters are covered and if not, reminds the staff to cover them. She further stated ,.I think nightshift is removing them and not replacing them, but I don't know why. According to the facility's policy provided titled, Catheter Care, Urinary, revised September 2014, it stated, .the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview, record review and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the accuracy of the Minimum Data Assessment (MDS) for one of 18 sampled Residents (R), R42 was incorrectly assessed as needing assistance with eating meals. Findings include: On 03/10/21 at 12:00 PM, R42 was observed independently eating lunch. R42 was observed sitting in a wheelchair in his/her room with a bedside table placed in front of the wheelchair. Certified Nursing Assistant (CNA)1 was observed serving R42 a lunch tray. CNA1 placed the tray on the bedside table in front of the resident and informed R42 what foods were on the tray During the continued observation, R42 was observed eating the food without any assistance. On 03/10/21 at 12:25 PM, an interview was conducted with CNA1. CNA1 stated R42 was a picky eater and only ate approximately 50% of the food on the lunch tray. CNA1 further stated R42 always eats meals independently and does not need any assistance with feeding. Review of R42's Admission Record located under the Profile tab of the Electronic Health Record (EHR) documented R42 was admitted to the facility on [DATE]. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R42's Annual MDS, with an Assessment Reference Date (ARD) of 01/28/21, the facility assessed R42 with the ability to eat meals independently. However, the assessment further indicated R42 needed one person to assist him/her with eating meals. On 03/10/21 at 12:48 PM, an interview was conducted with the facility's MDS Coordinator/Registered Nurse (RN). RN stated the CMS Long-term Care Facility RAI 3.0 User's Manual was the guidance the facility used for assessing residents. After reviewing R42's Annual MDS with the ARD of 01/28/21 with the RN, the RN stated the assessment did not accurately reflect the ability of the resident to eat meal on his/her own and R42 only needed facility staff to set up the resident's tray. On 03/11/21 at 12:49 PM, an interview was conducted with the Administrator. The Administrator stated he expected residents to be accurately assessed according to the facility's practices. Review of CMS Long-term Care Facility RAI 3.0 User's Manual related to the accuracy of MDS assessments revealed on page 1 - 7, .The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that.(1) the assessment accurately reflects the resident's status. In addition, on page 1 - 8 of the RAI 3.0 Manual, .An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, or significant other as appropriate or acceptable.

Based on observation, interview, and document review, the facility failed to post the nurse staffing timely and daily, resulting in the potential for inaccurate information to be presented to residents and visitors. Findings include: During an observation on 03/08/21 at 9:30 AM, the daily nursing staff report posted in the main lobby was dated 03/05/21. During an interview on 03/11/21 at 9:55 AM with the staffing scheduler, she stated she was the responsible person for posting the nurse staffing hours Monday through Friday. She also stated she did not work on the weekends and the staffing hours were not posted on the weekends. The staffing scheduler stated, .I was not aware the hours were to be posted on the weekends. and did not have any completed nursing staff hour postings for the weekend of 03/05/21 - 03/06/21. During an interview on 03/11/21 at 10:05 AM with the Administrator, he stated the facility expectation was that nurse staffing hours are to be posted 7 days a week. He was unable to state why the scheduler had not been informed, or trained, to post them on the weekends. According to the facility's policy provided Posting Direct Care Daily Staffing Numbers, revised July 2016, it stated .Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents.

Based on record review, interview and review of the facility's policy and procedures Advance Directives, the facility failed to ensure the medical record had documentation of discussion with three of three residents reviewed for Advance Directives. Resident (R) 25, R28, R67. Findings include: On 03/09/21 at approximately 2:00 PM during an interview with the Unit Manager (UM) 2 she reported if a resident is a Full Code status, there is no Advance Directive Form completed and placed in the resident's charts. 1. Review of the Electronic Medical Record (EMR), face sheet and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the updated face sheet and physician order, dated 11/04/19, documented Full Code status under resident status. Review of the EMR did not reveal a documentation of an Advance Directive discussed with R25. Review of the Significant Change Minimum Data Set (MDS), Assessment Reference Date (ARD) of 07/15/20 for R25. The resident's Brief Interview for Mental Status (BIMS) score 15, cognitively aware. 2. Record review for R28 EMR documented he was admitted to the facility on [DATE]. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The EMR did not document evidence that an Advance Directive had been discussed with R28. Review of the Admission MDS with an ARD of 01/13/21. The resident's BIMS score of 12, cognitively intact. 3. Review of R 67 face sheet and physician orders, found in the EMR, documented the resident was readmitted to the facility 02/12/21, initial admitted [DATE]. The face sheet and physician orders, dated February 2021, document Full Code status for R67.The resident was admitted to Hospice on 02/13/21. The EMR did not document evidence that an Advance Directive had been discussed with R67 and/or his representative. Review of the Significant Change MDS with an ARD of 02/12/21 revealed R67 had a BIMS score of 03, cognitively impaired. During an interview on 03/11/21 at 11:33 AM with Director of Nursing (DON), and the Social Worker Director (SWD) regarding residents' rights in the participation of Advance Directives being documented in the medical records. They stated, New admits are automatically listed as a Full Code until a signature is obtain by the doctor. If the resident is admitted from the hospital with a Full Code, they inform the doctor and get an order. When asked are families given the opportunity to decide for residents who may not be capable or their own responsible person. They stated, the Social Worker is responsible for following through with completing Advance Directives. On 03/11/21 at approximately 11:45 AM, the SWD and the DON confirmed that the discussion of the Advance Directives were not in the EMR and or paper book on the Unit for the three residents R25, R28, R67. Review of the facility's policy and procedures Advance Directives, revised December 2016 indicated, Policy Interpretation and Implementation.7.Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8/ If the resident indicated that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.

Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to appropriately transfer one resident (Resident #7), in a survey sample of 24 residents, to prevent serious injury that resulted in harm. For Resident #7, the facility staff failed to perform a two person transfer from the wheel chair to the bed, resulting in a laceration to the right leg that required stitches. The findings included: Resident #7 was originally admitted to the facility on [DATE] and readmitted post hospitalization of 10/12/13. Her [DIAGNOSES REDACTED]. Resident #7's most recent MDS (Minimum Data Set) assessment was a quarterly assessment with an ARD ( Assessment Reference Date) of 1/7/14. Resident #7 was coded a BIMS (Brief Interview of Mental Status) score of 5, severe cognitive impairment and required extensive assistance of 1 staff member with all activities of daily living except transfers. For transfers, Resident #7 was coded as requiring a two person assist. She was coded for balance as a (2) not steady, only able to stabilize with staff. She was coded for ROM (range of motion) with no impairment on upper extremity, and with impairment on one side on lower extremity. Resident #7 was observed on 3/18/14 at 4:10 p.m. dressed in long pants, a shirt and wearing tennis shoes while sitting in her wheelchair with her left leg stretched out and her right leg contracted toward her chest. A Kerlex wrap was visible around the ankle area of her right leg. Resident #7 was pleasantly confused. On 3/19/14 at 5:30 p.m., Resident #7 was observed having her dinner meal being set up by her son. On 3/20/14 at 9:00 a.m., Resident #7 was observed asleep and wearing foam boots to both feet, the right leg was contracted and the left leg was straight. On 3/20/14 at 2:15 p.m., Resident #7 was observed during the changing of the dressing to her right foot. Resident #7 was very protective of her right contracted leg as LPN (Licensed Practical Nurse) C and CNA A repositioned her leg during wound care. Review of a nurse's note dated 2/23/14 at 9:07 p.m. written by RN (Registered Nurse) C read, "CNA (Certified Nursing Assistant) transferring resident from wheelchair to the bed. The left leg rest bracket on the wheelchair caused a 5 cm x 4 cm x 2 cm (centimeter) laceration to the inside of right leg above ankle. Serosangious drainage noted, area cleaned, Telfa dressing and Kling applied to area. RP (responsible party) called x 3 with no answer, message left for him to return call. MD (physician) aware." Further review of the nurse's notes revealed Resident #7 was sent to the hospital emergency roiagnom on [DATE] where the laceration to the right leg was treated with stitches and she returned to the facility on [DATE] at 3:00 a.m. Review of the facility incident and accident report, nursing notes, and the CNA's (CNA B) written statement revealed that Resident #7 the incident occurred during a one person transfer performed by CNA B. The Resident was being transferred from her wheelchair to her bed when the incident occurred. Review of the comprehensive care plan did not reveal a plan of care or any interventions related to Resident #7's transfer assistance needs. Review of the ADL (Activities of daily living) data documentation performed by the CNA staff revealed during the month of February 2014 Resident #7 was documented as having been transferred by a two person assist on four occasions during the evening shift hours. All other documented transfers were performed by one staff person. Staff continued to perform one person staff assist transfers after the incident that occurred on 2/23/14. Review of the physical therapy notes revealed Resident #7's physical therapy was discontinued on 11/12/13. The Weekly Summary Discontinuation note dated 11/12/13 read, " Pt. as of late has had more difficulty participating in tx (treatment) program, resulting in decreased progress during this assessment period. She has met one ST (short term) goal w/ S bed mobility, though unable to meet other ST and LT (long term) goals. She continues to c/o (complaining of) R (right) hip pain, which x-ray revealed to be negative for fracture w/severe OA (osteoarthritis). During today's discharge treatment she c/o R (right) knee pain which also kept her from bearing weight on the RLE (right lower extremity) and thus she was unable to participate in gait training. Pt. (patient) is being discontinued from therapy due to significantly decreased activity tolerance and inability to participate in PT at a skilled level." On 3/19/14 at 2:30 p.m. an interview was conducted with CNA A, the CNA assigned to Resident #7. CNA A said she is routinely assigned to Resident #7. When asked how Resident #7 was transferred from the bed to the wheelchair, CNA A stated, "Oh, I know how to transfer her by myself. I'm very careful. CNA A said Resident #7 usually complained of hurting, that she sits with her right leg bent up toward her body and that Resident #7 didn't have any behavior concerns. On 3/20/14 at 10:40, an interview was conducted with the Corporate Nurse, Admin. G regarding Resident #7's ability to transfer and staff assistance with transfers. Admin G stated, "Sometimes she requires only one staff. She can bear weight." Interview with the MDS coordinator, Admin. A., was held 3/20/14 at 11:25 a.m., regarding the assessment coding of a two-person transfer requirement for Resident #7. Admin A stated, "I used the ADL Data Report coding and looked seven days back from the ARD date of 1/7/14." During this timeframe, Admin A said she coded the highest staff assistance for transfer the resident received. The ADL Data Report revealed Resident #7 was transferred with the assistance of two staff members on two occasions on the evening shift. All other transfers were performed by one staff member. On 3/20/14 at 11:30 a.m. an interview was held with the Rehabilitation Manager, Admin F, regarding Resident #7 transfer abilities. Admin F said Resident #7's physical therapy progress was inconsistent and that there were occasions when she could bear weight on her left leg and perform a stand-pivot transfer. Admin F stated, "She was more tired in the evenings, that is why she needed a lot more assistance. Her ability to bear weight varied." On 3/19/14 at 5:40 a.m. an interview was conducted with the RN C regarding the incident. RN C said she was informed by CNA B of the laceration to the Resident's right lower leg that occurred when CNA B was transferring the resident. When asked if any interventions were put in place after the incident, RN C stated, "I cleaned and bandaged the wound, notified the DON, the RP and the MD." RN C said the resident was sent out to the ER (emergency room ) and returned with stitches to the laceration." On 3/20/14 at 11:45 a.m. an interview was conducted with the DON (Director of Nursing) Admin. B regarding the expectations for safely transferring Resident #7. Admin. B stated, "Some weight bearing is good for her." When asked what interventions were put in place after the incident, Admin. B stated, "PT did screen her and made some changes to the wheelchair." Admin. F said, "A Foot Drop Stop was added to her wheelchair." When asked what plans were there now to ensure safe transfers for Resident #7, Admin. B responded, "We plan to start educating and fine tuning transfers for her and provide training to staff." On 3/20/14 at 1:10 p.m. an interview was conducted with CNA B. When asked how information regarding how to transfer a resident was obtained, CNA B stated, "There is nothing in writing on how to transfer a resident. You have to ask the nurse. New people (staff) usually get told during report. CNA B was asked how the incident that caused a laceration to Resident #7 right leg occurred. CNA B responded, "She was kind of 'iffy' that evening. She wasn't eating her dinner. She will help you sometimes. I had her put her hands around my neck and said 1,2,3. When I pivoted her toward the bed from the wheelchair her right leg hit the leg of the wheelchair." CNA B said that today was only her second time working with the resident and she added, "And I did a two person transfer with her today. I'd seen other staff working with two people with her. Never again." On 3/20/14 at 3:30 p.m. the Administrator and DON were made aware of the facility staff's inappropriate transfer of Resident #7 resulting in a serious injury that caused in harm. No additional information was provided.