Every finding on record at Windsormeade of Williamsburg

Based on observations and staff interviews, the facility staff failed to ensure that expired medications were not accessible for administration. The findings included: On 4/17/26 at approximately 11:35 AM, an inspection of the medication room was completed with Registered Nurse (RN) #1. Inside the refrigerator, among other medications available for administration, a bottle of Lorazepam Concentrate 2mg/ml was identified in the locked box. The Lorazepam bottle was filled on 01/17/2024 and had an expiration date of 01/2026. RN #1 stated that the direct care nurses notify the Director of Nursing (DON) of medications that need to be removed, and it was the DON who was responsible for destroying discontinued medication. On 4/17/26 at approximately 6:15 p.m., a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Operations, Regional Nursing Consultant, and Administrator-in-Training staff. The above information was provided, and the facility's staff were offered the opportunity to present information. The DON stated that the expired medication in the refrigerator had been brought to her attention today.

Based on observation and staff interviews, the facility's staff failed to maintain dignity during wound care for 1 of 21 residents (Resident #20) in the survey sample.The findings included: Resident #20 was originally admitted to the facility 4/03/26. The residents' diagnoses included Type 2 diabetes mellitus without complications, and Muscle weakness, generalized.The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/07/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #20's cognitive abilities for daily decision making were intact.The April 2026 Physician Order Summary (POS) Reads: Cleanse sacrum with normal saline (NS). Pat dry. Apply Medi honey to wound bed. Apply Calcium Alginate to wound bed. Cover with a foam dressing daily and as needed (PRN) if it becomes soiled. one time a day.On 04/17/2026 at approximately 10:25 am, during the initial tour, Resident #20 mentioned that he had a wound on his sacrum related to falling at home. Permission was received from the resident to observe wound care.On 04/17/26 at approximately 1:35 pm, wound care observation was conducted with Licensed Practical Nurse #1. No issues were observed involving wound care except when the wound care was completed, LPN #1 was observed dating and initialing the resident's dressing once it was placed on his sacrum.On 04/17/2026 at approximately 4:23 pm, a brief interview was conducted with LPN #1 concerning the wound care observation. LPN #1 said she will initial and date the resident's dressing before placing the dressing on his sacrum due to dignity.On 4/17/26 at approximately 5:45 PM, a final interview was conducted with the Administrator, the Director of Nursing (DON), the Regional Director of Operations, the Regional Nursing Consultant, and the Administrator-in-Training staff. The above information was provided, and the facility's staff were offered the opportunity to present information but no other information was presented.

Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide respiratory care consistent with professional standards of practice for 1 Resident (#18) in a survey sample of 21 Residents.The findings included:Resident #18. The facility staff failed to ensure the oxygen concentrator tubing and the humidification bottle attached to the oxygen concentrator were changed according to physician order for Resident #18. Resident #18 was originally admitted to the facility 4/6/26. The resident's diagnoses included chronic kidney disease, anxiety disorder, type 2 diabetes mellitus without complications, and essential hypertension. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/13/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #18's cognitive abilities for daily decision making were intact. On 4/17/26 at 12:05 PM during an observation tour of Resident #18's room, it was observed that the oxygen concentrator tubing read: dispose and replace on 4/16/26 and the humidification bottle attached to the oxygen concentrator for Resident #18 was dated 3/25/26. On 4/17/26 at 12:10 PM an interview was conducted with the Director of Nursing (DON). The DON stated that the oxygen concentrator tubing should have been changed on 4/16/26. The DON also stated that the humidifier bottle does not need to be changed and she is not sure why the bottle has a date on it. The DON further stated that the nurses just write the date on the bottle. A review of the Physician Order Summary with a start date of 04/07/2026 read: Change all respiratory tubing weekly (O2, nebulizers) every evening shift every Tue. The Facility's Respiratory Assessment Policy with a revised date of 4/1/23 read: V. Maintenance: A. The oxygen cannula, tubing and humidifier bottle are changed every week or as needed and should be dated and labeled on day of change. The weekly change is documented on the TAR. On 4/17/26 at approximately 6:15 p.m., a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Operations, Regional Nursing Consultant, and Administrator-in-Training staff. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observations, family and staff interviews, and a review of the clinical record, the facility staff failed to ensure that the hospice plan of care coordinated with the facility's plan of care and to provide symptom management for 2 of 21 residents (Resident #7 and #10) in the survey sample. The findings included:1. The facility's staff failed to have Resident #7's visit schedule and notes available.Resident #7 was admitted to the facility on [DATE]. The resident's current diagnoses included Alzheimer's disease, TIAs, and urinary retention. The admission significant change annual quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 01/23/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 12 out of 15. This indicated that Resident #7's cognitive abilities for daily decision-making were moderately impaired.A review of resident #7's clinical record failed to reveal hospice visit notes or a schedule of disciplines to support the resident and family. A review of the facility's care plan meeting documentation also failed to reveal that a member of the hospice agency participated. An interview was conducted with Certified Nursing Assistant (CNA) #1 on 4/17/26 at approximately 2:40 PM. CNA #1 stated that she was never informed when or what time to expect the hospice CNA to arrive, and she proceeded with caring for the resident as if there was no hospice support. On 4/17/26 at approximately 2:50 PM, an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated that she didn't have a schedule for who or when the hospice agency would visit, but she could attest that after visits with Resident #7, the hospice representative always stopped by and provided the nurse with an oral report.On 4/17/26 at approximately 4:30 PM, hospice documentation that had been faxed to the facility at 4:00 PM on 4/17/26 was provided to the survey team. On 4/17/26 at approximately 6:15 p.m., a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Operations, Regional Nursing Consultant, and Administrator-in-Training staff. The above information was provided, and the facility's staff were offered the opportunity to present information. They had no comments and voiced no concerns regarding the above information. 2. The facility's staff failed to assess and manage the symptoms for Resident #10.Resident #10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 02/26/2026, coded the resident as unable to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long-term and short-term memory problems, as well as severe impairment for daily decision making. In section GG0130, the resident was coded as dependent with all activities of daily living.On 4/17/26 at approximately 11:14 AM, the resident could be heard from the hallway making loud sounds. The sounds were so severe that the spouse had to leave the resident's room to speak with a caller. The sounds lasted approximately 45 minutes, and no staff came to the residents' aid. LPN #1 was observed at the distal end of the corridor; she was alerted to the resident's status. LPN #1 instructed the spouse not to hesitate to notify staff if she notices any change in the resident. LPN #1 administered 2mg of Lorazepam to the resident, which calmed him within 10 minutes. The spouse and the companion left after the resident quieted and appeared relaxed. On 4/17/26 at approximately 6:15 p.m., a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Operations, Regional Nursing Consultant, and Administrator-in-Training staff. The above information was provided. The above information was provided, and the facility's staff were offered the opportunity to present information. They had no comments and voiced no concerns regarding the above information.

Based on observation and family and staff interviews, the facility staff failed to ensure that the essential equipment for 1 of 21 residents (Resident #15) in the survey sample was operational. The findings included: Resident #15 was admitted to the facility on [DATE]. The residents' current diagnoses included. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 01/19/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident # 15's cognitive abilities for daily decision-making were intact. In section GG0130, the resident was coded as requiring partial/moderate assistance with toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear; supervision or touch assistance with upper body dressing; and is independent with eating, oral hygiene, and personal hygiene.On 4/17/26 at approximately 12:20 AM, an interview was conducted with the resident and his spouse. The spouse stated that the resident's bed had not been functioning properly for 2 weeks and that he still could not raise or lower the bed. An interview was conducted with Certified Nursing Assistant (CNA) #1 at 3:29 PM. CNA #1 stated that the resident had experienced problems with his bed, but it had been repaired 3 days ago. CNA #1 was unaware of the concerns the spouse spoke of on 4/17/26. On 4/17/26 at approximately 6:15 p.m., a final interview was conducted with the Administrator, the Director of Nursing (DON), the Regional Director of Operations, the Regional Nursing Consultant, and the Administrator-in-Training staff. The above information was provided, and the facility's staff were offered the opportunity to present information. The DON said the resident bed had not been operating properly, but it had been repaired. The DON also stated that today's concern was secondary to user error: the electrical portion was separating, preventing activation when the controls were pressed, and that a simple fix would prevent further problems.

Based on observations, resident and staff interviews, and a review of the clinical record, the facility staff failed to ensure activities of daily living (ADL) care was provided for 1 of 21 residents (Resident 2) in the survey sample. The findings included: Resident #2 was admitted to the facility on [DATE]. The residents' current diagnoses included lumbar compression fractures. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 3/26/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 13 out of 15. This indicated that Resident # 2's cognitive abilities for daily decision-making were intact. In section GG0130 (Functional Abilities), the resident was coded as requiring supervision or touching assistance with eating, partial/moderate assistance with oral hygiene and personal hygiene, substantial/maximal assistance with shower/bathe and upper body dressing, and dependent with lower body dressing, putting on/taking off footwear, and toileting hygiene. On 4/16/26 at approximately 1:20 PM and again on 4/17/26, Resident #2 was visited in his room. He was on contact precautions, and the room door was closed most of the time. The resident's fingernails were observed to be approximately 2 inches above the fingertips, brownish, and some of them had broken, irregular edges. Resident #2 stated that he didn't have his nail clippers with him, but when he returned to his townhouse, he would cut them. The resident further stated that he didn't like having long fingernails because they get caught on all kinds of things. On 4/17/26 at approximately 6:15 PM, a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Operations, Regional Nursing Consultant, and Administrator-in-Training. The above information was provided, and the facility's staff were offered the opportunity to present information. The DON stated that the resident wouldn't be returning to a townhouse. She stated that the staff would provide the necessary fingernail care

Based on observations, staff interviews, and a review of the clinical record, the facility staff failed to adhere to professional standards during medication administration for 1 of 21 residents in the survey sample (Resident #16). The findings included: Resident #16 was admitted to the facility on [DATE]. The resident's current diagnoses included anemia. The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 4/7/2026, coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 14 out of 15. This indicated that Resident # 16's cognitive abilities for daily decision-making were intact.The Physician's Order Summary had an order dated 4/1/26, for Ferrous Sulfate Oral Tablet 27 MG. Give 1 tablet by mouth once daily for anemia. On 4/17/26 at 9:54 AM, a medication administration observation was conducted with Registered Nurse (RN) #1. RN #1 assisted the resident in accepting 8 pills, including the Ferrous Sulfate. The resident took small sips with the pill until they had all been swallowed. The resident was not instructed to or encouraged to consume the full glass of water. An interview was conducted with RN #1 at approximately 10:10 AM regarding the amount of water Resident #16 consumed during the medication administration task. RN #1 stated that the resident had a diagnosis of heart failure; therefore, consumption of 8 ounces of water was not encouraged. RN #1 further stated that the physician didn't order fluid restrictions, but she believed it was a necessary intervention. On 4/17/26 at approximately 5:45 PM, a final interview was conducted with the Administrator, the Director of Nursing (DON), the Regional Director of Operations, the Regional Nursing Consultant, and the Administrator-in-Training staff. The above information was provided, and the facility's staff were offered the opportunity to present information. The DON stated that 8 ounces of water is the professional standard when administering Ferrous Sulfate to aid in dissolving the medication and help prevent constipation.Take tablets or capsules with a full glass of water (8 ounces or 240 milliliters) unless otherwise directed by your doctor. Do not lie down for at least 10 minutes after taking your tablet or capsule dose. (ferrous sulfate 325 mg (65 mg iron) tablet | Kaiser Permanente)

Based on observation, interview, and review of facility policy, the facility failed to ensure foods stored in the refrigerator were labeled and dated when opened. They also failed to make sure pans were clean when they came out of the dishwasher before stacking them. Findings include: Review of the facility's policy titled, Storage of Refrigerated Foods, dated 04/01/22, stated All prepared food that is leftover, should be labeled, dated, and used within three days. All raw food items should be labeled, dated, and used within six days. Review of the facility's policy titled, Temperature Log, dated 04/01/22, stated All food preparation equipment, dishes, and silverware, should be effectively sanitized and cleaned to destroy potential disease. On 04/04/23 at 10:30 AM, the following observations in the kitchen were made with and verified by Employee E. 1. The refrigerator contained four salads, six bowls of cottage cheese, six bowls of coleslaw, and six pieces of apple pie that were not labeled and/or dated with a use-by-date. 2. The dry storage shelf contained a metal baking pan and a loaf pan that had dried food particles on the inside and outside of the pans. An interview with Employee E on 04/04/23 at 10:47 AM revealed, That all food in the refrigerator should be labeled and dated. These items were dated labeled or dated. An interview with the Director of Nursing on 04/06/23 at 10:52 AM revealed, All food items should be labeled and dated. The kitchen staff should be checking for visible signs that pans are washed correctly before storing for future use.

Based on staff record review, staff interview and facility documentation review, the facility staff failed to offer and/or provide up to date COVID-19 immunization for 1 resident, Resident #120, in a survey sample of 5 residents reviewed for COVID-19 vaccination. The findings include: The facility staff failed to offer and/or provide a COVID-19 bivalent booster vaccine for Resident #120. On 4/5/23, a clinical record review was performed and revealed that Resident #120 completed a primary COVID-19 vaccine series on 2/17/21 and a monovalent booster on 10/13/21 but had not received a bivalent booster dose. On 4/5/23, an interview was conducted with the Facility Administrator and the Infection Preventionist (IP), both of whom confirmed the facility policies and procedures follow CDC (Centers for Disease Control and Prevention) guidance and recommendations for resident COVID-19 immunization. The IP did not verbalize any concern with the facility's ability to provide COVID immunizations to residents. The facility COVID vaccination policy was requested and received. Review of the facility's policy titled, COVID-19 Immunizations, subheading Policy, read, It is the policy of [name redacted] to provide its team members and residents with a safe and healthy environment. This will be accomplished, to the extent possible, by offering the COVID-19 Immunization to all team members and residents and providing education regarding the benefits and risks and potential side effects associated with the vaccine. The CDC (Centers for Disease Control and Prevention) document titled, Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States, updated March 16, 2023, page 3, Recommendations for COVID-19 vaccine use, subtitle, Booster vaccination, read, People ages 6 months and older are recommended to receive 1 bivalent mRNA booster dose after completion of any FDA-approved or FDA-authorized primary series or previously received monovalent booster dose(s). The CDC (Centers for Disease Control and Prevention) document titled, Stay Up to Date with COVID-19 Vaccines Including Boosters, updated March 2, 2023, page 2, COVID-19 Boosters, subtitle, Updated Boosters, read, The updated boosters are called 'updated' because they protect against both the original virus that causes COVID-19 and the Omicron variant BA.4 and BA.5 .Updated COVID-19 boosters became available on: September 2, 2022, for people aged [AGE] years and older .You are up to date with your COVID-19 vaccines when you have completed a COVID-19 vaccine primary series and got the most recent booster dose. The CDC (Centers for Disease Control and Prevention) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 23, 2022, page 2, item 1, read, 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Encourage everyone to remain up to date with all recommended COVID-19 vaccine doses .HCP [Healthcare Personnel], patients, and visitors should be offered resources and counseled about the importance of receiving the COVID-19 vaccine. On 4/5/23, an interview was conducted with the Director of Nursing (DON) and the Infection Preventionist (IP) who confirmed the findings for Resident #120. The IP stated that it is expected for all residents to be provided the opportunity to be up to date with COVID-19 immunizations, including the bivalent COVID booster. No further information was provided.

Based on clinical record review, staff interview and facility documentation review, the facility staff failed to provide education and/or offer influenza vaccination for 2 residents, Resident #13 and Resident #120, in a survey sample of 5 residents reviewed for influenza immunization. The findings included: The facility staff failed to provide education to Resident #13 and Resident #120. On 4/5/23, clinical record review was performed for Resident #13 and Resident #120. For both residents, a progress note read that the resident had refused a flu vaccine. There was no documentation which noted that either resident or their representatives had received education to consider the risks and benefits of influenza immunization. On 4/5/23, an interview was conducted with the Director of Nursing (DON) and the Infection Preventionist (IP) who confirmed the findings. The IP stated that it is expected, upon refusal of any immunization, for residents and/or their responsible parties to be provided with education and handouts in order to consider the risks and benefits of vaccination. Review of the facility policy revised 4/1/23 and entitled, Influenza and Pneumonia Vaccine, subheading Procedure, item #1A read: .Residents and/or their POA's will be educated on the vaccination risks and benefits . No further information was provided.

Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 2 Residents, Residents #168 and #170, in a sample of 3 Residents reviewed for new admission COVID-19 testing. The findings included: 1. For Resident #168, the facility staff failed to conduct a second COVID-19 test following her admission to the facility. On 5/18/22, a clinical record review was conducted and revealed facility staff performed and documented a negative COVID-19 test for Resident #168 on 5/9/22, the date of admission to the facility. There was no evidence of any further COVID-19 testing for Resident #168. On 5/18/22 at approximately 2:30 PM, an interview was conducted with the facility Infection Preventionist (IP) who confirmed the facility conducts COVID-19 testing for all residents in accordance with CDC (Centers for Disease Control and Prevention) recommendations. The IP was asked about the facility's protocol for testing newly admitted residents for COVID-19 and she stated, we test all new admits within 1-2 hours after arrival, if the result is negative, then it is business as usual, we don't have to quarantine them and we do not test them any further. The IP verified the findings for Resident #168. The IP provided a copy of the CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, and confirmed it was utilized in facility's COVID-19 policies and practices. The IP was asked to review page 4 of the previously referenced CDC document, subheading, Testing, item 3, which read, Newly-admitted residents and residents who have left the facility for (greater than) 24 hours, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV2 infection; immediately and, if negative, again 5-7 days after their admission. Following her review, the IP stated, This [lack of follow-up testing] has been an oversight, a second test should have been performed, I am correcting our protocols right now. On 5/18/22, during the end of day meeting, the Facility Administrator and Director of Nursing were made aware of the findings. 2. For Resident #170, the facility staff failed to conduct a second COVID-19 test following her admission to the facility. On 5/18/22, a clinical record review was conducted and revealed facility staff performed and documented a negative COVID-19 test for Resident #170 on 4/29/22, the date of admission to the facility. There was no evidence of any further COVID-19 testing for Resident #170. On 5/18/22 at approximately 2:30 PM, an interview was conducted with the facility Infection Preventionist (IP) who confirmed the facility conducts COVID-19 testing for all residents in accordance with CDC (Centers for Disease Control and Prevention) recommendations. The IP was asked about the facility's protocol for testing newly admitted residents for COVID-19 and she stated, we test all new admits within 1-2 hours after arrival, if the result is negative, then it is business as usual, we don't have to quarantine them and we do not test them any further. The IP verified the findings for Resident #170. The IP provided a copy of the CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated February 2, 2022, and confirmed it was utilized in facility's COVID-19 policies and practices. The IP was asked to review page 4 of the previously referenced CDC document, subheading, Testing, item 3, which read, Newly-admitted residents and residents who have left the facility for (greater than) 24 hours, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV2 infection; immediately and, if negative, again 5-7 days after their admission. Following her review, the IP stated, This [lack of follow-up testing] has been an oversight, a second test should have been performed, I am correcting our protocols right now. On 5/18/22, during the end of day meeting, the Facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an influenza vaccine for 1 resident out of 5 residents reviewed for influenza immunization. The findings included: The facility staff failed to provide influenza immunization for Resident #16. On 5/18/22, clinical record review was performed for Resident #16 and revealed a progress noted dated 2/1/22 which read, .she [Resident #16] was offered the flu vaccine and agreed to that one [flu vaccine]. A physician's order dated 2/7/22 read, [MEDICATION(S)] preservative free suspension prefilled syringe 0.5 ml .inject 0.5 ml intramuscularly one time only for flu prevention. There was no documentation of the flu vaccine being administered. An interview was conducted with the Infection Preventionist who accessed the clinical records for Resident #16 and verified the findings. A facility policy on influenza immunization was requested and received. Review of the facility policy revised 4/1/22 and entitled, Influenza and Pneumonia Vaccine, subheading Policy, read: To establish and maintain an infection control program designed to minimize the risk of developing and transmission of the influenza and pnemonia virus. The Facility Administrator and Director of Nursing were updated and verified the findings. No further information was provided.

Based on observation, staff interview, Resident interview, facility documentation review, and clinical record review, the facility staff failed to provide and document an ongoing activity program based on the preferences of the Resident, to support the physical, mental and psychosocial well-being for 4 Residents (Resident #7 , Resident #10, Resident #13, and Resident #16 ) in a survey sample of 16 Residents. The findings included: 1. For Resident #7 the facility staff failed to document in the clinical record, an ongoing program of activities based on the Resident's preferences to support the physical, mental and psychosocial well-being. Resident #7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #7's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 9/15/20, was coded as a quarterly assessment. Resident #7 was coded as having had a BIMS (brief interview for mental status) score of 9, which indicated moderately impaired cognitive skills. Resident #7 was coded as having required assistance of one staff member for help with transfers, dressing, toileting, personal hygiene and bathing. On 12/3/2020 at approximately 11:00 AM, Resident #7 was observed in his room with a word search puzzle. When asked if he does these often, Resident #7 stated, this is the first one I've seen in a long time. His telephone was noted on his over bed table with no receiver or cord being in place. When asked what he does to pass by time during the day, Resident #7 replied nothing really, just sit here. Resident #7 was asked if staff come in and talk with him and he replied no. When asked if he plays bingo, cards, does any kind of exercise, Resident #7 said, no they don't do that here. A television was observed in the room, no radio was observed. A newspaper was noted on the bed. No other reading material was noted. On 12/3/2020, a review of the clinical record for Resident #7 revealed a therapeutic recreation assessment that was conducted 3/16/2020. This assessment revealed Resident #7 stated the following items were current recreation pursuits: reading, news, 1:1's (one on one), visitors, telephone, exercise, sports, music, bible study, and worship. This assessment also indicated, Resident needs assistance from staff to participate in leisure activities: encouragement, verbal cues. The MDS conducted with an ARD of 3/18/20 revealed that Resident #7 found the following items very important to him: use the phone in private, have books, newspapers and magazines to read, music, to keep up with the news and religious services. Review of the entire clinical record revealed no evidence of activity attendance. Review of the careplan for Resident #7 revealed a focus area which read, 3/18/20 I am at risk for increased anxiety, fear, and/or depression related to implementation of CMS (Centers for Medicare and Medicaid Services) guidelines to limit exposure to COVID-19 and from news media on the outbreak. An intervention for this focus area read, 3/18/20 provide 1:1 activities as indicated/requested. On 12/3/2020 at 4:22 PM, Employee H, the household leader, provided the surveyor with a 3-ring binder which is used to log activity attendance. Review of Resident #7's records revealed no records for December. November revealed Resident #7 participated in 3 activities which were held on 11/4-11/5. October revealed Resident #7 attended 1 activity, in Sept. he was recorded as having participated in 10 activities. In the 94 days from Sept. 1- Dec. 3, and of the 268 activities scheduled during this time, Resident #7 had only attended 14 activities and there was no record of any 1:1 visits. On 12/4/2020 at approximately 11:00 AM, additional records for Resident #7 were received by the survey team. These records included a December activity calendar which now had Resident #7 recorded for participating in 5 activities 12/1-12/5. Additional records of visits and calls with family were also provided, none of which was included in the clinical record for Resident #7. 2. For Resident #10 the facility staff failed to provide and document in the clinical record, an ongoing program of activities based on the Resident's preferences to support the physical, mental and psychosocial well-being. Resident #10 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #10's most recent MDS, with an ARD of 10/15/2020, was coded as an admission assessment. Resident #10 was coded as having had a BIMS score of 9, which indicated moderately impaired cognitive skills. Resident #10 was also coded on this same assessment as having required, limited assistance of staff for ADL's (activities of daily living), including: bed mobility, transfers, walking, dressing, eating, toilet use and personal hygiene. On 12/2/2020 during initial tour, Resident #10 was observed to be in her room, asleep in her recliner chair. On 12/2/2020 at 2:40 PM, Resident #10 was observed sitting in the doorway of her room. On 12/4/2020, mid-morning, Resident #10 was observed laying in bed. Surveyor E entered into the room to talk with Resident #10, and observed magazines and word search puzzles in the window sill, and a television and telephone. No other activity supplies were noted and no other materials for sensory stimulation. Review of the clinical record for Resident #10 revealed no activity attendance records. A therapeutic recreation assessment that was conducted 11/16/2020 and indicated Resident #10's current interests were: reading, news, 1:1's, small groups, visitors, telephone, trivia, word games, exercise, bible study and worship. On 12/3/2020 review of the activity attendance calendars Employee H provided, revealed no records for October or December for Resident #10. November records revealed Resident #10 had attended 2 group activities. In the 56 days Resident #10 had resided at the facility and of the 168 activity sessions, Resident #10 had only participated in 2. Review of the careplan for Resident #10 revealed a focus area which read, 10/9/20 I am at risk for increased anxiety, fear, and/or depression related to implementation of CMS (Centers for Medicare and Medicaid Services) guidelines to limit exposure to COVID-19 and from news media on the outbreak. An intervention for this focus area read, 10/09/20 provide 1:1 activities as indicated/requested. On 12/4/2020 at approximately 11:00 AM, additional records for Resident #10 were received by the survey team. These records included a December activity calendar which now had Resident #10 recorded for participating in 2 activities 12/1-12/5. 3. For Resident #13 the facility staff failed to provide and document in the clinical record, an ongoing program of activities based on the Resident's preferences to support the physical, mental and psychosocial well-being. Resident #13 was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #13's most recent MDS, with an ARD of 11/17/2020, was coded as an annual assessment. Resident #13 was coded as having had a BIMS score of 15, which indicated no cognitive impairment. Resident #13 was also coded on this same assessment as having required, limited assistance of staff for ADL's, including: bed mobility, transfers, and toileting. On 12/3/2020 Resident #13 was visited in her room. She reported that she likes to watch the news and has some audio books that her family and friends help coordinate getting for her. Resident #13 did acknowledge that the facility staff will turn them on and change the CD for her due to her vision impairment she is unable to do so. When asked if she attends activities, Resident #13 said no. When asked if she participates in things like bingo she says I can't because I can't see, before we were quarantined I had a friend from independent that would come help me. When asked if she ever gets bored, she said yes, all the time. When advised that her assessment showed religion is important to her, Resident #13 said yes, but I can't see to read. My pastor and deacon used to come but they can't now due to the quarantine. When asked if someone comes by to pray with her or read the Bible with her, she said no, never. Review of the clinical record for Resident #13 revealed no activity attendance records. A therapeutic recreation assessment that was conducted 11/20/2020 and indicated Resident #13's current interests were: news, 1:1's, small groups, visitors, telephone, music, sensory stimulation and audio tapes. There was evidence of the social worker visiting Resident #13 on a regular basis (several times per month). Activity progress notes are observed on a quarterly basis that read, staff will encourage resident to attend hallway activities and provide 1:1 visits as needed. Review of the careplan for Resident #13 revealed a focus area which read, 3/18/20 I am at risk for increased anxiety, fear, and/or depression related to implementation of CMS guidelines to limit exposure to COVID-19 and from news media on the outbreak. An intervention for this focus area read, 3/18/20 provide 1:1 activities as indicated/requested. An additional careplan read, I require prompting with engaging in social and leisure activities. The goal for this focus area read, I will participate in social and leisure activities at a minimum of 3x/week. Interventions read, encourage me to participate in hallway activities such as trivia, music, refreshments and games. Inform me of upcoming activities as I many want to participate. On 12/4/2020 review of the activity attendance calendars revealed from September 1-December 3 the following: in the 94 days reviewed, Resident #13 participated in activities on 8 days (3 of which was Dec. 1-3 where books on tape was written in. Of the 268 activities provided Resident #13 only participated in 5. There was no indication that she had been offered to attend and declined, nor was there any evidence of 1:1 activities being provided. 4. For Resident #16 the facility staff failed to provide and document in the clinical record, an ongoing program of activities based on the Resident's preferences to support the physical, mental and psychosocial well-being. Resident #16 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #16's most recent MDS, with an ARD of 11/18/2020, was coded as an admission assessment. Resident #16 was coded as having had a BIMS score of 6, which indicated severe cognitive impairment. Resident #16 was also coded on this same assessment as having required, extensive to total assistance of staff for ADL's, including: bed mobility, transfers, toileting, dressing, eating, personal hygiene, and bathing. This assessment on section F, preferences for customary routine and activities was conducted by staff interview. The staff indicated that listening to music, doing things with groups of people, spending time outdoors and participating in religious activities or practices were important. On 12/2/2020 Resident #16 was observed mid-morning and again in the afternoon and was asleep both times. On 12/3/2020 Resident #16 was observed to be asleep and not easily awakened. On 12/4/2020 Resident #16 was observed to be in bed, asleep. On all 3 days of observation at no point was any sensory stimulation noted. There was no reading material in the room, no radio, the only personal items identified other than clothing was 2 photo books. Review of the clinical record for Resident #16 revealed no activity attendance records. A therapeutic recreation assessment that was initiated 11/18/2020 but had never been filled out. Therefore, Resident #16's past and current interests were unknown. Review of the careplan for Resident #13 revealed a focus area which read, 11/12/20 I am at risk for increased anxiety, fear, and/or depression related to implementation of CMS guidelines to limit exposure to COVID-19 and from news media on the outbreak. An intervention for this focus area read, 11/12/20 provide 1:1 activities as indicated/requested. On 12/4/2020 review of the activity attendance calendars revealed no activity attendance logs for Resident #16, from the time of admission through the date of survey. There was no indication that he had been offered to attend and declined, nor was there any evidence of 1:1 activities being provided. The only records were Social Services progress notes where she visited with the Resident on 2 occasions, met with the spouse of Resident #16 on admission to complete the paperwork and also talked with the family to coordinate careplan meetings. On 12/3/2020 at 4:01 PM, a telephone call was placed to Employee I, the certified recreational therapist. Employee I stated, up until November we did small group activities that were socially distanced. Sometime in Nov. we had to restrict small group activities and we are going a lot of rounds. When asked how activity attendance and offerings are documented, Employee I stated, we document on loose leaf paper that has a calendar of events and we highlight what they attend, if they do 1:1 or something separate I write it in the block for that day. Employee I stated, activities are provided daily, throughout the week, if they do not participate in groups each team member is responsible for life engagement and I document it. On 12/3/2020 at approximately 4:30 PM, Employee H was interviewed. Employee H stated, we usually do 3-4 activities per day, they last about 30 minutes each depending upon the activity. When asked about the weekend, Employee H stated (Employee I, name redacted) (the recreational therapist) comes in on weekends. We instruct the CNA's (certified nursing assistants) to do 1:1 and encourage activities on the weekends as well. Employee H was asked what her understanding of the requirements are for activities and Employee H acknowledged, one group activity per week in the evenings, activities are to be held on the weekends as well as during the week and if Resident's do not attend 2 group activities per week, then 1:1 visits/activities are to be provided. Employee H was asked what the importance of activities is, she stated, it is extremely important for life enhancement and quality of life. Employee H was asked to verify how they record activities with each Resident and she stated, we should be documenting all activities, this is a great method (referring to the monthly calendar and high lighting the groups they attend and then writing in any 1:1's on the date they were conducted). Employee H confirmed that these logs were locked in Employee I's office and Employee I had not been at work this week. On 12/3/2020 at approximately 5:15 PM, Employee H provided the survey team with a December activity calendar which had group activities listed, and on the reverse side she had written notes indicating 1:1 word games has been provided on 12/1/2020, with 2 Residents and hallway bingo had been provided with 1 Resident. On 12/2/2020 sittercise (sitting exercise) had been performed with 3 Residents, reminiscing with 1 Resident and 3 received hand massages. On 12/3/2020 Employee H had written that 1:1 word games were handed out to 6 Residents and bingo was offered with no Residents being interested. On 12/3/2020 at approximately 5:30 PM, an interview was conducted with the 2 CNA's (CNA C & CNA D) working on the non-COVID unit. They were observed to be sitting at a round table together, at the end of the hallway, talking. When asked, who is responsible for providing activities to Residents? CNA D stated, (employee I). CNA C stated, (Employee H) helps too. When asked if they provide any activities, CNA C and CNA D stated, no, they are tired from appointments and things during the day so we let them rest. On 12/4/2020 time records were reviewed for Employees H & I. Employee A, the facility Administrator indicated (Employee H) works one weekend a month, (Employee I) works one weekend per month. On a third weekend there is (another household leader) that works and then on the fourth weekend of the month no staff that are specifically assigned the roles of activities are scheduled but that all staff do activities since we do the household model. On 12/4/2020 at 10 AM, CNA B was interviewed. When asked who is responsible for activities, CNA B stated, (Employee I's). When asked if the CNA's provide activities, CNA B stated, I'm not sure. CNA B was asked if she does activities with the Residents, she replied I don't know, I will have to get back to you. Surveyor E commented on how quiet it is, CNA B stated, yeah, it's a little quiet, when asked if this is normal, CNA B stated, yeah, its always quiet. Surveyor E inquired as to how often they play bingo or do things in the hallway since the Residents can't come out of their rooms due to COVID, CNA B stated, not that often. On 12/4/2020 at 11:29 AM, an interview was conducted with CNA A. CNA A was asked what kind of activities she does with the Residents, CNA A stated, I like to do what they are interested in, I pray with (Resident #7), someday's I cut nails, do showers, put lotion on them. When asked how often Employees H and Employee I do activities, CNA A stated, every other day. Review of the facility policy titled Life Enhancement Opportunities with a revision date of 6/1/20 read, (facility name redacted) will provide opportunities designed to meet the specialized needs and interests of the residents and to promote maximum functioning. 1. The household team will meet with all residents and families upon move in to obtain information about the resident (sic) past and present leisure interests and daily routines. 4. In addition to the required scheduled activities, there shall be unscheduled team and resident interaction throughout the day. 8. Participation in activities will be documented for each resident. On 12/4/2020 during an end of day meeting, the facility staff to include the Administrator, Director of Nursing, Assistant Director of Nursing, Household leader, and Social Worker were made aware of the lack of evidence of ongoing activity programing in the clinical records for Residents. The facility staff provided the survey team with photos that they indicated were of various activities they have provided to include, staff dressing up, theme days, Veteran's Day celebration, acknowledgement of birthdays, and Residents with their hair styled. The facility staff agreed that these events are not documented in the clinical record. The survey team revealed there was no evidence of a consistent and ongoing activities program observed. Resident interviews did not indicate it is occurring, and staff interviews didn't collaborate this. No further information was provided.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to review and revise the careplan for 2 Residents (Resident #10 and Resident #13) in a survey sample of 16 Residents. 1. For Resident #10, the facility staff failed to revise the careplan to remove the intervention of one on one observation, when this service was discontinued. 2. For Resident #13 the facility staff failed to review and revise careplan to reflect Resident #13's Foley catheter was removed on 12/4/19. The findings included: 1. For Resident #10, the facility staff failed to revise the careplan to remove the intervention of one on one observation, once this service was discontinued. Resident #10 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #10's most recent MDS (minimum data set) (an assessment tool), with an ARD (assessment reference date) of 10/15/2020, was coded as an admission assessment. Resident #10 was coded as having had a BIMS (brief interview for mental status) score of 9, which indicated moderately impaired cognitive skills. Resident #10 was also coded on this same assessment as having required, limited assistance of staff for ADL's (activities of daily living), including: bed mobility, transfers, walking, dressing, eating, toilet use and personal hygiene. On 12/2/2020 during initial tour, Resident #10 was observed to be in her room, asleep in her recliner chair. No other persons were observed in the room. On 12/2/2020 at 2:40 PM, Resident #10 was observed sitting in the doorway of her room, no other people were observed with her. On 12/4/2020, mid-morning, Resident #10 was observed laying in bed. Surveyor E entered into the room to talk with Resident #10, no other people were noted in the room. On 12/4/2020 during a record review, Resident #10's fall careplan had an intervention that read, 10/11/20 Family going to provide a private sitter due to impaired cognition. Review of the progress notes for Resident #10 revealed no entries to indicate 1:1 was being provided, why or when this service ended. On 12/4/2020 at 11:29 AM, an interview was conducted with CNA A. CNA A stated, she (referring to Resident #10) is doing much better now, when she came here, she was very confused and would come out of her room saying, where is my car, I don't know what happened, or why am I here. CNA A confirmed that Resident #10 no longer has a sitter or 1:1. On 12/4/2020, review of the requested copies of the clinical record, revealed that the facility had provided Surveyor E with a schedule of the times Resident #10 had a sitter. These documents revealed Resident #10's 1:1 took place from 10/13/2020 at 10:30 PM and ended on 11/16/2020 at 10:00 PM. Resident #10's careplan had not been reviewed and revised since this service ended on 11/16/2020. Review of the facility policy titled Care Planning with a revision date of 6/1/20, read: A person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs shall be developed for each resident. 8. The resident will receive the services and/or items included in the plan of care. On 12/4/2020, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the findings. During this meeting, Employee F confirmed Resident #10 no longer has 1:1. No further information was provided. 2. For Resident #13 the facility staff failed to review and revise care plan to reflect Resident #13's Foley catheter was removed by facility staff on 12/4/19. Resident #13, a [AGE] year old woman, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13's most recent MDS with an ARD date 11/17/20 coded the Resident as requiring limited assistance with bed mobility and most aspects of ADL's. The Resident uses a walker and wheelchair with assistance for mobility. On 12/3/30 a review of the care plan revealed that Resident #13 was care planned for Foley Catheter since admission. During the investigation into this matter it was discovered that the Resident's MDS's from 2/26/20, 8/18/20 and 11/17/20 all reflect no catheter present. A review of the progress notes revealed the Resident was admitted to the facility from hospital with the Foley catheter on 11/6/19 and it was removed by facility nursing staff on 12/4/19 per physician order. On 12/4/20 an interview was conducted with the LPN A who stated she did not remember Resident #13 ever having a catheter, however she explained I used to work PRN and maybe that is when she had it. On 12/4/20 at approximately 11:00 AM an interview was conducted with the DON and the MDS Coordinator. The MDS Coordinator stated It's my mistake that the Foley didn't get removed from the care plan. I overlooked it and didn't assign it to Nursing so it got missed. The DON was asked how often the care plans reviewed and she are stated quarterly unless there are any changes in condition. When asked her expectation of her nurses when documenting changes in care, she stated they should document a Foley being discontinued and they can update care plans as well. On 12/4/20 during the end of day conference the Administrator was made aware of the concerns with the care plans and no further information as provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to obtain physician orders [REDACTED].#'s 1-#16) in a survey sample of 16 Residents. The findings included: For all residents in the sample (#'s 1-2-3-4-5-6-7-8-9-10-11-12-13-14-15 and 16) the facility staff failed to obtain physicians orders prior to performing routine weekly Covid testing for facility Residents. On 12/3/20 during clinical record reviews it was noted that the Residents did not have orders for Covid testing on their physician order [REDACTED]. On 12/4/20 at approximately 10:00 AM the DON was asked to provide proof of physician orders [REDACTED]. She brought in the Administrator and Infection Preventionist who stated that they had each Resident and or Responsible Party sign a consent. She submitted a form entitled COVID-19 Testing - Resident Consent A review of the form revealed that these forms were not signed by a physician they were only informed consent from Resident and Resident Family members giving consent to test and report results to physicians and VDH. The DON stated that this is the form they use. When asked by surveyor to they usually obtain physician orders [REDACTED]. In an end of day meeting, the Administrator asked if it was ok to have a blanket or standing order to cover all the Residents and have them sign it on admission. The Administrator submitted the Outbreak and Communicable Disease Policy which read: Page 2 # 8 & #9 8. Medical Director is responsible for: a. Working with the Attending Physician(s) and the health department to determine the need for laboratory specimens; and b. Overseeing the management of the outbreak. 9. The Attending Physicians will be responsible for: a. Ordering isolation barriers as needed. b. Working with the Medical Director and the Health Department to determine the need for laboratory Specimens. The Centers for Medicare and Medicaid Services (CMS) gave direction by way of a memo QSO memo 38,page 7, for facilities to follow the mandated instruction of the memo in regard to the associated regulation. The excerpt follows; Conducting Testing In accordance with 42 CFR § 483.50(a)(2)(i), the facility must obtain an order from a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with State law, including scope of practice laws to provide or obtain laboratory services for a resident, which includes COVID-19 testing (see F 773). This may be accomplished through the use of physician approved policies (e.g., standing orders), or other means as specified by scope of practice laws and facility policy. NOTE: Concerns related to orders for laboratory and/or POC testing should be investigated under F 773. On 12/4/20 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, observation, clinical record review, and facility documentation the facility staff failed to maintain an accurate clinical record for 1 Resident (#13) in a survey sample of 16 Residents. The findings included: For Resident #13 the facility staff failed to document in chart the correct number of days the resident was under quarantine, the room change and notification of POA of move back to room after being quarantined on the Covid Unit for 10 days. Resident #13, a [AGE] year old woman, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #13's most recent MDS with an ARD date 11/17/20 coded the Resident as requiring limited assistance with bed mobility and most aspects of ADL's. The Resident uses a walker and wheelchair with assistance of staff for mobility. On 12/2/20 during the entrance conference the Administrator made reference to Resident #13, Moving back to her room today, when giving surveyors the census on the Covid and Non Covid positive rooms. On 12/2/20 at approximately 100 PM observed Resident #13 receiving assistance from staff to transfer from her wheelchair to her recliner. At that time an interview was conducted with the Resident who stated. I feel just as good now as I did when they took me to the other room. I didn't even know I was sick I was a little tired that's all, but I'm glad to be back in my room. On 12/3/20 a review of the progress notes read: 12/1/20 at 10 53 PM General Note Resident is on quarantine 9/14 (day 9 of 14) for transmission based precaution for COVID 19. She remains without symptoms of [MEDICAL CONDITION] at this time to include fever, cough, SOB, difficulty breathing, chills, muscle pain, headaches, sore throat, or new loss of taste or smell. PPE being utilized for care as recommended by the CDC. Vital signs continue to be monitored daily and any abnormalities will be reported to the MD and DON immediately. 12/ 3/20 at 4:15 PM SW (Social Worker) spoke with resident to see how she was adjusting after the move back to her regular room yesterday; resident was sitting up in her chair and listening to the news; resident was smiling and chatting and engaged in a robust discussion of the day's current events, she remains alert and oriented and says she is happy to be back in the familiar surroundings of her regular room. On 12/3/20 at approximately 2:00 PM an interview with the DON was conducted. When asked how long Resident #13 had been quarantined she stated 10 days because we have 2 negative tests on her she went back to her room on the 2nd. The DON was then asked if it was her expectation that staff record room changes and quarantine time changes in the electronic health record. She indicated that the staff were expected to document any room changes, changes in treatment including quarantine and notifications of those changes in the chart. On 12/4/20 review of the clinical record was conducted, and the following note was found: 12/4/20 at 9:49 AM - Social Services SW visited with resident this morning to assess her readjustment to retuning to their regular room two days ago. Resident remains alert and oriented to her surroundings. Resident stated she feels settled back in and is her routine of listening to her audio books, and is also enjoying daily phone calls with her daughters. Resident exhibits clear cognition, aware of the month and year and knowledgeable in great detail national current events. Resident stated that on 12/2/20, the day she moved back to her regular room, she spoke to her daughter by phone and her daughter was made aware of resident's return to her regular room (Unit name redacted) Rm #3. On 12/4/20 during the end of day conference the Administrator was made aware of the concern and no further information was provided.

Based on staff interview, facility documentation review, and clinical record review the facility staff failed to review and revise the careplan for one Resident, (Resident #6) in a survey sample of 13 Residents. 1. For Resident #6, the facility staff failed to review and revise the careplan following 4 accidents and/or injuries of unknown origin to prevent reoccurance. The findings included: Resident #6 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #6 most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/15/19 was coded as a quarterly assessment. Resident #6 had a BIMS (brief interview for mental status) score of 13, which indicated Resident #6 was cognitively intact. Resident #6 was coded as requiring assistance of one staff member for ADL's (activities of daily living) which included: bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. 1. Review of Resident #6's nursing notes revealed that on 7/5/18, the resident had a scratch on the top of her right hand. Review of Resident #6's careplan revealed that no careplan was in place or initiated following the scratch noted on 7/5/18. There were no preventive interventions put in place following this injury of unknown origin and nothing was done to prevent reoccurrence. 2. Resident #6's nursing notes had an entry dated 10/16/18 at 14:40 that read, CNA informed writer that resident was participating in an activity and pushed w/c back from table and staff noticed a skin tear to the back of right hand. Slight bleeding noted to back of right hand and 1.0 crescent shape skin tear noted. (sic) Resident #6's careplan did not reveal any review or revision following this incident to prevent re-occurrence. 3. Nursing notes for Resident #6 revealed an entry dated 10/24/18 at 17:30 that read, during weekly skin assessment noticed bruises on right forearm. Resident denies knowing how she got the bruises. Bruises on right forearm: #1-4 on dorsal surface #5 on dorsal and ventral surface #1 1.7 x 2cm Oval bruise w/Dark purple boarder. Reddish purple in the middle #2 1 x 0.8 cm oval bruise, reddish purple #3 1/5 x 0.7 cm irregular shaped fading red bruise #4 1.7 x 2cm purplish red bruise with a spot of dark purple 0.5 cm in diameter #5 6 x 11.5 cm blue bruise, lighter on ventral surface Review of Resident #6's careplan did not reveal any mention of this injury, nor any intervention to prevent re-occurrence. 4. Review of nursing notes for Resident #6 revealed an entry dated 10/25/18 at 14:57 that read, Resident personal alarm sound and resident was found in the bathroom unassisted standing and resident was taken to the bathroom about 10 minutes prior to and resident has been reminded to use her call bell for assistance and at this time resident has been assisted and call bell is within reach and resident knows how to push call bell for assistance. Review of Resident #6's careplan reveals that this incident was not addressed in the careplan and no interventions were put in place to prevent re-occurrence. Review of the facility policy, titled Care Planning with a revision date of 6/1/18, read The comprehensive care plan will: a. Incorporate identified problem areas; b. incorporate risk factors associated with identified problems; c. build on the resident's strengths; d. be culturally competent and trauma-informed as applicable; e. reflect treatment goals, timetables and objectives in measurable outcomes; f. identify the professional services that are responsible for each element of care; g. aide in preventing or reducing declines in the resident's functional status and/or functional levels; h. promote resident safety; i. enhance the optimal functioning of the resident by focusing on a rehabilitative program; and j. reflect currently recognized standards of practice for problem areas and conditions. The facility Administrator and DON were made aware of the facility staff's failure to review and revise the careplan for Resident #6, during the end of day meeting on 5/9/19. No further information was provided.

Based on staff interview, facility documentation and clinical record review the facility staff failed to implement abuse policy for 2 Residents (Resident #5 and Resident #6) in a survey sample of 13 Residents. 1. For Resident #5 the facility staff failed to implement their abuse policy by not investigating and reporting of allegations of abuse or neglect and injuries of unknown source. 2. For Resident #6, the facility staff failed to implement their abuse policy as evidenced by not investigating and reporting abuse or neglect; not protecting during the investigation; and not reporting injuries of unknown source. The findings include: 1. For Resident #5 the facility staff failed to implement their abuse policy by not investigating and reporting of allegations of abuse or neglect and injuries of unknown source. Resident #5 is a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's most recent (Minimum Data Set) MDS with an (Assessment Reference Date) ARD of 3/15/19 coded as a Significant change assessment, section C the Resident as having a (Brief Interview of Mental Status) BIMS score of 10 indicating moderate cognitive impairment. Under G 0100 ADL Assistance the Resident is coded as: A. Bed mobility - 3 = Extensive Assistance - 2 = 1 person physical assistance B. Transfer - 3 = Extensive Assistance - 2 = 1 person physical assistance C. Walk in room - 8 = Activity did not occur D. Walk in corridor - 8 = Activity did not occur The Resident is also coded under section G 0300 -Balance during Transition and moving: A. Moving from seated to standing position - 8 = Action did not occur B. Walking - 8 = Action did not occur C. Turning around and facing opposite direction while walking. - 8 = Action did not occur D. Moving on and off toilet - 2 = Not steady only able to stabilize with human assistance E. Surface to surface transfer - 2 = Not steady only able to stabilize with human assistance On 5/8/19 it was discovered that between 5/1/2018 and 5/8/2019 the Resident had 34 facility incidents reports completed. Of the 34 incidents: 19 were injuries of unknown source 11 were unwitnessed falls (found on floor) 3 witnessed falls (1 of which involved the use of a sit to stand lift) 1 Elopement According to the incident reports the most recent incidents include: 3/5/19 at 7:00 AM - red /black bruise noted this AM to Left front calf measuring 15 cm X 7 cm also during the last day increased left sided weakness noted resident and staff are unsure how bruise occurred but it could be related to sit to stand usage. However, according to care plan sit to stand use was not discontinued until 3/19/19. 3/11/19 at 1:00 AM - New bruise noted on top and outer aspect of left foot (16 cm X 9 cm) site is tender to touch she is poor historian and unable to state how injury occurred. However she has left sided weakness and sometimes drags her foot or crosses her feet in bed and wheelchair. Additional comments and or steps taken to prevent reoccurrence: - Make sure L (left) foot is in leg rest. - In bed, place pillow between legs / feet. 3/17/19 at 2:50 PM - 8 cm X 7 cm red purple bruise noted to left forearm about 10 minutes BEFORE resident had fall resident and staff are unaware of cause. Additional comments and or steps taken to prevent reoccurrence: - Verify placement of arms before lifting on Hoyer 3/17/19 at 3:00 PM - Unwitnessed fall appears as if resident leaned over to pick up toy cat and fell on the floor found lying on right side. Additional comments and or steps taken to prevent reoccurrence: - OT to eval for placement of half tray (flip up) to put cat on. 3/26/19 at 2:20 PM - Resident was being put to bed for nap and CNA seen (sic) dried blood on resident support hose and writter (sic) went to assess and the area was dry and no active bleeding and had a bruise around skin tear. Additional comments and or steps taken to prevent reoccurrence: - Resident has been noted throughout day taking L (left) leg off of foot rest when staff elevate left leg. 4/8/19 at 7:50 PM - 4.5 cm X 3.5 cm brown bruise noted to left upper forearm appears to be similar to bruise noted in (MONTH) determined to probably be from sling. Additional comments and or steps taken to prevent reoccurrence: - Resident has been noted throughout day taking L (left) leg off of foot rest when staff elevate left leg. 4/8/19 at 7:50 PM - 4.5 cm X 3.5 cm brown bruise noted to left upper forearm appears to be similar to bruise noted in (MONTH) determined to probably be from sling. 5/9/19 at 8:43am an Interview was conducted with the Social worker and when asked if she is a part of the investigation of abuse she stated that They notify me if there is a suspicion of abuse and I would interview the resident. When asked who was responsible for reporting suspected abuse she answered Any employee is supposed to report any allegations of abuse and my administrator would call me. When asked had she seen all of the incidents of injuries of unknown origin she stated It is concerning that I have never seen these reports She indicated that the facility started a new morning meeting with the new leadership and they review incidents. She indicated that the reports should have been told to the supervisor and should have come to her to interview all parties and after the Administrator receives her report of identified concerns, the Administrator would then report. She further elaborated that she has not had any abuse referrals since the new administrator started. On 5/9/19/ at 9:30 AM an interview was conducted with the CEO and the Administrator stated, If any of our team has a concern, or they think something may be under the heading of abuse they are to report it to their administrative supervisor, and then immediately call myself and the DON (Director of Nursing). According to the facility abuse policy: Preventing Resident Abuse Injury of unknown origin- any injury to a resident for which there is no known etiology or reasonable explanation, and for which an origin in physical abuse or mistreatment cannot be ruled out. B. (facility name redacted) will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. C. Resident and environmental rounds will be conducted periodically throughout the day. These rounds and frequent monitoring are to ensure resident needs are being met in accordance with the plan of care, that residents are being supervised and the environment is free of hazards. The facility Administrator was made aware of the issues with injuries of unknown origin and no further information was provided. 2. For Resident #6, the facility staff failed to implement their abuse policy as evidenced by not investigating and reporting abuse or neglect; not protecting during the investigation; and not reporting injuries of unknown source. Resident #6 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #6 most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/15/19 was coded as a quarterly assessment. Resident #6 had a BIMS (brief interview for mental status) score of 13, which indicated Resident #6 was cognitively intact. Resident #6 was coded as requiring assistance of one staff member for ADL's (activities of daily living) which included: bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Resident #6's nursing notes dated 7/7/18 reveal that the resident was found lying supine on the floor with feet facing the bathroom door. There is no indication that anyone witnessed the resident fall. The Incident/Accident report states CNA was passing ice and found resident lying on the floor in a supine position near the bathroom. Resident pants were unzippered and hanging below waist. Resident was able to move all four extremities without pain. Resident had no injuries. resident's personal alarm was not activated. Resident was attempting to transfer w/out assist. (sic) The Fall Analysis/Investigation Form dated 7/7/18 stated removed bed/chair alarm- family member. There is no evidence of an investigation being conducted to exclude that the resident was not a victim of abuse or neglect. The facility staff suspected that Resident #6's spouse failed to connect the bed/chair alarm. This injury of unknown origin was not reported to the Office of Licensure and Certification. Review of nursing notes dated 8/2/18 reveal an entry that read: spouse asked this nurse to look at a bruise on resident's right wrist. Wrist examined. Noted bruise on dorsum of right wrist measuring 7cm x 7 cm. No guarding, ,grimacing or moaning during palpation of area. Resident denied pain in wrist. Notified nursing supervisor was made aware. PA made aware. New order received for ice to affected area. Resident was noted to have flailing of upper extremities on prior shift. Will monitor resident as needed. (sic) Review of nursing notes dated 8/1/18 there were no entries. There were no other entries on the day of 8/2/18 to indicate resident had flailing of upper extremities as noted in the incident note, previously mentioned. Review of Bruise/Skin Tear/Abrasion Investigation form under additional comments, it read timing of injury unknown. Suspect injury occurred last night. Unable to assess what resident was doing since timing unknown. There is no indication on the investigation form that staff were interviewed, any measures were taken to protect Resident #6 while an investigation was being conducted, and the injury of unknown origin was not reported to the Office of Licensure and Certification. Nursing notes revealed an entry on 8/7/18 at 22:19 that read, Resident's personal alarm was sounding. CNA noted resident sitting upright on the floor in the bathroom in her room with the wheelchair behind her. resident sustained [REDACTED]. The Incident/Accident Report stated, Resident's personal alarm was sounding. This nurse was called to resident's room by CNA who stated Resident is on the floor. Resident was noted sitting upright on floor in her bathroom with her wheelchair immediately behind her. The Fall analysis/investigation form revealed that no staff interviews were conducted. The CNA post fall investigation form revealed that no one was with the resident when Resident #6 fell . This unwitnessed event was not reported to the Office of Licensure and Certification. Review of nursing notes for Resident #6 revealed an entry dated 8/21/18 at 23:45 which read, during weekly skin assessment writer noticed bruise on resident's right wrist. 4cm x 2cm dark purple and reddish purple bruise. No swelling. Resident denies pain in right wrist. She does not know how she got the bruise. Under the intervention line: none was typed in. The bruise/skin tear/abrasion investigation form revealed that no staff interviews were conducted. An investigation was not conducted, no measures were taken to protect Resident #6 in the event the resident was a victim of abuse and the injury of unknown origin was not reported to the Office of Licensure and Certification. Nursing notes for Resident #6 revealed an entry dated 10/24/18 at 17:30 that read, during weekly skin assessment noticed bruises on right forearm. Resident denies knowing how she got the bruises. Bruises on right forearm: #1-4 on dorsal surface #5 on dorsal and ventral surface #1 1.7 x 2cm Oval bruise w/Dark purple boarder. Reddish purple in the middle #2 1 x 0.8 cm oval bruise, reddish purple #3 1/5 x 0.7 cm irregular shaped fading red bruise #4 1.7 x 2cm purplish red bruise with a spot of dark purple 0.5 cm in diameter #5 6 x 11.5 cm blue bruise, lighter on ventral surface Husband was notified at 11:45am. He has seen the bruises. He does not know how she got them. (sic) The bruise/skin tear/ abrasion investigation form revealed no staff interviews were conducted. Additional comments read as, resident seen by CNA reaching for walker with eye closed and bumping/hitting rt arm on walker today. Bruises were preset prior to this, however may be an explanation for how it occurred. Husband declined geri sleeves in past. (sic) There was a typed statement dated 10/26/18 that stated, nurse into assess areas to right arm. No fingerlike pattern noted, no pain noted on palpation. signed by the director of nursing. There is no evidence or any other information provided that would indicate an investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. Review of nursing notes for Resident #6 revealed an entry dated 10/25/18 at 14:57 that read, Resident personal alarm sound and resident was found in the bathroom unassisted standing and resident was taken to the bathroom about 10 minutes prior to and resident has been reminded to use her call bell for assistance and at this time resident has been assisted and call bell is within reach and resident knows how to push call bell for assistance. Review of the fall analysis/investigation form under the resident interview section it indicated that Resident #6 didn't respond to the questions asked except for one question which the resident responded no to. Only one staff member was interviewed and they indicated that Resident #6 was cooperative prior to the fall. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. Review of nursing note for Resident #6, revealed a entry dated 10/26/18 at 10:15am that read, resident was found sitting on the floor in her room after resident personal alarm sounded. No additional information was found in the entire clinical record that would indicate that this incident of unknown origin, which is an allegation of abuse, was investigated, staff interviewed, resident protected during the course of an investigation, measures taken to prevent reoccurrence, or that the injury of unknown origin was reported to the Office of Licensure and Certification. Resident #6's nursing notes on 12/5/18 at 7:15am read, resident was found in her bathroom lying on her back when personal alarm went off. Resident has a abrasion to her right index finger with bruising. (sic). Review of the bruise/skin tear/abrasion investigation form reveals that only one staff member was interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. On 12/11/18 at 3:00pm Resident #6 was noted to have 2 new bruise noted to top of right wrist (2 x 3 cm) and top of right forearm (0.5 x 1.2 cm). Resident is a poor historian d/t dementia and cognitive communication deficit and is unable to state when bruises occurred. (sic) Review of the bruise/skin tear/abrasion investigation form reveals that no staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. Nursing notes reveal that on 12/24/18 at 5:40pm while CNA was toileting resident she noticed area of concern on buttock and brought it to this writers attention. On right side of the gluteal cleft there is pink area of denuded skin measuring 1 x 0.7 cm. There are a few much smaller [MEDICAL CONDITION] superior to the largest lesion on either side of gluteal cleft. (sic) Review of the bruise/skin tear/ abrasion investigation form reveals that Resident #6, was non-interviewable. No staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. Resident #6's nursing notes had an entry dated 1/2/19 at 6:41am that read, during weekly skin assessment noticed a bruise on the dorsum of the resident's right hand. 4 x 3 cm ovoid soft raised blue bruise with a little reddish purple, resident states the pain is moderate. (sic) Review of the bruise/skin tear/abrasion investigation form states at the subheading resident interview unreliable answers. answered yes to every question There is no evidence that any staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. On 2/13/19 at 8am nursing notes for Resident #6 revealed and read bruise on right forearm noticed during weekly skin assessment. 3 x 3.5 cm irregularly shaped bruise on dorsal surface of distal forearm. It is dark purple with a reddish purple boarder, resident denies pain at the site. Resident is unable to tell me how is occurred. (sic) Review of the bruise/skin tear/ abrasion investigation form reveals that only one staff member was interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. On 2/16/19 at 4:03am a nursing note entry for Resident #6 read, new bruise seen on right hand (6 x 5 cm). Resident is a poor historian and unable to state how injury occurred. Resident is prone to frequent injuries from her hitting her arm on things. Review of the bruise/skin tear/ abrasion investigation form reveals no staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted. Nursing notes for Resident #6 revealed an entry dated 4/6/19 at 8:10am that read, new bruise right forearm noticed while toileting resident this AM right forearm, dorsal surface 3.2 x 1.8 cm bruise. Dark purple in the center and slightly raised. Red purple in the periphery. Resident denies pain. She has good ROM of right wrist and right arm. Resident has [MEDICAL CONDITION] and is unable to tell me when the bruise appeared or how it happened. Husband noticed the bruise this AM. He does not know how it happened. Review of the bruise/skin tear/ abrasion investigation form reveals that Resident #6, was non-interviewable. No staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. Nursing note dated 4/30/19 for Resident #6 had an entry at 15:15 that read, resident's personal alarm on back of the w/c went off and resident was found on the floor in from of the bathroom door on her back. resident was put on toilet, but did not have to use it. unable to determine why resident fell . (sic) Review of the bruise/skin tear/ abrasion investigation form reveals that only one staff member was interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted. On 5/9/19 at 8:43am an interview was conducted with Employee C, the SW (Social Worker). When asked if she was aware of the injuries of unknown origin for Resident #6, the SW stated, I don't specifically, it was reported or identified as abuse. This is not a resident that has ever been identified to me as a referral along those lines as being abused. She is not someone that has ever come up as someone for abuse. When abuse is identified the nurse does an interview, I do an interview. Any employee is supposed to report any suspicion of abuse and my Administrator would call me. I try to visit this resident weekly and I don't' really recall seeing any bruises. When asked if one resident with this amount of paperwork is concerning, the SW stated, I definitely hear your concerns. I've just never suspected it with her. This is concerning, I've never seen these reports. Yes, I probably should have been made aware. It should have been told to the supervisor but this should have also come to me to interview all parties. After my report, if there are concerns identified the Administrator would report the incidents. I haven't had a referral for abuse since the new Administrator started. On 05/09/19 at 09:39 AM an interview was conducted with the facility Administrator. When asked if she knew the cause of the injuries of unknown origin and multitude of bruises Resident #6 has sustained, the Administrator stated, I can't answer , I don't know what meds she is on, she is ataxic and does a lot of failing. The Administrator was made aware that the SW stated they investigate prior to reporting, she talked about mandated reporting, but reporting of abuse allegations is not occurring. The Administrator stated, if any of our team has a concern, or they think something may be under the heading of abuse they are to report it to their administrative supervisor, and then immediately call myself and the DON (Director of Nursing). When asked what would make them think an allegation of abuse, the Administrator stated, if it looks like a hand print, something out of ordinary, I would be questioning that right away, and depending on the placement of where things are. When an injury occurs and no one knows how it occurred. I would look, I would ask if they had a lab draw, if we don't know how it happened, if there is no reasonable expectation. When there is an injury of unknown source it should be reported no later than 24 hours, if there is hospitalization or sign injury you have a two hour time frame. When asked why reporting is not happening the Administrator stated, I can't answer for anything prior to [DATE]. I was not here, we did have a different DON. She was shown there were six injuries of unknown origin for Resident #6 since her tenure. The Administrator then said, I have no problem at all reporting every bruise and every skin tear, if we look at it immediately and if we can't give an answer if we don't have an immediate answer, we will report it. The Administrator was advised of the injury of unknown origin on 10/24/18 that appeared to be a hand print, the Administrator said If saw hand prints and that would raise my concern and I would investigate. I would talk to all team members, would talk to spouse, and the direct care team. I would want to know if anyone saw anything, someone maybe said she went to fall and they went to grab her, etc. I would be concerned about possible abuse. When asked about next steps, The Administrator stated, the nurse would then call the DON and myself, I have a concern here, I would send it in to you. If there is any thought that this could be abuse, it would be reported. A nurses writing the report is self reporting. This nurse is also a medical doctor, ,who didn't like being a doctor and is a nurse. She is a board certified practitioner. Review of the facility policy titled Preventing Resident Abuse with a revision date of 6/1/18 has a subheading of Procedure that read: Injury of unknown origin- any injury to a resident for which there is no known etiology or reasonable explanation, and for which an origin in physical abuse or mistreatment cannot be ruled out. Under the policy subheading, Prevention, it read b. (facility name) will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. Under the policy subheading, Identification, it read a. during orientation and annually at a minimum, team members will be educated on observation and reporting important information about resident care, condition or behavior. Team members are encouraged and protocols will be maintained to promote timely identification and reporting of events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. B. Team members are encouraged to identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Immediately following ensuring the resident's safety, team members are to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. C. Resident and environmental rounds will be conducted periodically throughout the day. These rounds and frequent monitoring are to ensure resident needs are being met in accordance with the plan of care, that residents are being supervised and the environment is free of hazards. D. Administrative and facility leadership staff will supervise team members to identify inappropriate behaviors, action and response to resident needs. Under the policy subheading, Investigation, it read, A. designated team members will immediately review and investigate all allegations or observations of abuse. B. (facility name) will conduct analysis for trends and patterns related to incidents (i.e. falls, skin tears, bruising or injury of unknown origin, unusual occurrences, reportable incidents, etc.) C. outside investigative bodies, such as the local police will be contacted as directed by the administrator or his or her designee and in accordance with federal, state and local law. Under the policy subheading, Protection, it read, A. In the event of an allegation or observation of abuse, (facility name) will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. B. The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident. Under the policy subheading, Reporting, it read, A. (facility name) will maintain systems to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. B. Each covered individual/mandated reporter shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or crime, or not later than 24 hours if the events that cause suspicion doe not result in serous bodily injury. i. The organization will report to local law enforcement agencies any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. Notification to the James City County Police is to be made by contacting (phone number listed). C. The organization will immediately report all alleged violations involving neglect, abuse, including injuries or unknown source, mistreatment and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator or his or her designee of the facility. D. The results of all investigations are to be communicated to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility Administrator and DON were made aware of the facility staff's failure to ensure Resident #6 was free from abuse during the end of day meeting on 5/9/19. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review the facility staff failed to report injuries of unknown origin for two Residents (Resident #6 and Resident #5) in a survey sample of 13 Residents. 1. For Resident #6, the facility staff failed to report accidents and injuries of unknown origin, which were allegations of abuse or neglect. 2. For Resident #5 the facility staff failed to report of allegations of abuse or neglect to include lack of supervision and injuries of unknown origin. The findings included: 1. For Resident #6, the facility staff failed to report accidents and injuries of unknown origin, which were allegations of abuse or neglect. Resident #6 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #6 most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/15/19 was coded as a quarterly assessment. Resident #6 had a BIMS (brief interview for mental status) score of 13, which indicated Resident #6 was cognitively intact. Resident #6 was coded as requiring assistance of one staff member for ADL's (activities of daily living) which included: bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Resident #6's nursing notes dated 7/7/18 reveal that the resident was found lying supine on the floor with feet facing the bathroom door. There is no indication that anyone witnessed the resident fall. The Incident/Accident report states CNA was passing ice and found resident lying on the floor in a supine position near the bathroom. Resident pants were unzippered and hanging below waist. Resident was able to move all four extremities without pain. Resident had no injuries. resident's personal alarm was not activated. Resident was attempting to transfer w/out assist. (sic) The Fall Analysis/Investigation Form dated 7/7/18 stated removed bed/chair alarm- family member. There is no evidence of an investigation being conducted to exclude that the resident was not a victim of abuse or neglect. The facility staff suspected that Resident #6's spouse failed to connect the bed/chair alarm. This injury of unknown origin was not reported to the Office of Licensure and Certification. Review of nursing notes dated 8/2/18 reveal an entry that read: spouse asked this nurse to look at a bruise on resident's right wrist. Wrist examined. Noted bruise on dorsum of right wrist measuring 7cm x 7 cm. No guarding, ,grimacing or moaning during palpation of area. Resident denied pain in wrist. Notified nursing supervisor was made aware. PA made aware. New order received for ice to affected area. Resident was noted to have flailing of upper extremities on prior shift. Will monitor resident as needed. (sic) Review of nursing notes dated 8/1/18 there were no entries. There were no other entries on the day of 8/2/18 to indicate resident had flailing of upper extremities as noted in the incident note, previously mentioned. Review of Bruise/Skin Tear/Abrasion Investigation form under additional comments, it read timing of injury unknown. Suspect injury occurred last night. Unable to assess what resident was doing since timing unknown. There is no indication on the investigation form that staff were interviewed, any measures were taken to protect Resident #6 while an investigation was being conducted, and the injury of unknown origin was not reported to the Office of Licensure and Certification. Nursing notes revealed an entry on 8/7/18 at 22:19 that read, Resident's personal alarm was sounding. CNA noted resident sitting upright on the floor in the bathroom in her room with the wheelchair behind her. resident sustained [REDACTED]. The Incident/Accident Report stated, Resident's personal alarm was sounding. This nurse was called to resident's room by CNA who stated Resident is on the floor. Resident was noted sitting upright on floor in her bathroom with her wheelchair immediately behind her. The Fall analysis/investigation form revealed that no staff interviews were conducted. The CNA post fall investigation form revealed that no one was with the resident when Resident #6 fell . This unwitnessed event was not reported to the Office of Licensure and Certification. Review of nursing notes for Resident #6 revealed an entry dated 8/21/18 at 23:45 which read, during weekly skin assessment writer noticed bruise on resident's right wrist. 4cm x 2cm dark purple and reddish purple bruise. No swelling. Resident denies pain in right wrist. She does not know how she got the bruise. Under the intervention line: none was typed in. The bruise/skin tear/abrasion investigation form revealed that no staff interviews were conducted. An investigation was not conducted, no measures were taken to protect Resident #6 in the event the resident was a victim of abuse and the injury of unknown origin was not reported to the Office of Licensure and Certification. Nursing notes for Resident #6 revealed an entry dated 10/24/18 at 17:30 that read, during weekly skin assessment noticed bruises on right forearm. Resident denies knowing how she got the bruises. Bruises on right forearm: #1-4 on dorsal surface #5 on dorsal and ventral surface #1 1.7 x 2cm Oval bruise w/Dark purple boarder. Reddish purple in the middle #2 1 x 0.8 cm oval bruise, reddish purple #3 1/5 x 0.7 cm irregular shaped fading red bruise #4 1.7 x 2cm purplish red bruise with a spot of dark purple 0.5 cm in diameter #5 6 x 11.5 cm blue bruise, lighter on ventral surface Husband was notified at 11:45am. He has seen the bruises. He does not know how she got them. (sic) The bruise/skin tear/ abrasion investigation form revealed no staff interviews were conducted. Additional comments read as, resident seen by CNA reaching for walker with eye closed and bumping/hitting rt arm on walker today. Bruises were preset prior to this, however may be an explanation for how it occurred. Husband declined geri sleeves in past. (sic) There was a typed statement dated 10/26/18 that stated, nurse into assess areas to right arm. No fingerlike pattern noted, no pain noted on palpation. signed by the director of nursing. There is no evidence or any other information provided that would indicate an investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. Review of nursing notes for Resident #6 revealed an entry dated 10/25/18 at 14:57 that read, Resident personal alarm sound and resident was found in the bathroom unassisted standing and resident was taken to the bathroom about 10 minutes prior to and resident has been reminded to use her call bell for assistance and at this time resident has been assisted and call bell is within reach and resident knows how to push call bell for assistance. Review of the fall analysis/investigation form under the resident interview section it indicated that Resident #6 didn't respond to the questions asked except for one question which the resident responded no to. Only one staff member was interviewed and they indicated that Resident #6 was cooperative prior to the fall. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. Review of nursing note for Resident #6, revealed a entry dated 10/26/18 at 10:15am that read, resident was found sitting on the floor in her room after resident personal alarm sounded. No additional information was found in the entire clinical record that would indicate that this incident of unknown origin, which is an allegation of abuse, was investigated, staff interviewed, resident protected during the course of an investigation, measures taken to prevent reoccurrence, or that the injury of unknown origin was reported to the Office of Licensure and Certification. Resident #6's nursing notes on 12/5/18 at 7:15am read, resident was found in her bathroom lying on her back when personal alarm went off. Resident has a abrasion to her right index finger with bruising. (sic). Review of the bruise/skin tear/abrasion investigation form reveals that only one staff member was interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. On 12/11/18 at 3:00pm Resident #6 was noted to have 2 new bruise noted to top of right wrist (2 x 3 cm) and top of right forearm (0.5 x 1.2 cm). Resident is a poor historian d/t dementia and cognitive communication deficit and is unable to state when bruises occurred. (sic) Review of the bruise/skin tear/abrasion investigation form reveals that no staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. Nursing notes reveal that on 12/24/18 at 5:40pm while CNA was toileting resident she noticed area of concern on buttock and brought it to this writers attention. On right side of the gluteal cleft there is pink area of denuded skin measuring 1 x 0.7 cm. There are a few much smaller [MEDICAL CONDITION] superior to the largest lesion on either side of gluteal cleft. (sic) Review of the bruise/skin tear/ abrasion investigation form reveals that Resident #6, was non-interviewable. No staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. Resident #6's nursing notes had an entry dated 1/2/19 at 6:41am that read, during weekly skin assessment noticed a bruise on the dorsum of the resident's right hand. 4 x 3 cm ovoid soft raised blue bruise with a little reddish purple, resident states the pain is moderate. (sic) Review of the bruise/skin tear/abrasion investigation form states at the subheading resident interview unreliable answers. answered yes to every question There is no evidence that any staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. Nursing notes for Resident #6 revealed an entry dated 4/6/19 at 8:10am that read, new bruise right forearm noticed while toileting resident this AM right forearm, dorsal surface 3.2 x 1.8 cm bruise. Dark purple in the center and slightly raised. Red purple in the periphery. Resident denies pain. She has good ROM of right wrist and right arm. Resident has [MEDICAL CONDITION] and is unable to tell me when the bruise appeared or how it happened. Husband noticed the bruise this AM. He does not know how it happened. Review of the bruise/skin tear/ abrasion investigation form reveals that Resident #6, was non-interviewable. No staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. This injury of unknown origin was not reported to the Office of Licensure and Certification. On 5/9/19 at 8:43am an interview was conducted with Employee C, the SW (Social Worker). When asked if she was aware of the injuries of unknown origin for Resident #6, the SW stated, I don't specifically, it was reported or identified as abuse. This is not a resident that has ever been identified to me as a referral along those lines as being abused. She is not someone that has ever come up as someone for abuse. When abuse is identified the nurse does an interview, I do an interview. Any employee is supposed to report any suspicion of abuse and my Administrator would call me. I try to visit this resident weekly and I don't' really recall seeing any bruises. When asked if one resident with this amount of paperwork is concerning, the SW stated, I definitely hear your concerns. I've just never suspected it with her. This is concerning, I've never seen these reports. Yes, I probably should have been made aware. It should have been told to the supervisor but this should have also come to me to interview all parties. After my report, if there are concerns identified the Administrator would report the incidents. I haven't had a referral for abuse since the new Administrator started. On 05/09/19 at 09:39 AM an interview was conducted with the facility Administrator. When asked if she knew the cause of the injuries of unknown origin and multitude of bruises Resident #6 has sustained, the Administrator stated, I can't answer , I don't know what meds she is on, she is ataxic and does a lot of failing. The Administrator was made aware that the SW stated they investigate prior to reporting, she talked about mandated reporting, but reporting of abuse allegations is not occurring. The Administrator stated, if any of our team has a concern, or they think something may be under the heading of abuse they are to report it to their administrative supervisor, and then immediately call myself and the DON (Director of Nursing). When asked what would make them think an allegation of abuse, the Administrator stated, if it looks like a hand print, something out of ordinary, I would be questioning that right away, and depending on the placement of where things are. When an injury occurs and no one knows how it occurred. I would look, I would ask if they had a lab draw, if we don't know how it happened, if there is no reasonable expectation. When there is an injury of unknown source it should be reported no later than 24 hours, if there is hospitalization or sign injury you have a two hour time frame. When asked why reporting is not happening the Administrator stated, I can't answer for anything prior to [DATE]. I was not here, we did have a different DON. She was shown there were six injuries of unknown origin for Resident #6 since her tenure. The Administrator then said, I have no problem at all reporting every bruise and every skin tear, if we look at it immediately and if we can't give an answer if we don't have an immediate answer, we will report it. The Administrator was advised of the injury of unknown origin on 10/24/18 that appeared to be a hand print, the Administrator said If saw hand prints and that would raise my concern and I would investigate. I would talk to all team members, would talk to spouse, and the direct care team. I would want to know if anyone saw anything, someone maybe said she went to fall and they went to grab her, etc. I would be concerned about possible abuse. When asked about next steps, The Administrator stated, the nurse would then call the DON and myself, I have a concern here, I would send it in to you. If there is any thought that this could be abuse, it would be reported. A nurses writing the report is self reporting. This nurse is also a medical doctor, ,who didn't like being a doctor and is a nurse. She is a board certified practitioner. Review of the facility policy titled Preventing Resident Abuse with a revision date of 6/1/18 has a subheading of Procedure that read: Injury of unknown origin- any injury to a resident for which there is no known etiology or reasonable explanation, and for which an origin in physical abuse or mistreatment cannot be ruled out. Under the policy subheading, Prevention, it read b. (facility name) will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. Under the policy subheading, Identification, it read a. during orientation and annually at a minimum, team members will be educated on observation and reporting important information about resident care, condition or behavior. Team members are encouraged and protocols will be maintained to promote timely identification and reporting of events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. B. Team members are encouraged to identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Immediately following ensuring the resident's safety, team members are to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. C. Resident and environmental rounds will be conducted periodically throughout the day. These rounds and frequent monitoring are to ensure resident needs are being met in accordance with the plan of care, that residents are being supervised and the environment is free of hazards. D. Administrative and facility leadership staff will supervise team members to identify inappropriate behaviors, action and response to resident needs. Under the policy subheading, Investigation, it read, A. designated team members will immediately review and investigate all allegations or observations of abuse. B. (facility name) will conduct analysis for trends and patterns related to incidents (i.e. falls, skin tears, bruising or injury of unknown origin, unusual occurrences, reportable incidents, etc.) C. outside investigative bodies, such as the local police will be contacted as directed by the administrator or his or her designee and in accordance with federal, state and local law. Under the policy subheading, Protection, it read, A. In the event of an allegation or observation of abuse, (facility name) will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. B. The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident. Under the policy subheading, Reporting, it read, A. (facility name) will maintain systems to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. B. Each covered individual/mandated reporter shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or crime, or not later than 24 hours if the events that cause suspicion doe not result in serous bodily injury. i. The organization will report to local law enforcement agencies any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. Notification to the James City County Police is to be made by contacting (phone number listed). C. The organization will immediately report all alleged violations involving neglect, abuse, including injuries or unknown source, mistreatment and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator or his or her designee of the facility. D. The results of all investigations are to be communicated to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility Administrator and DON were made aware of the facility staff's failure to ensure Resident #6 was free from abuse during the end of day meeting on 5/9/19. No further information was provided. 2. For Resident #5 the facility staff failed to report of allegations of abuse or neglect to include lack of supervision and injuries of unknown origin Resident #5 is a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's most recent (Minimum Data Set) MDS with an (Assessment Reference Date) ARD of 3/15/19 coded as a Significant change assessment, section C the Resident as having a (Brief Interview of Mental Status) BIMS score of 10 indicating moderate cognitive impairment. Under G 0100 ADL Assistance the Resident is coded as: A. Bed mobility - 3 = Extensive Assistance - 2 = 1 person physical assistance B. Transfer - 3 = Extensive Assistance - 2 = 1 person physical assistance C. Walk in room - 8 = Activity did not occur D. Walk in corridor - 8 = Activity did not occur The Resident is also coded under section G 0300 -Balance during Transition and moving: A. Moving from seated to standing position - 8 = Action did not occur B. Walking - 8 = Action did not occur C. Turning around and facing opposite direction while walking. - 8 = Action did not occur D. Moving on and off toilet - 2 = Not steady only able to stabilize with human assistance E. Surface to surface transfer - 2 = Not steady only able to stabilize with human assistance On 5/8/19 it was discovered that between 5/1/2018 and 5/8/2019 the Resident had 34 facility incidents reports completed. Of the 34 incidents: 19 were injuries of unknown source 11 were unwitnessed falls (found on floor) 3 witnessed falls (1 of which involved the use of a sit to stand lift) 1 Elopement According to the incident reports the most recent incidents include: 3/5/19 at 7:00 AM - red /black bruise noted this AM to Left front calf measuring 15 cm X 7 cm also during the last day increased left sided weakness noted resident and staff are unsure how bruise occurred but it could be related to sit to stand usage. However, according to care plan sit to stand use was not discontinued until 3/19/19. 3/11/19 at 1:00 AM - New bruise noted on top and outer aspect of left foot (16 cm X 9 cm) site is tender to touch she is poor historian and unable to state how injury occurred. However she has left sided weakness and sometimes drags her foot or crosses her feet in bed and wheelchair. Additional comments and or steps taken to prevent reoccurrence: - Make sure L (left) foot is in leg rest. - In bed, place pillow between legs / feet. 3/17/19 at 2:50 PM - 8 cm X 7 cm red purple bruise noted to left forearm about 10 minutes BEFORE resident had fall resident and staff are unaware of cause. Additional comments and or steps taken to prevent reoccurrence: - Verify placement of arms before lifting on Hoyer 3/17/19 at 3:00 PM - Unwitnessed fall appears as if resident leaned over to pick up toy cat and fell on the floor found lying on right side. Additional comments and or steps taken to prevent reoccurrence: - OT to eval for placement of half tray (flip up) to put cat on. 3/26/19 at 2:20 PM - Resident was being put to bed for nap and CNA seen (sic) dried blood on resident support hose and writter (sic) went to assess and the area was dry and no active bleeding and had a bruise around skin tear. Additional comments and or steps taken to prevent reoccurrence: - Resident has been noted throughout day taking L (left) leg off of foot rest when staff elevate left leg. 4/8/19 at 7:50 PM - 4.5 cm X 3.5 cm brown bruise noted to left upper forearm appears to be similar to bruise noted in (MONTH) determined to probably be from sling. Additional comments and or steps taken to prevent reoccurrence: - Resident has been noted throughout day taking L (left) leg off of foot rest when staff elevate left leg. 4/8/19 at 7:50 PM - 4.5 cm X 3.5 cm brown bruise noted to left upper forearm appears to be similar to bruise noted in (MONTH) determined to probably be from sling. 5/9/19 at 8:43am an Interview was conducted with the Social worker and when asked if she is a part of the investigation of abuse she stated that They notify me if there is a suspicion of abuse and I would interview the resident. When asked who was responsible for reporting suspected abuse she answered Any employee is supposed to report any allegations of abuse and my administrator would call me. When asked had she seen all of the incidents of injuries of unknown origin she stated It is concerning that I have never seen these reports She indicated that the facility started a new morning meeting with the new leadership and they review incidents. She indicated that the reports should have been told to the supervisor and should have come to her to interview all parties and after the Administrator receives her report of identified concerns, the Administrator would then report. She further elaborated that she has not had any abuse referrals since the new administrator started. On 5/9/19/ at 9:30 AM an interview was conducted with the CEO and the Administrator stated, If any of our team has a concern, or they think something may be under the heading of abuse they are to report it to their administrative supervisor, and then immediately call myself and the DON (Director of Nursing). According to the facility abuse policy: Preventing Resident Abuse Injury of unknown origin- any injury to a resident for which there is no known etiology or reasonable explanation, and for which an origin in physical abuse or mistreatment cannot be ruled out. B. (facility name redacted) will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. C. Resident and environmental rounds will be conducted periodically throughout the day. These rounds and frequent monitoring are to ensure resident needs are being met in accordance with the plan of care, that residents are being supervised and the environment is free of hazards. The facility Administrator was made aware and no further information was provided.

Based on staff interview, facility documentation, clinical and clinical record review the facility staff failed to investigate and protect Residents from abuse and neglect for 2 Residents (# 5 and # 6) in a survey sample of 13 Residents. 1. For Resident #5 the facility staff failed to investigate allegations of abuse or neglect to include lack of supervision and injuries of unknown origin. 2. For Resident #6, the facility staff failed to protect the resident, conduct an investigation for accidents and/or injuries of unknown origin. The findings include 1. For Resident #5 the facility staff failed to investigate allegations of abuse or neglect to include lack of supervision and injuries of unknown origin. Resident #5 is a [AGE] year old woman admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's most recent (Minimum Data Set) MDS with an (Assessment Reference Date) ARD of 3/15/19 coded as a Significant change assessment, section C the Resident as having a (Brief Interview of Mental Status) BIMS score of 10 indicating moderate cognitive impairment. Under G 0100 ADL Assistance the Resident is coded as: A. Bed mobility - 3 = Extensive Assistance - 2 = 1 person physical assistance B. Transfer - 3 = Extensive Assistance - 2 = 1 person physical assistance C. Walk in room - 8 = Activity did not occur D. Walk in corridor - 8 = Activity did not occur The Resident is also coded under section G 0300 -Balance during Transition and moving: A. Moving from seated to standing position - 8 = Action did not occur B. Walking - 8 = Action did not occur C. Turning around and facing opposite direction while walking. - 8 = Action did not occur D. Moving on and off toilet - 2 = Not steady only able to stabilize with human assistance E. Surface to surface transfer - 2 = Not steady only able to stabilize with human assistance On 5/8/19 it was discovered that between 5/1/2018 and 5/8/2019 the Resident had 34 facility incidents reports completed. Of the 34 incidents: 19 were injuries of unknown source 11 were unwitnessed falls (found on floor) 3 witnessed falls (1 of which involved the use of a sit to stand lift) 1 Elopement According to the incident reports the most recent incidents include: 3/5/19 at 7:00 AM - red /black bruise noted this AM to Left front calf measuring 15 cm X 7 cm also during the last day increased left sided weakness noted resident and staff are unsure how bruise occurred but it could be related to sit to stand usage. However, according to care plan sit to stand use was not discontinued until 3/19/19. 3/11/19 at 1:00 AM - New bruise noted on top and outer aspect of left foot (16 cm X 9 cm) site is tender to touch she is poor historian and unable to state how injury occurred. However she has left sided weakness and sometimes drags her foot or crosses her feet in bed and wheelchair. Additional comments and or steps taken to prevent reoccurrence: - Make sure L (left) foot is in leg rest. - In bed, place pillow between legs / feet. 3/17/19 at 2:50 PM - 8 cm X 7 cm red purple bruise noted to left forearm about 10 minutes BEFORE resident had fall resident and staff are unaware of cause. Additional comments and or steps taken to prevent reoccurrence: - Verify placement of arms before lifting on Hoyer 3/17/19 at 3:00 PM - Unwitnessed fall appears as if resident leaned over to pick up toy cat and fell on the floor found lying on right side. Additional comments and or steps taken to prevent reoccurrence: - OT to eval for placement of half tray (flip up) to put cat on. 3/26/19 at 2:20 PM - Resident was being put to bed for nap and CNA seen (sic) dried blood on resident support hose and writter (sic) went to assess and the area was dry and no active bleeding and had a bruise around skin tear. Additional comments and or steps taken to prevent reoccurrence: - Resident has been noted throughout day taking L (left) leg off of foot rest when staff elevate left leg. 4/8/19 at 7:50 PM - 4.5 cm X 3.5 cm brown bruise noted to left upper forearm appears to be similar to bruise noted in (MONTH) determined to probably be from sling. Additional comments and or steps taken to prevent reoccurrence: - Resident has been noted throughout day taking L (left) leg off of foot rest when staff elevate left leg. 4/8/19 at 7:50 PM - 4.5 cm X 3.5 cm brown bruise noted to left upper forearm appears to be similar to bruise noted in (MONTH) determined to probably be from sling. 5/9/19 at 8:43am an Interview was conducted with the Social worker and when asked if she is a part of the investigation of abuse she stated that They notify me if there is a suspicion of abuse and I would interview the resident. When asked who was responsible for reporting suspected abuse she answered Any employee is supposed to report any allegations of abuse and my administrator would call me. When asked had she seen all of the incidents of injuries of unknown origin she stated It is concerning that I have never seen these reports She indicated that the facility started a new morning meeting with the new leadership and they review incidents. She indicated that the reports should have been told to the supervisor and should have come to her to interview all parties and after the Administrator receives her report of identified concerns, the Administrator would then report. She further elaborated that she has not had any abuse referrals since the new administrator started. On 5/9/19/ at 9:30 AM an interview was conducted with the CEO and the Administrator stated, If any of our team has a concern, or they think something may be under the heading of abuse they are to report it to their administrative supervisor, and then immediately call myself and the DON (Director of Nursing). According to the facility abuse policy: Preventing Resident Abuse Injury of unknown origin- any injury to a resident for which there is no known etiology or reasonable explanation, and for which an origin in physical abuse or mistreatment cannot be ruled out. B. (facility name redacted) will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. C. Resident and environmental rounds will be conducted periodically throughout the day. These rounds and frequent monitoring are to ensure resident needs are being met in accordance with the plan of care, that residents are being supervised and the environment is free of hazards. The facility Administrator was made aware of the issues with injuries of unknown origin and no further information was provided. 2. For Resident #6, the facility staff failed to protect the resident, conduct an investigation for accidents and/or injuries of unknown origin. Resident #6 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #6 most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/15/19 was coded as a quarterly assessment. Resident #6 had a BIMS (brief interview for mental status) score of 13, which indicated Resident #6 was cognitively intact. Resident #6 was coded as requiring assistance of one staff member for ADL's (activities of daily living) which included: bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Resident #6's nursing notes dated 7/7/18 reveal that the resident was found lying supine on the floor with feet facing the bathroom door. There is no indication that anyone witnessed the resident fall. The Incident/Accident report states CNA was passing ice and found resident lying on the floor in a supine position near the bathroom. Resident pants were unzippered and hanging below waist. Resident was able to move all four extremities without pain. Resident had no injuries. resident's personal alarm was not activated. Resident was attempting to transfer w/out assist. (sic) The Fall Analysis/Investigation Form dated 7/7/18 stated removed bed/chair alarm- family member. There is no evidence of an investigation being conducted to exclude that the resident was not a victim of abuse or neglect. The facility staff suspected that Resident #6's spouse failed to connect the bed/chair alarm. Review of nursing notes dated 8/2/18 reveal an entry that read: spouse asked this nurse to look at a bruise on resident's right wrist. Wrist examined. Noted bruise on dorsum of right wrist measuring 7cm x 7 cm. No guarding, ,grimacing or moaning during palpation of area. Resident denied pain in wrist. Notified nursing supervisor was made aware. PA made aware. New order received for ice to affected area. Resident was noted to have flailing of upper extremities on prior shift. Will monitor resident as needed. (sic) Review of nursing notes dated 8/1/18 there were no entries. There were no other entries on the day of 8/2/18 to indicate resident had flailing of upper extremities as noted in the incident note, previously mentioned. Review of Bruise/Skin Tear/Abrasion Investigation form under additional comments, it read timing of injury unknown. Suspect injury occurred last night. Unable to assess what resident was doing since timing unknown. There is no indication on the investigation form that staff were interviewed, any measures were taken to protect Resident #6 while an investigation was being conducted. Nursing notes revealed an entry on 8/7/18 at 22:19 that read, Resident's personal alarm was sounding. CNA noted resident sitting upright on the floor in the bathroom in her room with the wheelchair behind her. resident sustained [REDACTED]. The Incident/Accident Report stated, Resident's personal alarm was sounding. This nurse was called to resident's room by CNA who stated Resident is on the floor. Resident was noted sitting upright on floor in her bathroom with her wheelchair immediately behind her. The Fall analysis/investigation form revealed that no staff interviews were conducted. The CNA post fall investigation form revealed that no one was with the resident when Resident #6 fell . Review of nursing notes for Resident #6 revealed an entry dated 8/21/18 at 23:45 which read, during weekly skin assessment writer noticed bruise on resident's right wrist. 4cm x 2cm dark purple and reddish purple bruise. No swelling. Resident denies pain in right wrist. She does not know how she got the bruise. Under the intervention line: none was typed in. The bruise/skin tear/abrasion investigation form revealed that no staff interviews were conducted. An investigation was not conducted, no measures were taken to protect Resident #6 in the event the resident was a victim of abuse. Nursing notes for Resident #6 revealed an entry dated 10/24/18 at 17:30 that read, during weekly skin assessment noticed bruises on right forearm. Resident denies knowing how she got the bruises. Bruises on right forearm: #1-4 on dorsal surface #5 on dorsal and ventral surface #1 1.7 x 2cm Oval bruise w/Dark purple boarder. Reddish purple in the middle #2 1 x 0.8 cm oval bruise, reddish purple #3 1/5 x 0.7 cm irregular shaped fading red bruise #4 1.7 x 2cm purplish red bruise with a spot of dark purple 0.5 cm in diameter #5 6 x 11.5 cm blue bruise, lighter on ventral surface Husband was notified at 11:45am. He has seen the bruises. He does not know how she got them. (sic) The bruise/skin tear/ abrasion investigation form revealed no staff interviews were conducted. Additional comments read as, resident seen by CNA reaching for walker with eye closed and bumping/hitting rt arm on walker today. Bruises were preset prior to this, however may be an explanation for how it occurred. Husband declined geri sleeves in past. (sic) There was a typed statement dated 10/26/18 that stated, nurse into assess areas to right arm. No fingerlike pattern noted, no pain noted on palpation. signed by the director of nursing. There is no evidence or any other information provided that would indicate an investigation was conducted or any protective measures were taken to protect Resident #6. Review of nursing notes for Resident #6 revealed an entry dated 10/25/18 at 14:57 that read, Resident personal alarm sound and resident was found in the bathroom unassisted standing and resident was taken to the bathroom about 10 minutes prior to and resident has been reminded to use her call bell for assistance and at this time resident has been assisted and call bell is within reach and resident knows how to push call bell for assistance. Review of the fall analysis/investigation form under the resident interview section it indicated that Resident #6 didn't respond to the questions asked except for one question which the resident responded no to. Only one staff member was interviewed and they indicated that Resident #6 was cooperative prior to the fall. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. Review of nursing note for Resident #6, revealed a entry dated 10/26/18 at 10:15am that read, resident was found sitting on the floor in her room after resident personal alarm sounded. No additional information was found in the entire clinical record that would indicate that this incident of unknown origin, which is an allegation of abuse, was investigated, staff interviewed, or the resident protected during the course of an investigation. Resident #6's nursing notes on 12/5/18 at 7:15am read, resident was found in her bathroom lying on her back when personal alarm went off. Resident has a abrasion to her right index finger with bruising. (sic). Review of the bruise/skin tear/abrasion investigation form reveals that only one staff member was interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. On 12/11/18 at 3:00pm Resident #6 was noted to have 2 new bruise noted to top of right wrist (2 x 3 cm) and top of right forearm (0.5 x 1.2 cm). Resident is a poor historian d/t dementia and cognitive communication deficit and is unable to state when bruises occurred. (sic) Review of the bruise/skin tear/abrasion investigation form reveals that no staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. Nursing notes reveal that on 12/24/18 at 5:40pm while CNA was toileting resident she noticed area of concern on buttock and brought it to this writers attention. On right side of the gluteal cleft there is pink area of denuded skin measuring 1 x 0.7 cm. There are a few much smaller [MEDICAL CONDITION] superior to the largest lesion on either side of gluteal cleft. (sic) Review of the bruise/skin tear/ abrasion investigation form reveals that Resident #6, was non-interviewable. No staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. Resident #6's nursing notes had an entry dated 1/2/19 at 6:41am that read, during weekly skin assessment noticed a bruise on the dorsum of the resident's right hand. 4 x 3 cm ovoid soft raised blue bruise with a little reddish purple, resident states the pain is moderate. (sic) Review of the bruise/skin tear/abrasion investigation form states at the subheading resident interview unreliable answers. answered yes to every question There is no evidence that any staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. On 2/13/19 at 8am nursing notes for Resident #6 revealed and read bruise on right forearm noticed during weekly skin assessment. 3 x 3.5 cm irregularly shaped bruise on dorsal surface of distal forearm. It is dark purple with a reddish purple boarder, resident denies pain at the site. Resident is unable to tell me how is occurred. (sic) Review of the bruise/skin tear/ abrasion investigation form reveals that only one staff member was interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. On 2/16/19 at 4:03am a nursing note entry for Resident #6 read, new bruise seen on right hand (6 x 5 cm). Resident is a poor historian and unable to state how injury occurred. Resident is prone to frequent injuries from her hitting her arm on things. Review of the bruise/skin tear/ abrasion investigation form reveals no staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted. Nursing notes for Resident #6 revealed an entry dated 4/6/19 at 8:10am that read, new bruise right forearm noticed while toileting resident this AM right forearm, dorsal surface 3.2 x 1.8 cm bruise. Dark purple in the center and slightly raised. Red purple in the periphery. Resident denies pain. She has good ROM of right wrist and right arm. Resident has [MEDICAL CONDITION] and is unable to tell me when the bruise appeared or how it happened. Husband noticed the bruise this AM. He does not know how it happened. Review of the bruise/skin tear/ abrasion investigation form reveals that Resident #6, was non-interviewable. No staff were interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted or any protective measures were taken to protect Resident #6. Nursing note dated 4/30/19 for Resident #6 had an entry at 15:15 that read, resident's personal alarm on back of the w/c went off and resident was found on the floor in from of the bathroom door on her back. resident was put on toilet, but did not have to use it. unable to determine why resident fell . (sic) Review of the bruise/skin tear/ abrasion investigation form reveals that only one staff member was interviewed regarding the injury of unknown origin. There is no evidence or any other information provided that would indicate a complete investigation was conducted. On 5/9/19 at 8:43am an interview was conducted with Employee C, the SW (Social Worker). When asked if she was aware of the injuries of unknown origin for Resident #6, the SW stated, I don't specifically, it was reported or identified as abuse. This is not a resident that has ever been identified to me as a referral along those lines as being abused. She is not someone that has ever come up as someone for abuse. When abuse is identified the nurse does an interview, I do an interview. Any employee is supposed to report any suspicion of abuse and my Administrator would call me. I try to visit this resident weekly and I don't' really recall seeing any bruises. When asked if one resident with this amount of paperwork is concerning, the SW stated, I definitely hear your concerns. I've just never suspected it with her. This is concerning, I've never seen these reports. Yes, I probably should have been made aware. It should have been told to the supervisor but this should have also come to me to interview all parties. After my report, if there are concerns identified the Administrator would report the incidents. I haven't had a referral for abuse since the new Administrator started. On 05/09/19 at 09:39 AM an interview was conducted with the facility Administrator. When asked if she knew the cause of the injuries of unknown origin and multitude of bruises Resident #6 has sustained, the Administrator stated, I can't answer , I don't know what meds she is on, she is ataxic and does a lot of failing. The Administrator was made aware that the SW stated they investigate prior to reporting, she talked about mandated reporting, but reporting of abuse allegations is not occurring. The Administrator stated, if any of our team has a concern, or they think something may be under the heading of abuse they are to report it to their administrative supervisor, and then immediately call myself and the DON (Director of Nursing). When asked what would make them think an allegation of abuse, the Administrator stated, if it looks like a hand print, something out of ordinary, I would be questioning that right away, and depending on the placement of where things are. When an injury occurs and no one knows how it occurred. I would look, I would ask if they had a lab draw, if we don't know how it happened, if there is no reasonable expectation. When there is an injury of unknown source it should be reported no later than 24 hours, if there is hospitalization or sign injury you have a two hour time frame. When asked why reporting is not happening the Administrator stated, I can't answer for anything prior to [DATE]. I was not here, we did have a different DON. She was shown there were six injuries of unknown origin for Resident #6 since her tenure. The Administrator then said, I have no problem at all reporting every bruise and every skin tear, if we look at it immediately and if we can't give an answer if we don't have an immediate answer, we will report it. The Administrator was advised of the injury of unknown origin on 10/24/18 that appeared to be a hand print, the Administrator said If saw hand prints and that would raise my concern and I would investigate. I would talk to all team members, would talk to spouse, and the direct care team. I would want to know if anyone saw anything, someone maybe said she went to fall and they went to grab her, etc. I would be concerned about possible abuse. When asked about next steps, The Administrator stated, the nurse would then call the DON and myself, I have a concern here, I would send it in to you. If there is any thought that this could be abuse, it would be reported. A nurses writing the report is self reporting. This nurse is also a medical doctor, ,who didn't like being a doctor and is a nurse. She is a board certified practitioner. Review of the facility policy titled Preventing Resident Abuse with a revision date of 6/1/18 has a subheading of Procedure that read: Injury of unknown origin- any injury to a resident for which there is no known etiology or reasonable explanation, and for which an origin in physical abuse or mistreatment cannot be ruled out. Under the policy subheading, Prevention, it read b. (facility name) will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. Under the policy subheading, Identification, it read a. during orientation and annually at a minimum, team members will be educated on observation and reporting important information about resident care, condition or behavior. Team members are encouraged and protocols will be maintained to promote timely identification and reporting of events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. B. Team members are encouraged to identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. Immediately following ensuring the resident's safety, team members are to report any allegation or observation of abuse to their supervisor, director of nursing, administrator or facility leadership member. C. Resident and environmental rounds will be conducted periodically throughout the day. These rounds and frequent monitoring are to ensure resident needs are being met in accordance with the plan of care, that residents are being supervised and the environment is free of hazards. D. Administrative and facility leadership staff will supervise team members to identify inappropriate behaviors, action and response to resident needs. Under the policy subheading, Investigation, it read, A. designated team members will immediately review and investigate all allegations or observations of abuse. B. (facility name) will conduct analysis for trends and patterns related to incidents (i.e. falls, skin tears, bruising or injury of unknown origin, unusual occurrences, reportable incidents, etc.) C. outside investigative bodies, such as the local police will be contacted as directed by the administrator or his or her designee and in accordance with federal, state and local law. Under the policy subheading, Protection, it read, A. In the event of an allegation or observation of abuse, (facility name) will immediately assess the resident, notify the physician and resident representative, and protect the resident and other residents from further harm or incident. B. The resident's plan of care will be revised to reflect interventions to minimize recurrence and to treat any injury or harm identified through assessment of the resident. Under the policy subheading, Reporting, it read, A. (facility name) will maintain systems to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. B. Each covered individual/mandated reporter shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or crime, or not later than 24 hours if the events that cause suspicion doe not result in serous bodily injury. i. The organization will report to local law enforcement agencies any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from, the facility. Notification to the James City County Police is to be made by contacting (phone number listed). C. The organization will immediately report all alleged violations involving neglect, abuse, including injuries or unknown source, mistreatment and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator or his or her designee of the facility. D. The results of all investigations are to be communicated to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility Administrator and DON were made aware of the facility staff's failure to ensure Resident #6 was free from abuse during the end of day meeting on 5/9/19. No further information was provided.