Every finding on record at Woodhaven Hall at Williamsburg Landing

Based on observation, interview, record review, and policy review, the facility failed to provide supervision and ensure resident safety for two of six Residents (Resident (R)14 and R59) reviewed for elopement. As a result, R14 and R59, who had been assessed as an elopement and fall risk with moderate cognitive impairment, exited the facility without staff knowledge. R14 was found sitting in the parking of the facility next to his wheelchair with a bruised laceration under his right eye and eloped a second time. R59 also eloped from the facility two times, with one of the times being found a mile from the entrance of the facility. This had the potential to result in serious injury, harm, impairment, or death. This deficient practice resulted in the identification of Immediate Jeopardy and substandard quality of care. On 02/26/26 at 7:14 PM, the Administrator was notified that Immediate Jeopardy (IJ), which also constituted Substandard Quality of Care (SQC), was identified at F689 at a Scope and Severity (S/S) of J and began on 06/07/24 when R59 eloped from the facility. The IJ was removed on 02/27/26 at 5:15 PM, and the scope and severity was lowered to an G actual harm. Findings include:1.Review of R14's Face Sheet located in the resident's electronic medical record (EMR) under the Admission tab revealed the resident was admitted to the facility on [DATE] with diagnoses of heart failure, acute respiratory failure, abnormality of gait and a history of falls.Review of R14's Elopement assessment dated [DATE] and located in the EMR under the Assessments tab, revealed the resident was identified with wandering behavior that had occurred one to three days, was at risk for getting to a dangerous place with behaviors worsening and wandering aimlessly.Review of R14's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/22/25 did not identify the resident as exhibiting wandering behaviors. R14 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating moderately impaired cognition. Review of R14's Care Plan dated 03/26/25 and located in the EMR under the Care Plan tab, revealed that the resident had been identified as exhibiting wandering behaviors. Interventions initiated included to assess for causes of wandering, record behaviors, redirect behaviors when wandering is observed, use wander guard/location monitor daily and offer periods of outside weather permitting. Review of the facility's provided investigation of R14's first elopement on 10/11/25 at 3:30 PM Utility Staff (US)3 was sitting in the parking lot located at the front entrance of the facility. US3 notified the receptionist that R14 was outside of the facility in the parking lot. The receptionist notified the nurse and campus security. Licensed Practical Nurse (LPN) 1 responded to the scene and assessed the resident. R14 had a bruise, laceration under his right eye, and no further injuries were noted. First aid was offered and emergency medical technicians (EMTs) were contacted. R14 was transferred to the hospital for further evaluation. A search of the resident's room at the time revealed his wander guard bracelet was found in his laundry bin. The Administrator met with the resident when he returned from the hospital. He was alert and recalled the events of the day. He stated, he waited until no one was looking and wanted to go outside. The receptionist was on a break at the time and did not see the resident. The Director of Nursing (DON) met with the resident separately when he returned from the hospital. He confirmed that he had intentionally removed the bracelet because it was uncomfortable. The root cause of the elopement was determined to stem from the resident intentionally removing this wander guard bracelet and timing his actions with intent. Upon his return, his bracelet was placed on the bottom of his wheelchair and a system has been implemented to check for the placement every shift. During an interview on 02/21/26 at 4:05 PM with LPN1 she stated that she was the nurse that was called to the front when R14 was located outside in the parking lot. She revealed that the resident rolled his wheelchair out the door to the front parking lot. She said she assessed the resident for any injury. The EMT's were contacted and transferred the resident to the hospital. She also confirmed that the resident had removed his wander guard bracelet which was found in his laundry bin in his room. She revealed the resident began exhibiting an increase in wandering and exit seeking behaviors. 2. Review of the facility's provided investigation revealed R14's second elopement of the facility was on 11/14/25 around 12:45 PM. The admission Coordinator (AC) noticed that R14 was sitting outside the facility in his wheelchair without staff supervision. She went outside and after determining the resident was not injured, she re-directed him back inside and notified the Administrator and Director of Nursing. The investigation revealed Certified Nursing Assistant (CNA)2 assisted R14 to the therapy gym in his wheelchair and informed the Physical Therapy Assistant (PTA). CNA 2 went back to the therapy gym 15 minutes later and the resident was still participating in therapy so she went back to her unit. When the resident was done with therapy PTA assisted R14 back to his wheelchair and began treating other residents. The resident left the therapy gym and turned left towards the lobby rather than right which leads to his unit. The receptionist which monitored the main entrance was on a scheduled break. When the resident was questioned, he acknowledged that the receptionist was not there and he stated that he wanted to go outside after his exercise.During an interview with the PTA on 02/27/26 at 12:00 PM, he stated after R14 was finished with therapy he got him back in this wheelchair and let him return on his own The PTA revealed he was not aware that the resident was a wanderer and he said he didn't remember him having a wander guard bracelet on. 3. Review of R59s Face Sheet located in the EMR under the admission tab reveled R59 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, schizophrenia disorder, anxiety, delusional disorders, post-traumatic stress disorder (PTSD), abnormality of gait and mobility. The resident was discharged from the facility on 11/07/24.Review of R59's quarterly MDS dated [DATE] located in the EMR under the MDS tab revealed a BIMS score of 11 out of 15, indicating moderate cognitive impairment.Review of R59's Care Plan dated 12/02/19, located in the EMR under the Care Plan tab, revealed the resident had the potential for falls and wandering behavior. Interventions in place were to keep the resident safe, keep side doors on unit locked, observe and monitor resident for wandering behavior, re-direct resident, monitor for placement of wander guard bracelet on wrist and offer 1:1 (one on one) staff when indicated. Review of a Wandering/Elopement Risk Assessment located in the EMR under the Assessment tab dated 12/02/19, revealed the resident was identified with no wandering behaviors at the present, had a history of wandering behaviors, was cognitively impaired, a recent change in medications to decrease behaviors and a hx (history) of wandering behavior to find family or pet. The resident scored a six out of a range of zero to nine. The decision was made to add an elopement deterrent device, develop an elopement care plan and refer to therapy.Review of the facility's investigation dated 12/14/23 and provided by the facility revealed that R59 eloped from the facility to the parking lot but remained within the staff's sight. Staff immediately brought the resident to safety inside the facility. Review of the five-day report dated 12/19/23, revealed that the morning of 12/14/23, the resident's daughter took her out for a car ride to look at Christmas lights. They left at 4:00 AM and returned around 7:00AM. Upon her return, there was an attempt to get her to eat but she was fixated on finding her daughter. This led to her elopement to the parking lot. She was in constant sight of facility staff and never more than 10 feet ahead. Staff remained with her, provided her walker and a coat for continued safety. Immediate interventions included medications to address anxiety. 4.Review of the facility's Incident/Accident Investigation provided by the facility revealed on 06/07/24, R59 eloped from the facility a second time. She was found at the security gate which was a mile from the entrance of the facility. She was in a resident's personal car who resided in the independent living. The resident stated, I am going home, I don't want to get out (of car), I don't know you. My daughter won't come up here again. I don't think she will. Are you going to call her? This kind lady was going to take me home. I don't think I'll ever see her again. After my daughter left, she (kind lady) can come back and pick me up. I don't think I can get out. I'm so tired, I don't know if I can go to the bathroom. Included in the investigation, revealed LPN3 indicated that staff alerted her while she was at the front reception desk that R59 was sitting in someone's vehicle at the Security guard gate. When LPN arrived the security the guard was talking with resident who was sitting in the passenger's seat of the independent resident's car. LPN3 introduced herself to the resident. R59 told LPN3 she didn't know her but she knew her daughter. R59 was taken back to the front of the facility. Staff assisted the resident back inside the facility and was taken to her room. The resident exhibited physical aggression toward staff when her vital signs were attempted. The daughter was notified of the incident and returned to the facility. Review of the follow up report submitted by the Administrator revealed that on 06/07/24, at approximately 4:00 PM, R59 was picked up on campus by an independent resident and taken to the guard house after she appeared to be lost. Staff were alerted by security staff who came to the guardhouse and brought the resident back to her room. LPN3 helped with getting the resident back to her room while working with staff. In speaking with various team members from the 3:00 PM to 11:00 PM shift and collecting statements from staff, it was suspected the resident followed a family or staff member out the side hall door closest to the guard house and main road on campus. Her comments upon return were that she was going home since her daughter won't come to the facility. She has a diagnosis of PTSD, schizoaffective disorder, and delusional disorder. As part of the investigation, a review of the statements by staff at the time of the incident revealed staff did not see the resident leave the facility. There was no time frame for when the last time the resident was observed. During an interview on 02/26/26 at 4:30 PM LPN2 she indicated that she was working the day R59 eloped from the facility but she did not remember the events around the incident. She stated that the resident had on a wander guard bracelet and was always trying to remove it. She considered the resident alert and oriented. She was not aware where the resident went or where she was found. Other staff involved in the incident were not available for interview. During an observation and interview on 02/26/26 at 11:20 AM the DON and Registered Nurse (RN)5 and the Director of Nursing (DON) demonstrated the alarm using the wheelchair for R14 with the bracelet attached. As the wheelchair passed though the sensor outside of the door of the nurses station, the audible alarm sounded. The sound of the alarm was not as loud as the alarm for the call bells. When the alarm is triggered, it is also reflected on a monitor located at the nurses station and another monitor further down the hallway next to a second station. RN5 stated that sometimes if there is a lot of noise around the nurses station, the alarm is hard to hear. An elevator was observed to the left of the nurses station before you exit the unit. A resident unit is located upstairs and downstairs for the basement. Following the hallway in the basement from the elevator door, a second wander bracelet alarm was present. There was no staff present in the area at the time of the observation. The hallway leads to a stairway with an unlocked exit door that leads to outside. Further down the hallway, a second unlocked door leads to a loading dock and ramp leading to the outside of the facility. Review of the facility's policy titled, Resident Elopement revised on 02/26, revealed; Williamsburg Landing shall take immediate action to ensure the safe return of residents who are reported as unaccounted for or missing.An elopement is defined as any instance where a resident has wandered away from his/her residence without staff knowledge, out of staff visual sight, and is incapable of finding his/her way back home. This is a serious situation requiring an immediate, coordinated response.any resident assessed as high elopement risk will be added to the Elopement Risk Binder.Upon discovery of a missing resident, immediate attempts shall be made to determine where the resident was last seen and what the resident was wearing. This deficient practice resulted in the identification of Immediate Jeopardy and substandard quality of care. On 02/26/26 at 7:14 PM, the Administrator was notified that Immediate Jeopardy (IJ), which also constituted Substandard Quality of Care (SQC), was identified at F689 at a Scope and Severity (S/S) of J and began on 6/7/24 when R59 eloped from the facility.On 02/27/26 the facility provided a Removal Plan that was accepted at 1:34 AM.The removal plan indicated the following:R59 was discharged from the facility on 11/07/24 and R14 still remains in the facility.On 02/26/26 the Administrator provided education to the Director of Nursing (DON), Director of Social Services, the Minimum Data Set Coordinator (MDSC) for the risk of wandering. Assessments were recorded in resident's medical record. No additional residents were identified to be at risk for wandering. There are currently four residents who were identified to have a wander guard. On 02/26/26 the Administrator checked all external and lobby doors within the health and rehabilitation center to ensure that all doors were secured or had a wander guard system in place. On 02/26/26 the facility immediately placed a staff member to continuously supervise and monitor the lobby area outside of the health and rehab center lobby, elevator, and unsecured areas. The facility will maintain supervision of this area until a wander guard is placed to ensure no access to an unsupervised area. On 02/26/26 the Administrator, DON, Director of Social Services, MDSC, ADON and the Medical Records Coordinator provided in-service education to all staff present to the wandering resident policy and wander guard protocol to include identification of residents at risk of wandering, the wander guard system and the newly placed monitoring system of the lobby leading to other doors, in secured areas and the elevator. All incoming shifts of nurses, certified nursing assistants and Health and Rehabilitation center administrative staff, dining, activities, maintenance and therapy staff who are scheduled to work within the Health and Rehabilitation and living center will receive in-service education to the wander guard system including the newly identified target areas (elevator and lobby) including newly hired staff including unscheduled and contracted staff on an ongoing basis prior their next shift of the health and rehabilitation center. The Administrator or DON will be responsible for the implantation of the removal plan. The facility will conduct an impromptu Quality Assurance Performance Improvement (QAPI) committee meeting on 02/27/26 to include the Medical Director through in person or google meet attendance to review the facilities plan of correction and removal of immediate jeopardy. The Administrator, DON, Security Guard, or nursing supervisor will inspect the wander guard system for proper function and all exterior doors five times per times four weeks, then three times per week times four weeks, then weekly there after in all areas of the Health and Rehabilitation Center to ensure substantial compliance is maintained. This plan of correction will be monitored and reviewed by the Quality Assurance plan for six months to ensure ongoing substantial compliance is met, amending the plan of correction to maintain compliance as needed. The date of compliance is implemented on 02/27/26. The survey team validated the implementation of the removal plan through observations, staff interviews, and record reviews. The IJ was removed on 02/27/26 at 5:15 PM, and the scope and severity was lowered to an G actual harm.

Based on observation, interview, record review, and policy review, the facility failed to ensure the dish machine wash and rinse temperature was at the proper temperature to sanitize the dishes. This had the potential to affect 44 of 44 skilled nursing residents who consumed food from the kitchen. Findings include:During an observation on 02/26/26 at 12:25 PM, revealed the dishwasher wash and rinse cycle's temperature was registering 158 degrees Fahrenheit (F) for the wash cycle and 150 degrees F for the rinse cycle from the gauge on the dish machine. A second temperature monitor mounted on the wall and connected to the dish machine registered the wash cycle at 155 degrees F and 188.8 degrees F for the rinse cycle. The monitor is designed to alert staff for any temperatures that are out of range. There had been no alerts on the monitor. Due to the discrepancy, the Executive Chef (EC) used an internal thermometer inside the machine to check water temperature. The internal thermometer registered 151.4 degrees F. A second rack was sent through the machine using the internal thermometer which registered 158 degrees F. Another thermometer was used to test the water inside the well of the machine, it registered 165 degrees F. The EC verified the water temperatures were not reaching the proper temperature. The three-compartment sink would be used in the interim. During an observation on 02/27/26 at 10:00 AM revealed several representatives from Ecolabs working on the dish machine. According to the Executive Chef, when the machine was turned on earlier in the morning, he heard a loud pop and lost all power to the machine. During an interview on 02/27/26 at approximately 10:30 AM, the EC stated that he was unable to locate previous temperature logs for the dish machine. It was the responsibility of the Sous Chef to monitor and record the water temperatures of the dish machine for all three meals of the day. He verified that he was unable to validate the logs since he could not locate any of the copies. The Sous Chef was not available and was not presently on the schedule according to the EC. Review of the facility policy titled, Standard Operating Procedure (SOP): Dish Machine Operation, not dated, revealed. 1. Purpose to ensure the dish machine operates safely and consistently within required sanitation standards by verifying proper setup, monitoring temperatures and pressures, and protecting the booster heater from overload.3. The Back of the House ([NAME]) Supervisor ensures the dish machine is set up correctly and that all temperature and pressure readings are recorded. All ware-washing staff follow this SOP and report any deviations immediately.4.3 Temperature Monitoring, monitor the temperature gauges located on the front of the machine throughout service. If the wash temperature drops to 170 degrees or below, immediately: stop washing dishes, initiate a 7-minute pause to allow the machine to recover, recheck temperatures before resuming operation. 4.4 If temperatures do not return to required levels after the recovery period: notify the supervisor, submit a maintenance request, switch to manual ware-washing procedures if required by policy. 5. Documentation: All temperature and PSI readings must be logged at setup and monitored throughout the shift; any deviations must be documented on the ware-washing log.

Based on record review, interview, and facility policy review, the facility failed to ensure an injury of unknown origin that required an emergent hospital transfer was investigated to determine if the incident was a result of abuse for one of one resident (Resident (R) 56) reviewed for injuries of unknown origin out of 14 sampled residents. The facility's failure to investigate R56's injury of unknown origin to determine if the injury was sustained because of abuse placed the resident at risk of being a victim of potential abuse. (Cross Reference: F600, F607 and F609). Findings include: Review of R56's printed Face Sheet, provided by the Administrator, revealed R56 was admitted to the facility on [DATE] with diagnoses including dementia and weakness.Review of a printed Incident/Accident Report dated 01/03/24, provided by the Administrator, revealed R56 was observed lying on the floor and complained of right leg pain. The report indicated the incident was unwitnessed. During an interview on 02/24/26 at 6:33 PM, the Day Shift Supervisor (DSS) stated she was informed by the Social Services Director (SSD) that a resident (R56) was discovered on the floor. The DSS also stated that she was responsible for doing a follow-up investigation of any incident/risk management reports that were completed. The DSS further stated she interviewed the assigned nurse and two certified nurse assistants (CNAs) assigned to the unit on the day of the incident, and all reported they did not witness the fall. However continued interview revealed no other interviews were conducted and it was not determined what led to the resident being discovered lying on the floor in pain and then emergently transferred to the hospital. On 02/25/26, Executive [NAME] President/Chief Operating Officer (ExVPCOO) provided no credible evidence to the inspectors that a thorough investigation had been completed when R56 was discovered on the floor and could not explain the incident. During an interview on 02/25/26 at 6:00 PM, the Chief Clinical Officer (CCO) stated that surveyors were not permitted to review incident/risk management reports, staff statements, or investigative documentation. The CCO provided no credible evidence to the inspectors that a thorough investigation had been completed after R56 was discovered lying on the floor, in pain, and then emergently transferred to the hospital for medical intervention. An attempt was made to contact the former Administrator and was unsuccessful. Review of the facility's policy titled, Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, approved 12/2025 revealed, .The facility will not tolerate abuse.It is the facility's policy to investigate all allegations, suspicions, and incidents of abuse.and injuries of unknown source.The Administrator will immediately begin an investigation.DEFINITIONS: Abuse- includes.injuries of unknown source.Injury of Uknown Source-An injury is classified as an 'Injury of Unknown Source' when both the following are met: a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular time, or the incidence of injuries over time.7. Investigate. Once the Administrator and DON [Director of Nursing] are notified, an investigation of the allegation or suspicion will be conducted. a.The investigation must be completed within five working days from the alleged occurrence. b.The person investigating the incident should generally take the following actions: I. Interview the resident., and all witnesses.II. If there are no direct witnesses, then the interviews may be expanded.For Injuries of Uknown Source, the investigation will generally involve talking with both the shift on duty when the injury was discovered and prior shifts as well. III. obtain written statements from the resident, if possible, the accused, and each witness. IV. Obtain all medical reports and statements from physicians and/or hospitals, if applicable. Review the resident's records.8. Reach a Conclusion. After completion of the investigation, all of the evidence should be analyzed, and the Administrator (or his/her designee) will make a determination regarding whether the allegation or suspicion is substantiated, and, for Injuries of Unknown Source, a determination regarding the probable source of the injury.

Based on record review, staff interview, and facility policy review, the facility failed to implement its policies and procedures related to abuse, neglect, and injuries of unknown origin. The facility failed to report an injury of unknown injury and failed to complete an investigation related to an injury for one Resident (Resident (R) 56) of one resident reviewed for potential abuse and neglect out of a total sample of 14 residents. R56 was found on the floor with no witnesses and sustained a right hip fracture requiring surgical repair. This had the potential for abuse as the injury was not reported or investigated. (Cross Reference F609 and F610)Findings include: Review of R56's printed Face Sheet, provided by the Administrator, revealed R56 was admitted to the facility's skilled nursing unit on 12/21/23 with diagnoses including dementia and weakness.Review of R56's printed admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/23, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. Review of a printed Incident/Accident Report, dated 01/03/24, provided by the Administrator, revealed R56 was observed lying on the floor. Upon assessment resident complained of pain in right leg. Unable to perform active range of motion without pain. First responder [Social Services Director (SSD)] approached nurse to inform resident observed lying on the floor. R56 was transferred to the hospital following the incident where he was found on the floor (unwitnessed) and subsequently underwent a right partial hip replacement due to a fracture. On 02/25/26, the Administrator provided a written statement composed by the Executive [NAME] President/Chief Operating Officer (ExVPCOO) and Chief Clinical Officer (CCO) of Independent Living Health Services indicating that the former Administrator did not complete a facility reportable incident within 24 hours because he believed the fracture was related to a fall and not an injury of unknown origin.An attempt was made to contact the former Administrator and was unsuccessful. Review of the facility's policy titled Abuse Prevention Program revealed that injuries of unknown origin must be reported, investigated, and managed in accordance with facility procedures and regulatory requirements.

Based on record review, interview, and facility policy review, the facility failed to ensure residents were protected from potential abuse for one of one resident (Resident (R) 56) reviewed for an injury of unknown origin. R56 was discovered on the floor with signs and symptoms of pain and was emergently transferred to the hospital for further evaluation. There were no witnesses to the incident, and the resident did not explain the reason he was on the floor and in pain. The facility's failure to identify the incident as an injury of unknown origin caused the resident to be a possible victim of abuse.Findings include: Review of R56's printed Face Sheet, provided by the Administrator, revealed R56 was admitted to the facility's on 12/21/23 with diagnoses including dementia and weakness.Review of R56's printed admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/23, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. Review of a printed Incident/Accident Report, dated 01/03/24, provided by the Administrator, revealed R56 was observed lying on the floor. Upon assessment resident complained of pain in right leg. Unable to perform active range of motion without pain. First responder [Social Services Director (SSD)] approached nurse to inform resident observed lying on the floor.During an interview on 02/25/26 at 1:34 PM, the SSD stated she arrived at the unit shortly after residents finished breakfast. The SSD stated that as she approached the entrance to the dining room, she observed R56 lying on the floor in a lateral position groaning and grimacing in pain. The SSD stated she visually inspected the resident for bleeding and attempted to ask if he was okay, but the resident responded only with a groan. The SSD stated there were no other people in the area, so she then left the resident and went and located a nurse. The SSD stated she returned to the location with the nurse where R56 remained lying on the floor.During an interview on 02/25/26 at 6:00 PM, the Executive [NAME] President/Chief Operating Officer (ExVPCOO) stated that (surveyors) were not allowed to view incident/risk management reports, statements, or investigation documents. The ExVPCOO did not provide any credible evidence that the facility identified the incident as an injury of unknown origin and possible abuse. On 02/25/26, the Administrator provided a written statement that provided no credible evidence the incident was identified as an injury of unknown origin and/or possible abuse. An attempt was made to contact the former Administrator and was unsuccessful. Review of the facility's policy titled, Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, approved 12/2025 revealed, .The facility will not tolerate abuse.DEFINITIONS: Abuse- includes.injuries of unknown source.Injury of Uknown Source-An injury is classified as an 'Injury of Unknown Source' when both the following are met: a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular time, or the incidence of injuries over time.3. Prevention & Identification. Facility's procedures will include: .e. The identification of events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation.Review of the facility's policy titled, Abuse, revised 10/2025 revealed .'Abuse' is defined.as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.'Injuries of unknown source' - An injury should be classified as an 'injury of unknown source' when ALL of the following criteria are met: The source of the injury was not observed by any person; and the resident could not explain the source of injury; and the injury is suspicious because of: The extent of the injury, or the location of the injury.or the number of injuries observed at one particular point in time, or the incidence of injuries over time.'Serious Bodily Injury' means an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.Identification. 1. Staff will be educated on observation and reporting importing information about resident care, condition, or behavior. Staff are encouraged and protocols will be maintained to promote timely identification and reporting of events, such as injuries of unknown etiology, occurrences, patterns, and trends that may constitute abuse.a. Physical Abuse. i. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking.iii. Examples of injuries that could indicate abuse include but are not limited to: 1. Injuries that are non-accidental or unexplained; 2. Fractures, sprains, or dislocations; .j. Injuries of Unknown Source. i. Injuries of Unknown Source that meet the criteria for reporting may include but are not limited to: 1. Unobserved/Unexplained fractures, sprains, or dislocations.13. Unobserved/unexplained injury requiring transfer to a hospital for examination and/or treatment .

Based on record review, interview, and facility policy review, the facility failed to ensure that an injury of unknown origin was reported to the State Survey Agency (SSA) immediately but not later than two hours for one of one resident (Resident (R) 56) reviewed for injuries of unknown origin out of 14 sampled residents. This failure placed the resident and other residents who are discovered to have an injury of unknown origin at risk of sustaining injuries that could have been caused by abuse. (Cross Reference: (F600, F607, and F610)Findings include: Review of R56's printed Face Sheet, provided by the Administrator, revealed R56 was admitted to the facility on [DATE] with diagnoses including dementia and weakness.Record review of a printed Incident/Accident Report, dated 01/03/24, provided by the Administrator, revealed R56 was observed lying on the floor and complained of right leg pain. The report indicated the incident was unwitnessed and R56 was not interviewed about the incident. On 02/25/26, the Administrator provided a written statement composed by the Executive [NAME] President/Chief Operating Officer (ExVPCOO) and Chief Clinical Officer (CCO) of Independent Living Health Services indicating that the former Administrator did not report to the SSA the incident where R56 was discovered on the floor, in pain, and emergently transferred to the hospital for medical intervention as an injury of unknown origin. An attempt was made to interview the former Administrator and was unsuccessful.Review of the facility's policy titled, Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, approved 12/2025 revealed, .It is the facility's policy to investigate all.injuries of unknown source.Facility staff must immediately report all such allegations to the Administrator. The Administrator will immediately.notify the applicable local and state agencies in accordance with the procedures in this policy.6. Initial Reports. a. Timing. All allegations of Abuse.Injuries of Unknown Source.must be reported immediately to the Administrator, Director of Nursing (DON) and to the applicable State Agency. If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported.immediately, but not later than 2 hours after the allegation is made.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with CDC (Centers for Disease Control) and CMS (Centers for Medicare & Medicaid Services) guidance/requirements for 4 out of 6 staff members, staff members #4, #5, #6, and #8, the facility staff failed to maintain documentation of COVID-19 testing occurrences and results for all facility staff, and the facility staff failed to conduct COVID-19 testing for 4 out of 4 newly admitted residents, residents #46, #57, #110, and #209. The findings included: 1. The facility staff failed to conduct expanded screening COVID-19 testing for staff members #4, #5, #6, and #8. On 8/16/22 at approximately 1:00 PM, a group interview was conducted with the Facility Administrator, Director of Nursing (DON), and the Infection Preventionist (IP). The IP stated the facility was currently conducting COVID-19 testing twice per week, on Tuesdays and Fridays, due to the high levels of transmissibility in the local community. The IP stated the community levels have been high for most of the year. The IP further stated that she is only responsible for resident testing and staff testing is handled by the Human Resources (HR) department. She stated, Human resources generates a list of staff members that need to be tested and then sends it down to me, we perform the tests and send the results back to them, I don't know what happens after that. The Facility Administrator confirmed that the HR department handles all matters involving staff members with regard to COVID vaccination and testing. A staff COVID vaccination matrix, staff testing records, and COVID testing policies were requested and received. A review was conducted of these documents and revealed the following: 1a. For staff member #4, the facility staff failed to perform COVID-19 testing. Staff member #4, who was agency staff, had completed a primary COVID-19 vaccine series on 2/15/21 but did not receive a booster, was not up to date with COVID-19 immunization. An interview with the HR Director was conducted and she stated, I do not handle anything with Agency staff, the Clinical Staff Coordinator is responsible for all of that, I do not know any of them [agency staff], I am not involved with following their [COVID-19] vaccination status nor do I prompt any COVID testing for them, that is the responsibility of the clinical team. An interview with the Clinical Staff Coordinator was conducted and she stated, We use 3 different agencies for nurses and nurse aides on almost a daily basis, I try to get the agency contact to send over some basic information on the employee that they may be sending over to us which would include their COVID vaccination status but I do not keep any records on agency staff and I am not involved with any COVID testing for them. A follow-up interview was conducted with the IP and the Facility Administrator who confirmed the facility is not performing COVID-19 testing for any agency staff members. 1b & 1c. For staff members #5 and #6, the facility staff failed to perform COVID-19 testing at the recommended frequency of twice per week. Staff members #5 and #6 were granted a non-medical exemption from COVID-19 immunization by the facility. Review of staff member #5's August 2022 work schedule and test results revealed that staff member #5 worked on August 2, 3, 4, 6, 7, 9, 10, 11, 12, 16, ten shifts in total, with one COVID-19 test performed on the 9th. Review of staff member #6's August 2022 work schedule and test results revealed that staff member #6 worked on August 1, 3, 5, 6, 7, 8, 9, 11, 12, 15, 16, eleven shifts in total, with one COVID-19 test performed on the 9th. An interview was conducted with the HR Director who confirmed the COVID-19 vaccination status for staff members #5 and #6 and stated, [names redacted, staff members #5 and #6] signed an agreement when the exemption was granted which required compliance with [COVID] testing, I do not send their names down on the staff testing rosters for privacy reasons, they know that they should be testing, I'm assuming that the clinical leadership is providing oversight for compliance, I get notified if a test is positive. 1d. For staff member #8, the facility staff failed to perform COVID-19 testing at the recommended frequency of twice per week. Staff member #8 had completed a primary COVID-19 vaccine series on 9/17/21 but did not receive a booster and therefore, was not up to date with COVID-19 immunization. Review of staff member #8's July 2022 work schedule revealed that staff member #8 worked on July 1, 2, 4, 6, 7, 8, 11, 12, 14, 15, 16, 17, 19, 20, 21, 22, 25, 26, 28, 29, 30, and 31, twenty-two shifts in total, with no documented COVID-19 test being completed, including results. Review of the facility policy titled, COVID-19 Infection Prevention Testing Guidelines, issued March 2021, Policy read, The Health and Rehab Center (HRC) will test residents and facility staff coming in and out of HRC, including individuals providing services under arrangement and volunteers, for COVID-19 and subheading, Conducting Testing, page 4, read, The facility will conduct testing according to nationally recognized guidelines, outlined by the Centers for Disease Control and Prevention (CDC). The CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 4, subheading, Testing, item 7, read, Expanded screening testing of asymptomatic HCP [Healthcare Personnel] should be as follows: .In nursing homes, HCP who are not up to date with all recommended COVID-19 doses should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, these HCP should have a viral test twice a week .If these HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). 2. The facility staff failed to maintain documentation of COVID-19 testing occurrences and results for all facility staff. An interview conducted with the HR Director was conducted and she stated, The clinical team will perform COVID testing on our staff members from the list that I give to them, they send the results to me, and I only record positive results, I do not keep any other results, the clinical leadership team--the Facility Administrator, Director of Nursing and Infection Preventionist are responsible for oversight for [COVID-19] testing compliance, I do not follow-up with staff members otherwise. Review of the facility policy titled, COVID-19 Infection Prevention Testing Guidelines, issued March 2021, Policy read, The Health and Rehab Center (HRC) will test residents and facility staff coming in and out of HRC, including individuals providing services under arrangement and volunteers, for COVID-19 and subheading, Documentation of Testing, page 5, item 3 read, .Also, document the date(s) that testing was performed for all staff, and the results of each test and For staff, including individuals providing services under arrangement and volunteers, the facility will document testing results in a secure manner . Review of the CMS (Centers for Medicare & Medicaid Services) Memo Ref: QSO-20-38-NH, revision date 3/10/2022, subheading Documentation of Testing, page 10, item 3 read, For staff routine testing, document the facility's level of community transmission, the corresponding testing frequency indicated (e.g., every week), and the date each level of community transmission was collected. Also, document the date(s) that testing was performed for staff, who are not up-to-date, and the results of each test and page 11, For staff, including individuals providing services under arrangement and volunteers, the facility must document testing results in a secure manner . 3. For Residents #46, #57, #110, and #209, facility staff failed to conduct COVID-19 testing upon admission to the facility. 3a. For Resident #46, the facility staff failed to conduct COVID-19 testing upon her arrival to the facility. On 8/17/22, a clinical record review was conducted and revealed that Resident #46 was admitted to the facility on [DATE], however there was no evidence of any COVID-19 testing. 3b. For Resident #57, the facility staff failed to conduct COVID-19 testing upon her arrival to the facility. On 8/17/22, a clinical record review was conducted and revealed that Resident #57 was admitted to the facility on [DATE], however there was no evidence of COVID-19 testing until 8/6/22. 3c. For Resident #110, the facility staff failed to conduct COVID-19 testing upon his arrival to the facility. On 8/17/22, a clinical record review was conducted and revealed that Resident #110 was admitted to the facility on [DATE], however there was no evidence of any COVID-19 testing. 3d. For Resident #209, the facility staff failed to conduct COVID-19 testing upon his arrival to the facility. On 8/17/22, a clinical record review was conducted and revealed that Resident #209 was admitted to the facility on [DATE], however there was no evidence of any COVID-19 testing. On 8/17/22 at approximately 2:30 PM, an interview was conducted with the IP who confirmed the facility conducts COVID-19 testing for all residents in accordance with CDC recommendations. The IP was asked about the facility's protocol for testing newly admitted residents for COVID-19 and she stated, The Admissions Coordinator requires that a COVID-19 test be conducted within 48 hours prior to their admission, we do not require any further testing after admission unless there is a specific reason. Review of the facility policy titled, COVID-19 Infection Prevention Testing Guidelines, issued March 2021, Policy read, The Health and Rehab Center (HRC) will test residents and facility staff coming in and out of HRC, including individuals providing services under arrangement and volunteers, for COVID-19 and subheading, Conducting Testing, page 4, read, The facility will conduct testing according to nationally recognized guidelines, outlined by the Centers for Disease Control and Prevention (CDC). The CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 4, subheading, Testing, item 3, 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 viral tests for SARS-CoV2 infection; immediately and, if negative, again 5-7 days after their admission. The Facility Administrator, Director of Nursing, Infection Preventionist and the Chief Operating Officer were made aware of the findings at the end of day meeting held on 8/18/22 and again at the pre-Exit Conference meeting held on 8/19/22. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to implement their policy and procedure to ensure that all facility staff were fully vaccinated for COVID-19. The facility staff failed to document the COVID-19 vaccination status for 56 contracted nursing agency staff members who provided direct resident care during the months of June, July, and August 2022. The findings included: On 8/18/22, an interview was conducted with the Facility Administrator and the Infection Preventionist (IP). The IP stated that the Human Resources (HR) department was responsible for all staff COVID vaccinations. A copy of the facility policy was requested and received. An interview was conducted with the HR Director who stated, I do not handle anything with Agency staff, the Clinical Staff Coordinator is responsible for all of that, I do not know any of them [agency staff], I am not involved with following their [COVID-19] vaccination status . An interview with the Clinical Staff Coordinator was conducted and she stated, We use 3 different agencies for nurses and nurse aides on almost a daily basis, I try to get the agency contact to send over some basic information on the employee that they may be sending over to us which would include their COVID vaccination status but I do not keep any records on agency staff . She verbally confirmed that there was no documentation of Agency staff COVID-19 vaccination status kept at the facility, stating, The people I work with at the agencies know that we want vaccinated staff. A request was made for agency clinical staff work schedules for June, July and August 2022 and was received. Review of the agency work schedules revealed a total of 56 agency nurses and nurse aides, with unknown COVID-19 vaccination status, were permitted by the facility to provide direct care to residents from 6/6/22 through 8/19/22. Review of the facility policy titled, COVID-19 Vaccination Mandate, reviewed January 2022, Policy read, As a condition of employment, all employees are required to be fully vaccinated against COVID-19 and Guidelines, item 2 read, .Documentation related to employees' COVID-19 vaccination status will be maintained by [name redacted, HR department], this tracking system will include any applicable booster vaccinations received by facility staff. The Facility Administrator, Director of Nursing, Infection Preventionist, and the Chief Operating Officer were made aware of the findings at the end of day meeting held on 8/18/22 and again at the pre-Exit Conference meeting held on 8/19/22. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to provide COVID-19 immunization for 2 staff members, staff #7 and #8, in a survey sample of 5 staff members reviewed for COVID-19 vaccination. The facility staff failed to provide COVID-19 booster vaccines for staff members #7 and #8. The findings included: On 8/16/22 at approximately 1:00 PM, a group interview was conducted with the Facility Administrator, Director of Nursing (DON), and Infection Preventionist (IP). The IP stated that the Human Resources (HR) department handles all matters involving staff members with regard to COVID vaccination and testing. A staff COVID vaccination matrix and COVID vaccination policies were requested and received. On 8/18/22, staff vaccination records for staff member #7 and #8 were reviewed and revealed the following: Staff member #7, hire date 10/27/20, had completed a primary COVID-19 vaccine series on 3/2/21 but had not received a booster dose. Staff member #8, hire date 6/15/21, had completed a primary COVID-19 vaccine series on 9/17/21 but had not received a booster dose. On 8/19/22, an interview was conducted with the HR Director who confirmed the findings and stated, I do not follow-up on whether or not a staff member gets a booster shot, I will send them an email when they become eligible to receive a booster vaccine but it's up to the staff member to go get one if they want one, I do not provide them with any education about the boosters and we don't have a declination form either--is this something that I should be doing?. Review of the facility policy titled, COVID-19 Vaccination Mandate, reviewed January 2022, Policy read, All persons with a employment arrangement with [facility name redacted] will take necessary precautions and adhere to mandated guidelines through this policy, the intent of this policy is to safeguard .from COVID-19, this policy will comply with all applicable laws and is based on guidance from federal, state, and local health authorities, as applicable. The CDC (Centers for Disease Control and Prevention) document titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 3, subtitle, Vaccinations, read, Remaining up to date with all recommended COVID-19 vaccine doses is critical to protect both staff and residents against SARS-CoV-2 infection. The Facility Administrator, DON, and IP were updated. No further information was received.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide pneumococcal immunizations for 3 residents in a survey sample of 5 residents reviewed for pneumococcal vaccination. The facility staff failed to provide pneumococcal immunizations for Residents #8, #14, and #53. The findings included: On 8/18/22, clinical record review was performed for Residents #8, #14, and #53 and revealed no documentation with regard to pneumococcal immunization including the resident's current pneumococcal vaccination status, offer to provide immunization against pneumococcal infection, or documentation of resident refusal or medical contraindication. The admitted s for these residents include, Resident #8 admitted [DATE], Resident #14 admitted [DATE], and Resident #53 admitted [DATE]. These findings were verified with the Infection Preventionist and stated, we are supposed to assess whether or not a resident has received a [pneumonia] vaccine or not when they are admitted here and offer them one if they have not had it, it does not appear that this was done for these residents [Residents #8, #14, and #53]. A facility policy on pneumococcal immunization was requested and received. On 8/18/22, review of the facility policy entitled, Pneumococcal Vaccination, dated June 2021, read: Policy .The facility supports vaccination activities to prevent the development of pneumonia in residents and Procedure, item 1, read, Upon admission to the nursing facility, the resident and/or resident representative will be interviewed to determine [resident's eligibility to receive a pneumococcal vaccination]. On 8/18/22 at approximately 5:00 PM, the Facility Administrator and the Director of Nursing were updated on the findings. No further information was provided.

Based on observation, interview, and facility documentation the facility staff failed to appropriately wear PPE in a facility currently in outbreak and failed to post the appropriate signage to indicate which PPE to wear in the quarantined Resident's room. The findings included 1. The Preventionist (IP) Nurse failed to wear a mask. The IP was observed behind the nurses' desk on the Annex Hall without a mask. On 08/18/22 at 11:26 AM, the IP Nurse was noted not to be wearing mask at the nurses station near annex unit. The Administrator was in hall and made aware, he told her to put on a mask. The Signage at the main entrance to facility as well as on entrance to the unit read Everyone must wear a mask in all buildings on campus. 8/18/22 at approximately 2:00 PM, an interview was conducted with the Director of Nursing (DON) who stated it is the expectation that everyone wear a mask while in the facility. She stated if you are in the Administration area (not in patient care areas) you may wear a surgical mask however if you are in a patient care area you must wear an N-95. On 8/18/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 40452 2. For Resident #158 (on Transmission-Based Precautions), the facility staff failed to post signage to indicate what personal protective equipment (PPE) should be worn prior to entering the room. On 08/16/2022 at approximately 1:05 P.M., this surveyor observed Transmission-Based Precautions (TBP) supplies outside Resident #158's room but there was no signage to indicate what PPE should be worn prior to entering the room. At approximately 1:10 P.M., Certified Nursing Assistant E (CNA E) was observed at nurse's station. When asked about what PPE should be worn prior to entering Resident #158's room, CNA E indicated that all PPE, except eye protection, should be worn upon entering Resident #158's room. On 08/16/2022 at 2:30 P.M., CNA D was interviewed. When asked what PPE should be worn prior to entering Resident #158's room, CNA D explained that all the staff know what to wear because it's all right here and pointed to the TBP supplies on Resident #158's room door. CNA D then noticed one of the pouches on the supply caddy was empty and stated that the masks needed to be replenished. CNA D then stated that they have morning meetings with all department heads so all the staff will know what PPE to wear. On 08/17/2022 at approximately 9:15 A.M., this surveyor observed signage outside Resident #158's room indicating Resident #158 was on Contact Precautions and PPE to be worn prior to entering the room was gown, gloves, mask, and eye protection. The pouch on the supply caddy that was empty on 08/16/2022 was now fully stocked with faceshields. On 08/17/2022 at 3:00 P.M., the Infection Preventionist was interviewed. When asked about the expectation for TBP signage, the Infection Preventionist stated the type of isolation and the donning/doffing sign should be posted outside the room. On 08/17/2022 at approximately 5:30 P.M., the Administrator and Director of Nursing were notified of findings. On 08/18/2022, the facility staff provided a copy of their policy entitled, Isolation Precautions.: In Section IV Part C, it was documented, Obtain appropriate signage and post outside doorframe of resident's room .

Based on interview, clinical record review, facility documentation and in the course of an investigation, the facility staff failed to provide and accurate clinical record for 1 Resident (# 114) in a survey sample of 47 Residents. The findings included: For Resident #114 the facility staff failed to ensure the accuracy of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/17/22 at approximately 1:00 PM a review of the clinical record was conducted and the following are excerpts from the physician's progress notes. 6/21/21 Exam Findings - Derm. [Dermatological] - NO Rash - Ulcer. 6/22/21 Right leg [CONDITION(S)] to the knee - +/- from walking boot too tight but will treat. 6/25/21 Exam Findings - Derm [Dermatological] - NO Rash - Ulcer. 6/28/21 Exam Findings - Derm [Dermatological] - NO Rash - Ulcer. 6/30/21 Boot on RLE [right lower extremity] 2+ pitting [CONDITION(S)] in LLE, multiple wounds in distal LLE with wound between 4th and 5th phalanges, slough build up noted, extremity is erythematous, but no warmth. A&P [CONDITION(S)] vs [CONDITION(S)] -Start [MEDICATION(S)] BID X 7 days. -Evaluate for Osteo. L foot XR; CBC, BMP, CRP, ESR A review of the Admission Assessment done on 6/15/21 revealed that the nurse who did the assessment did not list any wounds for Resident #114, nor did she initiate any wound assessment forms. A review of the clinical record also revealed a Braden Scale with a score of 19 out of a possible 19, indicating No Risk Pressure Sore. The Braden scale was performed on 6/19/21 excerpts are as follows: Sensory Perception: Ability to respond meaningfully to pressure-related discomfort. No Impairment Activity: Degree of Physical Activity - Walks occasionally Please note: this Resident uses a walker or wheelchair and has a boot to his right foot due to recent ankle fracture. Ability to change and control body position. NO Limitation Problem A review of the care plan revealed the following excerpts: [Resident name redacted] has a potential for impaired skin integrity effective: 6/15/22 GOAL [Resident name redacted] will not experience impaired skin Interventions: Inspect skin and report any bruises, open areas, or discoloration Encourage [Resident name redacted] to re-position or provide assistance with turning and repositioning as needed. Please note: this Resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This should have lowered the score of the assessment. A review of the MDS from July 2021 revealed that the Resident was coded as requiring #3 -Extensive assistance with bed mobility and transfers this also should have lowered the score of the Braden Scale. On 8/18/22 at approximately 2:45 PM an interview was conducted with the DON and the Administrator when asked about the Resident the Administrator stated that this Resident was in the facility prior to his starting there. The DON was aware of the Resident and the issues with this Resident, however she stated she was not the DON at the time Resident #114 was in the building. The Administrator also stated that the Medical Group (Doctors and Nurse Practitioners) that was working at the facility at that time are no longer working in the building. The DON was asked to read over the progress notes from the Physician and was asked if they appeared accurate. She indicated that they were not. She stated that the Resident had wounds the physician did not address in his notes. When asked if the Braden Scale appeared accurate she stated that it was not accurate it did not include factors that would have lowered the score. When asked if the Admission Assessment was accurate she stated that it was not because the Resident was admitted with a fractured right ankle wearing a cam boot and bilateral stage 1 pressure ulcers to heels. On 8/17/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, facility documentation and clinical record review the facility staff failed to appropriately label and store insulin in one of the two medication carts. The findings included: For one medication cart (located on Annex Hall), Surveyor C found 2 insulin pens opened and undated. On 8/19/22 at approximately 8:00 AM while completing the medication storage task it was noted that 2 insulin pens were not dated when opened. Pen #1 was a Lantus insulin pen opened but not dated, and pen #2 was a Humalog Lispro pen opened but not dated. When Licensed Practical Nurse F (LPN F) was asked about the pens, LPN F stated she thought the meds were brought from home. When asked how you would know when they were opened she stated she would not be able to tell. On 8/19/22 at approximately 10:00 AM an interview was conducted with the Director of Nursing (DON) who stated that insulin is to be dated when opened so that you will know when it expires. We keep insulin only for 28 or 30 days depending on which type of insulin that is why it's important to date the insulin when opened. She further stated that the LPN was wrong. The insulin in question came from the pharmacy when the Residents were admitted . One was 7/29/22 and the other was 8/4/22 therefore they were both still ok to use however should have been dated when opened. On 8/19/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure freedom from accident hazards by providing adequate supervision to prevent accidents, for 1 Resident (# 14) in a survey sample of 47 Residents. The findings included: For Resident # 14 the facility staff failed to ensure the Resident #14 was supervised to prevent falls. Resident #14 has diagnoses that include anxiety disorder, age related osteoporosis, cerebral infarction, dementia with behavioral disturbance, repeated falls, restlessness and agitation, and visual impairment from glaucoma with detached lens. On 8/17/22 a review of the clinical record revealed the following progress note: 8/13/22 11:02 PM - At 5:20 PM Assigned sitter reported to this writer resident fell out of chair and was on the floor Sitter stated she went to get food try [sic] off the cart on the unit and went back to room and found that her wheelchair was flipped over and the resident was laying on right side of her body on the floor with both legs sitting on top of the leg rests on the wheelchair with the wheelchair flipped forward. When this writer approached room [ROOM NUMBER], resident was laying on right side with blood pooling on the floor from the right forehead cut above the right eyebrow. Resident alert and oriented to self, and able to flex and extend bilateral lower and upper extremities independently and on command. Hospice notified. Resident taken to [hospital name redacted] by ambulance and 2 EMT's. Son [name redacted] notified. A revealed that the Resident has been care planned for falls and fall interventions included the following: Frequent room checks when not in common area. STATUS -Active (current) Created 12/14/16 Do not leave unsupervised in bathroom. STATUS - Active (current) 12/14/16 Assess on afternoon rounds if [Resident #14 name redacted] is positioned comfortably or is needing to get up. If already awake she needs to be placed in wheelchair and near to staff. Status: Active (current) Created 12/12/18 Try to keep [Resident #14 name redacted] near staff for close supervision when out of bed. STATUS: Active (current) 12/14/16 Reeducate family to not leave [Resident 14 name redacted] in the room in her wheelchair after visits. Request that they bring her back to be nearby staff or at least tell staff they are leaving so she can be easily viewed by staff. STATUS: Active (current) Created 3/22/20. On 8/18/22 at approximately 1:00 PM an interview was conducted with RN C who stated that the staff was aware of the history of repeated falls with this resident. She stated this resident had a sitter because she could not be left alone. She stated the fall was due to the sitter leaving the room to get the Resident's dinner tray. She was asked if the sitter should have left the resident unattended and she stated that she should have either asked staff to bring the tray to her or asked another staff to sit with the Resident while she went to get the tray. On 8/19/22 during the end of day conference the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, clinical record review, facility documentation and during the course of a complaint investigation the facility staff failed to provide care that meets professional standards of care for 2 Residents (# 113 and # 43) in a survey sample of 47 Residents. The Findings included 1. For Resident #113 the facility staff failed to accurately perform an admission assessment to include skin assessment. Resident #113 was admitted to the facility on [DATE]. The admission assessment was performed on 6/15/21 the Admission Assessment has many areas that have been left blank excerpts are as follows: Pg. 2 - Height - [area left blank] Weight - [area left blank] Pg. 3- Neurological Hand grasp - [area left blank] Pg. 3 Sleep Sleep Pattern- [area left blank] Pg. 6 - Pulmonary Presence of Sleep Apnea No History of Sleep Apnea [Please note Resident #114 uses a CPAP at night] Pg. 8 - Skin Integrity Skin intact- [area left blank] Skin color - Normal appearance for race Skin temperature - cool Skin Moisture - Dry Skin turgor - good Other skin problems - [area left blank] Wounds - [area left blank] Foot Problems - [area left blank] This Admission Assessment was signed by an LPN, with no RN co-signature and the last line on page 9 read: **Please do not lock form unless signed by an RN** On 8/16/22 an interview was conducted with the Director of Nursing (DON) who was asked if LPN's can do an Admission Assessment without an RN co-signature and she stated that they could not. When asked if this Resident's Admission Assessment had an RN co-signature she stated that it did not. On 8/16/22 during the end of day meeting the Administrator was made aware of the finding and no further information was provided. 40452 2. For Resident #43, the facility staff failed to complete neurological assessments, a fall risk assessment, or a fall investigation in accordance with professional standards of practice following an unwitnessed fall on 01/17/2022. On 08/18/2022, Resident #43's clinical record was reviewed. Resident #43's Minimum Data Set with an Assessment Reference Date of 03/16/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 6 out of possible 15 indicative of severe cognitive impairment. An excerpt of a nurse's note dated 01/17/2022 at 11:44 A.M. documented, Resident was observed on the floor near her bed. Resident was unable to state what happened or what she was trying to do. No new injury noted. Resident had no complaints of pain or discomfort. Nurse and CNA [certified nursing assistant] assist resident up and into her wheelchair. On 08/19/2022 at approximately 9:40 A.M., the neurological assessments, fall risk assessment and investigation pertaining to the fall on 01/17/2022 were requested and the Director of Nursing (DON) confirmed there were no neurological assessments, fall risk assessment, or investigation pertaining to Resident #43's fall on 01/17/2022. According to Perry & Potter Clinical Nursing Skills & Techniques, 2018, 9th Edition, under the header Fall Prevention in Health Care Agencies, the following excerpts were documented: Identified interventions that have shown some success in reducing .fall rates: Using validated fall risk assessments that are predictive of falls . Conducting post-fall follow-up and quality improvement. On 08/19/2022, the facility staff provided a copy of their policy entitled, Fall Prevention and Management. In Section I Part 1, an excerpt documented, All Residents will have a Fall Risk Assessment completed on admission or change in condition. An excerpt in Section II(4) documented, Take note of the Resident's positioning, environment, and activities involved in prior to the fall to assist in the investigation of causative factors and subsequent implementation of appropriate interventions. Section II(5)(c) documented, Neurological Assessment for all falls .where involvement to the head cannot be determined due to the Resident's cognitive status. On 08/19/2022 at approximately 2:00 P.M., the administrator and Director of Nursing were notified of findings.

Based on observations, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for 2 Residents (Resident #43, Resident #113) in a sample size of 47 Residents. 1) For Resident #43, the facility staff failed to revise the care plan for 10 out of 10 falls that have occurred in March and April 2022. 2) For Resident #113, the facility staff failed to review and revise care plan upon discovery of arterial and pressure wounds. The findings included: 1) For Resident #43, the facility staff failed to revise the care plan for 10 out of 10 falls that have occurred in March and April 2022. On 08/17/2022, Resident #43's clinical record was reviewed. According to the progress notes, Resident #43 had 6 unwitnessed falls in March 2022 and 4 unwitnessed falls in April 2022. An excerpt of a nurse's note dated 03/12/2022 at 6:33 A.M. documented, Bed in lowest position, fall mat in place, call bell within reach. Will continue to monitor resident for safety for duration of shift. The care plan was reviewed. A focus dated 12/17/2021 entitled [Resident #43] has a potential for falls. The care plan was not revised to include actual falls in March and April and any associated interventions. On 08/19/2022 at 11:00 A.M., the Director of Nursing (DON) was interviewed. When asked about expectations for reviewing/revising the care plan pertaining to falls, the DON stated the care plan should be reviewed quarterly and with any changes in condition. The DON also indicated that the care plan should be revised as necessary with each fall incident. On 08/19/2022 at 11:55 A.M., Certified Nursing Assistant B (CNA B) was interviewed. When asked about interventions in place for fall precautions for Resident #43, CNA B listed fall mats, scoop mattress, and bed in lowest position. This surveyor and CNA B entered Resident #43's room (which was situated near the nurse's station) for an observation. Resident #43 was not in the room at the time. There was a scoop mattress on the bed and fall mats up against the wall. On 08/19/2022 at approximately 12:00 P.M., Licensed Practical Nurse B (LPN B) was interviewed. When asked about interventions in place for fall precautions for Resident #43, LPN B stated that Resident #43 has a sitter during the day and also, Resident #43 was moved to a room closer to the nurse's station. On 08/19/2022, the facility staff provided a copy of their policy entitled, Care Plan Process - Person Centered. In Section 10, it was documented, The person-centered care plan is an on-going plan of care and will be revised as necessary as the needs, choices, or expectations of the resident change or are identified. On 08/19/2022, the facility staff provided a copy of their policy entitled, Fall Prevention and Management. In Section I Part 2 an excerpt documented, All Residents will have the potential falls addressed on their initial plan of care with revisions made as necessary. 2. For Resident #114 the facility staff failed to review and revise care plan upon discovery of arterial and pressure wounds. Resident #113 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/22 a review of Resident #113's clinical record was conducted and Resent #113 was found also found to have developed arterial wounds. A review of Resident #113 care plan revealed no care plan for his pressure ulcers and arterial wounds until 7/5/21. On 8/18/22 an interview was conducted with the Director of Nursing (DON) who stated that care plans should be updated with each change in condition or treatment change. When asked who updates the care plans she stated that the nurses and the Interdisciplinary Team (IDT) make the updates and changes. A review of the care plan policy read: Page 3 10. The person-centered care plan is an ongoing plan of care and will be revised as necessary as the needs, choices or expectations of the resident change or are identified. On 8/19/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview, and clinical record review the facility staff failed to maintain privacy of personal medical record for 1 Resident (#110) in a survey sample of 47 Residents. The findings included: For Resident #110 the facility staff failed to ensure the computer screen was locked and closed so that the Resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/18/22 08:35 AM, Surveyor C walked up to the medication cart across from room [ROOM NUMBER]. On the medication cart, the computer screen was open, and Resident #110's picture and Medication list were displayed. Surveyor C waited approximately 2 minutes for Licensed Practical Nurse E (LPN E) to return to her cart. LPN E was asked if she was working with the cart and she indicated that she was. LPN E was asked why she had left the cart and she stated I had to hurry into a room. When asked if there was an emergency or a Resident in danger and she stated that there was not. LPN E stated that she was an agency nurse and that she should have closed the screen. She stated she was only going to be in the room a minute. 08/18/22 10:00 AM an interview was conducted with the Director of Nursing (DON), who stated that the computer screen should be logged off to protect privacy of the resident. On 8/18/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on clinical record review and staff interview, the facility staff failed to provide an ABN (Advanced Beneficiary Notice) for one Resident (Resident #54) in a sample size of 3 Residents. The findings included: On 08/17/2022 at approximately 11:45 A.M., the facility staff provided a list of Residents who were discharged from a Medicare covered Part A stay with benefit days remaining. Three Residents on the list were identified and placed in the sample. One Resident that remained at the facility following a discharge from Medicare Part A services with benefit days remaining was Resident #54. On 08/18/2022, Resident #54's closed clinical record was reviewed. A Social Services discharge note dated 03/30/2022 at 11:40 A.M. documented, Writer met with resident and presented NOMNC [Notice of Medicare Non-Coverage] with last cover day by Medicare being April 1, 2022 with a discharge from Medicare A stay on April 2, 2022. Right to appeal was reviewed, and all questions addressed. Resident reported she is going to utilize respite days, and remain at [facility]. There was no evidence an ABN was provided. On 08/18/2022, the facility staff completed a Beneficiary Protection Notification Review form for Resident #54 as requested. According to the document, the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted and an ABN form was not provided. On 08/19/2022 at 12:50 P.M., the Administrator was notified of findings. When asked why the ABN form was not provided, the Administrator confirmed that the facility staff were not providing them. The facility policy for ABN provision was requested. At approximately 1:30 P.M., the Administrator stated they don't have a policy pertaining to ABN.

Based on interview, clinical record review, and facility documentation the facility staff failed to promote and facilitate resident self-determination through support of Resident choices, for 1 Resident (# 110) in a survey sample of 47 Residents. The findings included: For Resident # 110, the facility staff failed to assist the Resident out of bed at approximately 2:00 AM as he requested. On 8/16/22 at approximately 1:30 PM an interview was conducted with Resident #110 and his family member. Resident #110 was admitted to the facility on [DATE] and stated that he had no problems with the facility until Last night. When asked what happened, he stated that had recent hip surgery and often woke up uncomfortable and not able to sleep well. He stated that he wanted to get out of bed and get in his recliner and watch TV hoping the change of position would help his discomfort. Resident #110 stated that he rang his call bell and it was answered by the nurse who told him that he could not get out of bed. When he asked why he was told that he had been given pain medicine at 1:30 AM. The Resident stated that he then called his daughter to come to the facility at 2:00 AM. Resident #110's daughter stated that prior to the hip surgery her father was a restless sleeper and he did get up a few times a night and that was his normal routine. A review of the clinical record revealed the following note: 8/16/22 2:27 AM - Resident receiving skilled care for surgical repair of right hip d/t [due to] right hip FX [fracture]. Received awake and attempting to get oob [out of bed]. Resident at first stated he had no pain, then admitted that pain was 8/10. Nurse administered PRN [as needed] Oxycodone at 1:30 AM for pain, and he took it without issues. His daughter came in to visit because he called stating he wanted to get oob. (He is not and was told the same by the CNA [Certified Nurses Assistant] and myself. [Sic] He also stated that he needed to use the bathroom although urinal is next to bed. Daughter informed of pain med that was given. On 8/16/22 at approximately 3:45 PM an interview with the Director of Nursing (DON) was conducted and she stated that if a Resident prefers to get out of bed it does not matter what time it is, it is our staff's responsibility to assist them out of bed, should they require assistance, and as long as it is safe for the Resident to do so. On 8/17/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations, staff interview, and facility documentation review, the facility staff failed to adhere and maintain infection control practices in one out of 5 units. The findings include: A facility staff member was observed donning and doffing personal protective equipment (PPE) incorrectly. On 08/25/2020 at approximately 11:05 AM, the DON and this surveyor observed CNA B don and doff PPE. CNA B was already wearing a kn95 and faceshield. CNA B donned a gown then gloves. There was approximately 1 inch of exposed skin around each of CNA B's wrists. When asked if she felt safe and protected with her PPE on, CNA B stated yes. When asked about her wrists being exposed, CNA B stated and demonstrated she would pull the gown cuffs down over the gloves to cover the exposed skin. When asked if she always did it this way, CNA B stated Yes. CNA B was then asked to demonstrate doffing of PPE. CNA B then reached behind her neck and untied the gown with her gloved hands, removed the gown, rolled it up and placed it in the trash. CNA B then removed her gloves and placed them in the trash. When asked if she always took gown and gloves off in this sequence, CNA B stated, Yes. When asked about potential contamination by untying gown with gloved hands, CNA A stated, I see what you're saying. On 08/25/2020 at approximately 2:00 PM, an interview via telephone with Licensed Practical Nurse A (LPN A), the unit manager of the transitional unit, was conducted. When asked about donning doffing sequence, LPN A stated that the gown goes on first, then the kn95, the faceshield, and then gloves. When asked about the gown cuffs, LPN A stated the gloves go over the cuff so there is no gap. When asked why, LPN A stated that anything could get in there, infectious material, if not properly sealed. When asked about doffing sequence, stated first take off the gloves, if hands get contaminated, wash hands, then remove the faceshield, then the gown, put it in a small bundle to discard it then wash hands again. The facility staff provided a copy of their in-service sheets and donning and doffing poster. An in-service signature sheet dated 4/7/20 under the header, Subject Matter Covered documented, Donning and Doffing PPE on (transitional unit name). The form contained CNA B's signature. The facility staff also provided a copy of the document (CDC publication) entitled, Sequence for Putting On PPE contained 4 steps. Step 4 documented, 4. Gloves - extend to cover wrist of isolation gown. A document (CDC publication) entitled, How to safely remove PPE contained 5 steps. An excerpt of Step 1 documented, 1. Gloves - outside of gloves are contaminated! If your hands get contaminated during glove removal, immediately wash your hands or use alcohol-based hand sanitizer. On 08/25/2020 by the end of survey, the administrator and DON were notified of findings and they offered no further information.