Every finding on record at Worthington Healthcare Center

Based on observation, record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to maintain standards of infection control during medication administration. This was a random opportunity for discovery during the facility task of medication administration. The facility also failed to provide documentation of infection surveillance activities. This deficient practice had the potential to affect more than a limited number of residents. Resident Identifier: #48. Facility Census: 89. Findings included: a) Resident #48 The facility's policy titled, Medication Administration, with no implementation or revision dates, stated not to touch medication. On 08/11/26 at 9:15 AM, Licensed Practical Nurse (LPN) #93 was observed administering morning medications to Resident #48. The resident's medications were in a plastic packet. LPN #48 opened the packet and poured the medications into a medication cup set directly on the medication cart. One medication tablet fell onto the medication cart instead of into the medication cup. LPN #93 picked the tablet up from the medication cart with her bare hands and placed it into the medication cup for administration to Resident #93. After LPN #93 administered the oral medications to Resident #48, she confirmed she had picked the medication tablet off of the medication cart with her bare hands. She stated she did not know the facility's policy regarding dropping and touching medications. On 08/11/2026 at 12:48 PM, the Director of Nursing confirmed touching medications with bare hands was against the facility's medication administration policy. The facility's policy titled, Medication Administration, with no implementation or revision dates, stated to perform hand hygiene and don gloves to administer eye drops. On 08/11/26 at 9:15 AM, Licensed Practical Nurse (LPN) #93 was observed administering morning medications to Resident #48. Among the medication administered was Ciprofloxacin eye drops to the left eye. LPN #93 administered the eye drops to Resident #48 but did not perform hand hygiene before administration and did not don gloves. After LPN #93 administered the eye drops to Resident #48, she confirmed she had not performed hand hygiene or donned gloves before administering the eye drops. She stated she did not know the facility's policy regarding administering eye drops. On 08/11/2026 at 12:48 PM, the Director of Nursing confirmed the facility's medication administration policy stated to perform hand hygiene and don gloves before administering eye drops. b) Per interview with the Regional Director of Clinical Operations, the facility was unable to provide documentation demonstrating that infection surveillance activities had been completed for the months of June and July 2026. The Regional Director reported that the current Infection Preventionist (IP) assumed her position approximately a couple weeks prior to the interview and began conducting infection surveillance upon assuming the role. However, documentation supporting completion of infection surveillance for June and July 2026 was not available for review. This resulted in an inability to verify that infection surveillance was consistently conducted and documented during these two months. This was confirmed by Regional Director of Clinical Operations on 8/12/26 at 5:00 pm.

Based on observation, record review, and staff interview, the facility failed to ensure a resident's comprehensive care plan was updated when the resident's plan of care changed. This deficient practice had the potential to affect one (1) of two (2) residents reviewed for the care area of falls. Resident Identifier: #13. Faciility Census: 89. Findings included:Findings included: a) Resident #13 The facility's policy and procedure titled, Safe Use of Bed Rails (Grab Bars), with no implementation or revision date given, stated documentation for residents requiring the use of bed rails would include care planning the intervention. Observation of Resident #13 on 08/10/2026 at 2:14 PM, showed the resident had bilateral grab bar rails on his bed. Review of Resident #13's electronic health record showed the resident had a bed safety assessment performed on 07/23/26 and an order for bilateral assist rails for bed mobility and transfers on 07/24/26. Review of Resident #13's comprehensive care plan showed the resident had a focus related to mobility performance: functional deficits related to dementia impairing cognition, dysphagia, generalized muscle weakness. Bilateral assist bed rails were not listed as an intervention. On 08/12/26 at 2:53 PM, the Director of Nursing confirmed Resident #13 was not care planned for bilateral assist rails to assist with bed mobility and transfers.

Based on resident interview, record review and staff interview, the facility failed to provide dental services for a resident receiving Medicaid services. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the dental care area. Resident Identifier: #14. Facility Census: 89. Findings included: a) Resident #14 Resident #14 was interviewed on 08/10/26 at 2:54 PM. She was noted to be edentulous. Her speech was difficult to understand by the surveyor. When questioned, Resident #14 stated she had upper dentures, but she didn't like to wear them without her lower dentures. She stated she had lower dentures when she was admitted to the nursing home but they had been lost during a hospitalization. Resident #14 stated she didn't know when this hospitalization occurred. She stated she would like to have her lower dentures replaced. She stated she did not believe she had specifically told anyone at the facility that she wished to have her dentures replaced. The resident denied difficulty eating. Review of Resident #14's personal effect inventory upon admission showed the resident had upper and lower dentures. The inventory was dated October 21, but the year was not given. The resident was admitted in October 2025. Resident #14's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 10/15/25 showed the resident was edentulous and had broken or loosely fitting full or partial denture. The nursing admission assessment completed 10/08/26 reported no oral concerns. The resident's care plan had the following focus initiated on 10/24/25: Resident is at risk for oral/dental problems related to being edentulous with full upper and lower dentures. Review of the resident's census records showed the resident had a hospitalization from 05/03/26 through 05/14/26. The resident's current diet order was for a regular diet, regular texture, thin liquids consistency. A nutritional assessment completed 06/29/26 gave no information regarding the resident's oral status. Resident #14's MDS with ARD 06/29/26 showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The physician's determination of capacity completed 05/27/26 showed the resident had capacity to make her own medical decisions. On 08/12/2026 at 8:19 AM Nurse Aide (NA) #90 stated she did not know if resident had upper and lower dentures. She stated the resident did not want to wear her dentures. On 08/12/26 at 09:00 AM, MDS Nurse #89 was interviewed. She stated she was not the MDS Nurse when Resident #14's admission MDS reported a broken or loosely fitting full or partial denture. She stated that, in general, dental issues should be reported to the Director of Nursing (DON) when identified during MDS assessment. On 08/12/26 at 09:30 AM, Director of Clinical Operations (DCO) #121 and Social Worker (SW) #3 stated they had no knowledge regarding Resident #14's dentures but would look into the matter. On 08/12/2026 at 10:11 AM, DCO #121 stated she had spoken to Resident #14. The resident stated her lower dentures were lost during a hospitalization and she would like them replaced. DCO #121 stated an appointment had been made for the next day. The following progress note was written on 8/12/2026 at 10:03 AM, Spoke with Resident about current diet/dentures. Resident states she is tolerating a regular diet. States dentures are greater than [AGE] years old. She currently wears upper denture with adhesive. She currently does not use the lower denture. Resident is interested in having dental assessment for adjusting upper and having new lower made. She is okay with using [dental provider]. Appt [appointment] made at this time for 8/13 at 11:15 am. Will make Resident aware.On 08/12/2026 at 12:38 PM, SW #3 stated she had also spoken to Resident #14's daughter, who stated the resident's dentures had not fit for some time. SW #3 stated Resident #14 was able to eat well without her dentures, and supplied documentation showing the resident requested a regular texture diet. However, SW #3 acknowleged denture use could also promote dignity for edentulous residents.

Based on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. The staff failed to use proper hand hygiene and don a hairnet while in the kitchen. Lastly, failed to maintain the equipment in safe operating condition. This practice had the potential to affect more than an isolated number of residents. Facility census: 93. Findings included: a) On 04/02/2024 at 12:49 PM, during a visit to the kitchen the following was observed: -Corn flakes found stored without label opening and used by date -Breaded fish found in freezer left open to air. In an interview with The Food Service Supervisor, at 1:10 PM on 04/02/2024, she acknowledged the both the corn flakes were found stored without an opening and used by dated label, and the breaded fish was found left open to air in the freezer. On 04/02/25 at 11:50 PM During lunch dining observation it was observed that NA #79 wheeled a male resident into the dining room to a table and walked into the kitchen. Observing through the window on the door, NA #79 stood in the kitchen for approximately 3 minutes. The back of her head and hair were not covered with a hairnet. The NA re-entered the dining room and waited by the resident for his tray. When the tray was ready, The NA then took the tray from the kitchen staff and returned to the resident and began to assist with tray set up. She did not wash her hands before taking the food tray from kitchen staff. In an interview with the food service supervisor (FSS), on 04/02/25 at 12:15 PM, FSS acknowledged the CNA did come into the kitchen but did not realize NA #79 had not placed the hairnet on correctly. She stated she did not see the back of NA's hair not covered, she could only see her from the front, in which she stated the NA did have a hairnet on the top and front of her head. She also stated she was unaware the NA did not wash or sanitized her hands before taking the food tray. She stated the CNA should have washed/sanitized her hands before taking the tray to the resident and assisting in tray set up. 42120 c) Ice Machines On 03/31/25 at 10:16 AM the tour with the Dietary Manager found the ice machines located in the Kitchen area did not have the required water filter on the ice machines. The continuation of the tour found the east and west unit ice machines did not have the required water filters. On 03/31/25, the Maintenance Director stated that he was unsure if the ice machines should have water filters in place. Review of the manufacture's guide and guidance at www.manitowocice.com found that the Manitowoc ice machine water filter plays a critical role in ensuring the water supplied to your ice machine is clean, free from impurities, and properly filtered. During an interview and observation, on 04/01/25 at 1:37 PM, the Service Supervisor from DSO Service Company was placing water filters on all the ice machines in the facility. During the interview he stated the Manitowoc Ice Machine does not have an internal water filter. He continued to say that the external water filter is required for safe, clean ice. During an interview, on 04/01/25 at 1:45 PM, the Administrator stated he called DSO company to make sure all ice machines were functioning safely for the residents.

Based on record review and staff interview, the facility failed to obtain labs, as ordered by the physician, for Resident #41. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: #41. Facility census: 93. Findings include: A) Resident #41 During a review of Resident 41's record on 04/01/25, it was noted the resident had the following order- CBC, BMP and HGBA1C in the morning every three (3) months starting on the 2nd for one (1) day. This order was entered into the system on 11/4/24. Review of the resident's lab results, and progress notes indicated no labs were drawn in the month of March 2025. According to the order, the labs should have been taken on 03/02/25. Documentation regarding the labs was requested from the facility at approximately 11:45 AM on 04/01/25. On 04/01/25 at approximately 1:44 PM, the facility provided documentation related to Resident #41's labs. The only documentation for lab draws, were from labs completed on 12/02/24. Upon further review of Resident #41's orders, it was noted her orders for labs were changed at 12:38 PM on 04/01/25 to CBC, BMP, and HGA1C, every day shift every four (4) months starting on the 2nd for one (1) day. At approximately 1:50 PM on 4/1/2025, an interview was conducted with Registered Nurse Regional Director of Clinical Operations (RNRDCO) #120 regarding the labs and orders. RNRDCO #120 confirmed the labs were not drawn on 03/02/25, or any time in the month of March 2025, and that the order had recently been changed to every four (4) months, after surveyor intervention.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to ensure a physician order for pain was correctly followed for Resident #4. This failed practice was true for one (1) of one (1) residents reviewed for pain. Resident identifier: #4. Facility census: 93. Findings included: a) Resident #4 A medical record review, completed on 05/09/23 at 11:27 AM, revealed the following physician order, dated 02/09/25, Hydrocodone-Acetaminophen Tablet 7.5-325 MG. Give 1 tablet by mouth every 6 hours as needed for moderate to severe pain (5-10) not to exceed 3gm Tylenol in 24hr. Review of the February and March 2025 Medication Administration Records (MARs) revealed the following dates and times the medication was not given in accordance with the physician's order: -On 02/13/25, the medication was given with a pain level of 4 -On 02/22/25, the medication was given with a pain level of 4 -On 02/22/25, the medication was given with a pain level of 4 -On 03/18/25, the medication was given with a pain level of 4 -On 03/19/25, the medication was given with a pain level of 4 -On 03/21/25, the medication was given with a pain level of 4 -On 03/22/25, the medication was given with a pain level of 4 -On 03/23/25, the medication was given with a pain level of 4 -On 03/24/25, the medication was given with a pain level of 0 -On 03/27/25, the medication was given with a pain level of 4 During an interview, on 04/01/25 at 2:16 PM, the Mobile Director of Nursing (DON) acknowledged nursing staff had failed to follow the physician's order correctly and had administered medications outside the parameters of the designated pain scale.

Based on medical record review and staff interviews, the facility failed to aid a resident and/or their legal representatives with advance care planning, including but not limited to completion of advanced directives per professional standards. This is true for one (1) of 27 reviewed for advanced directives. Resident identifier #75. Facility census: 93. Findings included: a) Resident #75 A medical record review for Resident #75 revealed an admission to the facility on [DATE]. An Encounter Summary provided to the surveyor from the transferring hospital found the capacity statements from 02/29/25. -- Demonstrates Capacity to make medical decisions was marked. Continued review found that physician determination of capacity was completed on 02/20/25. -- Demonstrates Capacity to make decisions was marked. Subsequent review found that the review of Resident 75's Minimum Data Set (MDS) with the ARD date of 02/26/25, finds the resident has a score of 03. A BIMS score of 3 indicates that the resident is severely impaired. A Physician Orders for Scope of Treatment (POST) form completed by the directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1) was completed on 03/12/25 with the signature of Resident #75 by Social Worker #300. A nurse progress note was reviewed on 04/01/25. -- 4/1/2025 at 12:54 Note Text: Physician will be in on Thursday to see Resident and re-evaluate capacity due to BIMS of 3 per MDS. During an interview with the Regional Director of Clinical Operations, 121 confirmed that the BIMS score was 3 prior to Resident #75 signed the POST form.

Based on observation, record review and staff interview, the facility failed to maintain a safe and accident-free environment as possible. This deficient practice had the potential for Resident #46 to harm himself in the absence of 1:1 supervision. Resident identifier: #46. Facility census: 93. The state agency determined this failure placed Resident #46's 1:1 observation status in an immediate jeopardy situation due to the potential of serious injury and/or death because of recent documented suicidal ideations and recent suicide attempt. The state agency notified the Nursing Home Administrator of the immediate jeopardy at 3:52 PM on 04/03/24. The facility submitted a plan of correction (POC) at 5:41 PM. At 5:48 PM, the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 12:05 PM on 04/08/24. Findings included: a) Resident #46 On 04/03/24 at 2:16 PM, an observation was made of Resident #46 alone lying in his bed with eyes open. The resident was asked, where is the staff that was sitting with you? The resident stated, I don't know. On 04/03/24 at 2:18 PM, Licensed Practical Nurse (LPN) #33 was walking down the hall. LPN #33 was asked if the resident was still on 1:1 observation. LPN #33 stated, yes .I don't know where the staff member is. On 04/03/24 at 2:20 PM, Nurse Aide #101 returned to the resident's room. While standing at the doorway, NA #101 was asked, where did you go? You left the resident alone. NA #101 stated, I've just been gone for a few minutes, I went and got the resident some ice. NA #101 had been observed down the hall at the nurses' station during this time frame. Upon review of the medical record, the resident was admitted to the facility on [DATE]. The resident has a documented diagnosis of depression, unspecified. The resident was prescribed Zoloft (antidepressant) 25mg (milligram) by mouth daily and Remeron (antidepressant) 15 mg at bedtime. The resident was noted with a Brief Interview for Mental Status of 06 (six) on a Minimum Data Set (MDS) quarterly assessment dated [DATE]. The score indicates severe cognitive impairment. The resident demonstrated incapacity for making medical decisions. A progress note dated 03/08/24 at 6:09 PM states, Nurse states patient using grabber to pull pillow tight over his face. When she asked what he was doing, patient states, I'm trying to kill myself. Requests order to send patient out as 1:1 is not available for patient. (Typed as written.) A review of a progress note dated 03/11/24 at 11:36 AM states, Resident noted to have suicidal ideation with plan/attempt on 03/08/24. Resident was sent to an (Name of the acute care facility) and returned to the facility 03/10/24. See new orders. Resident remains a 1:1 at this time. (Name of psychologist) notified of ideation/attempt and visit requested. LSW (Licensed Social Worker) has also made a referral to (Name of in house psychiatric facility) for in house psychiatric tx (treatment). POC (plan of care) has been updated. (Typed as written.) A progress note dated 03/11/24 at 12:45 PM states, Updated HCS (Health Care Surrogate) on all that has transpired from Friday. States she was aware of the incident Friday and the hospital made her aware that he was being sent (Name of inpatient psychiatric facility). She has been updated that they sent Resident back to (Name of facility) instead. Also updated on new orders and that (Name of psychologist) would be in be in to see Resident today. HCS states Resident has a hx (history) of suicidal ideation/attempts prior to coming to the (Name of the facility) and that he was also dx (diagnosis) with Schizophrenia before coming to (Name of facility). (Typed as written.) A progress note dated 03/11/24 at 7:47 PM states, (Name of psychologist) in to see resident, order received to send resident back to (Name of acute care facility) d/t (due to) suicidal ideations. (Typed as written.) A progress note dated 03/11/24 11:12 PM states, Resident returned from (Name of acute care facility), according to d/c (discharge) papers (Name of psychologist) agreed to have resident returned to the facility. CNA (certified nursing assistant) sitting 1:1 with resident. (Typed as written.) On 03/13/24 at 7:43 AM, a progress note states, Change in condition noted today: Resident remains 1:1 for suicidal ideation. (Typed as written.) A progress note dated 03/14/24 at 11:37 AM states, Change in condition noted today. Resident remains a 1:1 and is being followed by (Name of psychologist). (Typed as written.) On 03/18/24 at 1:41 PM a progress note states, .Resident continues to be 1:1. No further suicidal ideation/attempts however Resident acknowledge depression (negative thoughts) . A progress note dated 03/19/24 at 2:23 PM states, .He (resident) did ask this nurse when he will be by himself and not have someone with him, I told him that is up to the physician and we have 1:1 for his safety, he stated he understands, no other concerns at this time. (Typed as written) A progress note dated 04/02/24 at 10:57 AM states, 1:1 sitter. On 04/03/24 at approximately 2:35 PM, the Corporate Registered Nurse (RN) #147 was notified of the observation of the resident being alone. Corporate RN #147 confirmed the resident should not be alone. Corporate RN #147 stated, we have kept him on 1:1 for safety reasons. b) Facility Policy The facility policy entitled One on One Intervention Process states, The expectation of this intervention is the staff are in observation of the resident at all times until the intervention is no longer required. Abatement Plan 1. Resident # 46 was again placed on 1:1 Supervision. The C N A was removed from 1:1 assignment reported for unintentional neglect, reeducated on not leaving resident alone. 2. All residents who are receiving 1:1 have the potential to be affected by the alleged deficient practice. All other residents receiving 1:1 were checked, and no issues identified. 3. All staff members in the facility on 4/3/24 were immediately re-educated on 1:1 process including not leaving resident alone at any time. OHFLAC, APS, Ombudsman or other licensing board contacted. All staff not available, will be re-educated on 1:1 process at the start of their next scheduled shift. 4. The DON or designee will monitor that he is 1:1 during duration of 1:1 orders. If they need to leave the 1;1 assignment, they will ring call light and remain with resident until another employee relieves them. All allegations of unintentional neglect will be reviewed at the facility QA&A monthly .

Based on record review and staff interview, the facility failed to develop and/or implement the care plan for Resident #92, #84, #39 and #95, four (4) of four (4) residents reviewed. Resident identifiers: #92, #84, #39 and #95. Facility Census: 93. Findings included: a) Resident #92 On 04/03/24 at 9:00 AM, a record review was completed for Resident #92. The review found the care plan had not been developed to include all the interventions based on the physician's orders and the Treatment Administration Record (TAR) dated 03/01/24 through 03/31/24. The interventions that were not found were as follows: --Daily assessment of the unstageable (UN) wound on the right heel --Wound care as ordered On 04/03/24 at 10:00 AM, the Corporate Registered Nurse (RN) was notified and confirmed the interventions were not listed. b) Resident #84 On 04/03/24 at 9:15 AM, a record review was completed for Resident #84. The record review found the care plan had not been developed to include an Unstageable wound on the sacrum and the interventions found in the physician's orders and the TAR dated 03/01/24 through 03/31/24. The following interventions were not found as follows: --Daily wound assessment on the bullae of the right thumb, the unstageable wound of the sacrum, vascular wound of the lateral thigh, the vascular wound of the right lower extremity --Wound care as ordered --Float heels while in bed --Encourage to turn and reposition while in bed On 04/03/24 at 10:00 AM, the Corporate Registered Nurse (RN) was notified and confirmed the interventions were not listed. c) Resident #39 On 04/03/24 at 9:25 AM, a record review was completed for Resident #39. The review found the care plan had not been implemented based on the TAR dated 03/01/24 through 03/31/24. The following interventions were not implemented: --Administer preventative treatment as ordered --Administer treatments as ordered and monitor for effectiveness --Daily wound assessments per orders --Resident may use pillowcases between knees and to prevent skin breakdown due to contractures On 04/03/24 at 10:00 AM, the Corporate Registered Nurse (RN) was notified and confirmed the interventions were not implemented. d) Resident #95 On 04/03/24 at 9:40 AM, a record review was completed for Resident #95. The review found the care plan had not been implemented based on the physician's orders and the TAR dated 02/01/24 through 02/29/24. The following interventions were not implemented: --Daily wound assessment of the surgical wound of the right iliac crest --Turn resident every 2 (two) hours (alternate right side and left side and back for meals as tolerated On 04/03/24 at 10:00 AM, the Corporate Registered Nurse (RN) was notified and confirmed the interventions were not listed.

Based on record review and staff interview, the facility failed to follow physician's orders four (4) of four (4) residents. Resident identifiers: #92, #84, #39 and #95. Facility Census: 93. Findings included: a) Resident #92 On 04/03/24 at 9:00 AM, a record review was completed for Resident #92. The review found the physician's orders on the Treatment Administration Record (TAR) for 03/01/24 through 03/31/24 were not followed. The following treatments and dates were left blank: --Daily wound treatment to the stage III to the sacrum --03/02/24 day shift --Daily wound assessment for the stage III to the sacrum --03/02/24 day shift --Preventative treatment to the coccyx and bilateral buttocks twice daily --03/25/24 night shift --Bilateral palm guards on hands may remove twice daily to clean and monitor skin --03/25/24 night shift --Float heels when in bed twice daily for preventative measures --03/25/24 night shift --Resident may use pillow cases between knees to prevent skin breakdown due to contractures twice daily --03/25/24 night shift --Ensure resident has been turned and repositioned every 2 (two) hours for stage 2 (two) --03/03/24 at 12:00 AM, 2:00 AM, and 4:00 AM --03/15/24 at 6:00 PM --03/25/24 at 8:00 PM and 10:00 PM --03/26/24 at 12:00 AM, 2:00 AM, and 4:00 AM --03/28/24 at 4:00 AM On 04/03/24 at 10:00 AM, Corporate Registered Nurse (RN) #147 was notified and confirmed the TAR should have been completed as ordered. The Corporate RN #147 stated, I can't fix holes. b) Resident #84 On 04/03/24 at 9:15 AM, a record review was completed for Resident #84. The review found the physician's orders on the Treatment Administration Record (TAR) for 03/01/24 through 03/31/24 were not followed. The following treatments and dates were left blank: --Daily treatment to the bullae to the right thumb --03/03/24 day shift --03/06/24 day shift --03/12/24 day shift --Daily wound assessment of the bullae to the right thumb --03/03/24 day shift --03/06/24 day shift --03/12/24 day shift --Dressing change to Peripherally Inserted Central Catheter (PICC) line site every Tuesday --03/19/24 day shift --Daily wound care to the unstagable (UN) to the sacrum --03/03/24 day shift --03/12/24 day shift --03/15/24 day shift --03/19/24 day shift --Daily wound assessment to the vascular wound lateral thigh --03/03/24 day shift --03/06/24 day shift --03/12/24 day shift --03/15/24 day shift --03/19/24 day shift --03/20/24 day shift --03/21/24 day shift --Daily wound care to the vascular wound lateral thigh --03/03/24 day shift --03/15/24 day shift --03/19/24 day shift --03/21/24 day shift --Wound care to the vascular wound right lower extremity every other day --03/06/24 day shift --03/12/24 day shift --03/20/24 day shift --Daily wound assessment to the vascular wound right lower extremity --03/03/24 day shift --03/06/24 day shift --03/12/24 day shift --03/15/24 day shift --03/19/24 day shift --03/20/24 day shift --03/21/24 day shift --Encourage to turn and reposition while in bed every shift --03/06/24 day shift --Monitor Peripherally inserted central catheter (PICC) line site for signs/symptoms of infection every shift --03/06/24 day shift On 04/03/24 at 10:00 AM, Corporate Registered Nurse (RN) #147 was notified and confirmed the TAR should have been completed as ordered. The Corporate RN #147 stated, I can't fix holes. c) Resident #39 On 04/03/24 at 9:25 AM, a record review was completed for Resident #39. The review found the physician's orders on the Treatment Administration Record (TAR) for 03/01/24 through 03/31/24 were not followed. The following treatments and dates were left blank: --Daily wound care to the stage III sacrum --03/02/24 day shift --Preventative care to the coccyx and bilateral buttocks every shift --03/25/24 night shift --Bilateral palm guards on hands every shift --03/25/24 night shift --Float heels when in bed every shift --03/25/24 night shift --Pillow cases between knees to prevent skin breakdown every shift --03/25/24 night shift --Ensure resident has been turned and repositioned every 2 (two) hours for stage 2 (two) --03/03/24 12:00 AM, 2:00 AM and 4:00 AM --03/15/24 6:00 PM --03/25/24 8:00 PM and 10:00 PM --03/26/24 12:00 AM, 2:00 AM and 4:00 AM --03/28/24 4:00 AM On 04/03/24 at 10:00 AM, Corporate Registered Nurse (RN) #147 was notified and confirmed the TAR should have been completed as ordered. The Corporate RN #147 stated, I can't fix holes. d) Resident #95 On 04/03/24 at 9:25 AM, a record review was completed for Resident #95. The review found the physician's orders on the Treatment Administration Record (TAR) for 02/01/24 through 02/29/24 were not followed. The following treatments and dates were left blank: --Cleanse suprapubic catheter and apply drain sponge daily --02/03/24 day shift --Encourage resident to wear prevalon boots during the night --02/03/24 night shift --02/04/24 night shift --Daily wound assessment for surgical wound right iliac crest --02/03/24 day shift --02/04/24 day shift --Daily wound care to right iliac crest --02/03/24 day shift --02/04/24 day shift --Suprapubic catheter to BSD (bedside drain) document output every shift --02/03/24 day shift --02/03/24 night shift --0204/24 day shift --02/04/24 night shift --Encourage resident to wear gray fleece AFO (ankle foot orthosis) boots daily apply during AM (morning) medication pass and remove around 2:00 PM --02/03/24 application and removal --02/04/24 application and removal --Encourage resident to allow staff to turn and reposition every shift --02/03/24 day shift --02/03/24 night shift --02/04/24 day shift --02/04/24 night shift In addition, there were multiple physician's orders to encourage resident to turn and reposition every two (2) hours which at times did show on the TAR and other times the physician's orders did not. The following dates are the multiple times the physician's order was input: --01/12/24 to 02/05/24 The review under the task tab entitled Turn and reposition, the documentation was not complete or multiple duplicate times were documented. A review of the January, 2024 documentation found the following: --01/01/24 No documentation 12:00 AM 2:00 AM 4:00 AM 6:00 AM 8:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM --01/02/24 12:00 AM 2:00 AM 6:00 AM 8:00 AM 12:00 PM 2:00 PM 4:00 PM 8:00 PM 10:00 PM --01/09/24 No documentation found --01/10/24 No documentation found --01/11/24 No documentation except for 10:00 PM --01/13/24 12:00 AM 2:00 AM 4:00 AM 6:00 AM 8:00 AM 10:00 AM 2:00 PM 4:00 PM 6:00 PM 10:00 PM --01/14/24 12:00 AM 2:00 AM 6:00 AM 8:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM --01/15/24 2:00 AM 6:00 AM 8:00 AM 2:00 PM 4:00 PM 6:00 PM 8:00 PM 10:00 PM --01/16/24 12:00 AM 2:00 AM 6:00 AM 8:00 AM 12:00 PM 2:00 PM 4:00 PM 6:00 PM --01/17/24 6:00 AM 8:00 AM 2:00 PM 6:00 PM 10:00 PM --01/18/24 12:00 AM 2:00 AM 4:00 AM 8:00 AM 12:00 PM 6:00 PM 10:00 PM --01/19/24 12:00 AM 2:00 AM 4:00 AM 8:00 AM 10:00 AM 2:00 PM 6:00 PM --01/20/24 12:00 AM 2:00 AM 6:00 AM 8:00 AM 4:00 PM 6:00 PM 10:00 PM --01/21/24 12:00 AM 6:00 AM 10:00 AM 12:00 PM 4:00 PM 6:00 PM 10:00 PM --01/22/24 12:00 AM 2:00 AM 4:00 AM 6:00 AM 8:00 AM 12:00 PM 4:00 PM 6:00 PM 10:00 PM --01/23/24 12:00 AM 2:00 AM 8:00 AM 10:00 AM 2:00 PM 6:00 PM 8:00 PM --01/24/24 6:00 AM 8:00 AM 12:00 PM 4:00 PM 6:00 PM 10:00 PM --01/25/24 4:00 AM 8:00 AM 12:00 PM 4:00 PM 8:00 PM --01/26/24 12:00 AM 2:00 PM 4:00 PM 6:00 PM --01/27/24 12:00 AM 6:00 AM 8:00 AM 10:00 AM 2:00 PM 4:00 PM 8:00 PM 10:00 PM --01/28/24 12:00 AM 4:00 AM 8:00 AM 10:00 AM 12:00 PM 4:00 PM 6:00 PM 8:00 PM --01/29/24 12:00 AM 4:00 AM 2:00 PM 4:00 PM 6:00 PM 8:00 PM --01/30/24 6:00 AM 8:00 AM 2:00 PM 6:00 PM 8:00 PM --01/31/24 12:00 AM 2:00 AM 6:00 AM 8:00 AM 12:00 PM 4:00 PM 6:00 PM 10:00 PM On 04/03/24 at approximately 11:00 AM, the Corporate Registered Nurse (RN) #147 was notified and stated, I don't know why the physician's order is not showing on the TAR. --

Based on record review, review of legislative rule S 69-10-1 TITLE 69 Rule Department of Health and Human Resources, Series 10 [NAME] Virgnia Clearance for Access: Registry and Employment Screening and staff interview, the facility failed to implement the facility policies to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property ensure provisional employment screening. The facility also failed to ensure completion of background checks before allowing staff to work and have direct access to the residents. All residents had the potential to be affected. The facility failed to provisionally employ staff pending the [NAME] Virginia Cares fitness determination and the facility failed to require a fingerprint-based background check before hiring staff. The facility had identified and corrected this issue prior to the survey. Staff identifiers: #28, #44, #80, #109, #110, #119 and #127. Facility Census: 93. Findings included: a) Certified Nursing Assistant (CNA) #28 CNA #28 was hired on 08/30/22. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/15/24. The Notification of Eligible Fitness Determination was received 03/26/24. b) Certified Nursing Assistant (CNA) #44 CNA #44 was hired on 08/18/21. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 02/23/24. The Notification of Eligible Fitness Determination was received 03/26/24. c) Maintenance Technician (MT) #80 MT #80 was hired on 12/05/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 12/12/23. d) Receptionist #109 Receptionist #109 was hired on 02/05/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/01/24. A Notification of Ineligible Fitness Determination was received on 02/21/24. A notification of variance request determination - Granted was received on 03/22/24. e) [NAME] #110 Cook #110 was hired on 05/11/22. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/08/24. The Notification of Eligible Fitness Determination was received 03/27/24. f) Certified Nursing Assistant #119 CNA #28 was hired on 11/19/21. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/20/24. The Notification of Eligible Fitness Determination was received 03/26/24. g) Receptionists #127 Receptionist #127 was hired on 04/04/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 04/03/23. A Notification of Variance request Determination letter was provided that denied the variance request. This denial letter was dated 03/20/24 and had a copy of an email attached that was sent from the facility. Nursing Staff Scheduler #84 stated the denial letter for Receptionist #127 was attached and that she would need to have her termed out of the system and her job posted. This email was dated 03/21/24. A review of the facility policy titled Policies and Standard Procedures, [NAME] Virginia Abuse, Neglect & Misappropriation (Policy # NS-1018-03) section entitled Procedure, I. Screening identified the following facility Policies and Standard Procedures: #2. A pre-hire criminal background check will be performed for all potential [NAME] Virginia staff including but not limited to; a) Federally mandated Health and Human Services (HHS) Office of Inspector General's (OIG) List of Excluded Individuals/Entitles (LEIE) b) System for Award Management (SAM) formerly known as the General Services administrations (GSA). c) Criminal state, criminal federal, sex offender, Federal and State Excluding screening and Elder Abuse (NRDD) screenings. d) Criminal State Background checks. e) Criminal Federal Background checks. f) Sex offender background screen. g) Federal and State Exclusions screening. h) Elder Abuse screening S 69-10-1 TITLE 69 Legislative Rule Department of Health and Human Resources, Series 10 [NAME] Virgnia Clearance for Access: Registry and Employment Screening S 69-10-3. Prescreening. 3.1. A covered provider or covered contractor shall prescreen all direct access personnel applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. The Department shall prescreen all applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. The Secretary will charge a $20 fee for its use. 3.2. A covered provider shall ensure that all covered contractors who provide direct access personnel prescreen their applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. 3.3. The Department shall ensure that all covered contractors who provide direct access personnel prescreen their applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. 3.4. If the applicant has a negative finding on any required registry or licensure database, the Department, covered provider, or covered contractor shall notify the applicant, in writing, by regular U.S. mail, of such finding and shall not employ that applicant. S 69-10-5. Employment Fitness Determination. 5.1. If the Secretary's review of the criminal history record information provided by the State Police reveals the applicant does not have a disqualifying offense, the applicant may be employed. S 69-10-6. Provisional Employees. 6.1. Provisional basis employment for no more than 60 days may occur when: 6.1.1. An applicant does not have a negative finding on a required registry or licensure database, and the employment fitness determination is pending the criminal history record information; or 6.1.2. An applicant has requested a variance of the employment fitness determination and that decision is pending. On 04/08/24 at approximately 6:00 PM during an interview with the Administrator, the Administrator acknowledged there had been issues identified within the IDT team regarding the WV Cares background check completions not being timely. He also acknowledged that staff were permitted to work more than the provisional 60 days and they had been hired before the fingerprint-based background check. He further stated the facility had identified the issue and had put a plan in place to correct the issue and to monitor it to ensure the process is corrected. The Administrator provided the Quality Assessment and Performance Improvement (QAPI) Performance Improvement Team Documentation dated 02/21/24 and submitted the following narrative of the plan that was put in place. On 02/21/24 the Executive Director and Human Resource Director created a Performance Improvement Plan on compliance with WV Cares. It was identified that there were issues with employees getting WV Cares completed within the 60 days of hire. An Audit was completed to determine what employees had been missed. Those employees missing were submitted to WV Cares upon identification. The Human Resource Director along with eh Executive Director started monitoring WV Cares weekly to ensure all employees stayed in the 60-day window for compliance. Those employees that trigger a variance will be placed on leave until a final decision is made. All new hires are now being monitored by the Human Resource Director and/or Executive Director weekly. Any decision that takes longer than 60 days will result in the employee being suspended pending the WV Care results. Dated and signed by the Administrator (Executive Director) on 04/08/24. On 04/09/24 at approximately 10:30 AM a review of the completion of the [NAME] Virginia (WV) Cares notification of eligibility fitness determination for ten (10) staff with hire dates on or after 10/31/23 revealed there were no further issues identified with the [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form completion, the Notification of Eligible Fitness Determinations, staff working in excess of the 60 provisional days permitted or with staff being hired before requiring the fingerprint-based background check.

Based on record review, review of legislative rule S 69-10-1 TITLE 69 Rule Department of Health and Human Resources, Series 10 [NAME] Virgnia Clearance for Access: Registry and Employment Screening and staff interview, the facility failed to operate and provide services in compliance with all applicable State and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility failed to ensure provisional employment screening. The facility also failed to ensure completion of background checks before allowing staff to work and have direct access to the residents. All residents had the potential to be affected. The facility failed to provisionally employ staff pending the [NAME] Virginia Cares fitness determination and the facility failed to require a fingerprint-based background check before hiring staff. The facility had identified and corrected this issue prior to the survey. Staff identifiers: #28, #44, #80, #109, #110, #119 and #127. Facility Census: 93. Findings included: a) Certified Nursing Assistant (CNA) #28 CNA #28 was hired on 08/30/22. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/15/24. The Notification of Eligible Fitness Determination was received 03/26/24. b) Certified Nursing Assistant (CNA) #44 CNA #44 was hired on 08/18/21. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 02/23/24. The Notification of Eligible Fitness Determination was received 03/26/24. c) Maintenance Technician (MT) #80 MT #80 was hired on 12/05/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 12/12/23. d) Receptionist #109 Receptionist #109 was hired on 02/05/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/01/24. A Notification of Ineligible Fitness Determination was received on 02/21/24. A notification of variance request determination - Granted was received on 03/22/24. e) [NAME] #110 Cook #110 was hired on 05/11/22. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/08/24. The Notification of Eligible Fitness Determination was received 03/27/24. f) Certified Nursing Assistant #119 CNA #28 was hired on 11/19/21. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 01/20/24. The Notification of Eligible Fitness Determination was received 03/26/24. g) Receptionists #127 Receptionist #127 was hired on 04/04/23. The [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form was completed and signed on 04/03/23. A Notification of Variance request Determination letter was provided that denied the variance request. This denial letter was dated 03/20/24 and had a copy of an email attached that was sent from the facility. Nursing Staff Scheduler #84 stated the denial letter for Receptionist #127 was attached and that she would need to have her termed out of the system and her job posted. This email was dated 03/21/24. A review of the facility policy titled Policies and Standard Procedures, [NAME] Virginia Abuse, Neglect & Misappropriation (Policy # NS-1018-03) section entitled Procedure, I. Screening identified the following facility Policies and Standard Procedures: #2. A pre-hire criminal background check will be performed for all potential [NAME] Virginia staff including but not limited to; a) Federally mandated Health and Human Services (HHS) Office of Inspector General's (OIG) List of Excluded Individuals/Entitles (LEIE) b) System for Award Management (SAM) formerly known as the General Services administrations (GSA). c) Criminal state, criminal federal, sex offender, Federal and State Excluding screening and Elder Abuse (NRDD) screenings. d) Criminal State Background checks. e) Criminal Federal Background checks. f) Sex offender background screen. g) Federal and State Exclusions screening. h) Elder Abuse screening S 69-10-1 TITLE 69 Legislative Rule Department of Health and Human Resources, Series 10 [NAME] Virgnia Clearance for Access: Registry and Employment Screening S 69-10-3. Prescreening. 3.1. A covered provider or covered contractor shall prescreen all direct access personnel applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. The Department shall prescreen all applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. The Secretary will charge a $20 fee for its use. 3.2. A covered provider shall ensure that all covered contractors who provide direct access personnel prescreen their applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. 3.3. The Department shall ensure that all covered contractors who provide direct access personnel prescreen their applicants considered for hire for negative findings by way of an internet search of registries and licensure databases through the WV CARES website. 3.4. If the applicant has a negative finding on any required registry or licensure database, the Department, covered provider, or covered contractor shall notify the applicant, in writing, by regular U.S. mail, of such finding and shall not employ that applicant. S 69-10-5. Employment Fitness Determination. 5.1. If the Secretary's review of the criminal history record information provided by the State Police reveals the applicant does not have a disqualifying offense, the applicant may be employed. S 69-10-6. Provisional Employees. 6.1. Provisional basis employment for no more than 60 days may occur when: 6.1.1. An applicant does not have a negative finding on a required registry or licensure database, and the employment fitness determination is pending the criminal history record information; or 6.1.2. An applicant has requested a variance of the employment fitness determination and that decision is pending. On 04/08/24 at approximately 6:00 PM during an interview with the Administrator, the Administrator acknowledged there had been issues identified within the IDT team regarding the WV Cares background check completions not being timely. He also acknowledged that staff were permitted to work more than the provisional 60 days and they had been hired before the fingerprint-based background check. He further stated the facility had identified the issue and had put a plan in place to correct the issue and to monitor it to ensure the process is corrected. The Administrator provided the Quality Assessment and Performance Improvement (QAPI) Performance Improvement Team Documentation dated 02/21/24 and submitted the following narrative of the plan that was put in place. On 02/21/24 the Executive Director and Human Resource Director created a Performance Improvement Plan on compliance with WV Cares. It was identified that there were issues with employees getting WV Cares completed within the 60 days of hire. An Audit was completed to determine what employees had been missed. Those employees missing were submitted to WV Cares upon identification. The Human Resource Director along with eh Executive Director started monitoring WV Cares weekly to ensure all employees stayed in the 60-day window for compliance. Those employees that trigger a variance will be placed on leave until a final decision is made. All new hires are now being monitored by the Human Resource Director and/or Executive Director weekly. Any decision that takes longer than 60 days will result in the employee being suspended pending the WV Care results. Dated and signed by the Administrator (Executive Director) on 04/08/24. On 04/09/24 at approximately 10:30 AM a review of the completion of the [NAME] Virginia (WV) Cares notification of eligibility fitness determination for ten (10) staff with hire dates on or after 10/31/23 revealed there were no further issues identified with the [NAME] Virginia (WV) Cares Self-Disclosure Application and Consent Form completion, the Notification of Eligible Fitness Determinations, staff working in excess of the 60 provisional days permitted or with staff being hired before requiring the fingerprint-based background check.

Based on record review, staff interview and resident interview the facility failed to be administered in a manner which enabled it to use its resources effectively and efficiently to enable each resident to attain or maintain the highest practicable physical mental and psycho social well being. The facility's administration failed to identify and substantiate physical abuse and involuntary seclusion and take appropriate actions to ensure the alleged perpetrators did not abuse residents in the future. Neither resident was able to verbalize how these actions made them feel therefore the reasonable person standard was applied. These actions placed these two (2) residents and the remaining 93 residents at risk for serious harm and/or death because both alleged perpetrators were still employed by the facility and actions were not taken to ensure they did not abuse other residents in the future. All 95 residents were in an immediate jeopardy (IJ) situation. The facility was first notified of the IJ at 6:15 PM, on 02/20/24. The state agency (SA) received the Plan of Correction (POC) at 10:23 PM on 02/20/24. The SA accepted the POC on 02/20/24 at 10:28 PM. The survyeors observed for the implementation of the POC and the IJ was abated on 02/21/24 at 2:00 PM. Resident identifiers: #43 and #11. Facility census: 95. Findings included: a) Resident#43 On 02/20/24 at 9:45AM a medical record review was completed for Resident #43 regarding a reportable incident dated 11/21/23. The reportable was regarding an incident on 11/17/23 during the 2:00 PM - 10:00 PM shift. Resident #43's head was held by Nurse Aide (NA) #55 while Registered Nurse (RN) #40 completed a nasal swab for Covid testing. Upon reviewing RN #40's written statement it was determined that RN #40 felt she was holding the resident's head to help her calm down. The investigation completed by the facility includes statements from RN #40, NA #13, and NA #66. Further review of the statements gathered by the facility as a result this investigation found the following statements. RN #40 (statement collected by the facility) In a statement collected by the facility, on 11/17/23, RN #40 stated she was doing medication pass when a resident came and asked her to check Resident #43.The resident said Resident #43 was complaining of a sore throat. RN #40 said she explained to Resident #43 that she would be doing a COVID test. According to RN #40, Resident #43 became agitated and was afraid of having her nose swabbed. RN #40 said she explained the protocol to the resident and tried to convince her she would be careful, and it would not hurt. RN #40 said Resident#43's roommate tried to calm her down too. RN #40 said NA #55 helped by holding the resident's hand and her head while she (RN#40) performed the test. NA#55 The surveyor obtained a statement from the facility for NA#55. NA#55 gave her statement to Nursing Staff Scheduler (NSS) #51 on 11/20/23 by phone. In her statement the NA said she was, Pulled to west for 1:1. Tried to calm the resident down by holding her hand and her head. Trying to relax resident. NA #55's statement also reflected (RN #40's name) was the nurse trying to administer the Covid test.(Activity Aide(AA)#143's name) was walking by and stopped to help.(AA #143name) was holding the resident's hand. NA #55 stated she was making the resident laugh and smile when it was over. NA #66 The statement from the facility for NA #66 was given by NA #66 on 11/20/23 to NSS #51 NA #66 stated she was in a room on front hall when she heard screaming. NA #66 said she went into the hall and saw RN#40, Activity Aide #143, and NA #55 with Resident #43. RN #40 had a swab in her hand. NA #55 was holding the resident's hands and Activity Aide #143 was holding the resident's head. NA #66 said by the time she got all the way to them they had finished the test. Activity Assistant (AA) #143 The surveyor received a statement taken by the facility from AA #143. AA #143's statement was taken on 11/20/23. I was walking down the hall and saw the nurse trying to give (Resident #43's name) a Covid test. I saw the aide holding head to assist the nurse with the test. Employee #145 The surveyor obtained a statement taken by the facility for Employee #145 on 11/20/23. I spoke to the resident, explained who I was and ask her if she recall attempting to get a Covid test on Friday(11-17-23).The resident was non-verbal/Did not indicate she remembered in anyway. Resident #8 The surveyor obtained a statement from Resident #8 dated 11/19/23.This statement was taken by an RN. Resident was asked in interview if he's ever seen resident being abused, he stated, 'The other night I was in my room and came out and seen the nurse and the CAN holding resident down to swab her. Resident was asked if he knew who they were he said he didn't know their names, but they were foreign. Employee #146 The surveyor obtained a facility statement from Employee #146. This statement was given by the employee on 11/19/23 to Clinical Manager/RN #109 They came to give her a covid test. She didn't want I told her it's okay, I was holding her hand. The one girl held her head and the nurse swabbed her nose, she was screaming the whole time. I told someone but I can't remember who. Certified Occupational Therapy Assistant(COTA)#139 The surveyor obtained a facility statement from COTA #139 During session with (Name of Resident #54) and (name of Resident #8) both in therapy room at same time at approx.12:30 PM on 11/19/2023, it was brought up that another patient (Resident #43's name) was being covid tested on Friday (11-17-2023) and that a nurse aide that talks funny with dark hair and a foreigner was holding (Resident #143's name) head back as she was screaming very loudly and that they were disturbed by the screaming and thought that she was allowed to refuse ea covid test if she wanted to refuse .Both patients reported that she could be identified if they saw her. NA#13 The surveyor obtained a statement taken by the facility from NA #13. The statement was dated 11/19/23. (NA#66'sname) & I were providing care to a resident on the front hall when we heard screaming. We finished with this resident and we nt to the hall to see (NA#55's name) holding (Resident#43's name) head back for (RN#40's name) to covid swab resident's nose. This incident happened Friday 11/17 after dinner. Further review of the reportable incident found a finding of unsubstantiated despite the multiple staff and resident statements who confirmed it did happen. The survey team completed staff interviews during the course of the survey with the following findings: Director of Nursing During an interview with the Director of Nursing (DON) on 02/20/24 at 9:20 AM she stated, I don't really know about it. Let me get the Administrator and Clinical Manager(CL)#109. An interview with CL#109 at 9:50 AM on 02/20/24 was conducted. CL#109,stated,I got the call about the incident .I came in and got statements, and completed this skin checks .Then I handed it over to the administration. Administrator An interview with the Administrator at 10:00 AM on 02/20/24 was conducted regarding Resident #43.The administrator reviewed d all the paperwork. The administrator stated, They held her head and hand to comfort her .I don't see a problem with this. Resident#8 During an interview on 02/20/24 at 10:37 AM with Resident #8 who has a BIMS of 15 the resident stated, I remember what happened. She was screaming. My room was across from hers at the time. I wanted to smack them off of her. An interview on 02/20/24 at 10:51 AM with NA #66 she stated, I feel like what I remember ,we heard screaming, and we came out, (Name of Activity Assistant #143) was behind her and (Name of RN #40) was in front of her. I don't remember much, but I did feel like it was an issue. I felt like she had the right to say no. An interview on 02/20/24 at 10:54 AM with NA #13 she states, I was in a room up the hall, and I heard screaming, I came out of the room and saw (Name of NA#55) was holding her head, and the nurse was putting a swab in her nose. I don't remember what nurse I reported it to but the east wing (Name of CL #109 came in and told me to write down what I had seen on the paper, So I did. Just the way she was screaming I felt like I needed to report it. They definitely did the swab ;she was taking the swab out of her nose when I went into the room. Telephone interview with NA #55 on 02/20/24 at 2:39 PM she stated, What I remember r is the nurse needed help. I went to help her. I was holding her head and hands to calm her down. If I knew I was going to be in trouble I would have never gone into the room. The nurse was so busy she was just trying to get it done. An attempt was made to contact RN #40 via telephone, as well as RN #26 pm 02/20/2 at 2:00 PM with no answer or return call. At the time of this survey NA #55 and RN #40 were both still employed at the facility and this allegation was unsubstantiated event though there were multiple witness statements confirming the incident did happen on11/17/23. Resident#11 A facility reportable incident (FRI) dated 10/03/23 in the (AM), was reviewed involving Resident #11. The allegations contained in this reportable was RN #40 , locked Resident #11's wheelchair and held the back of the wheelchair which prevented the resident from freely leaving the room which she was confined to. This allegation was reported as possible involuntary seclusion. The facility investigated and gathered the following statements: NA#141 The surveyor obtained a statement taken by the facility on10/02/23. NA #41 said while giving NA a lunch break and taking on the 1:1 she was stopped by the RN #40 and was asked to give another patient care while she took the 1:1. NA#41 said RN #40 forced Resident #11 back into her room locking her wheelchair and holding the back of the wheelchair so Resident #11was unable to leave her room. RN#40 gave a statement on10/03/23: RN#40 said she was doing her medication pass when a family member of one of the resident's asked her to call for Resident#101's nurse aide. RN #40 said she asked NA#141 if she was assigned to Resident #101. NA #141 said she was the aide for Resident #101. NA #141 also said she was watching Resident #11 because the nurse aide assigned to Resident#11 was on break and had asked her to watch Resident#11 while also attending Resident #101. NA #141 said she had a conversation with Resident #11 while walking around the facility. She said Resident #11 was as going to the exit door and kept saying she was going home. When RN #26, who was the assigned nurse to Resident#11 noticed this behavior she said she would take over Resident #11 so RN #40 could finish medication pass. Resident #11 started hitting and punching us and kept on saying bad words. The staff took Resident #11 to her room while RN #26 had a conversation with the resident trying to have her calm down. Then wrote at the bottom of this same statement was a short statement from RN #26. The summarization of the statement is: RN#26 agreed with RN#40's statement that the incident with the wheelchair was for a limited period and was therapeutic. This allegation was unsubstantiated by the facility. However, an in-service entitled Abuse and Neglect dated 10/03/23 was completed by Clinical Manager #7 for the staff. Further education was completed with RN#40 by Clinical Manager #7 on 10/03/23 which involved reviewing the facility policy entitled [NAME] Virginia Abuse, Neglect and Misappropriation. The section regarding involuntary seclusion was highlighted. Both RN#40 and the clinical manager #7 signed and dated the facility policy. Clinical Manager #7 verified RN#40 was still employed by the facility as a night shift nurse. During an interview with Clinical Manager (CL) #7 on 02/20/24 at approximately11:15 AM she stated, I was directed by the administrator to conduct an in-service and to do individual education with RN#40. I did not have any further action regarding this reportable. An attempt was made to contact RN #40 via phone, as well as RN#26 On 02/20/24 at 2:00 PM with no answer or call back at this time. NA#142 was not able to be interviewed because she no longer works at this facility. During an interview with the Administrator on 02/20/24 at 5:00 PM regarding the incident with Resident #11 he stated, During the investigation you have to weigh the totality of all the statements received and 2 RNs were in the room, versus an Activity Assistant. Sometimes you have to see what actually happened versus someone seeing what they think happened .The statement from both RN's does not conclude that the wheelchair was held. c) Plan of Correction On 02/20/24 the Nursing Home Administrator, Director of Nursing, and the Corporate Office implemented the following plan: Employee(RN) #40 was suspended pending investigation and legal review and HR review, if it determined that the employee could return to work, employee #40 will have extensive abuse and neglect training, by the Regional Team Member. Employee (NA) #55 was suspended pending investigation and legal review and HR review ,if is it determined that the employee could return to work Employee #55 will have extensive abuse and neglect training by the Regional Team Member. Residents with BIMS scores of 12 and above were interviewed for potential physical abuse. Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical Abuse. Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy, through in person, text blast will be physically educated prior to the next shift with signatures. The training will be conducted by the Regional Team Member. There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms. The training will be conducted by the Regional Team Member. Staff will be reeducated on restraint alternatives. There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include, Social Services, Director of Nursing or Designee, and Executive Director. After a thorough review the team will determine if substantiated. Audits will be conducted by the regional Director of Clinical Operations weekly x 4 weeks and monthly x 6 months and randomly thereafter with correction upon discovery. Audit results will be reviewed by the QAPI Committee monthly x 6months.

Based on record review, staff interview and resident interview the facility failed to ensure residents were free from physical abuse due to being physically restrained. Resident #43 was physically restrained by a nurse aide who held her head preventing movement when a nurse swabbed her nose to test for COVID. Resident #11 became agitated and a nurse took the resident to their room where they locked the resident's wheelchair and physically held the resident's wheelchair preventing the residnet from moving and leaving the room. Neither resident was able to verbalize how these actions made them feel therefore the reasonable person standard was applied. These actions placed these two (2) residents and the remaining 93 residents at risk for serious harm and/or death because both alleged perpetrators were still employed by the facility and actions were not taken to ensure they did not abuse other residents in the future. All 95 residents were in an immediate jeopardy (IJ) situation. The facility was first notified of the IJ at 6:15 PM, on 02/20/24. The state agency (SA) received the Plan of Correction (POC) at 10:23 PM on 02/20/24. The SA accepted the POC on 02/20/24 at 10:28 PM. The survyeors observed for the implementation of the POC and the IJ was abated on 02/21/24 at 2:00 PM. Resident identifiers: #43 and #11. Facility census: 95. Findings included: a) Resident#43 On 02/20/24 at 9:45AM a medical record review was completed for Resident #43 regarding a reportable incident dated 11/21/23. The reportable was regarding an incident on 11/17/23 during the 2:00 PM - 10:00 PM shift. Resident #43's head was held by Nurse Aide (NA) #55 while Registered Nurse (RN) #40 completed a nasal swab for Covid testing. Upon reviewing RN #40's written statement it was determined that RN #40 felt she was holding the resident's head to help her calm down. The investigation completed by the facility includes statements from RN #40, NA #13, and NA #66. Further review of the statements gathered by the facility as a result this investigation found the following statements. b) RN #40 (statement collected by the facility) In a statement collected by the facility, on 11/17/23, RN #40 stated she was doing medication pass when a resident came and asked her to check Resident #43.The resident said Resident #43 was complaining of a sore throat. RN #40 said she explained to Resident #43 that she would be doing a COVID test. According to RN #40, Resident #43 became agitated and was afraid of having her nose swabbed. RN #40 said she explained the protocol to the resident and tried to convince her she would be careful, and it would not hurt. RN #40 said Resident #43's roommate tried to calm her down too. RN #40 said NA #55 helped by holding the resident's hand and her head while she (RN #40) performed the test. c) NA #55 The surveyor obtained a statement from the facility for NA #55. NA#55 gave her statement to Nursing Staff Scheduler (NSS) #51 on 11/20/23 by phone. In her statement the NA said she was, Pulled to west for 1:1. Tried to calm the resident down by holding her hand and her head. Trying to relax resident. NA #55's statement also reflected (RN #40's name) was the nurse trying to administer the Covid test.(Activity Aide(AA)#143's name) was walking by and stopped to help.(AA #143name) was holding the resident's hand. NA #55 stated she was making the resident laugh and smile when it was over. d) NA #66 The statement from the facility for NA #66 was given by NA #66 on 11/20/23 to NSS #51 NA #66 stated she was in a room on front hall when she heard screaming. NA #66 said she went into the hall and saw RN#40, Activity Aide #143, and NA #55 with Resident #43. RN #40 had a swab in her hand. NA #55 was holding the resident's hands and Activity Aide #143 was holding the resident's head. NA #66 said by the time she got all the way to them they had finished the test. e) Activity Assistant (AA) #143 The surveyor received a statement taken by the facility from AA #143. AA #143's statement was taken on 11/20/23. I was walking down the hall and saw the nurse trying to give (Resident #43's name) a Covid test. I saw the aide holding head to assist the nurse with the test. f) Employee #145 The surveyor obtained a statement taken by the facility for Employee #145 on 11/20/23. I spoke to the resident, explained who I was and ask her if she recall attempting to get a Covid test on Friday(11-17-23).The resident was non-verbal/Did not indicate she remembered in anyway. g) Resident #8 The surveyor obtained a statement from Resident #8 dated 11/19/23.This statement was taken by an RN. Resident was asked in interview if he's ever seen resident being abused, he stated, 'The other night I was in my room and came out and seen the nurse and the CAN holding resident down to swab her. Resident was asked if he knew who they were he said he didn't know their names, but they were foreign. h) Employee #146 The surveyor obtained a facility statement from Employee #146. This statement was given by the employee on 11/19/23 to Clinical Manager/RN #109 They came to give her a covid test. She didn't want I told her it's okay, I was holding her hand. The one girl held her head and the nurse swabbed her nose, she was screaming the whole time. I told someone but I can't remember who. i) Certified Occupational Therapy Assistant(COTA )#139 The surveyor obtained a facility statement from COTA #139 During session with (Name of Resident #54) and (name of Resident #8) both in therapy room at same time at approx.12:30 PM on 11/19/2023, it was brought up that another patient (Resident #43's name) was being covid tested on Friday (11-17-2023) and that a nurse aide that talks funny with dark hair and a foreigner was holding (Resident #143's name) head back as she was screaming very loudly and that they were disturbed by the screaming and thought that she was allowed to refuse ea covid test if she wanted to refuse .Both patients reported that she could be identified if they saw her. j) NA#13 The surveyor obtained a statement taken by the facility from NA #13. The statement was dated 11/19/23. (NA#66'sname) & I were providing care to a resident on the front hall when we heard screaming. We finished with this resident and we nt to the hall to see (NA#55's name) holding (Resident#43's name) head back for (RN#40's name) to covid swab resident's nose. This incident happened Friday 11/17 after dinner. Further review of the reportable incident found a finding of unsubstantiated despite the multiple staff and resident statements who confirmed it did happen. The survey team completed staff interviews during the course of the survey with the following findings: k) Director of Nursing During an interview with the Director of Nursing (DON) on 02/20/24 at 9:20 AM she stated, I don't really know about it. Let me get the Administrator and Clinical Manager (CM) #109. l) Clinical Manager (CM) #109 An interview with CM#109 at 9:50 AM on 02/20/24 was conducted. CM#109,stated,I got the call about the incident .I came in and got statements, and completed this skin checks .Then I handed it over to the administration. m) Administrator An interview with the Administrator at 10:00 AM on 02/20/24 was conducted regarding Resident #43.The administrator reviewed d all the paperwork. The administrator stated, They held her head and hand to comfort her .I don't see a problem with this. n) Resident#8 During an interview on 02/20/24 at 10:37 AM with Resident #8 who has a BIMS of 15 the resident stated, I remember what happened. She was screaming. My room was across from hers at the time. I wanted to smack them off of her. An interview on 02/20/24 at 10:51 AM with NA #66 she stated, I feel like what I remember ,we heard screaming, and we came out, (Name of Activity Assistant #143) was behind her and (Name of RN #40) was in front of her. I don't remember much, but I did feel like it was an issue. I felt like she had the right to say no. An interview on 02/20/24 at 10:54 AM with NA #13 she states, I was in a room up the hall, and I heard screaming, I came out of the room and saw (Name of NA#55) was holding her head, and the nurse was putting a swab in her nose. I don't remember what nurse I reported it to but the east wing (Name of CL #109 came in and told me to write down what I had seen on the paper, So I did. Just the way she was screaming I felt like I needed to report it. They definitely did the swab ;she was taking the swab out of her nose when I went into the room. Telephone interview with NA #55 on 02/20/24 at 2:39 PM she stated, What I remember r is the nurse needed help. I went to help her. I was holding her head and hands to calm her down. If I knew I was going to be in trouble I would have never gone into the room. The nurse was so busy she was just trying to get it done. An attempt was made to contact RN #40 via telephone, as well as RN #26 pm 02/20/2 at 2:00 PM with no answer or return call. At the time of this survey NA #55 and RN #40 were both still employed at the facility and this allegation was unsubstantiated event though there were multiple witness statements confirming the incident did happen on11/17/23. o) Resident#11 A facility reportable incident (FRI) dated 10/03/23 in the (AM), was reviewed involving Resident #11. The allegations contained in this reportable was RN #40 , locked Resident #11's wheelchair and held the back of the wheelchair which prevented the resident from freely leaving the room which she was confined to. This allegation was reported as possible involuntary seclusion. The facility investigated and gathered the following statements: p) NA#141 The surveyor obtained a statement taken by the facility on10/02/23. NA #41 said while giving NA a lunch break and taking on the 1:1 she was stopped by the RN #40 and was asked to give another patient care while she took the 1:1. NA#41 said RN #40 forced Resident #11 back into her room locking her wheelchair and holding the back of the wheelchair so Resident #11was unable to leave her room. q) RN#40 gave a statement on10/03/23: RN#40 said she was doing her medication pass when a family member of one of the resident's asked her to call for Resident#101's nurse aide. RN #40 said she asked NA#141 if she was assigned to Resident #101. NA #141 said she was the aide for Resident #101. NA #141 also said she was watching Resident #11 because the nurse aide assigned to Resident#11 was on break and had asked her to watch Resident#11 while also attending Resident #101. NA #141 said she had a conversation with Resident #11 while walking around the facility. She said Resident #11 was as going to the exit door and kept saying she was going home. When RN #26, who was the assigned nurse to Resident#11 noticed this behavior she said she would take over Resident #11 so RN #40 could finish medication pass. Resident #11 started hitting and punching us and kept on saying bad words. The staff took Resident #11 to her room while RN #26 had a conversation with the resident trying to have her calm down. Then wrote at the bottom of this same statement was a short statement from RN #26. The summarization of the statement is: r) RN #26 RN#26 agreed with RN#40's statement that the incident with the wheelchair was for a limited period and was therapeutic. This allegation was unsubstantiated by the facility. However, an in-service entitled Abuse and Neglect dated 10/03/23 was completed by Clinical Manager #7 for the staff. Further education was completed with RN #40 by Clinical Manager #7 on 10/03/23 which involved reviewing the facility policy entitled [NAME] Virginia Abuse, Neglect and Misappropriation. The section regarding involuntary seclusion was highlighted. Both RN #40 and the Clinical Manager (CM) #7 signed and dated the facility policy. Clinical Manager #7 verified RN #40 was still employed by the facility as a night shift nurse. s) Clinical Manager (CM) #7 During an interview with Clinical Manager (CM) #7 on 02/20/24 at approximately11:15 AM she stated, I was directed by the administrator to conduct an in-service and to do individual education with RN#40. I did not have any further action regarding this reportable. An attempt was made to contact RN #40 via phone, as well as RN #26 On 02/20/24 at 2:00 PM with no answer or call back at this time. t) NA #142 NA#142 was not able to be interviewed because she no longer works at this facility. During an interview with the Administrator on 02/20/24 at 5:00 PM regarding the incident with Resident #11 he stated, During the investigation you have to weigh the totality of all the statements received and two (2) RNs were in the room, versus an Activity Assistant. Sometimes you have to see what actually happened versus someone seeing what they think happened. The statement from both RN's does not conclude that the wheelchair was held. u) Plan of Correction On 02/20/24 the Nursing Home Administrator, Director of Nursing, and the Corporate Office implemented the following plan: Employee(RN) #40 was suspended pending investigation and legal review and HR review, if it determined that the employee could return to work, employee #40 will have extensive abuse and neglect training, by the Regional Team Member. Employee (NA) #55 was suspended pending investigation and legal review and HR review ,if is it determined that the employee could return to work Employee #55 will have extensive abuse and neglect training by the Regional Team Member. Residents with BIMS scores of 12 and above were interviewed for potential physical abuse. Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical Abuse. Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy, through in person, text blast will be physically educated prior to the next shift with signatures. The training will be conducted by the Regional Team Member. There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms. The training will be conducted by the Regional Team Member. Staff will be reeducated on restraint alternatives. There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include, Social Services, Director of Nursing or Designee, and Executive Director. After a thorough review the team will determine if substantiated. Audits will be conducted by the regional Director of Clinical Operations weekly x 4 weeks and monthly x 6 months and randomly thereafter with correction upon discovery. Audit results will be reviewed by the QAPI Committee monthly x 6months.

Based on record review, staff interview and resident interview the facility failed to ensure residents were free from physical abuse. Staff physically restrained two (2) residents. Resident #43 was and #11 were both physically restrained. A nurse aide (NA) nurse aide held her head preventing movement so the nurse could perform a swab of the nose to test Resident #43 for COVID. Resident #11 became agitated and a nurse took the resident to their room where they locked the resident's wheelchair and physically held the resident's wheelchair preventing them from moving and leaving their room. Neither resident was able to verbalize how these actions made them feel therefore the reasonable person standard was applied. Not only did these failures harm Resident #11 and Resident #43 but they also placed them and the remaining 93 residents at risk for serious harm and/or death. The alleged perpetrators were still employed by the facility and actions were not taken to ensure they did not abuse other residents in the future. This placed all 95 residents in an immediate jeopardy (IJ) situation. The facility was notified of the IJ at 6:15 PM, on 02/20/24. The state agency (SA) received the Plan of Correction (POC) at 10:23PM on 02/20/24. The SA accepted the POC on 02/20/24 at 10:28 PM. The SA observed for the implementation of the POC and the IJ was abated on 02/21/24 at 2:00 PM. Resident identifiers: #43 and #11. Facility Census: 95. Findings include: a) Resident #43 On 02/20/24 at 9:45AM a medical record review was completed for Resident # 43 regarding a reportable incident dated 11/21/23. The report was in regards to an incident on 11/17/23 where the resident's head was held by Nurse Aide (NA) #55 while Registered Nurse (RN) #40 completed a nasal swab for Covid testing. Upon reviewing RN #40's written statement, she states, She (Referring to NA #55) holds Resident #43's head just to make her calm down. The time of the of incident was documented as the 2 PM - 10 PM shift. The investigation included statements from RN #40, NA #13, and NA #66. b) RN #40 (statement collected by the facility) In a statement collected by the facility, on 11/17/23, RN #40 stated she was doing medication pass when a resident came and asked her to check Resident #43.The resident said Resident #43 was complaining of a sore throat. RN #40 said she explained to Resident #43 that she would be doing a COVID test. According to RN #40, Resident #43 became agitated and was afraid of having her nose swabbed. RN #40 said she explained the protocol to the resident and tried to convince her she would be careful, and it would not hurt. RN #40 said Resident#43's roommate tried to calm her down too. RN #40 said NA #55 helped by holding the resident's hand and her head while she (RN#40) performed the test. c) NA#55 The surveyor obtained a statement from the facility for NA#55. NA#55 gave her statement to Nursing Staff Scheduler (NSS) #51 on 11/20/23 by phone. In her statement the NA said she was, Pulled to west for 1:1. Tried to calm the resident down by holding her hand and her head. Trying to relax resident. NA #55's statement also reflected (RN #40's name) was the nurse trying to administer the Covid test.(Activity Aide(AA)#143's name) was walking by and stopped to help.(AA #143name) was holding the resident's hand. NA #55 stated she was making the resident laugh and smile when it was over. d) NA #66 The statement from the facility for NA #66 was given by NA #66 on 11/20/23 to NSS #51 NA #66 stated she was in a room on front hall when she heard screaming. NA #66 said she went into the hall and saw RN#40, Activity Aide #143, and NA #55 with Resident #43. RN #40 had a swab in her hand. NA #55 was holding the resident's hands and Activity Aide #143 was holding the resident's head. NA #66 said by the time she got all the way to them they had finished the test. e) Activity Assistant (AA) #143 The surveyor received a statement taken by the facility from AA #143. AA #143's statement was taken on 11/20/23. I was walking down the hall and saw the nurse trying to give (Resident #43's name) a Covid test. I saw the aide holding head to assist the nurse with the test. f) Employee #145 The surveyor obtained a statement taken by the facility for Employee #145 on 11/20/23. I spoke to the resident, explained who I was and ask her if she recall attempting to get a Covid test on Friday(11-17-23).The resident was non-verbal/Did not indicate she remembered in anyway. g) Resident #8 The surveyor obtained a statement from Resident #8 dated 11/19/23.This statement was taken by an RN. Resident was asked in interview if he's ever seen resident being abused, he stated, 'The other night I was in my room and came out and seen the nurse and the CAN holding resident down to swab her. Resident was asked if he knew who they were he said he didn't know their names, but they were foreign. h) Employee#146 The surveyor obtained a facility statement from Employee #146. This statement was given by the employee on 11/19/23 to Clinical Manager/RN #109 They came to give her a covid test. She didn't want I told her it's okay, I was holding her hand. The one girl held her head and the nurse swabbed her nose, she was screaming the whole time. I told someone but I can't remember who. Certified Occupational Therapy Assistant(COTA)#139 The surveyor obtained a facility statement from COTA #139 During session with (Name of Resident #54) and (name of Resident #8) both in therapy room at same time at approx.12:30 PM on 11/19/2023, it was brought up that another patient (Resident #43's name) was being covid tested on Friday (11-17-2023) and that a nurse aide that talks funny with dark hair and a foreigner was holding (Resident #143's name) head back as she was screaming very loudly and that they were disturbed by the screaming and thought that she was allowed to refuse ea covid test if she wanted to refuse .Both patients reported that she could be identified if they saw her. i) NA#13 The surveyor obtained a statement taken by the facility from NA #13. The statement was dated 11/19/23. (NA#66'sname) & I were providing care to a resident on the front hall when we heard screaming. We finished with this resident and we nt to the hall to see (NA#55's name) holding (Resident#43's name) head back for (RN#40's name) to covid swab resident's nose. This incident happened Friday 11/17 after dinner. Further review of the reportable incident found a finding of unsubstantiated despite the multiple staff and resident statements who confirmed it did happen. The survey team completed staff interviews during the course of the survey with the following findings: j) Director of Nursing During an interview with the Director of Nursing (DON) on 02/20/24 at 9:20 AM she stated, I don't really know about it. Let me get the Administrator and Clinical Manager(CL)#109. An interview with CL#109 at 9:50 AM on 02/20/24 was conducted. CL#109,stated,I got the call about the incident .I came in and got statements, and completed this skin checks .Then I handed it over to the administration. k) Administrator An interview with the Administrator at 10:00 AM on 02/20/24 was conducted regarding Resident #43.The administrator reviewed d all the paperwork. The administrator stated, They held her head and hand to comfort her .I don't see a problem with this. l) Resident#8 During an interview on 02/20/24 at 10:37 AM with Resident #8 who has a BIMS of 15 the resident stated, I remember what happened. She was screaming. My room was across from hers at the time. I wanted to smack them off of her. An interview on 02/20/24 at 10:51 AM with NA #66 she stated, I feel like what I remember ,we heard screaming, and we came out, (Name of Activity Assistant #143) was behind her and (Name of RN #40) was in front of her. I don't remember much, but I did feel like it was an issue. I felt like she had the right to say no. An interview on 02/20/24 at 10:54 AM with NA #13 she states, I was in a room up the hall, and I heard screaming, I came out of the room and saw (Name of NA#55) was holding her head, and the nurse was putting a swab in her nose. I don't remember what nurse I reported it to but the east wing (Name of CL #109 came in and told me to write down what I had seen on the paper, So I did. Just the way she was screaming I felt like I needed to report it. They definitely did the swab ;she was taking the swab out of her nose when I went into the room. Telephone interview with NA #55 on 02/20/24 at 2:39 PM she stated, What I remember r is the nurse needed help. I went to help her. I was holding her head and hands to calm her down. If I knew I was going to be in trouble I would have never gone into the room. The nurse was so busy she was just trying to get it done. An attempt was made to contact RN #40 via telephone, as well as RN #26 pm 02/20/2 at 2:00 PM with no answer or return call. At the time of this survey NA #55 and RN #40 were both still employed at the facility and this allegation was unsubstantiated event though there were multiple witness statements confirming the incident did happen on11/17/23. m) Resident #11 A facility reportable incident (FRI) dated 10/03/23 in the (AM), was reviewed involving Resident #11. The allegations contained in this reportable was RN #40 , locked Resident #11's wheelchair and held the back of the wheelchair which prevented the resident from freely leaving the room which she was confined to. This allegation was reported as possible involuntary seclusion. The facility investigated and gathered the following statements: n) NA #141 The surveyor obtained a statement taken by the facility on10/02/23. NA #41 said while giving NA a lunch break and taking on the 1:1 she was stopped by the RN #40 and was asked to give another patient care while she took the 1:1. NA#41 said RN #40 forced Resident #11 back into her room locking her wheelchair and holding the back of the wheelchair so Resident #11was unable to leave her room. o) RN #40 gave a statement on10/03/23: RN#40 said she was doing her medication pass when a family member of one of the resident's asked her to call for Resident#101's nurse aide. RN #40 said she asked NA#141 if she was assigned to Resident #101. NA #141 said she was the aide for Resident #101. NA #141 also said she was watching Resident #11 because the nurse aide assigned to Resident#11 was on break and had asked her to watch Resident#11 while also attending Resident #101. NA #141 said she had a conversation with Resident #11 while walking around the facility. She said Resident #11 was as going to the exit door and kept saying she was going home. When RN #26, who was the assigned nurse to Resident#11 noticed this behavior she said she would take over Resident #11 so RN #40 could finish medication pass. Resident #11 started hitting and punching us and kept on saying bad words. The staff took Resident #11 to her room while RN #26 had a conversation with the resident trying to have her calm down. p) RN #26 Then wrote at the bottom of this same statement was a short statement from RN #26. The summarization of the statement is: RN#26 agreed with RN#40's statement that the incident with the wheelchair was for a limited period and was therapeutic. This allegation was unsubstantiated by the facility. However, an in-service entitled Abuse and Neglect dated 10/03/23 was completed by Clinical Manager #7 for the staff. Further education was completed with RN#40 by Clinical Manager #7 on 10/03/23 which involved reviewing the facility policy entitled [NAME] Virginia Abuse, Neglect and Misappropriation. The section regarding involuntary seclusion was highlighted. Both RN#40 and the clinical manager #7 signed and dated the facility policy. Clinical Manager #7 verified RN#40 was still employed by the facility as a night shift nurse. q) Clinical Manager (CM) #7 During an interview with Clinical Manager (CL) #7 on 02/20/24 at approximately11:15 AM she stated, I was directed by the administrator to conduct an in-service and to do individual education with RN#40. I did not have any further action regarding this reportable. An attempt was made to contact RN #40 via phone, as well as RN#26 On 02/20/24 at 2:00 PM with no answer or call back at this time. r) NA#142 NA #142 was not able to be interviewed because she no longer works at this facility. s) Administrator During an interview with the Administrator on 02/20/24 at 5:00 PM regarding the incident with Resident #11 he stated, During the investigation you have to weigh the totality of all the statements received and 2 RNs were in the room, versus an Activity Assistant. Sometimes you have to see what actually happened versus someone seeing what they think happened .The statement from both RN's does not conclude that the wheelchair was held. t) Plan of Correction On 02/20/24 the Nursing Home Administrator, Director of Nursing, and the Corporate Office implemented the following plan: Employee(RN) #40 was suspended pending investigation and legal review and HR review, if it determined that the employee could return to work, employee #40 will have extensive abuse and neglect training, by the Regional Team Member. Employee (NA) #55 was suspended pending investigation and legal review and HR review ,if is it determined that the employee could return to work Employee #55 will have extensive abuse and neglect training by the Regional Team Member. Residents with BIMS scores of 12 and above were interviewed for potential physical abuse. Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical Abuse. Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy, through in person, text blast will be physically educated prior to the next shift with signatures. The training will be conducted by the Regional Team Member. There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms. The training will be conducted by the Regional Team Member. Staff will be reeducated on restraint alternatives. There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include, Social Services, Director of Nursing or Designee, and Executive Director. After a thorough review the team will determine if substantiated. Audits will be conducted by the regional Director of Clinical Operations weekly x 4 weeks and monthly x 6 months and randomly thereafter with correction upon discovery. Audit results will be reviewed by the QAPI Committee monthly x 6months.

Based on observation and staff interview, the facility failed to maintain appropriate infection control standards for the cleaning and disinfecting of the [NAME] Unit and maintaining the storage of clean linen. These were random opportunities for discovery. Facility Census: 95. Findings Include: a) Cleansing Dwell Time On 02/20/24 at 9:25 AM, Housekeeper (HK) #46 on the [NAME] wing was asked what type of cleanser does the facility use for surfaces and floors? HK #46 stated (Name of Cleanser) for the floors and surfaces. HK #46 was then asked, what is the dwell time? HK #46 stated, about 5 (five) minutes . On 02/20/24 at 9:40 AM, the Housekeeping Director (HKD) #41 confirmed the name of the cleanser and the dwell time was 10 minutes .it must remain wet . HKD #41 stated, we have reviewed the dwell times .I'm not sure why HK #46 didn't know. On 02/20/24 at 10:00 AM, the label and directions were reviewed for the facility cleanser. The directions state, Treated surfaces must remain visibly wet for 10 minutes. No further information was obtained during the survey process. b) Linen Cart On 02/20/24 at 1:45 PM, the linen cart on the East wing was observed. The linen cart was uncovered with a flap across the top the cart. On 02/20/24 at 1:50 PM, Nurse Aide (NA) #31 and NA #87 confirmed the linen cart had the flap across the top of the cart and was not covered. On 02/21/24 at approximately 3:00 PM, the Director of Nursing (DON) was notified and confirmed the linen cart should be covered. No further information was obtained during the survey process.

Based on record review, staff interview and resident interview the facility failed to ensure their policy as it pertained to abuse, abuse investigation, and abuse prevention was implemented. Two (2) residents were found to have been abused by being physically restrained. Resident #43 was physically and restrained by a nurse aide who held her head preventing movement so the nurse could perform a swab of the nose to test Resident #43 for COVID. Resident #11 became agitated and a nurse took the resident to her room where they locked the residents wheelchair and physically held the resident's wheelchair preventing her from moving and leaving her room. The state agency (SA) determined these failures caused Resident #11 and Resident #43 to suffer physically and mentally. Neither resident was able to verbalize how these actions made them feel. Not only did these failures harm Resident #11 and Resident #43 but they also placed the remaining 93 residents at risk for serious harm and/or death because both alleged perpetrators were still employed by the facility and actions were not taken to ensure these perpetrators did not abuse other residents in the future. This placed all 95 residents in an immediate jeopardy (IJ) situation. The facility was first notified of the IJ at 6:15 PM, on 02/20/24. The SA received the Plan of Correction (POC) at 10:23 PM on 02/20/24. The SA accepted the POC on 02/20/24 at 10:28 PM. The SA observed for the implementation of the POC and the IJ was abated on 02/21/24 at 2:00 PM. Resident Identifiers: #43 and #11. Facility Census: 95. Findings included: a) Abuse Policy A review of the facility's abuse policy titled: [NAME] Virginia Abuse, Neglect, & Misappropriation Policy # NS 1018-03 revealed the following definition of immediately read: means as soon as possible, in the absence of a shooter state time frame requirements, but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in bodily injury, or not later than 24 hours if the events that cause the allegation do no involve abuse and do result in serious bodily injury. Under section titled Protection: In the event an allegation is made the facility will take measures to protect residents from harm during an investigation. Accurate and timely reporting of incidents, both alleged and substantiated, will be sent to officials in accordance with state law. Under section II Training, Number 2 section B Read: Understanding behavioral symptoms of resident including those with dementia and related diseases that may increase the risk of abuse and neglect and how to respond (including interventions to deal with aggressive behaviors). Aggressive and/or catastrophic reactions to residents Wandering or elopement- type behaviors Resistance to care Outbursts of yelling out Difficulty in adjusting to new routines or staff. Under Prevention #4 read: An employee who is alleged or accused of being a party to abuse, neglect, misappropriation of property will be immediately removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone If multiple employees are involved, the employees will be separated until individual statements are completed. The employees will not be permitted to be alone in the facility at any time until the investigation is complete. #5 reads After completing statement(s), the employee(s) will be asked to vacate the facility until further investigation of the incident is completed. The employee(s) will be notified of the finding of the investigation Appropriate measures will be taken with the employee(s) post investigation including but not limited to: I. Returning to work including no change in regular pay during off time. Ii. Additional education and training III. Disciplinary action if appropriate including termination following facility HR termination policies and guidance. b) Resident #43 On 02/20/24 at 9:45AM a medical record review was completed for Resident # 43 regarding a reportable incident dated 11/21/23. The reportable was in regard to an incident on 11/17/23 were the resident's head was held by Nurse Aide (NA) #55 while Registered Nurse (RN) #40 completed a nasal swab for Covid testing. Upon reviewing RN #40's written statement it was determined NA #55 held Resident #43's heaad just to calm her down. The time of the of incident was documented as the 2 PM - 10 PM shift. The investigation included statements from RN #40, NA #13, and NA #66. Further review of the statements gathered by the facility as a result this investigation found the following statements: c) Registered Nurse #40 Registered Nurse (RN) #40 gave the following statement on 11/17/23: RN #40 (statement collected by the facility) In a statement collected by the facility, on 11/17/23, RN #40 stated she was doing medication pass when a resident came and asked her to check Resident #43.The resident said Resident #43 was complaining of a sore throat. RN #40 said she explained to Resident #43 that she would be doing a COVID test. According to RN #40, Resident #43 became agitated and was afraid of having her nose swabbed. RN #40 said she explained the protocol to the resident and tried to convince her she would be careful, and it would not hurt. RN #40 said Resident#43's roommate tried to calm her down too. RN #40 said NA #55 helped by holding the resident's hand and her head while she (RN#40) performed the test. d) NA#55 The surveyor obtained a statement from the facility for NA#55. NA#55 gave her statement to Nursing Staff Scheduler (NSS) #51 on 11/20/23 by phone. In her statement the NA said she was, Pulled to west for 1:1. Tried to calm the resident down by holding her hand and her head. Trying to relax resident. NA #55's statement also reflected (RN #40's name) was the nurse trying to administer the Covid test.(Activity Aide(AA)#143's name) was walking by and stopped to help.(AA #143name) was holding the resident's hand. NA #55 stated she was making the resident laugh and smile when it was over. f) NA #66 The statement from the facility for NA #66 was given by NA #66 on 11/20/23 to NSS #51 NA #66 stated she was in a room on front hall when she heard screaming. NA #66 said she went into the hall and saw RN#40, Activity Aide #143, and NA #55 with Resident #43. RN #40 had a swab in her hand. NA #55 was holding the resident's hands and Activity Aide #143 was holding the resident's head. NA #66 said by the time she got all the way to them they had finished the test. g) Activity Assistant (AA) #143 The surveyor received a statement taken by the facility from AA #143. AA #143's statement was taken on 11/20/23. I was walking down the hall and saw the nurse trying to give (Resident #43's name) a Covid test. I saw the aide holding head to assist the nurse with the test. h) Employee #145 The surveyor obtained a statement taken by the facility for Employee #145 on 11/20/23. I spoke to the resident, explained who I was and ask her if she recall attempting to get a Covid test on Friday(11-17-23).The resident was non-verbal/Did not indicate she remembered in anyway. i) Resident #8 The surveyor obtained a statement from Resident #8 dated 11/19/23.This statement was taken by an RN. Resident was asked in interview if he's ever seen resident being abused, he stated, 'The other night I was in my room and came out and seen the nurse and the CAN holding resident down to swab her. Resident was asked if he knew who they were he said he didn't know their names, but they were foreign. j) Employee#146 The surveyor obtained a facility statement from Employee #146. This statement was given by the employee on 11/19/23 to Clinical Manager/RN #109 They came to give her a covid test. She didn't want I told her it's okay, I was holding her hand. The one girl held her head and the nurse swabbed her nose, she was screaming the whole time. I told someone but I can't remember who. k) Certified Occupational Therapy Assistant(COTA)#139 The surveyor obtained a facility statement from COTA #139 During session with (Name of Resident #54) and (name of Resident #8) both in therapy room at same time at approx.12:30 PM on 11/19/2023, it was brought up that another patient (Resident #43's name) was being covid tested on Friday (11-17-2023) and that a nurse aide that talks funny with dark hair and a foreigner was holding (Resident #143's name) head back as she was screaming very loudly and that they were disturbed by the screaming and thought that she was allowed to refuse ea covid test if she wanted to refuse .Both patients reported that she could be identified if they saw her. l) NA#13 The surveyor obtained a statement taken by the facility from NA #13. The statement was dated 11/19/23. (NA#66'sname) & I were providing care to a resident on the front hall when we heard screaming. We finished with this resident and we nt to the hall to see (NA#55's name) holding (Resident#43's name) head back for (RN#40's name) to covid swab resident's nose. This incident happened Friday 11/17 after dinner. Further review of the reportable incident found a finding of unsubstantiated despite the multiple staff and resident statements who confirmed it did happen. The survey team completed staff interviews during the course of the survey with the following findings: m) Director of Nursing During an interview with the Director of Nursing (DON) on 02/20/24 at 9:20 AM she stated, I don't really know about it. Let me get the Administrator and Clinical Manager(CL)#109. An interview with CL#109 at 9:50 AM on 02/20/24 was conducted. CL#109,stated,I got the call about the incident .I came in and got statements, and completed this skin checks .Then I handed it over to the administration. n) Administrator An interview with the Administrator at 10:00 AM on 02/20/24 was conducted regarding Resident #43.The administrator reviewed d all the paperwork. The administrator stated, They held her head and hand to comfort her .I don't see a problem with this. o) Resident#8 During an interview on 02/20/24 at 10:37 AM with Resident #8 who has a BIMS of 15 the resident stated, I remember what happened. She was screaming. My room was across from hers at the time. I wanted to smack them off of her. An interview on 02/20/24 at 10:51 AM with NA #66 she stated, I feel like what I remember ,we heard screaming, and we came out, (Name of Activity Assistant #143) was behind her and (Name of RN #40) was in front of her. I don't remember much, but I did feel like it was an issue. I felt like she had the right to say no. An interview on 02/20/24 at 10:54 AM with NA #13 she states, I was in a room up the hall, and I heard screaming, I came out of the room and saw (Name of NA#55) was holding her head, and the nurse was putting a swab in her nose. I don't remember what nurse I reported it to but the east wing (Name of CL #109 came in and told me to write down what I had seen on the paper, So I did. Just the way she was screaming I felt like I needed to report it. They definitely did the swab ;she was taking the swab out of her nose when I went into the room. Telephone interview with NA #55 on 02/20/24 at 2:39 PM she stated, What I remember r is the nurse needed help. I went to help her. I was holding her head and hands to calm her down. If I knew I was going to be in trouble I would have never gone into the room. The nurse was so busy she was just trying to get it done. An attempt was made to contact RN #40 via telephone, as well as RN #26 pm 02/20/2 at 2:00 PM with no answer or return call. At the time of this survey NA #55 and RN #40 were both still employed at the facility and this allegation was unsubstantiated event though there were multiple witness statements confirming the incident did happen on11/17/23. p) Resident#11 A facility reportable incident (FRI) dated 10/03/23 in the (AM), was reviewed involving Resident #11. The allegations contained in this reportable was RN #40 , locked Resident #11's wheelchair and held the back of the wheelchair which prevented the resident from freely leaving the room which she was confined to. This allegation was reported as possible involuntary seclusion. The facility investigated and gathered the following statements: q) NA#141 The surveyor obtained a statement taken by the facility on10/02/23. NA #41 said while giving NA a lunch break and taking on the 1:1 she was stopped by the RN #40 and was asked to give another patient care while she took the 1:1. NA#41 said RN #40 forced Resident #11 back into her room locking her wheelchair and holding the back of the wheelchair so Resident #11was unable to leave her room. r) RN#40 gave a statement on10/03/23: RN#40 said she was doing her medication pass when a family member of one of the resident's asked her to call for Resident#101's nurse aide. RN #40 said she asked NA#141 if she was assigned to Resident #101. NA #141 said she was the aide for Resident #101. NA #141 also said she was watching Resident #11 because the nurse aide assigned to Resident#11 was on break and had asked her to watch Resident#11 while also attending Resident #101. NA #141 said she had a conversation with Resident #11 while walking around the facility. She said Resident #11 was as going to the exit door and kept saying she was going home. When RN #26, who was the assigned nurse to Resident#11 noticed this behavior she said she would take over Resident #11 so RN #40 could finish medication pass. Resident #11 started hitting and punching us and kept on saying bad words. The staff took Resident #11 to her room while RN #26 had a conversation with the resident trying to have her calm down. Then wrote at the bottom of this same statement was a short statement from RN #26. The summarization of the statement is: s) RN#26 agreed with RN#40's statement that the incident with the wheelchair was for a limited period and was therapeutic. This allegation was unsubstantiated by the facility. However, an in-service entitled Abuse and Neglect dated 10/03/23 was completed by Clinical Manager #7 for the staff. Further education was completed with RN#40 by Clinical Manager #7 on 10/03/23 which involved reviewing the facility policy entitled [NAME] Virginia Abuse, Neglect and Misappropriation. The section regarding involuntary seclusion was highlighted. Both RN#40 and the clinical manager #7 signed and dated the facility policy. Clinical Manager #7 verified RN#40 was still employed by the facility as a night shift nurse. During an interview with Clinical Manager (CL) #7 on 02/20/24 at approximately11:15 AM she stated, I was directed by the administrator to conduct an in-service and to do individual education with RN#40. I did not have any further action regarding this reportable. An attempt was made to contact RN #40 via phone, as well as RN#26 On 02/20/24 at 2:00 PM with no answer or call back at this time. t) NA#142 was not able to be interviewed because she no longer works at this facility. During an interview with the Administrator on 02/20/24 at 5:00 PM regarding the incident with Resident #11 he stated, During the investigation you have to weigh the totality of all the statements received and 2 RNs were in the room, versus an Activity Assistant. Sometimes you have to see what actually happened versus someone seeing what they think happened .The statement from both RN's does not conclude that the wheelchair was held. u) Plan of Correction On 02/20/24 the Nursing Home Administrator, Director of Nursing, and the Corporate Office implemented the following plan: Employee(RN) #40 was suspended pending investigation and legal review and HR review, if it determined that the employee could return to work, employee #40 will have extensive abuse and neglect training, by the Regional Team Member. Employee (NA) #55 was suspended pending investigation and legal review and HR review ,if is it determined that the employee could return to work Employee #55 will have extensive abuse and neglect training by the Regional Team Member. Residents with BIMS scores of 12 and above were interviewed for potential physical abuse. Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical Abuse. Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy, through in person, text blast will be physically educated prior to the next shift with signatures. The training will be conducted by the Regional Team Member. There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms. The training will be conducted by the Regional Team Member. Staff will be reeducated on restraint alternatives. There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include, Social Services, Director of Nursing or Designee, and Executive Director. After a thorough review the team will determine if substantiated. Audits will be conducted by the regional Director of Clinical Operations weekly x 4 weeks and monthly x 6 months and randomly thereafter with correction upon discovery. Audit results will be reviewed by the QAPI Committee monthly x 6months.

Based on observation, record review and staff interview the facility failed to implement care plans related to fall interventions. This failed practice was found true for (2) two of (3) three residents reviewed for falls. Resident identifiers #44 and #1. Facility Census 95. Findings Include: a) Resident #44 A record review on 02/19/24 at 1:00 PM of Resident #44's care plan revealed the resident was at risk for falls and had a fall from bed on 02/10/24. Further record review of Resident #44's care plan found an intervention for, Fall mat to side of bed this intervention was initiated 02/13/24. An observation on 02/19/24 at 1:46 PM of Resident #44 found her lying in bed. No fall mat was beside the bed or in the room. An Observation on 02/21/24 at 11:30 AM of Resident # 44 in her bed, the fall mat was not at bedside. An interview on 02/21/24 at 11:40 AM with Clinical Manager (CM) # 109, confirmed the fall mat was not at bedside. b) Resident #1 A record review on 02/19/24 at 1:10 PM of Resident #1's care plan revealed Resident #1was at risk for falls and has had the following falls: 01/24/24 Fall in the dining room 02/13/24 Fall in the lobby 02/02/24 Fall in the room 02/18/24 Fall in the dining room Further record review of Resident #1's care plan reads, {recessed cup with lid to decrease spillage of hot liquids.} An observation on 02/21/24 at 11:30AM, Resident #1 was in the dining room. She had a cup of coffee in a regular coffee cup. During an interview on 02/21/24 at 2:30 PM with Occupational Therapy Assistant (OTA) # 139 describes a recessed cup as being a cup with a concave lid with a hole in the top . sometimes it has 2 handles and sometimes it has one handle. She confirmed that a regular coffee cup is not a recessed cup.

Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident #97. This is true for one (1) of five (5) residents reviewed during the survey process. Resident Identifier: #97. Facility Census: 95. Findings Included: a) Resident #97 On 02/20/24 at 11:00 PM, a record review was completed for Resident #97. The record review found a discharge summary dated 10/23/23. The discharge summary under the section 3 Course of Illness/Progress stated, Resident has been unable to participate in getting up with therapy due to FX (fracture). (Typed as written.) After reviewing the physical therapy notes throughout the stay at the facility, the resident did participate fully and attended the therapy sessions in the facility gym while seated in a wheelchair. In addition, other therapy progress notes state, Pt (patient) propel wc (wheelchair) x (times) 75' (feet) sba (stand by assistance). On 02/20/24 at 1:30 PM, Clinical Manager (CM) #109 reviewed the discharge summary. CM #109 confirmed the statement was incorrect based on the therapy notes. No further information was obtained during the survey process.

.Based on observation, staff interview, and record review the facility failed to report alleged violation related to, neglect, or abuse, and report the results of investigations to the proper authorities within prescribed time frames. This was true for three (3) of five (5) grievances reviewed during a complaint investigation. Resident identifiers: #2, #4 and #3. Facility Census: 89. Findings Included: a) Resident #2 A review of the facility's concern forms revealed a concern form from Resident #2 which read as follows: -Resident States on 06/11/23 and the morning of 06/12/23 he had to wait for up to two hours to receive a changing of a soiled adult brief. Subsequent review of the medical record revealed the complaint/concern on 06/12/23 for Resident #2 was not investigated or reported to the appropriate agencies as required. Resident #2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 13. A BIMS score of 13 indicates the resident is cognitively intact and has capacity. An interview with the administrator on 08/28/22 at 3:13 PM verified the complaint/concern on 06/12/23 for Resident #2 was not reported to state agencies as an allegation of neglect. He stated he did not feel the concern rose to an allegation of neglect. b) Resident #4 A review of the facility's concern forms revealed a concern form from Resident #4 dated 06/25/23 which read as follows: -The morning bed Check presented with Resident #4's bed was saturated with urine and stool. The action to resolve the concern read as follows: -10:00 PM to 6:00 AM Nurse Aides (two named) had only completed one bed check/ change throughout the shift and left beds that were saturated with urine. Subsequent review of the medical record revealed the complaint/concern on 06/25/23 for Resident #4 was not reported to the appropriate state agencies. Resident #4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/23 noted the resident had a score for Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 indicates that the resident is cognitively intact and has capacity. An interview with the administrator on 08/28/22 at 3:13 PM verified the complaint/concern on 06/25/23 for Resident #4 was not reported. He stated he did not feel the concern rose to an allegation of neglect in resident care. c) Resident #3 During review of the concern form for Resident #3, dated 07/08/23, it was identified that a concern was expressed by Resident #3 stating she rang her call bell to let Employee #500, her nursing assistant, know she was wet. The Nursing Assistant #500 assisted Resident #3 to bed with her wet gown still on. Resident #3 also was incontinent of stool. Resident #3 alleged once she was placed in bed Employee #500, her assigned nursing assistant, changed her brief without cleaning her up, covered her with three (3) heavy blankets and left the room. Resident #3 stated she put her call light on again and Nursing Assistant #500, came to her room and put a wheelchair in the doorway and sat there and watched her for a specified amount of time. Review of Resident #3's medical record, revealed on 04/23/23, the physician determined by the physician Resident #3 had the capacity to make her own decisions. On 06/29/23, Resident #3 scored fifteen (15) out of possible fifteen (15) on the Brief Interview of Mental Status Assessment (BIMS). This score indicated the resident was cognitively intact. Review of incidents reported to the state agencies by the facility, revealed the allegation of neglecting to provide adequate care (putting to bed wet and not cleaning after changing a brief with feces) was identified on a concern form but was not investigated, or reported to the appropriate state agencies. During an interview with the Administrator, on 08/28/2023, at 4:10 PM, he was questioned about the reporting of this incident, it was identified he did not feel this rose to the level of reporting and investigating. The Director of Nursing was made aware of the incident at 5:00 PM and verified she would report this issue today.

Based on observation, resident interview, staff interview, medical record review, review of inservice records, and policy review, the facility failed to complete accurate and complete assessments, adequately monitor the residents' condition and revise the plan of care to the extent possible for four (4) of nineteen (19) Stage 2 sample residents. The facility failed to adequately assess and treat pain for Resident #35, resulting in actual harm. Resident #104 was allowed to self-administer a medication without an evaluation by the interdisciplinary team and physician's orders [REDACTED]. For Resident #76 the facility failed to complete pre and post [MEDICAL TREATMENT] skin assessments as ordered by the physician. For Resident #173, who had experienced a fall, failed to follow the physician's orders [REDACTED]. Resident identifiers: #35, #104, #173, and #76. Facility census: 98. Findings include: a) Resident #35 The paper medical record, reviewed on 06/15/16 at 4:14 p.m., indicated Resident #35's [DIAGNOSES REDACTED]. An observation of a wound treatment to the left calcaneous pressure ulcer on 06/16/16 at 9:55 a.m., revealed an elongated, rectangular-shaped black area. The resident complained her heel was really tender and her eyebrows were drawn together in a frowned expression. Registered Nurse (RN) #95 informed the resident that pain was to be expected. She did not ask the resident to rate the intensity of her pain, further evaluate it or offer interventions to relieve the pain. The medical record, reviewed on 06/16/16 at 11:20 a.m., revealed orders for Tylenol 325 milligrams (mg) - administer two (2) tablet to equal 650 mg every four (4) hours as needed for mild/moderate pain not to exceed three (3) grams (g) in 24 hours and non-pharmacological interventions for pain. On 06/20/16 at 9:35 a.m., the wound assessment notes dated 06/13/16 and 06/20/16, indicated orders for a wound treatment every three (3) days and as needed. During an interview with Resident #35 at 12:03 p.m. on 06/20/16, she said she still had pain in her heel and also had pain in her bottom, but had not received any form of intervention to relieve the pain. The Medication Administration Record [REDACTED]. Additionally, no evidence was present from 06/16/16 - 06/20/16 to indicate Resident #35 received interventions prior to wound care to prevent pain. The resident's medical record, reviewed on 06/20/16 at 11:32 a.m., found no evidence a revision in the plan of care had been made to ensure Resident #35 did not experience pain during wound treatments. Upon inquiry as to how often pain was assessed, Licensed Practical Nurse (LPN) #51 related LPNs did not evaluate pain. She said the registered nurses completed all of the assessments. Registered Nurse (RN) #87, who was present during the conversation, related she evaluated pain once a day, but did not note it in the medical record. During an interview with the assistant director of nursing (ADON) on 06/20/16 at 5:48 p.m., she said the nurse was supposed to complete a pain assessment whenever the resident complained of pain and the RN should have evaluated Resident #35's pain during the wound care treatment on 06/16/16 to determine what interventions might be necessary. The MARS, reviewed on 06/20/16 at 12:10 p.m., revealed Resident #35 was administered pain medication on 06/01/16, 06/04/16, 06/05/16, 06/08/16, 06/09/16, 06/12/16 and 06/14/16. The pain management flow sheet provided an assessment dated [DATE], indicating moderate pain occasionally. During another interview and observation with Resident #35, on 06/21/16 at 10:58 a.m., she related she felt rough. When asked to explain, she said her legs hurt real bad. Her eye brows were furrowed. Upon request, the DON completed an interview and observation immediately following the observation at 10:58 a.m. Resident #35 informed the DON that her legs hurt frequently. She also complained her butt hurt down in the hole. The DON completed an assessment and identified the location of the resident's leg pain. Upon inquiry of the DON, Resident #35 said her pain occurred during the daytime and the nighttime. The resident also confirmed she had pain in her heel at the site of the calcaneous pressure ulcer. The pain management in-service training provided by the facility indicated everyone caring for the resident would know to report pain. Charge nurses were to assess all reports of pain and determine the necessary interventions according to the resident's plan of care, and assessments must be ongoing. Documentation of the interventions and outcome was required. The policy and procedure changes section required pain be monitored three (3) times a day, each shift by a licensed nurse. The director of nursing reviewed the resident's medical record, on 06/21/16 at 11:10 a.m., and acknowledged no information was present to indicate the facility had adequately monitored and/or treated Resident #35's pain. The failure to provide appropriate pain management resulted in actual harm to Resident #35. b) Resident #173 An observation on 06/14/16 at 10:37 a.m. revealed a yellow/purple discoloration around Resident #173's right eye. Upon inquiry, the resident said she had fallen out of bed. She related she could not reach her call bell and laid there for about 20 minutes. She denied calling out for assistance. On 06/16/16 at 10:51 a.m., an interview with LPN #51 said she was unable to find a written copy of the care plan for Resident #173. The nurse related the care plans were kept in the binder at the desk, but the resident did not have one. Review of the electronic medical record, immediately following, revealed an interim care plan which did not address the bruises or falls. An interview with minimum data set (MDS) coordinator (MDSC) #40 and MDSC #17, at 10:58 a.m., confirmed a comprehensive care plan had not been developed to address the fall with injury. Nurse Aide (NA) #16 interviewed on 06/16/16 at 1:26 p.m., said Resident #173 was supposed to have grippy socks. The NA related she was not sure whether the resident had any in her room. The nurse aide went to the resident's room and asked her if she had any socks. Resident #173 picked up her pillows, moved her sheets, looked around, and related she could not find any. NA #16 looked in Resident #73's closet and found a pair of socks on the top shelf. The nurse aide related the resident provided most of her own care, but the NA provided set-up of items. She also related the resident required assistance of one (1) staff member for a ambulation. The NA acknowledged she had not provided the resident with socks. NA #16 asked Resident #173 if she would wear the socks and the resident voiced that she would if they were available. During multiple observations throughout the day, on 06/14/16 from 8:00 a.m. - 5:30 p.m.; on 06/15/16 from 8:30 a.m. - 5:30 p.m., and 06/16/16 from 7:00 a.m. - 1:30 p.m., Resident #173 was not wearing socks. Review of the medical record revealed physician's orders [REDACTED]. The treatment administration record (TAR) dated 06/01/16-06/30/16, indicated the nurse would check for the use of nonskid socks each shift (6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 a.m.). No evidence was presented to indicate the nurse had monitored/evaluated the resident on five (5) of twenty-two (22) opportunities from 06/09/16 - 06/16/16 (over a seven (7) day period) to ensure the resident was wearing or had been offered non-skid socks. Additionally, the neurological assessment revealed no entry indicating assessments were completed for six (6) of eighteen (18) opportunities as follows: 06/09/16 from 6:30 a.m.-7:30 a.m., for the 2:00 p.m.-10:00 p.m. shift on 06/10/16, 06/11/16 or 06/12/16; nor for the 6:00 a.m. -2:00 p.m. shift on 06/12/16. The facility provided no evidence Resident #173 was assessed and monitored as per the physician's orders [REDACTED]. c) Resident #104 1. On 06/20/16 at 3:21 p.m., during a medication observation, LPN #123 administered [MEDICATION NAME] to Resident #104. The nurse exited the room without ensuring the resident finished taking the medication. The resident took a sip and placed it on the over-the-bed table. Upon inquiry, LPN #123 related she was unsure if the resident had an order to self-medicate. She reviewed the medical record at 3:48 p.m. and was unable to find a physician's orders [REDACTED]. Registered Nurse (RN) #57 also reviewed the medical record and confirmed the resident did not have an assessment or order to self-medicate. The annual minimum data set (MDS), with an assessment reference date (ARD) of 02/16/16, reviewed on 06/20/16 at 4:57 p.m., indicated Resident #104 was not capable of self-administration and did not wish to self-medicate. 2. Further review of physician's orders [REDACTED].#123 had administered two (2) tablets of Gerikot (senna) 8.6 mg. ([MEDICATION NAME] is a stool softener and senna is a stimulant laxative.) On 06/20/2016 at 5:11 p.m., a follow-up interview with LPN #123 confirmed Resident #104 received Gerikot 8.6 mg., and said it was what the facility had always given her. The medication had the resident's name handwritten on the bottle cap. The LPN voiced, I don't even know if we have it ([MEDICATION NAME]/senna 50/8.6 mg) in stock. Upon inquiry as to why it was administered at 3:21 p.m., when scheduled for 8:00 p.m., the nurse said, Yea, I messed up on that. The bowel movement vitals report, dated 05/28/16 through 06/21/16, was reviewed with LPN #173 on 06/21/16 at about 8:30 a.m. The report indicated Resident #104 had a large bowel movement on 05/28/16, a small bowel movement on 06/11/16 and a medium bowel movement on 06/13/16. The plan of care kardex noted (0) zero for 06/18/16 and 06/19/16 on the 10-6 shift, and incontinent for 06/13/16, but did not note the size, and none noted the consistency. The activity of daily living (ADL) flow sheet noted continent or incontinent with episodes, but did not note the size or consistency of the bowel movement and the plan of care kardex indicated Resident #104 was incontinent of bowel on 06/13/16 on 2:00 p.m. - 10:00 p.m. shift, but did not indicate the size or consistency. The nurse confirmed the reports were difficult to decipher and acknowledged an accurate assessment could not be completed based on the information provided. Upon inquiry as to who monitored the resident's bowel movements to determine whether the bowel protocol was required, LPN #173 related the night shift nurse completed a lax (laxative) list each night. The lists were reviewed from dates of 05/28/16 - 06/20/16. The lists indicated Resident #104 received the bowel protocol of milk of magnesia (MOM) on 05/31/16, 06/02/16, 06/15/16, 06/19/16 (last bowel movement noted as 06/15/16) and 06/20/16. However, the MAR indicated [REDACTED]. On 06/21/16 at 8:45 a.m. the DON reviewed the bowel elimination records and acknowledged the information was disorganized and provided a medium for error. She confirmed an accurate assessment/evaluation of bowel elimination could not be made based on the elimination entries. An observation and interview, completed with Registered Nurse (RN) #67, on 06/21/16 at about 9:00 a.m., revealed Resident #104 sitting up in bed, coherent, alert, with no complaints of discomfort. Upon inquiry, the resident said she did not remember whether she had recently had a bowel movement. The progress note, dated 06/21/16, indicated Resident #104 had positive bowel sounds, but her abdomen was firm and distended, and the physician was notified via fax at that time. The care plan, reviewed on 06/21/16 at 9:45 a.m., noted Resident #104 was incontinent of bowel. The goal was for the resident to have a soft formed continent BM (bowel movement) without undue strain at least three (3) times per week. Interventions included auscultation of bowel sounds and assess for abdominal distention if the resident is having pain or is unable to have a BM, rectal exam as indicated. Medications to manage bowel function as ordered, see MAR. Observe for effectiveness. During a follow-up interview with the DON on 06/21/16 she said Resident #104 had not had a bowel movement in the past five (5) days, and confirmed the facility had not implemented the bowel protocol per physician's orders [REDACTED]. d) Resident #76 Medical record review on 06/16/16 at 9:30 a.m., found a physician's orders [REDACTED]. Another order dated 04/07/16 stated, Skin assessment before and after [MEDICAL TREATMENT] - document findings. Review of the care plan in use at the time of the survey, dated 05/08/15, reviewed on 06/16/16 at 9:45 a.m., stated to complete a skin assessment before and after [MEDICAL TREATMENT] and to document findings in the chart. Further review of the medical record on 06/16/16 at 10:30 a.m. revealed there were no skin assessments completed before and after [MEDICAL TREATMENT] on the following days: 05/02/16, 05/09/16, 05/16/16, 05/20/16, 05/23/16, and 06/13/16. An interview with Licensed Practical Nurse (LPN) #116 on 06/16/16 at 11:00 a.m., revealed the resident was to have a complete skin assessment done before going to [MEDICAL TREATMENT] and upon returning from [MEDICAL TREATMENT]. The documentation of the skin assessment along with all findings was to go into the progress notes of the resident's medical record. An interview with the Director of Nursing (DON) on 06/16/16 at 11:30 a.m. revealed she could not provide any evidence of skin assessments being completed before and after [MEDICAL TREATMENT] on 05/02/16, 05/09/16, 05/16/16, 05/20/16, 05/23/16, and 06/13/16. The DON stated the staff should have completed the skin assessments before and after [MEDICAL TREATMENT] and charted the completion of the assessment as well as any findings in the progress notes. The DON stated she would in-service her nurses immediately to ensure the skin assessments were being completed as ordered.