Autumn Care Of Portsmouth

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure allegations of resident-to-resident abuse involving four of six residents (Resident (R) 111, R121, R122, and R123) reviewed for abuse were reported to the State Agency (SA) within required time frames. The failure had the potential to allow potential abuse without recognition or regulatory follow-up to prevent recurrence.Findings include:
1. Review of R111's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, depression, and muscle weakness. Review of R111's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/25 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. He did not exhibit any mood or behavioral symptoms.
Review of R111's Nursing Note written on 08/31/25 at 3:25 AM by Licensed Practical Nurse (LPN) 2 and located under the Progress Notes tab of the EMR revealed, Resident in bed awake watching TV. Roommate grabbed his bed remote and hit him on his left arm and left leg several times. Resident immediately removed from room at this time.
Review of R121's Face Sheet, located under the Face Sheet tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including history of stroke, malnutrition, encephalopathy, and diabetes. He was discharged from the facility on 08/31/25 and did not return.
Review of a facility's Facility Reported Incident form, dated 08/31/25 and provided on paper by the Regional [NAME] President of Operations (RVPO), revealed the above allegation of resident-to-resident abuse by R121 to R111 was reported to the SA. An attached fax Tx [Transmission] Result Report revealed the initial report of the allegation was made to the SA on 08/31/25 at 10:15 AM, over seven hours after the allegation was first documented.
During an interview on 02/26/26 at 12:01 PM, LPN2 stated the incident happened around 3:00 AM on 08/31/25 and she had reported it to the on-call physician and Administration right away.
During a telephone interview on 02/26/26 at 5:06 PM, the Administrator stated her understanding of reporting timelines was to report any allegation of abuse that causes severe bodily injury within two hours and any other allegation within 24 hours. The Administrator was not aware of the regulatory requirement and facility policy to report any allegations of abuse or events that cause serious bodily injury within two hours. The Administrator stated she could not remember the details of this incident but stated she had probably sent in the initial report when she arrived at work later that morning since it happened around 3:00 AM.
2. Review of R122's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R122 was discharged on 07/25/25 and did not return.
Review of R122's Care Plan, dated 05/01/25 and located in the residents' EMR under the Care Plan tab, revealed R122 was care planned for a history of physical and verbal behaviors. Interventions in place dated 05/28/25 were for a psychiatric evaluation and treat as needed; monitor for changes in behaviors, and care provided by two staff members.
3. Review of R123's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of cerebral infarction and muscle weakness.
Review of R123's 5-day Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment.
Review of R123's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R123 discharged [DATE]
Review of R122's Nurse's Note dated 05/24/25 at 10:10 PM and located in the EMR under the Notes'' tab written by Licensed Practical Nurse (LPN) 5 revealed, Resident R122 was observed cursing and yelling at resident in room [ROOM NUMBER]-1 (R123) saying that he continues to urinate on the toilet seat. R122 threatened resident in room [ROOM NUMBER]-1 with physical harm and continued to tell him that he was from Russia. R122 had to be redirected by staff multiple times before he walked away from resident in room [ROOM NUMBER]-1. R122 walked into his room and slammed the door behind him. Monitoring behavior will continue.
Review of R123's Nurse's Note dated 05/24/25 at 10:22 PM and located in the EMR under the Notes'' tab written by LPN 5 revealed, R123 stated that while he was lying in bed watching television, R122 approached his bedroom door and begin yelling and cursing at him. R122 was observed cursing and yelling at R123, saying that R123 continue to urinate on the toilet seat. R123 stated that R122 threatened him with physical harm and continued to tell him that he was from Russia. Nursing staff redirected R122 multiple times before he would even walk away from R123 door. R123 was asked if he felt safe and he stated that he was starting to feel uncomfortable because no one should be coming to his door yelling and cursing at him.
Review of the Facility Reported Incident dated 05/26/25 revealed the incident occurred on 05/24/26 but was not reported until 05/26/25 at 4:09 PM.
During an interview on 02/26/26 at 11:05 AM, LPN5 stated she did not report the incident between R122 and R123 to a supervisor that night because she said it was the 3-11 shift and there was nobody to report to. She stated she did report it the next morning, but she could not remember who. She thought she mentioned it to the Administrator and informed her that R123 was fearful. She stated she did not feel like any actions were taken to properly address these types of situations. She said R122 had told her, He could do whatever he wanted and get away with it.
During an interview on 02/26/2026 at 5:06 PM, the Administrator stated she did not remember getting a call on 05/24/25 around 10 PM when the incident occurred. She stated she would have expected the incident be reported immediately to a supervisor, and it was not appropriate to just redirect R122 back into his room. The Administrator was unable to answer why the allegation was not reported to the state survey agency until two days later on 05/26/25 at 4:09 PM.
Review of the facility's policy titled, Virginia Resident Abuse Policy, dated 01/16/26, revealed, All allegations of Abuse, Neglect, Involuntary Seclusion, Injuries of Unknown Source, and Misappropriation of resident property must be reported immediately to the Administrator, Director of Nursing (DON), and to the applicable State Agency. If the event that caused the allegation involves an allegation of Abuse or serious bodily injury, it should be reported to the [SA] immediately, but not later than 2 hours after the allegation is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to implement their abuse policy and thoroughly investigate an allegation of resident-to-resident abuse for two of five residents (Resident (R) 122, R123) reviewed for abuse out of 38 sample residents. This had the potential to affect residents in the facility who were at risk for abuse. Findings include:1. Review of R122's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R122 discharged on 07/25/25. Review of R122's Care Plan, dated 05/01/25 and located in the residents' EMR under the Care Plan tab, revealed R122 was care planned for a history of physical and verbal behaviors. Interventions in place dated 05/28/25 were for a psychiatric evaluation and treat as needed; monitor for changes in behaviors, and care provided by two staff members. 2. Review of R123's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of cerebral infarction and muscle weakness. Review of R123's 5-day Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R123 discharged [DATE]. Review of R123's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R123 discharged [DATE]. Review of R122's Nurse's Note dated 05/24/25 at 10:10 PM and located in the EMR under the Notes'' tab written by Licensed Practical Nurse (LPN) 5 revealed, Resident R122 was observed cursing and yelling at resident in room [ROOM NUMBER]-1 (R123) saying that he continues to urinate on the toilet seat. R122 threatened resident in room [ROOM NUMBER]-1 with physical harm and continued to tell him that he was from Russia. R122 had to be redirected by staff multiple times before he walked away from resident in room [ROOM NUMBER]-1. R122 walked into his room and slammed the door behind him. Monitoring behavior will continue.Review of R123's Nurse's Note dated 05/24/25 at 10:22 PM and located in the EMR under the Notes'' tab written by LPN5 revealed, R123 stated that while he was lying in bed watching television, R122 approached his bedroom door and begin yelling and cursing at him. R122 was observed cursing and yelling at R123, saying that R123continue to urinate on the toilet seat. R123stated that R122 threatened him with physical harm and continued to tell him that he was from Russia. Nursing staff redirected R122 multiple times before he would even walk away from R123 door. R123 was asked if he felt safe and he stated that he was starting to feel uncomfortable because no one should be coming to his door yelling and cursing at him.Review of the Facility's Five Day Follow Up dated 06/01/25 revealed the findings did not indicate the date the incident occurred. The incident occurred on 05/24/25 and only R122, R123 and LPN1 were interviewed. R122 was interviewed on 05/26/25 and R123 was interviewed on 05/28/25. Other residents were interviewed and asked four basic questions, Has staff, a resident, or anyone else here mistreated you?, Did you tell staff about the mistreatment?, Have you seen any resident here being mistreated?, and if yes, did you tell anyone the mistreatment? None of the residents interviewed were asked about the incident that occurred on 05/24/25 or their observations and interactions with R122. During an interview on 02/26/26 at 11:05 AM LPN5 stated she did not report the incident between R122 and R123 to a supervisor that night because she said, It was the 3-11 shift and there was nobody to report to. She stated she did report it the next morning, but she could not remember who. She thought she mentioned it to the Administrator and informed her that R123 was fearful. She said she was Not interviewed about what happened or asked to write a statement about it. During an interview on 02/26/2026 at 5:06 PM, the Administrator stated they would interview all staff working on the unit at the time an incident occurred and other residents. She was unsure why no other staff besides LPN5 was interviewed. Review of the facilities policy titled Virginia Abuse Policy dated 01/05/26 revealed the facility staff must immediately begin an investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, facility document review, and policy review, the facility failed to honor the food choices for 11 of 98 facility residents (Resident (R) R5, R15, R94, R93, R103, R120, R84, R63, R49, R8, and R22). This failure had the potential to lead to dissatisfaction with meals, malnutrition or weight loss, or feelings of helplessness among resident whose preferences were not honored.Findings include:1. Review of R5's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including diabetes, anemia, and malnutrition. Review of R5's the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/26 and located under the Resident Assessment Instrument (RAI) tab of the EMR revealed a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition.2. Review of R15's Face Sheet, located under the Face Sheet tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including obesity and cirrhosis of the liver.Review of R15's Quarterly MDS with an ARD of 02/06/26 and located under the RAI tab of the EMR revealed a score of 15 out of 15 on the BIMS, indicating intact cognition.3. Review of R94's Face Sheet, located under the Face Sheet tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses including diabetes, dysphagia, reflux, depression, and malnutrition.Review of R94's admission MDS with an ARD of 01/22/26 and located under the RAI tab of the EMR revealed a score of 15 out of 15 on the BIMS, indicating intact cognition.4. Review of R93's Face Sheet, located under the Face Sheet tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including diabetes, gastrointestinal hemorrhage, obesity, anxiety, and depression.Review of R93's Annual MDS with an ARD of 11/25/25 and located under the RAI tab of the EMR revealed a score of 15 out of 15 on the BIMS, indicating intact cognition.5. Review of R103's Face Sheet, located under the Face Sheet tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including diabetes, obesity, anxiety, and malnutrition.Review of R103's admission MDS with an ARD of 12/02/25 and located under the RAI tab of the EMR revealed a score of 15 out of 15 on the BIMS, indicating intact cognition.6. Review of R120's Face Sheet, located under the Face Sheet tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses including diabetes, anemia, end stage renal disease, anorexia, and malnutrition.Review of R120's Quarterly MDS with an ARD of 01/30/26 and located under the RAI tab of the EMR revealed a score of 11 out of 15 on the BIMS, indicating moderately impaired cognition.7. Review of R84's Face Sheet, located under the Face Sheet tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including anemia and peptic ulcer.Review of R84's Quarterly MDS with an ARD of 01/16/26 and located under the RAI tab of the EMR revealed a score of eight out of 15 on the BIMS, indicating moderately impaired cognition.8. Review of R63's Face Sheet, located under the Face Sheet tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, reflux, obesity, and malnutrition. Review of R63's Quarterly MDS with an ARD of 12/29/25 and located under the RAI tab of the EMR revealed a score of 15 out of 15 on the BIMS, indicating intact cognition.9. Review of R49's Face Sheet, located under the Face Sheet tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including anemia, depression, obesity, and anxiety.Review of R49's Quarterly MDS with an ARD of 01/29/26 and located under the RAI tab of the EMR revealed a score of 15 out of 15 on the BIMS, indicating intact cognition.10. Review of R8's Face Sheet, located under the Face Sheet tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including chronic kidney disease and cirrhosis of the liver.Review of R8's Quarterly MDS with an ARD of 01/17/26 and located under the RAI tab of the EMR revealed a score of 15 out of 15 on the BIMS, indicating intact cognition.11. Review of R22's Face Sheet, located under the Face Sheet tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including dysphagia, depression, and malnutrition.Review of R22's Quarterly MDS with an ARD of 01/27/26 and located under the RAI tab of the EMR revealed a score of six out of 15 on the BIMS, indicating moderately impaired cognition.12. Resident CouncilReview of the [NAME] Resident/Family Council Agenda Minutes provided on paper by the Regional [NAME] President (VP) of Operations and dated 11/16/25 revealed R5, R15, and R94 attended the meeting. The minutes documented, Residents put alternate order for lunch [and] dinner but dietary sends what they want. The resolution was, Has alternate dietary sheets [and] put in mailbox. Paper, no longer verbal.During a resident group interview on 02/26/26 at 1:12 PM with R5, R15, R94, R93, R103, R120, R84, R63, and R49, all residents agreed they did not receive the foods they ordered on the alternate order sheet at times. R15 explained residents had to have their alternate order forms completed by 10:00 AM for lunch and by 1:00 PM for supper. R93 stated Even when the forms go in on time, you don't get what you ordered, they just give you what they want to give you. All residents in the group agreed this was true and stated there was a lack of communication in the kitchen. R93 added the kitchen often ran out of menu items and served something else in place of the items without letting you know. All residents in the group agreed. R93 stated if you did not receive the food you ordered, you had to wait until everyone else was served to receive what you wanted and often times the kitchen would be out of that item. R5, R15, and R94 stated these concerns had come up in the Resident Council meetings but things had not improved. During an interview on 02/27/26 at 3:06 PM, the Dietary Regional Manager stated that when the Resident Council brought upmentioned concerns regarding receiving alternates as ordered at meals, the dietary department initiated use of the alternate order sheets rather than a verbal ordering system. The DRM stated there was no formal education done with staff or residents at this time, but the Dietary Manager (DM) had verbally educated the kitchen staff and showed them the new forms. The DRM stated there was no documented follow up to this concern to ensure the new form had made improvements. 13. Meal ServiceDuring an interview on 02/27/26 at 11:27 AM, the DRM stated residents' preferences were recorded on the alternate order forms, which were in a pile on the counter next to the tray line. The DRM stated residents' preferences were only recorded on the order forms, the tray card was not updated and listed the regular menu meal for all residents with their applicable texture and portion size.During an observation of the lunch service in the kitchen on 02/27/26 beginning at 11:27 AM, the following were noted:Observation of the 02/27/26 lunch Alternate Order Forms at 11:34 AM on the countertop in the kitchen revealed:A. R93 ordered two hamburgers, the veggie of the day (Capri mixed vegetables), and a side salad.B. R8 ordered a grilled chicken sandwich, the veggie of the day, and a side salad.C. R22 ordered a chicken pot pie.Observation of meal service beginning at 11:43 AM at the tray line revealed:A. R93 was served two hamburgers and a side salad. He did not receive the veggie of the day as ordered.B. R8 was served a grilled chicken sandwich and French fries. She did not receive the veggie of the day or the side salad as ordered.C. R22 was served herb baked chicken legs, yellow rice, Capri mixed vegetables, and dinner roll. She did not receive a chicken pot pie as ordered.D. At 12:19 PM, [NAME] (C) 1 had run out of the Capri mixed vegetables and began serving green peas to residents who had ordered the regular meal. During an interview on 02/27/26 at 12:39 PM, C1 stated he had run out of the Capri mixed vegetables and served green peas instead. During a concurrent interview on 02/27/26 at 12:43 PM, the DM stated it was unusual for food to run out of mid-service, and those changes would not necessarily be announced to residents. However, if menu substitutions were made before meal service began, she would update the menu to notify the residents. The DRM stated education was needed on portion forecasting and menu preparation to ensure adequate amounts of food are available to all residents who order it. The DM stated alternate order forms were filled out by residents or staff and dropped off in the mailbox. They were due around 10:30 AM for lunch and 1:30 PM for supper. The DM stated the kitchen staff should be using and following the alternate order forms during tray service. The DM added the alternate order forms were kept on the counter near the tray line, but orders were not added to tray tickets. During an interview on 02/27/26 at 1:03 PM, R93 stated he did not receive the Capri mixed vegetables on his lunch tray as ordered and he had to request a dish of vegetables from the kitchen. R93 stated, I shouldn't have to ask for them. If I ordered them, they should be on the plate.During an interview on 02/27/26 at 1:15 PM, R8 stated she received fries with her chicken sandwich today instead of the Capri mixed vegetables and side salad she had ordered. She stated she did not eat the fries and wanted vegetables with the meal but never received them. R8 stated it frequently occurred where she did not receive her order as requested. She added, What's the point of having a paper if they don't do it. During an interview on 02/27/26 at 2:21 PM, R22 stated she did not receive a chicken pot pie at lunch today as she ordered; she received the regular meal of baked chicken, rice, vegetables, and a roll. R22 stated she ate what she was served and did not request it be replaced with the pot pie. R22 stated this happened frequently.Review of the facility's policy titled, Menu Planning Policy dated 03/28/25 revealed, Based on a facility's reasonable efforts, menus will reflect the religious, cultural, and ethnic needs of the resident population, as well as individual resident and resident groups.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to provide written information on how to formulate an Advance Directive for one of five residents (Resident (R)30) reviewed for Advance Directives out of a total of 38 sampled residents. This failure has the potential for R30 not to be able to make her desires known if she was unable to speak for herself.Findings include:Review of R30's Face Sheet, located under the Resident tab in the electronic medical record (EMR) indicated R30 admitted to the facility on [DATE] with the diagnoses including chronic obstructive pulmonary disease (COPD) and congested heart failure (CHF). R30 was also documented as being a Full Code.Review of R30's admission Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab in the EMR with an Assessment Reference Date (ARD) of 01/29/26 indicated R30 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R30 had moderately impaired cognition. During an interview on 02/26/26 at 11:00AM, R30 was asked if her heart stopped or she stopped breathing what would she want the staff to do for her. R30 stated, I want everything to be done for me.During an interview on 02/27/26 at 12:14 PM, the Social Services Director (SSD) stated, There is a path meeting within three days of admission, and we go over the Advance Directive and code status with the resident and/or family member. This is done at the bedside.During an interview on 02/27/26 at 1:00 PM, Registered Nurse (RN) 2 stated, When we do an admission, we will ask if they have an Advance Directive and what they would like the code status to be. But I don't give the residents any information on Advance Directives.During an interview on 02/27/26 at 4:30 PM, the Admissions Director (ADMD) stated, We will ask if the resident has an Advance Directive when they are admitted to the facility but that is all that I do. I don't give them anything about this.Review of R30's admission Packet, provided by the ADMD, and dated 01/29/26 indicated, . A written summary of the FACILITY Advance Directive policy. (App [Appendix] C) I _____ have __X____ have not executed an Advance Directive .Review of the facility's policy titled, Advanced Care Planning Meeting Protocol, dated 08/27/25 indicated, . Information (ex. Living Wills, Medical [NAME] of Attorney including the resident's right to form an Advance Directive and the right to refuse medical/surgical treatment is provided to the resident and family by the facility on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policy review, the facility failed to implement their abuse policy, and protect three out of 38 sampled residents, (Resident (R123) R112 and R111) from a resident-to-resident encounter. Encounters involved R123 & R122; R112 and R26, and R111 and R121. R123 expressed fear to staff and did not feel safe after R122 threatened R123 with physical violence. This resulted in the potential for mental harm for R123 and had the potential to affect other residents. Findings include:
1. Review of R122's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R122 was discharged on 07/25/25 and did not return.
Review of R122's Care Plan, dated 05/01/25 and located in the residents' EMR under the Care Plan tab, revealed R122 was care planned for a history of physical and verbal behaviors. Interventions in place dated 0528/25 were for a psychiatric evaluation and treat as needed; monitor for changes in behaviors, and care provided by two staff members.
2. Review of R123's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE] with diagnosis of cerebral infarction and muscle weakness.
Review of R123's 5-day Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/20/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment.
Review of R123's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R123 was discharged [DATE].
Incident:Review of R122's Nurse's Note dated 05/24/25 at 10:10 PM and located in the EMR under the Notes'' tab written by Licensed Practical Nurse (LPN) 5 revealed, Resident R122 was observed cursing and yelling at R123 in his room, (R123) saying that he continues to urinate on the toilet seat. R122 threatened R123 with physical harm and continued to tell him that he was from Russia. R122 had to be redirected by staff multiple times before he walked away from R123. R122 walked into his room and slammed the door behind him. Monitoring behavior will continue.
Review of R123's Nurse's Note dated 05/24/25 at 10:22 PM and located in the EMR under the Notes'' tab written by LPN5 revealed, R123 stated that while he was lying in bed watching television, R122 approached his bedroom door and begin yelling and cursing at him. Resident R122 was observed cursing and yelling at resident R123, saying that R123 continue to urinate on the toilet seat. R123 stated that R122 threatened him with physical harm and continued to tell him that he was from Russia. Nursing staff redirected R122 back to his room multiple times before he would even walk away from R123's door. R123 was asked if he felt safe and he stated that he was starting to feel uncomfortable because no one should be coming to his door yelling and cursing at him.
During an interview on 02/26/26 at 11:05 AM LPN5 stated R122 kept saying R123 was urinating on the toilet seat in their shared bathroom, but she did not think R123 was physically able to get up on the toilet. R122 had to be redirected multiple times away from R123's room. R122 kept telling R123 I will come in that room and put my hands on you; he was from Russia and knew people that would take care of R123. LPN1 said R123 was absolutely scared of R122. She asked R123 if he felt safe, and he replied no. She asked him if he wanted a room change, but he replied no. She stated she did not report the incident to a supervisor that night because she said, It was the 3-11 shift and there was nobody to report to. She stated she did report it the next morning, but she could not remember who. She thought she mentioned it to the Administrator and informed her that R123 was fearful. She stated she did not feel like any actions were taken to properly address these types of situations. She said R122 had told her, He could do whatever he wanted and get away with it.
During an interview on 02/26/2026 at 5:06 PM, the Administrator stated she did not remember getting a call on 05/24/25 around 10 PM when the incident occurred. She stated she would have expected the incident to be reported immediately to a supervisor, and it was not appropriate to just redirect R122 back into his room. The Administrator was unable to answer if staff did enough to ensure the safety of R123 and the other residents in the facility. 2. R112 and R26A. Review of R112's Face Sheet located under the Face Sheet tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses of Charcot's joint of the right ankle and foot [a severe, progressive condition causing rapid destruction of joints and bones] and end stage renal disease. R112 was discharged from the facility on 04/18/25 and did not return.
Review of R112's admission MDS with an ARD of 03/18/25 and located under the RAI tab of the EMR revealed a score of 15 out of 15 on the BIMS, indicating intact cognition. R112 did not exhibit mood or behavioral symptoms.
B. Review of R26's Face Sheet, located under the Face Sheet tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, schizoaffective disorder, depression, insomnia, gout, malnutrition, anxiety, and restlessness/agitation. Review of R26's Quarterly MDS with an ARD of 03/27/25 and located under the RAI tab of the EMR revealed she was unable to complete the BIMS as she was rarely/never able to make herself understood. She had impaired short- and long-term memory and moderately impaired cognition. She did not exhibit any mood or behavioral symptoms. She was dependent on staff for assistance with activities of daily living but was independently mobile in her wheelchair.
Review of R26's Significant Change of Condition MDS with an ARD of 12/14/25 and located under the RAI tab of the EMR revealed a score of one out of 15 on the BIMS, indicating severely impaired cognition. She exhibited moderate symptoms of depression. The MDS indicated R26 did not exhibit any behavioral symptoms. Review of R26's Care Plan located under the RAI tab of the EMR with a start date of 07/22/24 and revision date of 02/18/26 revealed R26 exhibited increased agitation at times as evidenced by hitting/kicking at staff and an episode of kicking a resident on 04/16/25. The approaches included, Divert resident's behavior . Seat resident where constant/near constant observation is possible . Allow distance in seating other residents around resident . Remove resident from group activities when behavior is unacceptable . Provide structured rest periods . Simplify ADLs . Assign staff people to assist with direct care . Prepare and organize supplies before caring for resident. Avoid delays and interruptions in care . When resident becomes physically abusive, keep distance between resident and others (e.g., staff, other residents, visitors) . When resident becomes physically abusive, STOP and try task later. Do not force to do task . When resident becomes physically abusive, move to a quiet, calm environment . Provide consistent staff as much as possible . Maintain a calm, slow, understandable approach with the resident . psychosocial therapy . Provide care, activities, and a daily schedule that resembles the resident's prior lifestyle . If resident has delusions/hallucinations, do not try to reason with or confront resident. Offer reassurance . [and] Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). C. Review of a facility's Facility Reported Incident (FRI) form dated 04/16/25 and provided on paper by the Regional [NAME] President of Operations (RVPO) revealed an allegation of resident-to-resident abuse by R26 to R112 was reported to the SA. The form documented R112 alleged was kicked on the external fixator (a surgical method using metal plates, screws, rods, or pins to stabilize and align fractured bones from inside the body) on his right leg by R26 while in the hallway.
Review of the facility's untitled follow-up report to the SA, dated 04/22/25 and provided on paper by the RVPO, revealed R112 was being escorted in a wheelchair by a transportation aide (TA) from an outside company through the hallway upon return from a dialysis appointment. R26 was in the middle of the hallway and would not move when asked by the TA. R112 alleged R26 kicked her leg out and made contact with his injured leg with an external fixator in place. Staff removed R26 from the hallway and R112 was assessed with no noted injuries and was sent to the emergency room per his request for evaluation of the external fixator. R26 was unable to recall the incident or explain the situation due to dementia. A witness statement from the TA at the time of the investigation revealed R26's foot came in contact with R112's leg/external fixator. There were no other witnesses to the actual resident-to-resident contact, though additional staff had witnessed the two residents in the hall and R26's leg being raised in a kicking motion. The report documented, After completion of interviews, it was established that resident to resident contact occurred. During a telephone interview on 02/26/26 at 5:06 PM, the Administrator stated the incident of resident-to-resident abuse was substantiated through investigation.
During an interview on 02/26/26 at 5:36 PM, LPN1 stated he was behind the nurses' station desk when R112 was being wheeled down the hall by the TA in a wheelchair. R26 was in the hallway, and the TA confronted her to get through because he was not familiar with her, and she reacted by raising her leg, which was a typical reaction for her that facility staff were aware of. LPN1 stated he did not witness R26's foot come in contact with R112, he only saw her leg go up. LPN1 stated he assessed R112's external fixator and lower extremity but found no injury or displacement. LPN1 stated R112 requested to go to the emergency room for evaluation, though there was no clinical reason he needed to go. 3. R111 and R121A. Review of R111's Face Sheet located under the Face Sheet tab of the EMR revealed he was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, depression, and muscle weakness. Review of R111's admission MDS, with an ARD of 07/03/25 and located under the RAI tab of the EMR revealed a score of 15 out of 15 on the BIMS, indicating intact cognition. He did not exhibit any mood or behavioral symptoms.
Review of R111's Quarterly MDS, with an ARD of 01/03/26 and located under the RAI tab of the EMR, revealed a score of 12 out of 15 on the BIMS, indicating moderately impaired cognition. He exhibited mild mood symptoms and no behavioral symptoms.
Review of R111's Nursing note written on 08/31/25 at 3:25 AM by LPN2 and located under the Progress Notes tab of the EMR revealed, Resident in bed awake watching TV. Roommate grabbed his bed remote and hit him on his left arm and left leg several times. Resident immediately removed from room at this time.
B. Review of R121's Face Sheet, located under the Face Sheet tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including history of stroke, malnutrition, encephalopathy, and diabetes. He was discharged from the facility on 08/31/25 and did not return.
C. Review of a facility's Facility Reported Incident form, dated 08/31/25 and provided on paper by the RVPO, revealed an allegation of resident-to-resident abuse by R121 to R111 was reported to the SA. The form documented R111 alleged he was hit with the bed remote by R121.
Review of the facility's untitled follow-up report to the SA, dated 09/08/25 and provided on paper by the RVPO, revealed R121 had just moved in, shared a room with R111, became agitated, and had used the bed remote to hit R111's arm and leg. Staff separated the residents and R121 was sent to the emergency room for evaluation and was not planning to return to the facility. R111 did not have any injuries. A statement from R111 at the time of the investigation revealed he was hit by R121 with the remote. There were no other witnesses to the event and R121 was unable to make a statement due to agitation The form documented, After completion of interviews, it was established that resident to resident contact occurred.
During a telephone interview on 02/26/26 at 5:06 PM, the Administrator stated the incident of resident-to-resident abuse was substantiated through investigation.
During an interview on 02/27/26 at 9:39 AM, R111 stated he did not recall the incident on 08/31/25.
Review of the facilities policy titled Virginia Abuse Policy dated 01/05/26 revealed, the facility will not tolerate the abuse, neglect, mistreatment, exploitation of residents or misappropriation of residents property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure a written transfer notice that contained all required information and the bed hold notice was provided for one of seven residents (Resident (R) 74) and/or their responsible party (RP) reviewed for hospital transfer out of 38 sampled residents. This failure had the potential to result in the resident and their RP not having the knowledge of where and why a resident was transferred, the bed holds policy, and/or how to appeal the transfer, if desired.Findings include:Review of R74's Face Sheet, located under the Resident tab in the electronic medical record (EMR) indicated R74 was readmitted to the facility on [DATE] with the diagnosis of transient cerebral ischemic attack (TIA).Review of R74's quarterly Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab in the EMR, with an Assessment Reference Date (ARD) of 09/24/25 indicated R74 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R74 had moderately impaired cognition. Review of R74's Nursing Progress Note, located under the Resident tab in the EMR and dated 11/09/25 at 7:02 PM indicated, Went in to take residents evening vitals, he was alert but unable to speak when his name was called. Vitals and blood sugar were within normal limits; hand grips were weak bilateral. Notified NP [nurse practitioner] and informed them [sic] that resident will be sent out for further evaluation .Review of R74's EMR did not indicate documentation of the facility providing a written transfer and bed hold policy to the resident and RP when R74 was transferred to the hospital on [DATE].During an interview on 02/27/26 at 11:57 AM, the Social Services Director (SSD) stated, The process is for the nurses to fill out the information for the transfer notice and bed hold policy. After that I am not aware of what happens with the information.During an interview on 02/27/26 at 1:00 PM, Registered Nurse (RN)2 stated, We fill out the information on the transfer notice and bed hold policy, then after they are completed, the forms are placed in the envelope that is given to the EMTs [Emergency Medical Transports] and is taken to the hospital with the resident. RN2 stated they were not sure how the transfer notice and bed hold policy was provided to the RP. During an interview on 02/27/26 at 6:30 PM, the Regional [NAME] President of Operations (RVPO) stated, The Social Worker is to call the resident's representative and/or the resident as a follow up after the resident is transferred to the hospital to go over this information with them.Review of the facility's policy titled, Discharge Planning Policy, and dated 02/03/26 indicated, Transfers and discharges will meet regulatory requirements. The facility will take steps to ensure that the transfer or discharge is documented in the resident's medical record and necessary information is communicated to the receiving healthcare institution or provider .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status for two of 38 sampled residents (Resident (R) 34 and R76). Specifically, the MDS did not accurately assess presence of pressure ulcers for R34 and the use of oxygen for R76. These failures placed the residents at risk for unmet care needs related to pressure ulcers for R34 and oxygen for R76.Findings include:
1. Review of R34's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including stroke, malnutrition, gout, muscle weakness, seizures, and diabetes.
Review of R34's admission MDS with an Assessment Reference Date (ARD) of 01/29/26 and located under the RAI (Resident Assessment Instrument) tab of the EMR revealed a score of 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderately impaired cognition. The MDS documented R34 had one unstageable pressure ulcer.
Review of R34's Care Plan dated 01/26/26 and located under the RAI tab of the EMR revealed, Wound Focus: PU [pressure ulcers] to sacrum left heel.
Review of R34's Admission/readmission Observation dated 01/23/26 and located under the Observations tab of the EMR, revealed R34 had pressure ulcers to her sacrum and left heel upon admission to the facility. Review of R34's EMR under the Wound Care tab revealed Wound Observation dated 01/24/26, revealed two wounds: a stage IV pressure ulcer to the sacrum and an unstageable pressure ulcer to the left heel, both of which were present on admission. Review of subsequent Wound Observation, dated 01/31/26, revealed both the stage IV sacrum and unstageable heel pressure ulcers were still present. During an interview on 02/27/26 at 2:35 PM, the MDS Coordinator (MDSC) stated she was unsure why R34's MDS only reflected one pressure ulcer and not two, adding that section had been completed by the Infection Preventionist (IP).
During an interview on 02/27/26 at 3:13 PM, the IP stated R34 had two pressure ulcers with which she was admitted . The IP stated both pressure ulcers should have been reflected on the MDS and this was a discrepancy that needed to be corrected.
2. Review of R76's admission Record, located in the Profile tab of the EMR revealed admission to the facility on [DATE] and with diagnoses of chronic obstructive pulmonary disease (COPD). Review of R76's quarterly MDS under the MDS tab of the EMR, with an ARD of 01/26/26, revealed the BIMS, revealed a score of 12 out of 15 which indicated no cognitive impairment. The resident was not coded as receiving oxygen therapy. Review of R76's Care Plan, located under the Care Plan tab of the EMR, dated 02/12/25, revealed The resident required the use of oxygen due to a diagnosis of COPD. The Resident was at risk for altered respiratory status. Intervention in place was to administer oxygen per physician orders. Review of R76's Physician Orders located under the Orders, tab in the EMR, dated 10/17/25, revealed oxygen at 2 LPM (liters per minute) via (by way of) nasal cannula continuously. Review of the Medication Administration Record (MAR) located under the Records tab in the EMR, dated January and February 2026, revealed on 02/26/2024, LPN did not document R76's oxygen at 3 LPM continuously. Further review noted nothing had been documented on the MAR about R76's oxygen administration. Review of R76's Nurse's Note dated 01/20/26 and located in the EMR under the Notes'' tab written by the Nurse Practitioner (NP) revealed, R76, [AGE] years old female, is seen today per nursing request for reports of poor appetite times the last 1-2 days. She reports she is drinking fluids but has been refusing meals. Her scopolamine patch was discontinued 3 days ago due to complaint of dry mouth. Patient is seen sitting up in bed awake and cooperative, CNA (Certified Nurse Assistant) is offering ADL (Activities of Daily Living) care at this time. Patient reports not feeling well but is nonspecific, appears slightly dyspneic on exam. Has oxygen in place via nasal cannula 3 L with oxygen saturations of 98%. CNA reports patient has been coughing. ROS is challenging due to her dementia.During an interview on 02/27/2026 at 3:10 PM, the MDS Coordinator confirmed she did not indicate that R76 was on oxygen when she completed the 01/26/26 MDS assessment. She stated she looked at the MAR and there was no indication that R76 received oxygen therapy. She stated she made an observation of R76 in her room, and she did not have an oxygen concentrator or nasal cannula. The MDS Coordinator did not have any documentation of that observation. During an interview on 02/27/26 at 3:32 PM the Director of Nursing (DON) stated she did not know much about MDS assessments, but she expected them to be completed accurately.
The facility did not have a policy addressing MDS accuracy. Review of the Centers for Medicare and Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual dated 10/01/25, An accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian, and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [interdisciplinary team] completing the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that an accurate Preadmission Screening and Resident Review (PASARR) Level I assessment was completed for two residents (Resident (R) 102 and R9) out of 38 sampled residents. This had the potential to affect all residents who were admitted to the facility.Findings include:
1. Review of R102's ''admission Record, located under the ''Profile'' tab of the electronic medical record (EMR), revealed R8 admitted to the facility on [DATE] with diagnoses including unspecified intellectual disabilities.
Review of R102's DMAS-95 [Department of Medical Assistance Screening] Level I Screening, dated 12/20/24 and located in the resident's EMR under the Miscellaneous tab, revealed no indication of intellectual developmental disability (IDD) identified.
2. Review of R9's ''admission Record,'' located under the ''Profile'' tab of the EMR, revealed R9admitted to the facility on [DATE] with diagnoses including anxiety disorder, schizoaffective disorder bipolar type.
Review of R9's DMAS-95 Level I Screening, dated 04/13/24 and located in the resident's EMR under the Miscellaneous tab, revealed no indication of mental illness identified.
During an interview on 02/27/2026 at 10:41 AM the Social Services Director (SSD) stated she was not responsible for the completion of the PASARR Level I. She stated the Administrator completed them, but the Administrator was unavailable at this time for interview. The SSD stated she would find out who was available to answer questions about the PASARR's.
During an interview on 02/27/26 at 3:32 PM, the Director of Nursing (DON) stated she expected PASARR assessments to be completed accurately.
3. Review of R30's Face Sheet, located under the Resident tab in the EMR indicated R30 admitted to the facility on [DATE] with the diagnosis of bipolar disorder.
Review of R30's admission Minimum Data Set (MDS,) located under the RAI tab in the EMR, with an ARD of 01/29/26 indicated R30 had a BIMS score of 11 out of 15 which indicated R30 had moderately impaired cognition.
Review of R30's EMR in its entirety indicated there was no documentation of a PASSAR being completed prior to or within 30 days from admission to the facility.
During an interview on 02/27/26 at 6:15 PM, the Regional [NAME] President of Operations (RVPO) stated, I could not find a PASSAR for this resident, but she should have had one completed.
The Administrator was unavailable on 02/27/26 for interviews by the survey team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to develop a care plan for three of four residents (Resident (R) 64, R30, and R5) that included targeted behaviors for the use of anxiety medication out of a total sample of 38 residents. This failure had the potential for residents to experience adverse effects of an anxiety medication which was not specifically monitored. Findings include:1. Review of R64's Face Sheet, located under the Resident tab in the electronic medical record (EMR) indicated R64 was readmitted to the facility on [DATE] with the diagnosis of multiple sclerosis and congested heart failure (CHF).Review of R64's quarterly Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab in the EMR, with an Assessment Reference Date (ARD) of 01/18/26 indicated R64 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R64 had moderately impaired cognition.Review of R64's Care Plan, located under the RAI tab in the EMR and dated 02/24/26 for a Problem of Resident receives anxiety medication R/T [related to] Terminal [sic] agitation, restlessness, anxiety, insomnia, or hallucinations. The interventions included, Monitor resident's mood and response to medication.Review of R64's Physician Orders, located under the Resident tab in the EMR indicated an order dated 02/23/26 for lorazepam concentrate two milligram [mg] per milliliter [ml] give 0.5 milliliter [a short term, prescription-only benzodiazepine used to treat anxiety, insomnia, acute seizures, and for pre-anesthesia sedation] every four hours as needed for terminal agitation, restlessness, anxiety, insomnia, or hallucinations times 14 days.During an interview on 02/27/26 at 2:37 PM, the Minimum Data Set Coordinator (MDSC) was asked what targeted behaviors R64 exhibited that the staff knew to look for and monitor while R64 was taking lorazepam for anxiety. The MDSC stated, Each resident is different. I guess we could look at how she acts when she has anxiety and add them to the care plan.2. Review of R30's Face Sheet, located under the Resident tab in the EMR indicated R30 admitted to the facility on [DATE] with the diagnosis of generalized anxiety disorder and bipolar disorder.Review of R30's admission MDS, located under the RAI tab in the EMR, with an ARD of 01/29/26 indicated R30 had a BIMS score of 11 out of 15 which indicated R30 had moderately impaired cognition. R30 was also coded for receiving antipsychotic and antianxiety medication.Review of R30's Care Plan, located under the RAI tab in the EMR and dated 01/26/26 indicated a Problem which stated, Resident receives antianxiety medication R/T anxiety/bipolar [sic]. The interventions included, . Monitor resident's mood and response to medication.Review of R30's Physician Orders, located under the Resident tab in the EMR indicated an order dated 01/23/26 for Abilify 15 mg by mouth give one tablet once a day for bipolar disorder [a prescription antipsychotic used to treat schizophrenia, bipolar 1 disorder, depression, Tourette's disorder and irritability in autism) Bupropion HCI tablet extended release 24 hour 150 mg give one tablet once a day for bipolar disorder [an atypical antidepressant], Buspirone 10 mg give one tablet once a day for anxiety, and Xanax one mg give one tablet three times a day for anxiety/bipolar disorder [a fast acting benzodiazepine primarily used for short term management of anxiety disorders].3. Review of R5's Face Sheet, located under the Resident tab in the EMR indicated R5 was admitted to the facility on [DATE] with the diagnosis of adjustment disorder with mixed anxiety and depressed mood.Review of R5's quarterly MDS, located under the RAI tab in the EMR, with an ARD of 11/08/25 indicated R5 was coded as having a BIMS score of 15 out of 15 which indicated R5 was cognitively intact. R5 was also coded as receiving antianxiety and antidepressant medication. Review of R5's Physician's Orders, located under the Resident tab in the EMR indicated an order dated 11/15/25 for duloxetine delayed released capsule 20 mg give one tablet once a day for depression and anxiety [medication used to treat major depressive disorder and generalized anxiety disorder], and mirtazapine 15 mg give one tablet at bedtime for depression/insomnia [a medication used to treat major depressive disorder].Review of R5's Care Plan, located under the RAI tab in the EMR and dated 01/29/26 indicated a Problem of Resident is on an antidepressant medication D/T [due to] Depression and Anxiety [sic]. The interventions included Medication per MD [medical doctor] orders Monitor for s/s of adverse side effects Monitor for behaviors psych per MD orders [sic].During an interview on 02/27/26 at 3:33 PM, the Director of Nursing (DON) stated, I expect the resident's care plan to reflect the care they are receiving. This would include the behaviors that the resident is known to exhibit.Review of the facility's policy titled, Comprehensive Care Planning Policy, dated 02/24/26 indicated, . The facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure timely review and revision of care plans for one resident (Resident (R) 42) of four reviewed for care plan revisions out of a total sample of 38 residents. The facility failed to ensure R42's care plan was updated to reflect the resident's current smoking status. Failure to ensure care plan accuracy had the potential for the residents who smoke to be at risks for accidents/hazards during smoke breaks by not reflecting accurate smoking assessments for all residents who smoke.Findings include:1. Review of R42's Face Sheet, under the Resident tab of the electronic medical record (EMR) revealed the resident was originally admitted to the facility on [DATE] with diagnoses that included B-cell lymphoma with intrapelvic lymph nodes, unspecified psychosis, glaucoma, dementia, and schizoaffective disorder. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 02/10/26 and located under the Resident Assessment Instrument (RAI), tab of the EMR revealed a Brief Interview for Mental Status (BIMS) of nine out of 15 indicating the resident had moderately impaired cognition. The EMR also revealed that the resident was admitted to hospice care as of 5/16/25 and a significant change MDS was completed. During an observation on 02/25/2026 at 3:59PM, R42 was observed returning from the smoking area without evidence of burns or safety concerns.During an observation on 02/25/2026 at 4:01 PM, Certified Nursing Assistant (CNA) 5 entered the facility following R42. CNA5 was asked if the resident smoked independently, and she confirmed that the resident was an independent smoker and confirmed he could hold his own cigarette. CNA5 added that he was provided with a locker with a key to house his smoking materials. Review of the Smoking Care Plan, initiated on 09/23/25, and located under the RAI tab of the EMR documented the resident as an unsupervised smoker with interventions that included intermittent supervision, required smoking gloves, designated-area smoking, use of a cigarette holder, and 1:1 supervision-many of which were inconsistent with the resident's current abilities.During an interview on 02/26/26 at 8:47AM, R42 confirmed that he does not wear an apron or gloves when smoking, and that he does not need assistance to hold his smoking materials. During an observation on 02/26/26 at 8:58AM, R42 was observed in the smoking area, smoking unassisted. The resident was able to hold his own cigarette/cigar and no concerns were observed. During an interview on 2/26/26 at 4:55 PM, the Director of Nursing (DON) confirmed that although the resident experienced a prior decline, he subsequently regained the ability to smoke independently, and the care plan should have been updated accordingly. The DON stated it was the Minimum Data Set Coordinator's (MDSC) responsibility to update the care plan. During an interview on 2/27/26 at 2:33PM, the MDSC acknowledged that outdated interventions should not remain on the care plan and that revisions are required when resident status changes. Review of the facility's policy titled, Comprehensive Care Planning Policy, dated 01/27/11, revealed the facility will develop a comprehensive person-centered plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. The plan will be focused on resident choices and abilities with the intent of maintaining or improving resident functional abilities and quality of life. Further review of the policy revealed, The care plan is reviewed on an ongoing basis and revised as indicated by the residents' needs, wishes, or a change in condition. At a minimum, this will occur with each comprehensive and quarterly assessment in accordance with the Resident Assessment Instrument (RAI) requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to ensure staff maintained professional standards of practice by ensuring one resident (Resident (R) 122) was not administered crushed medications when there was not a clinical indication to do so. Findings include:Review of R122's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. R122 discharged on 07/25/25. Review of R122's Care Plan, dated 05/01/25 and located in the residents' EMR under the Care Plan tab, revealed R122 was care planned for behavioral symptoms. 07/16/25 Resident pocketing medications and refusing to give to the nurse. Review of R122's Orders located under the Resident tab of the EMR, revealed a physician order, dated 02/10/25, for may crush medications unless contraindicated.Review of R122's Nurse's Note dated 07/21/25 at 8:13 AM and located in the EMR under the ''Notes'' tab written by the Assistant Director of Nursing (ADON) revealed This writer entered resident room to administer AM medications (11-7 shift). Resident looked into medication cup and threw it in the trash due to medications being crushed.Review of R122's Nurse's Note dated 07/21/25 and located in the EMR under the ''Notes'' tab written by the Nurse Practitioner (NP) revealed R122, [AGE] years old male, is seen today for reports that he has refused to take his Abilify. Nurses report he was noted taking his Abilify tablet out of medication and refuses to take it several days ago. Nurses obtained a crushed order for medications, however patient refused to take any medications this morning because the medications were crushed and he wants to take them whole.Review of R122's Nurse's Note dated 07/21/25 at 7:33PM and located in the EMR under the ''Notes'' tab written by the Licensed Practical Nurse (LPN)6 revealed Resident has new order to administer Abilify in the A.M, and medications no longer have to be crushed. Resident aware.During an interview 02/26/2026 at 5:48 PM, LPN6 said R122 wanted to hold his medication, and he didn't want to take it at the time staff administered it. He wanted to hold onto the medication and take it later. She stated staff would crush all his medications. She said if the order says to crush, they will crush all of them. She said they did not have a list on the medication cart that listed medications that should not be crushed and that they would trust the order. She said she assumed the person who put the order in would know which medications could and could not be crushed and she did not double check. If the order says crush, they crushed all the medications. During an interview on 02/27/2026 at 10:06 AM the NP said that R122 medications should not have been crushed. During an interview on 02/27/26 at 3:32 PM the Director of Nursing (DON) said the physician order should state to crush only the particular medication that needed to be crushed and that medications that should not be crushed should not be. She stated she believed that there was only one specific medication (Abilify) of R122 that was crushed, but she was not sure which or if all his medications were crushed. According to a review by the Cleveland Clinic, Abilify should not be crushed, chewed, or divided; they should be swallowed whole. Crushing the tablet can alter how the medications is absorbed by the body. If swallowing is a problem, liquid formulations, or orally disintegrating tablets are available alternatives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and policy review, the facility failed to administer oxygen in accordance with physician orders for two of four residents (Resident (R) 30 and R76) reviewed for oxygen therapy out of a total of 38 sampled residents. This failure had the potential for the residents not to receive the correct amount of oxygen causing hyperoxia (cells, tissues and organs are exposed to an excess supply of oxygen) or hypoxia (cells, tissues and organs are exposed to a decrease in oxygen). Findings include:
1. Review of R30's Face Sheet, located under the Resident tab in the electronic medical record (EMR) indicated R30 admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease (COPD) and congested heart failure (CHF).
Review of R30's admission Minimum Data Set (MDS), located under the Resident Assessment Instrument (RAI) tab in the EMR, with an Assessment Reference Date (ARD) of 01/29/26 indicated R30 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R30 had moderately impaired cognition. R30 was also coded as receiving oxygen therapy.
Review of R30's Care Plan, located under the RAI tab in the EMR and dated 01/26/26 indicated a Focus which stated, Resident requires oxygen therapy R/T [sic] [related to] SOB [shortness of breath] The intervention indicated, . Administer oxygen at [three] 3L/min [liters per minute] .
Review of R30's Physician Orders, located under the Resident tab in the EMR indicated an order dated 01/23/26 for Oxygen: Administer oxygen (O2) via nasal cannula (NC) continuously at: [three] 3 liters/minute [liters per minute] .
During observations on 02/24/26 at 3:03 PM, 01/28/26 at 11:25 AM, and 02/25/26 at 10:23 AM, and 02/25/26 at 6:05 PM, R30 was lying in bed with the oxygen concentrator approximately two feet from the left side of the bed, administering oxygen at two LPM via nasal cannula.
During an interview and observation on 02/25/26 at 6:07 PM, Registered Nurse (RN)1 confirmed R30's oxygen concentrator setting and stated, It is on two liters right now. RN1 returned to the medication cart outside of R30's doorway and reviewed R30's EMR for orders and confirmed the orders were for three LPM. RN1 went back into the resident's room and adjusted the oxygen concentrator to deliver three LPM to R30.
2. Review of R76's admission Record, located under the Profile tab of the EMR revealed admission to the facility on [DATE] and with diagnoses of COPD. Review of R76's quarterly MDS, under the MDS tab of the EMR, with an ARD of 01/26/26, revealed a BIMS, score of 12 out of 15 which indicated the resident had moderate cognitive impairment. The resident was not coded as receiving oxygen therapy.
Review of R76's Care Plan, located under the Care Plan tab of the EMR, dated 02/12/25, revealed The resident required the use of oxygen due to a diagnosis of COPD. The Resident was at risk for altered respiratory status. An intervention in place was to administer oxygen per physician orders.
Review of R76's Physician Orders located under the Orders, tab in the EMR, dated 10/17/25, revealed oxygen at two LPM via nasal cannula continuously.
Review of Medication Administration Record (MAR), located under the Records tab in the EMR, for the month of January and February 2026, revealed the nurses did not document that R76 was on oxygen at two LPM continuously. Further review noted nothing had been documented on the MAR about R76's oxygen administration.
During observations on 02/25/26 at 9:59 AM, and again on 02/26/26 at 9:02 AM the resident was lying in bed with nasal cannula and oxygen cannister at three LPM. Further review revealed a sign was on the oxygen concentrator that indicated keep O2 level at [two] 2 LPM.
During an observation and interview on 02/25/26 at 10:02 AM, Licensed Practical Nure (LPN) 3 confirmed R76's oxygen setting was at three LPM. She was not sure if that was correct or not. She stated she administered R76 her nebulizer treatment this morning but did not remember looking at the oxygen concentrator. She confirmed she did not document on R76's MAR related to the resident's oxygen order. She was unsure why there was no documentation for the entire month of February related to the resident's continuous oxygen order.
During an interview on 02/27/26 at 3:32 PM, the Director of Nursing (DON) stated she expected staff to follow physician orders and monitor oxygen.
During an interview on 02/27/26 at 3:33 PM, the DON stated, The staff should follow physician orders.
Review of the facility's policy titled, Oxygen Administration Policy, dated 06/23/25 revealed, licensed clinicians with demonstrated competence will administer oxygen and check the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure that staff followed physician orders and weighed (Resident #4) prior to and after dialysis for one of one resident reviewed for dialysis, out of a sample of 38 residents. This had the potential to affect all residents who went out for dialysis treatment. Findings include:Review of R4's Face Sheet in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease with end stage renal disease and dependence on renal dialysis. Review of R4's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/26 EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was not cognitively impaired. R4 was documented as receiving hemodialysis. Review of R4's Care Plan dated 08/26/25 and located in the EMR under the Care Plan tab revealed R4was not care planned for dialysis treatment. Review of R4's Physician Orders located under the Orders tab in the EMR dated 12/17/25 revealed hemodialysis every Tuesday, Thursday, and Saturday. Further review revealed an order dated 09/03/25 pre dialysis and post dialysis weights on Tuesday, Thursday, and Saturday. Review of R4's weights revealed weights were only completed in February on 02/05/26 pre and post dialysis, and on 02/21/24 and 02/24/26 post dialysis. During an interview on 02/27/26 at 6:40 PM, Licensed Practical Nurse (LPN)1 stated residents receiving dialysis should be weighed prior to exiting the facility, and again upon their return. He stated there is an option in the MAR to include the weight. He said R4 should have a pre and post. But he said R4 does refuse at time but that should be documented. There should either be a documented weight refusal or a documented weight. He also stated there should not be an unavailable on the MAR where the weight should be documented, and said that was a good question when asked how the resident would not be available for his weight to be taken. He said the pre and post weights were important because it helps staff have a rough estimate of how much fluid was removed from the dialysis process and not having weights could cause hypovolemic or hypervolemic. During an interview on 02/27/26 at 3:32 PM the Director of Nursing (DON) stated she expected staff to absolutely follow physician orders. Review of the facility's policy titled Hemodialysis Care dated 07/02/25 revealed, Licensed staff with demonstrated competence will care for residents who require hemodialysis (via onsite third-party providers or who travel to an outpatient setting). Communication between the dialysis provider and facility staff will occur before and after each hemodialysis treatment and as needed. Document assessment in the Dialysis Communication Tool. Assessment includes Pre-treatment weight and post-treatment weight.

Based on observations, facility document review, and policy review, the facility failed to ensure staff followed the menus for mechanical soft and puree diets for 14 residents who received these diet textures (five residents on puree diets and nine residents on mechanical soft diets) out of a census of 98. This failure placed those residents at risk of malnutrition, weight loss, or dissatisfaction with meals.Findings include:Review of an untitled, undated handwritten document, provided on paper by the Director of Nursing (DON), revealed the facility had nine residents who received a mechanical soft diet and five residents who received a puree diet.Review of the facility's Diet Guide Sheet for lunch on 02/27/26, provided on paper by the Dietary Regional Manager (DRM), revealed the regular texture meal was herb roasted chicken, yellow rice, Capri mixed vegetables, and a dinner roll. For a mechanical soft texture, the menu was ground herb roasted chicken, Capri mixed vegetables, buttered noodles, and a dinner roll. For a puree texture, the menu was pureed herb roasted chicken, pureed Capri mixed vegetables, cream of rice, and pureed bread.During an observation of the lunch service in the kitchen on 02/27/26 beginning at 11:27 AM, the DRM asked the [NAME] (C1) what he was serving instead of rice for the mechanical soft diet, and he responded, mashed potatoes. The DRM stated it should be buttered noodles. The DRM then asked C1 what sides were being served for a pureed diet. C1 responded he had made mashed potatoes. The DRM stated he should be serving cream of rice but stated it was a substitute of equal nutritive value, so it was ok. Throughout meal service, C1 served residents on a mechanical soft diet mashed potatoes instead of the buttered noodles and served residents on a puree diet mashed potatoes instead of cream of rice that was called for on the menu. Additionally, there was no pureed bread on the tray line or served to the residents on a pureed diet. During an interview on 02/27/26 at 12:39 PM, C1 stated he served mashed potatoes instead of noodles for the mechanical soft diet and instead of cream of rice for the puree diet. C1 stated there was no reason he used mashed potatoes but stated, I just know they can eat it. C1 confirmed he had not prepared or served pureed bread and stated he had forgotten. C1 stated he did not look at the menu to determine what to serve for mechanical soft and pureed diets. During a concurrent interview on 02/27/26 at 12:43 PM, the Dietary Manager (DM) stated she did not think C1 looked at the menu to determine the correct foods to serve and the DRM stated C1 needed more training on following menus. The DM stated she had recently done an in-service training on following menus; however, C1 had not attended. The DM stated C1 should have pureed bread and served it with the puree meal.Review of the facility's policy titled, Menu Substitutions Policy, dated 03/28/25, revealed, Regular and therapeutic menus will be written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances . Regular and therapeutic menus will be written by the facility's food and nutrition professional(s) in accordance with the facility's approved diet manual . A registered dietitian nutritionist (RDN) or designee will approve all menus . A computerized nutritional analysis is used to evaluate nutritional adequacy in menu planning. The menus have been evaluated for Dietary Reference Intake (DRI) based on the Recommended Dietary Allowances (RDA), Estimated Average Requirements (EAR), Adequate Intakes (AI), and Acceptable Macronutrient Distribution Ranges (AMDR).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review, the facility failed to follow infection control guidelines during the medication administration observation by touching pills prior to being administered to two of four residents (Resident (R)84 and R119) and failed to don appropriate personal protective equipment for two of four residents in transmission-based precautions (R50 and R63) out of 38 total sampled residents. These failures had the potential to expose R84, R119, R50, and R63 to infections in an already vulnerable population.Findings include:
1. During the medication administration observation on 02/26/26 at 7:54 AM, Licensed Practical Nurse (LPN) 3 was observed preparing Aspirin 81 milligrams (mg) to administer to R119. LPN3 poured the pills into the lid of the Aspirin bottle. While doing so, LPN3 was observed placing her bare index finger on the extra tablet of Aspirin so as not to pour this tablet into the medication cup. LPN3 then proceeded to put this tablet of Aspirin back in the Aspirin bottle.
2. During another observation on 02/26/26 at 8:06 AM, LPN3 was observed preparing Tylenol 325 mg two tablets to administer to R84. As LPN3 was pouring the Tylenol tablets in the lid of the bottle, three tablets of this medication were noted to be in the lid of the bottle. LPN3 then proceeded to place her bare index finger on the extra Tylenol so as not to pour this tablet into the medication cup. LPN3 then poured the extra tablet back into the bottle of Tylenol. LPN3 performed this procedure when attempting to put one tablet of Aspirin 81 mg chewable into the lid of the bottle. Again, as the nurse poured the Aspirin into the resident's medication cup, LPN3 placed her bare index finger on the tablet and then returned this tablet into the remaining bottle of Aspirin tablets.
During an interview on 02/26/26 at 11:15 AM, LPN3 stated, I didn't realize that I put my finger on the pills so I wouldn't get the wrong number of tablets in the resident's medication cup. When I did that, I should have worn gloves so that I would not be touching the pills with my bare fingers.
During an interview on 02/27/26 at 3:33 PM, the Director of Nursing (DON) stated, The nurse should never touch the pills with her bare hands. If she was going to touch the pills, she should have worn gloves so this would not be a problem.
Review of the pharmacy's policy titled, General Dose Preparation and Medication Administration, dated 11/15/24 indicated, . Appropriate hand hygiene should be performed before and after direct resident contact. Medications should not come in contact with any surface except for the medication cup.
3. Review of R63's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with a diagnosis of malignant breast cancer. Review of R63's EMR under the Orders tab revealed a physician's order dated 09/15/25 for Neutropenic Precautions at all times. Review of R63's Care Plan located under the Resident Assessment Instrument (RAI) tab of the EMR revealed, Neutropenic Precautions. The approaches included, Precautions per protocol, monitor for compliance.
During an observation on 02/24/26 at 12:05 PM outside of R63's room, a sign on the door indicated, Neutropenic Precautions and directed anyone entering the room to perform hand hygiene, don a gown, gloves, and mask before entering the room, and doff the Personal Protective Equipment (PPE) before exiting the room. The door also held a supply of PPE needed for room entry. Certified Nursing Assistant (CNA) 5 entered R63's room to deliver and set up her lunch tray while only wearing a mask and no additional PPE.
During an interview on 02/24/26 at 12:05 PM, CNA5 stated she only donned a mask because she was just serving R63's food and was not coming in close contact with the resident. CNA5 stated she would don a gown and gloves if she was entering the room to provide care.
During an observation on 02/25/26 at 5:48 PM, CNA6 entered R63's room with only a mask on and no additional PPE to deliver and set up her dinner tray.
During an interview on 02/25/26 at 5:50 PM, CNA6 stated he should have donned a gown and gloves in addition to his mask before entering the room and stated he had forgotten.
During an interview on 02/27/26 at 4:23 PM, the DON stated for neutropenic precautions, the staff should clean their hands and apply gloves, mask, and gown prior to entering a room, no matter the situation. The DON stated PPE should be donned for every room entry.
Review of the facility's undated Neutropenic Precautions signage, provided on paper by the DON revealed, Put on gloves before entering and remove before leaving room. Put on a gown before entering and remove before leaving room. Put on mask before entering room if you have a respiratory infection . 4. Review of R50's Face Sheet, located under the Face Sheet tab of the EMR, revealed he was admitted to the facility on [DATE].
Review of R50's EMR under the Diagnostic Order Review tab revealed a C. Difficile (c-diff) test result reported 02/21/26.
Review of R50's EMR under the Orders tab revealed a physician's order dated 02/21/26 for Contact Precautions related to a diagnosis of c-diff. Review of R50's Care Plan located under the RAI tab of the EMR and dated 02/24/25 revealed, Resident has need for isolation related to c-diff. The approaches included, Have adequate PPE available for staff and visitors.The resident is on Transmission-Based Precautions (Contact, Droplet, or Airborne) - not just standard precautions. The Care Plan had not been updated to specify contact precautions.
During an observation on 02/24/26 at 12:28 PM outside R50's room, signage on the door indicated Contact Precautions and directed anyone entering the room to perform hand hygiene, don a gown and gloves before entering the room, and doff the PPE before exiting the room. The door also held a supply of PPE needed for room entry. CNA7 entered R50's room to check on the resident and did not don any PPE prior to entrance. During an interview on 02/24/26 at 12:28 PM, CNA7 stated staff were supposed to wear gloves, a mask, and a gown when providing care to R50 but only a mask if not providing direct resident care. CNA7 stated she did not don any PPE because she was just rushing in to check on the resident due to a report he had not received his lunch tray.
During an observation on 02/25/26 at 5:48 PM, CNA6 entered the room wearing only a mask and no additional PPE. He delivered R50's meal tray, moved the bedside table, then was reminded by another staff member to don a gown and gloves, which he began to do.
During an interview on 02/25/26 at 5:50 PM, CNA6 he had forgotten to don a gown and gloves prior to room entrance but was reminded and would be putting them on. During an interview on 02/27/26 at 4:23 PM, the DON stated for contact precautions, the staff should clean their hands and apply gloves and gown prior to entering a room, no matter the situation. The DON stated PPE should be donned for every room entry.
Review of the facility's undated Contact Precautions signage, provided on paper by the DON, revealed, Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person.

Based on staff interviews, clinical record reviews and facility documentation review, the facility staff failed to ensure 2 of 38 residents in the survey sample, (Resident #10 and #33) were given the opportunity to formulate an advance directive.
The findings included:
1. The facility staff failed to ensure Resident #10 and or their Representative was given the opportunity to formulate an Advance Directive. Resident #10 was originally admitted to the nursing facility on 03/06/19. Diagnosis for Resident #10 included but not limited to Chronic Obstructive Pulmonary Disease (COPD).
The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 04/14/22 coded the resident with a 02 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment.
Review of the clinical record revealed that there was no Advance Directive for Resident #10.
Review of Resident #10's Physician Order Sheet (POS) for April 2022 revealed the following order: Do Not Resuscitate (DNR) starting on 03/01/21.
An interview was conducted with the Social Worker on 04/13/22 approximately 3:59 p.m., who said an Advance Directive should have been completed upon admission then updated yearly. When asked if there was evidence that Resident #10 and or their Representative was given the opportunity to formulate an Advance Directive, she replied, No.
On 04/14/22 at approximately 10:40 a.m., an interview was conducted with the Director of Nursing (DON) and Regional Director of Clinical Services who stated, Resident #10 and or their representative should have been given the opportunity to formulate an Advance Directive. The DON was asked what is the purpose of an Advance Directive. She stated, In the event the resident becomes incapacitated, the medical professionals will know what the resident wishes are or who to contact in that event.
A debriefing was held with the Administrator, Director of Nursing,, [NAME] President of Operations and Regional Director of Clinical Services on 04/14/22 at approximately 4:32 p.m., who were informed of the above findings; no further information was provided prior to exit.
Definitions:
-COPD is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing (https://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes).
2. The facility staff failed to execute the opportunity to provide an advance directive for Resident #33. Resident #33 was originally admitted to the facility 08/02/2019 after an acute care hospital stay. The current diagnoses included; Unspecified Psychosis not due to a substance or known physiological condition and Acquired absence of the left leg above the knee.
The Quarterly Revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/16/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #33 cognitive abilities for daily decision making were intact.
In sectionG(Physical functioning) the resident was coded as independent with no set- up help in bed mobility, transfers, locomotion on and off the unit and toilet use. Requiring set-up help only in personal hygiene, eating and bathing.
A review of the clinical record on 4/14/22 revealed there was no advance directive in the clinical record on the above resident or that the resident was offered an opportunity to create one.
On 4/14/22 at approximately 2:00 PM., an interview was conducted with OSM (Other Staff Member) #3 concerning the above issue. She stated, It wasn't done. I can't find it.
On 4/15/2022 at approximately 1:15 PM., the above findings were shared with the Administrator, The Corporate Consultant, The DON and with the ADON. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee record review, facility document review and staff interviews the facility staff failed to implement their Abuse/Neglect Prevention Policy for screening of new employees. Criminal Background Checks were not obtained for 5 current employees 2 of which were agency staff within 30 days of their hire date and Sworn Statements were not obtained for 2 current agency staff employees upon hire.
The findings included:
On 4/13/22 twenty-five current employee records were reviewed. The employee record review revealed that 5 current employees 2 of which were agency staff did not have a Criminal Background Checks. There were also 2 current agency staff employees that had no Sworn Statements upon hire.
On 4/13/22 at 1:00 p.m. an interview was conducted with the Director of Human Resources regarding the missing employee Criminal Background Checks and Sworn Statements. The Director of Human Resources stated, I know I ran them but I can't find them. I called the agency and spoke with the owner. The owner said that they were independent contractors and use a different company for the criminal background checks not the Virginian State Police. The also said they did not have the sworn statements for their 2 employees either. I will get it taken care of.
The facility policy titled Contractor and Vendor Background Screening last revised 3/2/2017 was reviewed and is documented in part as follows:
Policy: It is the policy of [NAME] to undertake background checks of all vendors and contractors to the fullest extent required by applicable law, and to retain on file applicable records of current contractors and vendors regarding such investigations.
B. All contractors and vendors must certify that they have not been convicted of any offense that would preclude them from providing items and services in a nursing facility.
The facility policy titled Virginia Resident Abuse Policy last revised 5/26/2021 was reviewed and is documented in part, as follows:
Policy: This facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone.
Procedure:
1. Screening: It is the policy of the facility to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks.
a. The facility will do the following prior to hiring a new employee:
iv. Conduct a criminal background check in accordance with State law and facility policy.
On 4/13/21 at 3:00 p.m. a pre-ext debriefing was held with the Administrator and the [NAME] President of Operations regarding the missing employee Criminal Background Checks and Sworn Statements. The Administrator was asked what is the importance of the obtaining the Criminal Background Checks and Sworn Statements upon hire for all employees. The Administrator stated, To ensure we do not hire staff with criminal records in order to keep our residents and other staff safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a closed record review, staff and family interviews, and a complaint investigation, the facility staff failed to thoroughly investigate an incident of an injury of unknown source for one resident (Resident #89) in the survey sample of 38 residents.
The findings included:
Resident #44 was admitted to the facility on [DATE] with diagnoses which included coronary artery disease, dementia, benign prostatic hyperplasia and COPD. Resident #89 was sent out to the hospital with a change of condition and being unresponsive to verbal and tactile stimuli. This resident was identified as having a large subdural hematoma of unknown source.
A [DATE] Quarterly Minimum Data Set (MDS) assessed this resident in the area of Cognitive Pattern - Brief Interview for Mental Status (BIMS) as having a score of 15. This resident was assessed as requiring extensive assistance of one person in the areas of bed mobility, transfer, dressing and personal hygiene.
A care plan dated [DATE] assess Resident #89 as-
Focus: - Self care deficit- Goal- Will increase ability to provide own care needs. intervention: Assist with activities of daily living, dressing, grooming. toileting and oral care.
A Nursing Progress Note dated [DATE] at 1:09 (Late Entry) indicated: After eating breakfast resident became unresponsive is not responding to verbal or tactile stimuli. Resident appears to be in a daze, staring into space. The , resident nonverbal at this time and drooling, will not obey commands, NP made aware with order to sent (sic) to ER, all paperwork sent with transport including careplan and bed hold policy, family notified.
A Interact SBAR summary dated [DATE] 1:08:45 (Late Entry) indicated: The change of condition/s reported on this CIC Evaluation are/were: Altered mental status Unresponsiveness at the time of evaluation resident/patient vital signs, weight and blood sugar were:
Blood Pressure: BP 119/86-[DATE] 09:00 position: lying l/arm
Pulse: P 81- [DATE] 09:00 Type Regular - RR
R-18.0 -[DATE] 09:00
Temp: T 97.9 - [DATE] 09:00 Route: Oral
Weight: W 118.0 lb - [DATE] - 09:58 Scale- Mechanical lift scale
Pulse Oximetry: O 2 98.0 %- 09:00 Method: Room Air
Blood Glucose: Resident/Patient is in the facility for: Long Term Care
Primary Diagnosis is: Transient Cerebral Ischemic Unspecified
Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)
Nursing observations, evaluation, and recommendations are Primary Care Provider Feedback:
Primary Care Provider responded with the following feedback:
A- Recommendations: Send to ER
B- New Testing Orders
C- New Intervention Orders
An EMT Patient Care Report dated [DATE] indicated: Incident Date/Time [DATE] 08:54:29- address facility-
Information: Obtained from Health Care Personnel
Medical History: Dementia: Anemia; Neutropenia- Transient ischemic Attack (TIA)
Narrative: Arrived on scene pt was in care of nurse gave staff (sic). Called because pt had altered mental status. Pt has dementia and is confused at baseline and is wanderer. Staff stated pt had an episode of staring off and drooling and was not responding. On arrival pt was alert but confused. Pt turned over to RN at hospital.
Patient Complaints:
Complaint: Altered mental status
Duration of Complaint:
Not Reporting
Protocols Used: Altered mental Status- Airways/Oxygenation/Ventilation
Incident Times:
PSAP Call- [DATE] 08:49:27
Unit arrived at Scene [DATE] 08:59:09
Unit left Scene [DATE] 09:08:41
Patient Transfer Time- - Turn-Around Delay- None/No Delay
Destination_ Hospital (Reason- Closest Facility).
ED Record - Comment:
Clinical Impression: Diagnosis- SDH (subdural hematoma) (HCC) Altered mental status, unspecified altered mental status type.
Diagnostic Study Results:
CT with large subdural with 1.2 cm of shift.
A Hospital ED Record dated [DATE] indicated: Arrival Date/Time [DATE] 09:16, Resident #89 name. Emergency Department History and Physical Exam: [DATE] 09:21 AM
Chief Complaint:
Resident #89 is a [AGE] year old male past medical history of TIA's advanced dementia presents for transient alteration of awareness. Patient was seen in the nursing home and went unresponsive and was drooling. Unclear if he lost postural tone or not. EMS states he was normal just prior to that making his last known well time probably around 8:30 AM. Patient now arrives without complaint has baseline confusion but is oriented to self ad he feels pretty good.
Medical Decision Making:
Discussed with neurosurgery requested mannitol at 1 mg/kg and request transfer to another hospital.
Critical Care Time:
The services provided to this patient were to treat and/or prevent clinically significant deterioration that could result in the failure of one or more body systems and/or organ systems due to SDH with shift and mental status change.
Pt transferred to other hospital ER via ambulance. Stable at the time - date of service [DATE] 1530 (3:30 PM).
Hospital #2 notes indicated: Arrived at Hospital [DATE] at 1550 (3:50 PM). admitted with Subdural hematoma (HCC). Pt requires access to a telemetry box.
Hospital Course: Pt was admitted with acute hypoxic respiratory failure, suspect due to aspiration so he was started on abx (antibiotic). CT was done for his altered mental status and he was found to have a large right hemispheric subacute subdural hematoma with 12 mm midline shift and Stable, small left frontal subacute subdural hematoma without significant mass effect but with brain compression. PC consulted to discuss goals of care given poor prognosis and pt was transitioned to hospice. Pt eventually expired on [DATE].
During an interview on [DATE] at 9:59 AM with the Authorized Representative (AR) she stated, the facility had called her on [DATE] around 9:00 AM and informed her that Resident #89 was being sent to the hospital. The RP stated, she went to the hospital and observed Resident #89 slumped over in wheelchair. He was responding to her when she got to the hospital. The AR stated, she had taken care of Resident #89 for 9 years. She stated, she contacted the nursing home and the patient has been wheelchair bound with severe generalized weakness for the past 2 weeks unclear if he had a fall at that time but when she took him to the VA 1 month ago he was able to ambulate and that he was oriented x 3.
During an interview on [DATE] at 2:13 PM with Licence Practical Nurse (LPN #5) she was asked what condition was Resident #89 in when she sent him out. LPN #5 stated, it was a Sunday morning after breakfast and she could not remember his condition or why he was sent out. She said she could not remember if Resident #89 hand any injuries or had fallen.
During an interview on [DATE] at 1:18 PM with the Director of Nursing (DON) she stated, We called to the hospital and was told he was being admitted for hemorrhage. The DON was asked did the facility staff conduct an investigation or file a Facility Reported Incident (FRI). The DON stated, No.
The DON was asked if the hospital had made them aware that Resident #89 had a large subdural hematoma which was the source of the hemorrhage and she stated, yes, the hospital made the staff aware.
A facility policy and procedure revised [DATE]: Definitions: Injury of Unknown Source: An injury is classified as an Injury of Unknown Source when both the following conditions are met:
a. The source of the injury is classified was not observed by any person, or the source of the injury could not be explained by the resident;and
b. The injury is suspicious because of the extent of the injury, the location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time.
Complaint Deficiency

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan to include their goals after being transferred and admitted to the hospital for one resident (Resident #35) in survey sample of 38 residents.
The findings included:
Resident #35 was admitted to the facility 9/26/1991 and readmitted to the facility on [DATE]. Diagnoses for Resident #35 include: Contracture, unspecified and Quadriplegia, unspecified.
The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/21/2022 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was not conducted. Resident's cognitive skills for decision making were coded as severely impaired for daily decision making.
A review of the clinical record show that Resident #35 was admitted to the hospital from [DATE] through 2/15/22 due to a clogged Foley catheter.
On 04/14/22 at approximately 4:15 PM., an interview was conducted with the DON (Director of Nursing) concerning the above issue. She said that they can't find evidence that a care plan was sent.
On 4/14/22 at approximately 4:35 PM., an interview was conducted with LPN (Licensed Practical Nurse) #1 concerning the above issue. She stated, The documents are sent with the residents in a checklist folder. We also write a note in PCC (Point Click Care) saying we sent all of the documents.
A review of the facility's documentation show that no care plan to include goals were sent with the resident to the hospital.
On 4/15/2022 at approximately 1:15 PM., p.m., the above findings were shared with the Administrator, The Corporate Consultant, The DON and with the ADON. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 1 of 38 residents (Resident #88, a closed record resident) in the survey sample.
The findings included;
Resident #88 was originally admitted to the facility on [DATE] and discharged on 2/23/2022 to an acute care facility. The current diagnoses included; Anemia and Coronary Artery Disease.
The quarterly Revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/12/2022 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #88 cognitive abilities for daily decision making were intact.
In section G(Physical functioning) the resident was coded as requiring extensive assistance of two persons with bed mobility. Requires total dependence of two person's physical assist with transfers. Requires total dependence of one person physical assist with bathing, locomotion on and off the unit and with toilet use. Requiring extensive assistance of one person with dressing and personal hygiene. Independent set-up help only with eating.
The Discharge MDS assessments was dated for 2/19/2022 - discharged with return anticipated.
According to the facility's documentation, on 2/19/2022 Resident #88 was transported to the local hospital.
According to the facility's documentation on 2/21/22 Resident #88 was admitted back to the facility from the local hospital.
A review of the Monthly List of Emergency Transfers for March 2022 does not include Resident #88's name on the list.
On 4/15/22 at approximately 1:15 PM an interview was conducted with OSM (Other Staff Member/Social Worker) #3 concerning The Ombudsman Notification. She stated, The Ombudsman Notification was not sent.
On 4/15/2022 at approximately 1:15 PM., p.m., the above findings were shared with the Administrator, The Corporate Consultant, The DON and with the ADON. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to revise 1 of 38 residents (Resident #10) comprehensive personal-centered care plan in the survey sample.
The findings included:
The facility staff failed to revise Resident #10's comprehensive person centered care plan to include her current code status of Do Not Resuscitate (DNR). Resident #10 was originally admitted to the nursing facility on 03/06/19. Diagnosis for Resident #10 included but not limited to Chronic Obstructive Pulmonary Disease (COPD).
The current Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) of 04/14/22 coded the resident with a 02 of a total possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment.
Review of Resident #10's Physician Order Sheet (POS) for April 2022 revealed the following order: Do Not Resuscitate (DNR) starting on 03/01/21.
Resident #10's person-centered comprehensive care plan created on 03/07/19 document the resident/Responsible Party has chosen Full Code.
On 04/13/22 at approximately 8:58 a.m., an interview was conducted with the Social Worker and MDS Coordinator. When asked who is responsible for update/revising the Advance Directive/code status on the care plan. The MDS Coordinator stated, The Social Worker is responsible for updating that portion of the care plan. On the same day at approximately 9:40 a.m., the MDS Coordinator presented a revise care plan.
Resident #10's person-centered comprehensive care plan with a revision date of 04/13/22 document the resident/Responsible Party has chosen DNR. The goal set for the resident by the staff was that the resident code status wish will be honored. Some of the interventions/approaches the staff would use to accomplish this goal is to notify the physician of any changes, if resident/responsible party chooses to change code status, necessary protocol will be completed as evidence of new order, update documentation/care plan and review code status annually, quarterly and as needed.
A debriefing was held with the Administrator, Director of Nursing, [NAME] President of Operations and Regional Director of Clinical Services on 04/14/22 at approximately 4:32 p.m., who were informed of the above findings; no further information was provided prior to exit.
The facility's policy titled Comprehensive Care Planning - revised on 07/19/19. An interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal requirements and on an as needed basis.
-Procedure include but not limited to:
P) The MDS Coordinator is responsible for reviewing and updating the Resident Assessment (MDS) as well as the previous plan of care prior to the scheduled Resident Care Plan conference.
S) Adjustments are made by the interdisciplinary team to ensure that all programs and identified category of needs are addressed and that the plan is oriented toward preventing a decline in functioning. Plans for discharged are viewed, revised and addressed accordingly.
V) The MDS Coordinator is to review the 24-Hour Report daily for significant changes or changes in resident's ADL status. The Care Planning coordinator will add minor changes in resident's status to the existing Care Plans on a daily basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to obtain weights and labs necessary for management of acute on chronic hypoxic and hypercapnic respiratory failure due to CHF and COPD exacerbations for 1 of 38 residents (Resident #61), in the survey sample.
The findings included:
Resident #61 was originally admitted to the facility 1/5/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; obstructive sleep apnea (OSA)congestive Heart failure (CHF), chronic obstructive pulmonary disease (COPD) and post COVID-19.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 3/18/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #61's cognitive abilities for daily decision making were intact.
In section G (Physical functioning) the resident was coded as requiring total care of two with transfers, total care of one with locomotion in room and toileting, extensive assistance of two with bed mobility, extensive assistance of one person with locomotion off the unit, personal hygiene and dressing, help with bathing, and independent after set-up with eating.
During the initial tour on 4/12/22 at approximately 12:25 p.m., the resident was observed receiving oxygen therapy at 3 liter per minute by nasal cannula, and with a nebulizer machine and C-pap at her bedside.
An interview was conducted with Resident #61. She stated she had been to the hospital three times recently for problems breathing and there were more flare-ups since having COVID-19. The resident also stated the hospital physician's stated her problems were related to congestive heart failure and COPD not another case of COVID-19. The resident was with a cough during the interview but capable of conversation without breathing problems
Review of the hospital's discharge summary revealed the resident was admitted to the hospital 1/24/22 - 1/27/22, 2/11/22 - 2/14/22 and 3/22/22 -3/28/22 for shortness of breath. The 1/27/22 hospital's discharge summary read the resident was admitted for acute on chronic hypoxic and hypercapnic respiratory failure due to CHF and COPD exacerbation. The 2/14/22 discharge summary read the resident was admitted for acute on chronic hypoxic and hypercapnic respiratory failure due to CHF and COPD exacerbation. The 3/28/22 discharge summary revealed the resident was admitted to the hospital for an acute exacerbation of COPD.
Review of the clinical record revealed upon readmission 3/28/22, Resident #61 had the following order; weigh on admission, for 3 days afterwards and then weekly for 4 weeks.
Review of the clinical record revealed Resident #61's admission weight on 3/28/22 was 302 pounds, 3/29/22, 302 pounds, 3/30/22 311.4 pounds, 311.4 pounds on 3/31/22 and 311.4 pounds on 4/1/22. A practitioner's progress note dated 4/8/22 read continue weight 3 times each week.
Basic Metabolic Panels (BMP) were ordered for 4/1/22, 4/4/22, 4/7/22 and 4/11/22 for CHF. The 4/1/22 and 4/11/22 labs weren't available on the clinical record for review and there was no weight documentation available for 4/4/22.
An interview was conducted with the Licensed Practical Nurse (LPN) on 4/14/22 at approximately 11:10 p.m. LPN #2 stated she had no information regarding the undocumented information regarding the weights and labs but she would get the information and get back with me.
An interview was conducted with the Director of Nursing (DON) on 4/14/22 at approximately 12:00 p.m. The DON stated she had no additional information regarding the the missing weights for Resident #61 but; the DON stated the 4/1/22 lab was completed and she obtained it directly from the laboratory. She stated she couldn't attest the practitioner was aware of the results but the DON provided a progress note written by the practitioner on 4/8/22 in, it included lab results from the 4/4/22 and 4/7/22 lab draws but not the 4/1/22 results. The progress note also stated the plan was to increase the potassium to 40 mEq two times each day for 4 days then resume 20 mEq two times each day. Repeat BMP next week, Continue Lasix 40 mg two times daily and Metolazone 2.5 mg 3 times a week. Continue to weigh 3 times a week. The DON stated the 4/11/22 results weren't available because the staff didn't process the order in the system for the lab to be obtained.
An active order to weigh the resident 3 times a week related to CHF, was not on the active physician order summary on or before 4/8/22.
Review of the active care plan revealed a problem with a revision date of 08/12/2021 (name of resident) requires oxygen and C-pap on at bedtime for CHF, COPD, and OSA. The goal read; Residents oxygen levels will be kept as desired levels per MD orders through next review, 6/17/22. The interventions included; medications as ordered, monitor lung sounds as ordered and as needed. Observe for signs and symptoms of dyspnea; labored respirations, low O2 sats, use of accessory muscles, cyanosis, change in mental status, and tachypnea.
There was no care plan for management of CHF and COPD related to the three hospitalizations secondary to acute on chronic hypoxic and hypercapnic respiratory failure due to exacerbations.
On 4/13/22, Resident #61 continued with periods of shortness of breath and cough requiring an evaluation by the practitioner. The chest x-ray obtained 4/12/22 revealed pneumonia of bilateral lower lobe. Antibiotic therapy was ordered 4/13/22.
On 4/15/22 at approximately 1:00 p.m., the above information was shared with the Administrator, Director of Nursing, Regional Director of clinical Services and Regional Director of Operations. The Facility's staff offered no further information regarding the above information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to provide care and services to prevent pressure ulcer development and to identify a left heel pressure ulcer prior to progression to an advanced stage (stage 3) measuring 0.4 centimeters by 0.4 centimeters by 0.2 centimeters (cm), for Resident #58) which constituted harm.
Resident #58 was originally admitted to the facility 11/12/21 after an acute care hospital stay. The resident has not been discharged from the facility. The current diagnoses included; coronary artery disease, peripheral vascular disease and congestive heart failure.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/15/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #58's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with personal hygiene, dressing, toileting, limited assistance of one person with bed mobility, transfers, walking and locomotion, help with the bathing activity, and supervision after set-up with eating.
On 4/12/22 at approximately 12:15 p.m., Resident #58 was observed in bed lying on her left side. The resident stated my left foot hurts. She stated she hadn't told her nurse but the nurse knew it was painful that's why she puts a bandage on it. The resident stated she knew of nothing that helps her left foot feel better. Beneath the bed linens, bilateral feet were observed to be elevated by some type of device.
Review of the facility's matrix revealed Resident #58 had a current pressure ulcer staged at a stage IV.
Review of the clinical record revealed a progress note dated 4/6/22 which revealed Resident #58 was identified with a stage 3 pressure of the left heel which measured 0.4 cm by 0.4 cm by 0.2 cm. The stage 3 left heel pressure ulcer's wound bed was red, the periwound was pink there was scant drainage, and no odor. The treatment order was Santyl ointment and Dakins solution.
The 3/12/22, 3/19/22, 3/26/22, 4/2/22, and 4/9/22 Weekly Skin Evaluation were coded for no current skin issues.
The Nutrition Monitor and Nutrition Evaluation dated 2/15/2022 revealed Resident #58's weight was 127.6 pounds and the Resident showed significant weight gain soon after admission to the facility but had a significant weight loss over the past 30 days at 5.5%. Resident is currently within her ideal body weight range. Weight maintenance within 5 pounds of current weight is planned at this time. Po intake of Regular consistency diet is typically 26 to 100% with most meals at 50%. Nutritional needs for wound healing and weight maintenance are currently being met. Daily use of multiple laxatives. Fluids should be strongly encouraged during waking hours. Added to the weekly weight schedule for close monitoring.
The 4/6/22 Braden Scale Pressure Ulcer Risk Assessment revealed Resident #58 was a low risk for pressure ulcer development because she had no sensory deficit which would limit her ability to feel or voice pain or discomfort, her skin is only occasionally moist, her ability to walk is severely limited or non-existent, she makes frequent though slight changes in body or extremity position independently, rarely eats a complete meal and generally eats only about half of any food offered and moves feebly or requires minimum assistance.
Further review of the clinical record revealed a wound assessment report by the wound care physician dated 4/11/22 which read, Resident presents with a wound on her left heel. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. She has a stage 3 pressure wound of the left heel. There is light sero-sanguinous exudate. There is no indication of pain associated with this condition. The left heel pressure ulcer measured 0.3 x 0.3 x 0.2 cm and presented with 100 percent granulation tissue. The dressing treatment plan was documented as Iodosorb gel followed by a gauze island with border every two days for 30 days.
The active care plan was reviewed on 4/12/22. It revealed a potential for a skin integrity problem with a revision date of 11/16/21 but there wasn't a left heel pressure ulcer problem. On 4/15/22 a care plan problem was developed for the stage 3 pressure ulcer to the left heel which was identified on 4/6/22. The goal read; Area to the left heel will show signs of healing through next review 5/19/22. The interventions included; treatments as per physicians/designee order, monitor for signs and symptoms of infection and weekly wound documentation
Review of the physician order summary revealed there wasn't a treatment order in place for Resident #58's left heel pressure ulcer until 4/12/22. There was no evidence in the clinical record that an active treatment was in place and care and services were rendered to the resident's left heel pressure ulcer from 4/6/22 through 4/11/22.
The physician order summary's revealed an order dated 04/12/22, which read Iodosorb Gel 0.9 % (Cadexomer Iodine); Apply to the left lateral heel topically every day shift for wound care. This order was not what the wound care physician ordered. The wound care physician order was for every two days not daily. Completion of the left heel pressure ulcer treatment was documented on the TAR for 4/12/22, 4/13/22 and 4/14/22.
An interview was conducted with Certified Nursing Assistant CNA) #2 on 4/14/22 at approximately 5:57 p.m. CNA #2 stated Resident #58 is fully alert and oriented and capable of making her needs known. She stated the resident likes one pillow at her back, one under each arm and one under her legs when in bed and she wears boots in bed Crocs when out of bed. CNA #2 stated the resident is unable to self turn since she wears the boots therefore she is fully dependent upon staff when wearing them. She stated she wasn't aware of what was wrong with Resident #58's left foot but she knew a dressing was on it. CNA #2 stated the resident is always compliant with care and feeds herself usually 50% of the dinner meal.
An interview was conducted with Certified Nursing Assistant CNA) #3 on 4/15/22 at approximately 9:55 a.m. CNA #2 stated Resident #58 is out of bed about three days per week and she can walk from the bathroom door to the commode in the room. She stated when the resident is out of bed she wears Crocs, does a lot for herself and feeds herself approximately 50% of meals.
An interview was conducted with MDS Coordinator #4 on 4/15/22 at approximately 11:30 a.m. MDS Coordinator #4 stated Resident #58's care plan wasn't updated with the left heel pressure ulcer because she was off and didn't get the update until 4/15/22.
An interview was conducted with the wound care nurse on 4/15/22 at approximately 10:45 a.m. The wound care nurse stated she couldn't explain how the resident obtained the pressure ulcer for the resident has always been so particular about relieving pressure with multiple pillows propping her body. The wound care nurse also stated she assessed the resident's pressure ulcer on 4/6/22 but failed to document the results timely. The wound care nurse stated it is not good to find a pressure ulcer at stage 3 or above. She stated they should be identified early, where there is redness, ideally.
An observation was made of Resident #58's left lateral heel pressure ulcer on 4/15/22 at approximately 11:05 a.m., with the wound care nurse. The resident was again lying on the left side, wearing bilateral pressure reducing boots and there were pillows beneath her knees and bilateral arms. The previous dressing was undated and the gauze next to the pressure ulcer was medium brown and dry. The wound was without odor or drainage and the resident didn't express pain when the wound care nurse touched the left foot pressure ulcer.
On 4/15/22 at approximately 1:00 p.m., the above information was shared with the Administrator, Director of Nursing, Regional Director of clinical Services and Regional Director of Operations. The Director of Nursing and the Regional Director of Clinical Services stated they knew they had pressure ulcer problems therefore they developed an in-house plan of correction but it failed January 2022 and they didn't revise or develop an new plan for pressure ulcers. They also acknowledged they had more recent pressure ulcer concerns as well. The Regional Director of Operations stated they tried to manage the pressure ulcers, they just weren't successful.
A stage 3 pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. (CMS RAI Version 3.0 Manual, Chapter 3 page M-14).
The information below was obtain from the following website on 4/19/22. Iodosorb Gel is a sterile antimicrobial dressing formulation of Cadexomer Iodine. When applied to the wound, Iodosorb absorbs fluids, removing exudate, slough and debris and forming a gel over the wound surface. As the gel absorbs exudate, iodine is released, killing bacteria and changing color as the iodine is used up. (https://www.[NAME]-nephew.com/professional/products/advanced-wound-management/iodosorb--iodoflex/iodosorb-gel/)
The information below was obtain from the following website on 4/19/22.
Iodosorb Gel speeds up the healing process and reduces pain. Can be used for up to 3 months in a single course of treatment. 1. IODOSORB Paste should be changed when saturated with wound fluid, indicated by a loss of color, usually 2-3 times a week or daily if the wound is discharging heavily (https://www.[NAME]-nephew.com/documents/canada/canada%20english/iodo-ag-1601en%20(ca11740)%20-%20application%20and%20usage%20guide%20(1).pdf).
3. The facility staff failed to provide care and services to prevent development of an unstageable deep tissue injury (DTI) of the right buttock measuring 6.5 cm by 5.5 cm by 0., for Resident #88B; a new stroke victim who required extensive assistance to total care with all activities of daily living (ADL).
Resident #88B was originally admitted to the facility 5/26/21 after an acute care hospital stay and discharged home 6/15/21. The resident's diagnoses included; a stroke, aphasia, dysphagia, right hemiparesis, and coronary artery disease.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/1/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #88B's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with personal hygiene, dressing, bathing, toileting and locomotion, extensive assistance of one person with transfers and eating, and extensive assistance of two people with bed mobility. Section H0100 Bowels and Bladder; the resident was coded as utilizing an indwelling catheter. In section M0100 (Skin Disorders) the Resident was coded as having no pressure ulcer, a scar over bony prominence, or a non-removable dressing/device. M0150 - Resident was coded as at risk of developing pressure ulcers.
A deep tissue injury is a Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. A deep tissue injury may precede the development of a stage 3 or 4 pressure ulcer even with optimal treatment. (CMS RAI Version 3.0 Manual, Chapter 3 page M-24)
During investigation of a complaint, information was gleamed revealing Resident #88 B acquired skin impairments including an unstageable DTI.
An interview was conducted with Resident #88B's daughter on 4/14/22 at approximately 2:05 p.m. The daughter stated the mother's husband visited the resident daily at her window because the facility was not allowing visitors inside the facility. The mother's husband told the daughter the staff wasn't repositioning the resident or consistently assisting her with meals and she wasn't capable of feeding herself. The husband stated often the meals were placed far away from the resident.
The 5/26/21, 5/27/21, and 6/3/2, 6/10/21 Weekly Skin Evaluation revealed no skin problems. The 6/10/21 Weekly Skin Evaluation revealed a right buttock area.
The 6/11/21 Weekly Wound Assessment revealed an unstageable deep tissue injury (DTI) of the right buttock, etiology pressure. The DTI measured 3.0 centimeters (cm) by 4.0 cm by 0 cm., and presented with maroon discoloration on intact skin. The assessment stated Triad cream was ordered as the treatment.
The Treatment Administration Record (TAR) revealed and order dated 6/11/21 for Triad Hydrophilic Wound Dress Paste (Wound Dressings) Apply to right buttock topically every day and evening shift for unstageable DTI. The treatment wasn't signed as completed on 6/11/21.
The care plan had a problem dated 6/11/21 which read; wounds to right buttock on 6/11/21, left medial buttock on 6/11/21, right medial buttock on 6/11/21. The goal read; Area to right buttock with show signs of healing through next review 6/15/21, Area to left medial buttock will show signs of healing through next review 6/15/21, and Area to right medial buttock will show signs of healing through next review 6/15/21. The Interventions included; treatment as ordered, specialty mattress, and turn and reposition every two hours.
The specialty mattress was ordered and instituted on 6/11/21 after the DTI and other skin impairment developed, based on the TAR.
The wound to the left medial buttock resolved on 6/15/2021 but the right buttock unstageable DTI and right medial buttock cluster wound remained unhealed per the wound care physician progress note dated 6/15/21.
The Treatment Administration Record (TAR) revealed an order dated 6/11/21 for Triad Hydrophilic Wound Dress Paste (Wound Dressings) Apply to right buttock topically every day and evening shift for unstageable DTI. The treatment wasn't signed as completed on 6/11/21.
On 6/15/21 the unstageable DTI was assessed by the wound care physician. The findings was the Resident had an unstageable DTI of the right buttock for at least 4 days duration. It measured 6.5 cm x 5.5 cm. x Not Measurable cm. There was no exudate. There is no indication of pain associated with this condition. Wound progress: Deteriorated. Primary Dressing Skin prep apply once daily for 30 days; Gauze island (with a border) apply once daily for 30 days. Recommendations included reposition per facility protocol; Off-load wound.
The TAR revealed the following order to be started 6/16/21; cleanse right buttock with seaclens, apply skin prep to wound bed, cover with a dressing daily every day shift for an unstageable DTI.
Review of a hospital admission assessment dated [DATE], the resident presented to the emergency department with septic shock, a perirectal abscess and a stage 2 pressure ulcer.
The Braden Scale for Prediction of Pressure completed on 10/6/21; revealed Resident #58 had no sensory deficit which would limit ability to feel or voice pain or discomfort, skin was occasionally moist, requiring an extra linen change approximately once a day, was confined to bed, made occasional slight changes in body or extremity position but unable to make frequent or significant changes independently, rarely eats a complete meal and generally eats only half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement, and moves feebly or requires minimum, and required moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.
Nutrition Risk/Diagnosis (Dx): Resident has increased nutrition/hydration risk related to dx of dysphagia, hyperlipidemia, gout, high blood pressure, malnutrition; need for mechanically altered diet and thickened liquids related to dysphagia; inadequate intakes. The Resident is being seen for an admission assessment. The Nutrition assessment conducted 5/27/2021 revealed the following; Diet order: Regular/pureed texture/nectar thickened liquids. Resident is with poor by mouth intake. Current Body Weight: 175.2 pound and Body Mass Index was 29.2 reflecting overweight/ in healthy range for age. No skin breakdown noted per skin assessment. Resident may benefit from high calorie supplement to increase available nutrients given poor intakes as well as fortified foods. Estimated Needs: calories: 1420-1705 protein: 57-68 fluid: 1500 ml. Diet Provides: calories: 2000-2400 protein: 80-90 fluid: not <1500 ml Intake meets needs. Intake meets resident's needs.
On 4/15/22 at approximately 1:00 p.m., the above information was shared with the Administrator, Director of Nursing, Regional Director of clinical Services and Regional Director of Operations. The Director of Nursing and the Regional Director of Clinical Services stated other than the clinical record documentation there was no additional information regarding the status of Resident #88B.
COMPLAINT DEFICIENCY
Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to ensure one resident (Resident #38) entering the facility did not develop pressure ulcers unless they were unavoidable. For Resident #38, the facility failed to identify two pressure ulcers prior to being found at an advanced stage (unstageable), which constituted in harm. For Resident #58, the facility staff failed to provide care and services to prevent pressure ulcer development and to identify a left heel pressure ulcer prior to progression to an advanced stage (stage 3) which constituted harm. For Resident #88B, a new stroke victim who required total care for all activities of daily living (ADL), the facility staff failed to provide care and services to prevent development of an unstageable deep tissue injury (DTI) of the right buttock. The survey sample consisted of 38 residents.
The findings included:
1. The staff failed to identify Resident #38's pressure ulcer to his left and right heel prior to being found at an advanced stage (unstageable) which constituted in harm. The first wound was to the left heel, identified on 11/15/21 as an unstageable pressure ulcer measuring 3 cm x 3.5 cm; appearance necrotic/black. The second pressure ulcer was to the right heel, identified as an unstageable pressure ulcer measuring 3 cm x 2.7 cm; appearance necrotic/black.
Resident #38 was originally admitted to the facility on [DATE]. Diagnoses for Resident #38 included but are not limited to Tracheotomy, absent of a larynx, Peripheral Vascular Disease (PVD) and Protein-Calorie Malnutrition.
Resident #38's admission Assessment (14-day) with an ARD of 09/21/21 coded Resident #38 a 15 out of a possible score of 15 indicating no cognitive impairment. Resident #38 was coded extensive assistance of one with toilet use, personal hygiene, dressing, toilet use and bathing, limited assistance of one with bed mobility and transfer and supervision with eating for Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for frequently incontinent of bladder and bowel. Under section G0400 - Functional Limitation in
Range of Motion (ROM) coded Resident #38 with no impairment to his upper and lower extremity. Resident #38 was coded as having no mood, rejection of care or behavioral problems.
Resident #38's admission Assessment (14-day) with an ARD of 09/21/21 under section M; (Skin Condition - M0100) was coded no for Resident #38 having a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Under section (M0150) at risk for developing pressure ulcers was coded yes, under section (M0210) for unhealed pressure ulcers was coded no and under section (M0300) for having current number of unhealed pressure ulcer at each stage for admitted with or facility acquired was coded as none under section (0130), number of venous and arterial wound present coded with one. Under section (M1040), other ulcers, wounds, and skin problems (foot) problems were coded for none present and under section (1200) for skin, ulcer treatments were coded for having pressure reducing device for chair and bed, and applications of ointments/medications other than feet.
Resident #38's quarterly MDS with an ARD date of 02/22/22 coded Resident #38 a 15 out of a possible score of 15 indicating no cognitive impairment. Resident #38's MDS coded Resident #38 requiring supervision with all ADLs except for bathing which requires extensive assistance of one for Activities of Daily Living (ADL) care. Under section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #38 with no impairment to his upper and lower extremity. Resident #38 was coded as having no mood, rejection of care or behavioral problems. Under section M; (Skin Condition - M0100) was coded for the using a
Formal Assessment Instrument/tool (e.g., Braden, [NAME] or other) for the determination of Pressure Ulcer Risk. Under section (M0300) the resident was coded as having two (2) facility acquired unstageable pressure ulcers.
Resident #38's person-centered care plan initiated on 11/17/21 identified a pressure ulcer to left and right heel. The goal set for the resident by the staff was that the resident will show signs of healing. Some of the interventions/approaches the staff would use to accomplish this goal is to turn and reposition every 2 hours, keep the physician and Responsible Representative (RR) updated, treatment as ordered and weekly wound documentation.
Resident #38's person-centered care plan with a revision date 12/01/21 identified the resident at risk for impaired skin integrity related to current wounds, occasional bladder incontinence and diagnosis of PVD. The goal set for the resident by the staff was that the resident will be free of further skin breakdown. Some of the interventions/approaches the staff would use to accomplish this goal is to elevate heels off mattress per routine and/or as needed, inspect skin during routine care daily, treatments as ordered, help to reposition resident for comfort per routine and as needed, and skin assessment per routine and as needed.
A Braden Risk Assessment Report was completed on 10/06/21 with the following coded under sensory perception slightly limited and responds to verbal commands, but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
The clinical record revealed the weekly skin assessment to be completed by the license nurse for the week of 11/07/21, but it was not completed for Resident #38.
Review of Resident #38's Weekly Wound Assessment completed by License Practical Nurse (LPN) #1 (wound nurse) revealed the following documentation:
-11/15/21 - an unstageable pressure ulcer to the left heel measured 3.0 cm x 3.5 cm; appearance necrotic/black with no drainage or odor. The treatment on 11/16/21 is to paint left heel with Betadine Solution every day shift.
-11/15/21 - an unstageable pressure ulcer to the right heel measured 3.0 cm x 2.7 cm; appearance necrotic/black with no drainage or odor. The treatment on 11/16/21 is to paint right heel with Betadine Solution every day shift.
A phone interview was conducted with the VOHRA wound care specialist/physician on 04/14/22 at approximately 9:04 a.m., who stated the left and right heel were both identified at an unstageable stage. The wound specialist (VOHRA) initial assessment made on 11/17/21 documented an unstageable Deep Tissue Issue (DTI) to the right heel but it should have been documented unstageable pressure ulcer because the area was noted with thick black necrotic tissue (eschar).
The wound care specialist documented the following:
-11/17/21 - unstageable DTI to right heel (partial thickness) etiology of wound (pressure) area measured 1.5 cm x 1.5 cm with no drainage. Chief complaint: resident has multiple wounds. Treatment: continue betadine daily. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed. The resident appears to have associated pain evidenced by restless and grimacing.
-11/17/21 - unstageable to left heel due to necrosis, etiology of wound (pressure)
area measured 2 cm x 2 cm with no drainage. Chief complaint: resident has multiple wounds. Treatment: continue betadine daily. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed. The resident appears to have associated pain evidenced by restless and grimacing.
-12/27/21 - unstageable to the right heel (due to necrosis - full thickness), area measured 0.7 cm x 0.6 cm with 50 % thick adherent black necrotic tissue and 50% thick adherent devitalized necrotic tissue. This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Treatment plan: apply Dakins solution moistened gauze with Santyl ointment daily. Debridement refused. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed.
-12/27/21 - unstageable to left heel due to necrosis, area measured 1.5 cm x 1.5 cm with no drainage with 20 % thick adherent black necrotic tissue and 50% thick adherent devitalized necrotic tissue and 30% granulation tissue. This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Treatment plan: apply Dakin's solution moistened gauze with Santyl ointment daily. Debridement refused. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed.
-01/17/22 - unstageable to the right heel (due to necrosis - full thickness), area measured 1.1 cm x 1.0 cm with 20% thick adherent black necrotic tissue and 50% thick adherent devitalized necrotic tissue and 30% granulation tissue and light serous drainage. This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Treatment plan: apply Dakins solution moistened gauze with Santyl ointment daily. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed.
-01/17/22 - unstageable to left heel (due to necrosis) area measured 1.8 cm x 1.5 cm with light sero-sanguinous drainage with 50% thick adherent devitalized necrotic tissue and 50% granulation tissue. This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm (wound has improved). Treatment plan: Treatment plan: apply Dakin's solution moistened gauze with Santyl ointment daily. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed.
The clinical record revealed Resident #38 had a wound evaluation from (name of podiatry center) on 01/26/22 with the following new orders: apply Santyl to Right and Left foot wound daily and offload lower extremities in prevalon boots while in bed. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed.
During the initial tour on 04/12/22 at approximately 1:30 p.m., and again on 04/13/22 around 9:30 a.m. During each observation, Resident #38 was observed lying in bed with prevalon boots in place to bilateral heels.
On 04/13/22 at approximately 9:30 a.m., an interview was conducted with Resident #38. Resident #38 is without his voice box which made him not able to communicate verbally but is able to point to areas on his body with concerns and nodded his head when asked simple and direct questions. When asked if he had sores to his heels, he nodded his head yes but was not able to identify when the areas occurred.
On 04/13/22 at approximately 10:05 a.m., wound care observation was conducted with LPN #1. Resident #38 was lying in bed, positioned in a supine position with prevalon boot in place to both heels. The left heel pressure ulcer wound bed noted with necrotic tissue with a moderate amount of serosanquineous drainage with no odor present. The right heel pressure ulcer noted with yellow/red wound bed with a small amount of serous drainage with no odor present. Wound care was conducted per wound care orders and infection control precautions
maintained.
A phone call was placed to Resident #38's Resident Representative (RR) on 04/14/22 at approximately 1:35 p.m., who stated, My brother, Resident #38 FaceTimed me complaining of severe pain to both of his heels. I called the facility and spoke to his nurse, LPN #1, who stated she would assess Resident #38 and call me back. On the same day, not sure of the time, LPN #1 called me and said my brother had an unstageable pressure ulcer to both of his heels.
On 04/14/22 at approximately 3:25 p.m., an interview was conducted with LPN #1 who was assigned to Resident #38 on 11/15/21 (7-3 shift). The LPN stated she spoke with Resident #38's (RR) on 11/15/21 who said Resident #38 had called her and reported having severe pain to his heels. The LPN said a skin assessment was completed and observed an unstageable pressure ulcer to both heels. When asked, if the CNA's had reported any skin issues with Resident #38 heels, she replied, No.
A phone call was placed Certified Nursing Assistant (CNA) #4 on 04/14/22 at approximately 1:40 p.m. The CNA was assigned to provide care and services to Resident #38 on 11/15/21 (7-3 shift). A message was left, the CNA never returned the call.
A phone call was placed CNA #5 on 04/14/22 at approximately 1:40 p.m. The CNA was assigned to provide care and services to Resident #38 on 11/15/21 (7-3 shift). A message was left, the CNA never returned the call.
An interview was conducted with the Director of Nursing (DON) and Regional Director of Clinical Services on 04/14/22 at approximately 10:37 a.m. The DON stated, (Resident #38's Name) FaceTimed his sister and showed her the areas located to his bilateral heels. She said the sister called and spoke to LPN #1 who was Resident #38's nurse. The nurse assessed Resident #38 heels and observed an unstageable pressure ulcer to his left and right heel. The DON was asked, at what stage should pressure ulcer to be first identified, she replied, Preferably at a stage one. The DON stated, The CNA's are to do skin checks while providing care daily on every shift and on their shower days. She (DON) said, the CNA 's are looking at all pressure point areas including the resident heels and if they identify any changes in the resident skin condition such a redness, bruising or an open area, the changes are to be reported to the nurse right away who will document the findings in the resident clinical record and notify the physician. When asked if there were preventative measure put in place prior to the development of Resident #38's unstageable pressure first identified on 11/15/21, she replied, No, none that I could find.
Another interview was conducted with the DON on 4/14/22 at 3:46 p.m. When asked if the weekly skin assessment was completed the week of 11/07/21, she replied, I did not see where a skin assessment was completed. The DON said she expect for the nurse nurse's to do their skin assessments on a weekly basis. When asked, What was the purpose of weekly skin assessment and why are they important, she replied,It's imperative that weekly skin assessments are being done and that way we could have found Resident #38's pressure ulcers prior to being found at an unstageable pressure ulcer.
A debriefing was held with the Administrator, Director of Nursing, [NAME] President
of Operations and Regional Director of Clinical Services on 04/14/22 at approximately 4:32 p.m., who were informed of the above findings; no further information was

Based on observation, staff interview, and facility document review, the facility staff failed to ensure a Registered Nurse (RN) coverage for 8 hours, 7 days a week.
The facility staff failed to ensure RN coverage for 8 consecutive hours for 24 days.
The findings included:
On 04/14/22 at approximately 11:00 AM, the facility's actual worked schedule was reviewed with Other Staff #2 (Nursing Scheduler) and revealed there was no RN coverage for the following days: 1/01/22,1/02/22, 1/08/22, 1/15/22, 1/16/22, 1/22/22, 1/23/22, 1/30/22, 1/31/22, 2/05/22, 2/12/22, 2/13/22, 2/19/22, 2/20/22, 2/26/22, 2/27/22, 3/05/22, 3/06/22, 3/12/22, 3/13/22, 3/19/22, 3/19/22, 4/02/22, 4/03/22.
04/15/22 at approximately, 1:15 PM a pre-exit interview was conducted with The Director of Nursing (DON) and the facility Administrator concerning the above issue. The DON was asked what should have been done concerning the above issue. She stated, I have an RN (Registered Nurse) that provides weekend coverage. The ADON (Assistant Director of Nursing) stated she worked weekends since she started in October (2021). Neither the DON or the ADON could not explain why the above dates were not covered by an RN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility staff failed to ensure drug regimen of each resident were reviewed monthly for two residents (Resident #44 and #56) in the survey sample of 38 residents.
The findings included:
1. Resident #56 was admitted to the facility on [DATE] with diagnoses which included hypertension, depression, dementia, Parkinson's disease, hypothyroidism, coronary artery disease and psychosis. This resident did not have monthly drug regimen reviews provided by a pharmacist for irregularities.
Resident #56 was coded on a Quarterly Minimum Data Set (MDS) dated [DATE] in the area of Cognitive Pattern for Basic Interview for Mental Status (BIMS) as a (06). In the area of medications this resident was coded as receiving Antipsycotic and Antidepressant medications on a routine basis.
Resident #56 was noted to be receiving the following medications Seroquel, Klonopin, and Effexor on a routine basis.
A review of Pharmacy Reviews did not include reviews for the months of October 2021 through January 2022.
2. Resident #44 was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, depression, end stage renal disease, epilepsy, legal blindness, type 2 diabetes , hypertension and A-Fib. This resident did not have monthly drug regimen reviews provided by a pharmacist for irregularities.
Resident #44 was coded on a re-admission MDS dated [DATE] in the area of Cognitive pattern for BIMS as a (15). In the area of medications this resident was coded as receiving Insulin and Antidepressant medications on a routine basis.
A review of the Pharmacy Reviews did not include reviews from October 2021 through January 2022.
A facility Medication Regimen Review dated 12/01/07 indicated:
Policy for Medication Regimen Review (MRR)
Procedures: 1. The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement.
5. Facility should independently review each resident's medication regimen directly from the resident's medical chart and with Interdisciplinary Care Team members, resident or Responsible Party, as needed.
6. Facility should ensure that Facility Physicians/Prescribers are provided with copies of the MRRs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, review of facility documents and during the course of a complaint investigation, the facility's staff failed to accurately document in one residents medical record for 1 of 38 residents (Resident #35), in the survey sample.
The findings included:
Resident #35 was admitted to the facility 9/26/1991 and readmitted to the facility on [DATE]. Diagnoses for Resident #35 include: Contracture, unspecified and Quadriplegia, unspecified.
The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/21/2022 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was not conducted. Resident's cognitive skills for decision making were coded as severely impaired for daily decision making.
In section G(Physical functioning) the resident was coded as requiring total dependence of one person with bed mobility, locomotion on and off units, dressing, eating, toilet use, personal hygiene and bathing. Requiring total dependence of two persons with transfers.
The Care Plan dated 3/01/22 reads: Focus: Wound focus: Stage 3 right ischium (worsen upon re-admission). Stage 3 to scrotum. Stage 3 to lateral lower back. Stage 3 to medial lower back. DTI to L ankle, L elbow, R elbow, medial upper back. (Found upon admission). Goals: Areas to will show signs of healing through next review. Interventions: Assess for pain PRN (as needed), Encourage compliance, Keep MD and RP updated, Monitor for S/S (signs/symptoms) of infection, Pressure relieving mattress to bed, Treatment's per MD (Medical Doctor) orders, turn and reposition every 2 hours as tolerated, Weekly wound documentation.
A review of the POS (Physician Order Summary) and TAR (Treatment Administration Record) for April 2022 reads:
Cleanse Left ear wound with wound cleanser, cover with DSD (Dry Sterile Dressing) every day shift for wound care. Start date: 3/22/2022. (Missed wound care days per the April 2022 TAR/Treatment Administration Record): 4/04/22, 4/05/22, 4/08/22, 4/11/22 and 4/13/22).
Cleanse mid-upper back with wound cleanser, paste with betadine every day shift for wound care. Start date: 02/18/2022. (Missed wound care days per the April 2022 TAR/Treatment Administration Record): 4/04/22, 4/05/22, 4/08/22, 4/11/22 and 4/13/22).
Cleanse wound to Lateral lower back, apply santyl and calcium, alginate, cover with DSD every day shift for wound care. Start date: 02/23/2022. (Missed wound care days per the April 2022 TAR/Treatment Administration Record): 4/04/22, 4/05/22, 4/08/22, 4/11/22 and 4/13/22).
Santyl Ointment 250 UNIT/GM (Collagenase) Apply to groin topically every day shift for wound care. Start date: 03/15/2022. (Cleanse left elbow with wound cleanser, apply calcium alginate and 2 x 2 gauze every day shift for wound care. Start Date: 3/04/2022. Discontinue Date: 4/06/2022). (Missed wound care days per the April 2022 TAR (Treatment Administration Record): 4/04/22, 4/05/22, 4/08/22, 4/11/22 and 4/13/22).
Santyl Ointment 250 UNIT/GM (Collagenase) Apply to lower medial back topically every day shift for wound care. Apply calcium alginate. Start date: 2/23/2022. Discontinue date: 4/06/2022. (Missed wound care days per the April 2022 TAR (Treatment Administration Record): 4/04/2022 and 4/05/2022).
Cleanse Right elbow with wound cleanser, paste with betadine. Every day shift for wound care. Start Date: 2/23/2022. Discontinue date: 4/06/2022. (Missed wound care days per the April 2022 TAR (Treatment Administration Record): 4/04/2022 and 4/05/2022).
Cleanse left ankle with wound cleanser, paste with betadine every day shift for wound care. Start date: 2/18/2022. Discontinue date: 4/06/2022. (Missed wound care days per the April 2022 TAR (Treatment Administration Record): 4/04/2022 and 4/05/2022).
A review of the facility's wound care documentation on Resident #35's shows improvement of resident's wounds with some wounds being healed with no deterioration of wounds per wound care documentation.
On 4/15/22 at approximately 10:00 AM., an interview was conducted with the DON (Director of Nursing) concerning Incomplete TARs (Treatment Administration Records) for wound care. She stated, The TARs should be completed before you leave off your shift.
On 4/15/22 at approximately 10:30 AM an interview was conducted with LPN (Licensed Practical Nurse/Wound Care Nurse) #3 concerning the above issues. She stated, Some of the missed days on the TARs were on the days that I did the woud care treatments. I never missed doing treatments. I may have forgotten to check them off. The wounds were improving or healed. I will double check the TARs the next time.
On 4/15/2022 at approximately 1:15 PM., the above findings were shared with the Administrator, The Corporate Consultant, and The DON and with the ADON (Assistant Director of Nursing). An opportunity was offered to the facility's staff to present additional information but no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility documentation review, it was determined that the facility failed to replace personal property damaged by facility laundry for one resident out of 39 records reviewed.
The findings included:
Resident #32 was initially admitted to the facility on [DATE] with most recent admission occurring on 4/26/2019 with diagnoses of, but not limited to, chronic pain syndrome and epilepsy.
Resident #32's most recent MDS (minimum data set) assessment was a quarterly review assessment with an ARD (assessment reference date) of 7/21/19. Resident #32 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (brief interview for mental status) exam. The resident was assessed to have clear speech and no impairments in understanding others. Resident #32 was assessed at requiring extensive support with dressing and personal hygiene.
An interview conducted on 10/2/2019 at approximately 12:37 p.m. with Resident #32 who reported two of her clothing items returned from the laundry, bleached.
An interview was conducted on 10/2/2019 at approximately 3:30 p.m. with Other Staff # 3, the social worker, regarding complaints from Resident #32 and damaged clothing. The social worker stated (Resident #32) will usually speak with the unit manager. Residents are supposed to complete grievance forms. A lot of grievances don't make it to me. I don't have any grievances from (Resident #32). She stated she would see housekeeping about this.
An interview was conducted on 10/2/2019 at approximately 3:50 p.m. with the Housekeeping Director, Other Staff #2, regarding Resident #32's damaged clothing concern. The Housekeeping Director stated She had clothes that were faded. The facility was going to replace them. I took it to the administrator, Activities was supposed to go out shopping to replace them.
An interview conducted on 10/2/2019 at approximately 3:56 p.m. with the Activities Director, Other Staff #1, regarding Resident #32's damaged clothing. The Activities Director stated The sister was out of town and we could not go out. Her sister was supposed to pick out the outfit. Activities actually pays for it. I never had a chance to discuss it with her sister.
An interview conducted on 10/3/2019 at approximately 11:00 am with the facility Administrator regarding Resident #32's damaged clothing. The Administrator stated We came to an agreement about the clothes that were bleached. The sister would come in and pick them out for her. The sister went out of town and we weren't able to get her clothing. We have no policy regarding damaged property.
The Facility Administrator provided a copy of the Concern Form dated 7/17/2019 regarding damaged clothing offering a resolution of replacement of damaged items at Facility's expense. No further information was provided by the facility staff.

Based on observation, resident interview, and staff interviews, the facility's staff failed to assure 1 of 39 residents (Resident #59), in the survey sample call bell was within reach at all times.
The findings included:
Resident #59 was originally admitted to the facility 2/5/18 and has never been discharged from the facility. The current diagnoses included, left sided hemiplegia (paralysis).
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/27/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #59 cognitive abilities for daily decision making were intact. In section G (physical functioning) the resident was coded as requiring extensive assistance of two people with transfers and toileting, extensive assistance of one person with bed mobility, dressing and personal hygiene and total care of one person bathing and locomotion.
One 10/1/19 at approximately 12:30 p.m., the resident was observed seated in a wheelchair close to the foot of the bed with the lunch meal on the table before her. She called out I need my pan because I throw up a lot. The resident was referring to a gray bathing basin sitting on her bed out of her reach. The resident was reminded to press her call bell which was attached to the foot of her bed on the resident's left side. The resident's left arm and hand had no movement therefore she attempted to reach across her body to press the call bell with her right hand and arm but she was unable to reach it after putting much effort into the task. Certified Nursing Assistant (CNA) #2 was notified the resident needed assistance and was observed handing the resident the requested basin but the call bell was not placed in a reachable place.
On 10/2/19 at approximately 12:40 p.m., Resident #59 was observed again seated in a wheelchair near the foot of the bed. The call bell was observed midway on the bed which was to her left.
On 10/2/19 at approximately 12:45 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #2 about the location of the resident's call bell as it was placed. LPN #2 stated No she can't reach it as placed because she can't reach that far. LPN #2 attached the call bell to the front of Resident #59 shirt, where she could easily reach it when needed.
On 10/3/19, at approximately 6:00 p.m., the above findings were shared with the Director of Nursing and the Corporate Consultant. The Director of Nursing stated the resident is with left hemiplegia and is unable to reach items on her left beyond the right hands reach and staff would be asked to ensure all residents can each their call bell based on their capabilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, the facility staff failed to ensure one of 39 residents in the survey sample, Resident #68, was free from physical restraints. The facility staff had tube socks in use to Resident #68's bilateral arms to prevent scratching of a wound.
The findings included:
Resident #68 was re-admitted to the facility on [DATE] with diagnoses that included, but not limited to, dementia, Type 2 Diabetes mellitus without complications, dementia, depression, sepsis, osteomyelitis of vertebra, sacral and sacrococcygeal region.
A Quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #68 Brief Interview for Mental Status (BIMS) a score of 6 which indicated severe cognitive impairment. In the area of Functional Status this resident was assessed in the area of Activities of Daily Living (ADL'S) as requiring total dependence of two persons for bed mobility and toileting. Extensive assistance of one person physical assist for dressing and personal hygiene. In the area of Bladder and Bowel this resident was assessed as requiring an Indwelling Catheter.
A Care Plan dated 09/16/19 indicated: Focus- Resident #68 is at risk for impaired skin integrity R/T impaired mobility, bed/chair confined, F/C (Foley catheter) use, bowel incontinence, psychotropic med use, Underlying Disease, dementia, depression, DM, PVD, COPD, H/O, CVA with left side weakness. Goal- residents skin will be free of further breakdown through next review. Resident re-admitted with open wounds to sacrum, right hip, right medical shin, and left hip. Open wounds on 09/24/19 to right lateral 3rd toe (healed 10/1/19) and right medial 4th toe. Resident noted with wound vac due to multiple areas of skin impairment with deterioration.
On 10/01/19 at 12:45 PM Resident #68 was observed in bed with a pair of tube socks on both hands extending up his arms. This resident was observed again on 10/01/19 at 2:30 PM in bed with a pair of tube socks on both hands extending up his arms. This resident was observed on 10/02/19 at 8:53 AM in bed with a pair of tube socks on both hands extending up his arms.
A review of the clinical records did not include a physician's order for the use of tube socks, nor did Resident #68's care plan include measures for how the tube socks would be used to treat the resident's scratching.
During an interview on 10/03/19 at 3:20 P.M. with LPN #6 (Licence Practical Nurse) she stated, Resident #68 scratches the wound on his wound vac and some times pulls the wound vac out. During an interview on 10/04/19 at 11:15 A.M. with the Director of Nursing (DON) he was asked if Resident #68 had a physician's order for the use of the tube socks. The DON stated, Resident #68 did not have a physician's order for the use of tube socks. There was no restraint assessments for the use of the socks, no interventions for the treatment of itching or scratching behaviors and no alternate methods attempted prior to the use of the tube socks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to send the required documentation upon transfer to the hospital for two of 39 residents in the survey sample, Resident #33 and #26.
The findings include:
1. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to, major depressive disorder, bipolar disorder, high blood pressure, and type two diabetes. Resident #33's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/25/19. Resident #33 was coded as being moderately impaired in cognitive function scoring 11 out of 15 on the BIMS (Brief Interview for Mental Status) exam.
Review of Resident #33's clinical record revealed that Resident #33 was transferred to the hospital on 8/27/19. The following note was documented:
8/27/2019 14:36 (2:36 p.m.) SBAR S Situation: Change in condition, symptoms or signs I am calling about is/are: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Altered mental status This started on 08/27/2019 and the time of day Afternoon .Send to E.D. (emergency department) for evaluation.
There was no evidence in Resident #33's clinical record that care plan goals were sent with Resident #33 upon transfer to the hospital.
Further review of Resident #33's clinical record revealed she arrived back to the facility on 9/2/19 with diagnoses of pneumonia.
On 10/3/19 at 12:34 p.m., an interview was conducted with RN (Registered Nurse) #1, the Assistant Director of Nursing. When asked what documents were sent out with a resident upon transfer to the hospital, RN #1 stated that nurses send the face sheet, SBAR note, bed hold policy, care plan and orders. When asked how to know what items were sent with a resident upon transfer, RN #1 stated that nurses should fill out a transfer check list that will list every item. When asked if that checklist included the care plan, RN #1 stated that it did. When asked if a checklist could not be found how to know that the care plan was sent with the resident, RN #1 stated that sometimes the nurses will document a note.
On 10/4/19 at 10:46 a.m., during the pre-exit meeting, ASM (administrative staff member) #1, the administrator, ASM #2, the Director of Nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. ASM #3 stated that she would try to find evidence that care plan goals were sent with Resident #33 at the time of transfer.
On 10/4/19 at approximately 11:30 a.m., ASM #3 stated that she could not find evidence that care plan goals were sent with Resident #33. No further information was provided prior to exit.
2. Resident #26 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia without behavioral disturbance, high cholesterol, type two diabetes and adult failure to thrive. Resident #26's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/16/19. Resident #26 was coded as being severely impaired in cognitive function scoring 04 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam.
Review of Resident #26's clinical record revealed that she was had a fall on 9/3/19 and was transferred to the hospital.
Review of Resident #26's INTERACT check list failed to evidence that care plan goals were sent with Resident #26 at the time of transfer.
On 10/3/19 at 12:34 p.m., an interview was conducted with RN (Registered Nurse) #1, the Assistant Director of Nursing. When asked what documents were sent out with a resident upon transfer to the hospital, RN #1 stated that nurses send the face sheet, SBAR note, bed hold policy, care plan and orders. When asked how to know what items were sent with a resident upon transfer, RN #1 stated that nurses should fill out a transfer check list that will list every item. When asked if that checklist included the care plan, RN #1 stated that it did. When asked if a checklist could not be found how to know that the care plan was sent with the resident, RN #1 stated that sometimes the nurses will document a note.
On 10/4/19 at 10:46 a.m., during the pre-exit meeting, ASM (administrative staff member) #1, the administrator, ASM #2, the Director of Nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. ASM #3 stated that she would try to find evidence that care plan goals were sent with Resident #26 at the time of transfer.
On 10/4/19 at approximately 11:30 a.m., ASM #3 stated that she could not find evidence that care plan goals were sent with Resident #26. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to send written bed hold notification upon transfer to the hospital for one of 39 residents in the survey sample, Resident #33.
The findings include:
Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to major depressive disorder, bipolar disorder, high blood pressure, and type two diabetes. Resident #33's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/25/19. Resident #33 was coded as being moderately impaired in cognitive function scoring 11 out of 15 on the BIMS (Brief Interview for Mental Status) exam.
Review of Resident #33's clinical record revealed that Resident #33 was transferred to the hospital on 8/27/19 for a change in condition. There was no evidence in Resident #33's clinical record that written bed hold notification was sent with Resident #33 upon transfer to the hospital.
Further review of Resident #33's clinical record revealed she arrived back to the facility on 9/2/19 with diagnoses of pneumonia.
On 10/01/19 at 2:56 p.m., an interview was conducted with Resident #33. Resident #33 could not recall anyone going over the written bed hold notice at the time of her transfer. Resident #33 could not recall receiving any information regarding bed hold. Resident #33 stated that she was able to go back to her room once admitted back to the facility.
On 10/3/19 at 12:34 p.m., an interview was conducted with RN (Registered Nurse) #1, the Assistant Director of Nursing. When asked what documents were sent out with a resident upon transfer to the hospital, RN #1 stated that nurses send the face sheet, SBAR note, bed hold policy, care plan and orders. When asked how to know what items were sent with a resident upon transfer, RN #1 stated that nurses should fill out a transfer check list that will list every item. When asked if that checklist included the bed hold notification, RN #1 stated that it did. When asked if a checklist could not be found how to know that the bed hold notice was sent with the resident, RN #1 stated that sometimes the nurses will document a note.
On 10/4/19 at 10:46 a.m., during the pre-exit meeting, ASM (administrative staff member) #1, the Administrator, ASM #2, the Director of Nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. ASM #3 stated that she would try to find evidence that the written bed hold notice was sent with Resident #33 at the time of transfer.
On 10/4/19 at approximately 11:30 a.m., ASM #3 stated that she could not find evidence that written bed hold notice was sent with Resident #33. No further information was provided prior to exit.
Facility policy titled, Bed Hold Letter Policy, did not address the above concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #59 was originally admitted to the facility 2/5/18 and has never been discharged from the facility. The current diagnoses included; left hemiplegia and a left heel pressure ulcer.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/27/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #59 cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with transfers and toileting, extensive assistance of one person with bed mobility, dressing and personal hygiene and total care of one person bathing and locomotion. In section M0300G1 the resident was coded as not having a suspected deep tissue injury to the left heel between 8/21/19 and 8/27/19.
On 10/3/19 at approximately 11:00 a.m., Resident #59 wound care to the left heel was observed. The heel wound was now opened measuring approximately 3 centimeters by 2 centimeters and 0.1 centimeters deep. It contained dark brown to black tissue in the center and the surrounding tissue was red and the outer tissue was with areas of white tissue. The resident expressed it wound was painful to touch but insisted the staff complete the care.
At approximately 1:20 p.m., an interview was conducted with the wound care nurse. She stated Resident #59's was observed by staff with a blister to her left heel on 7/22/19, but when she assessed the left heel on 7/23/19, a blister wasn't present but the left heel was with a 5 centimeter by 5 centimeter maroon color area and the skin was intact. The wound care nurse stated she classified the left heel wound as an unstageable deep tissue injury. The wound care nurse stated on 8/20/19 the wound care physician began management of the resident left heel pressure ulcer and on 8/27/19 the area remained an unstageable deep tissue injury per the wound care physician's progress note dated 8/27/19. The wound care nurse viewed Resident #59's MDS assessment at M0300G1 which was coded the resident didn't have an unstageable deep tissue injury present. The wound care nurse stated this is not coded correctly.
On 10/3/19 at approximately 3:05 p.m., an interview was conducted with the MDS Coordinator about the coding of Resident#59's 8/27/19, MDS assessment at M0300G1. The MDS Coordinator stated it wasn't coded correctly therefore the MDS had been modified at to reflect at that time the resident did have unstageable deep tissue injury. The copy of the modified MDS assessment was given to the survey team.
On 10/3/19, at approximately 6:00 p.m., the above findings were shared with the Director of Nursing and the Corporate Consultant. The Director of Nursing stated he was aware of the error and no additional information was provided.
Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to ensure an accurate MDS (minimum data set) assessment for two of 39 residents in the survey sample, Residents # 102 and #59.
The findings include:
Resident #102 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, type 2 diabetes, atrial fibrillation, high blood pressure and muscle weakness. Resident #102's most recent MDS (minimum data set) assessment was a discharge, return not anticipated, assessment with an ARD (assessment reference date) of 8/2/19. Resident #102 was coded as being intact in cognitive function scoring 15 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Further review of Resident #102's MDS coded Resident #102 in Section A2100. Discharge Status, as being sent to the hospital.
Review of Resident #102's August 2019 nursing notes revealed the following notes:
8/2/19 at 08:52 a.m.: (Name of Resident #102) will discharge home with (Name of home health). Transport will pick up at 10:45 a.m.
8/2/19 at 9:41 a.m. Reviewed all discharge paperwork and medications with resident. Answered all questions and concerns. Resident voiced understanding.
8/2/19 at 14:56 (2:56 p.m.) Resident discharged from facility at 10:30 (a.m.) with medical transport via wheel chair.
On 10/3/19 at 9:38 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #3, the MDS nurse. When asked the process for filling out Section A2100., LPN #3 stated that prior to filling out Section A2100, she would search the Resident's chart and find out how the resident was discharged (i.e. hospitalized , sent home, death). LPN #3 stated she would then code section A2100 accordingly. LPN #3 confirmed that Resident #102 was discharged and home and that his 8/2/19 MDS assessment was coded in error. LPN #3 stated that she would modify the MDS.
On 10/4/19 at 10:46 a.m., during the pre-exit meeting, ASM (administrative staff member) #1, the Administrator, ASM #2, the Director of Nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was presented prior to exit.
CMS' RAI Version 3.0 Manual (Chapter 1: Resident assessment Instrument (RAI)
A2100: OBRA Discharge Status
Review the medical record including the discharge plan and discharge orders for documentation of discharge location.
Coding Instructions: Select the 2-digit code that corresponds to the resident's discharge status.
Code 01, community (private home/apt., board/care, assisted living,
group home): if discharge location is a private home, apartment, board and care,
assisted living facility, or group home.
Code 02, another nursing home or swing bed: if discharge location is an
institution (or a distinct part of an institution) that is primarily engaged in providing
skilled nursing care and related services for residents who require medical or nursing care
or rehabilitation services for injured, disabled, or sick persons. Includes swing beds.
Code 03, acute hospital: if discharge location is an institution that is engaged in
providing, by or under the supervision of physicians for inpatients, diagnostic services,
therapeutic services for medical diagnosis, and the treatment and care of injured,
disabled, or sick persons .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility staff failed to revise the comprehensive care plan for two of 39 residents in the survey sample, Resident #23 and Resident #68.
The findings included:
For Resident #23, the facility staff failed to include a focus, interventions, or goals for inappropriate sexual comments/requests made to staff.
Resident #23 was admitted to the facility on [DATE] with diagnoses that included hypertension, contractures of left hip, sleep disorder, anxiety disorder, major depression and osteoporosis.
An annual Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns as scoring a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated intact cognition. In the area of Mood this resident was assessed as feeling down, depressed or hopeless. In the area of Functional Status Activities of Daily Living (ADL's) this resident was assessed as requiring total dependence of two person physical assist in the area of transfer. This resident was assessed as requiring total dependence of one person physical assist in the area of locomotion, toilet and personal hygiene. This resident was assessed as always incontinent of bowel and bladder.
A Care Plan dated 09/15/19 included: Focus- Resident #23 has altered behavior due to refusal to get OOB (out of bed) on a daily basis, refuses showers, activities, and interaction with others. Refuses efforts to elevate heels when in bed. Goal- Will have fewer episodes of refusing out of bed. Interventions- Call family for assist when refusing out of the bed. Encourage diversional activities. Re-direct as needed.
Resident has history of attention seeking behavior of excessively ringing call bell. Goal- Resident's emotional and physical needs will be addressed when she rings the call bell excessively. Interventions- When resident rings the call bell excessively after needs have all been addressed determine if she is lonely or feeling badly by verbally asking her and request that Psych, NP or social worker speak with her to address her concerns of loneliness and anxiety if applicable to situation.
An Abuse Allegation conducted by the Administrator dated 03/19/19 Indicated: (Resident #23) had been giving advice to all the younger staff for as long as she can remember and that a former CNA had been one of the younger staff she had recently mentored. Resident stated, that the former CNA had been coming to her as somewhat of a matchmaker and had been attempting to arrange sexual encounters with other staff members through her. The resident stated that this had been going on for a year now and provided names of a few staff members which she had said she did attempt to inform of the CNA's intentions.
Resident #23 also stated that the CNA washed her very well and took good care of her. The resident stated that she had asked him to clean an itch up inside her during perineal care and on occasion had requested that he go further inside while cleaning. She stated that she probably shouldn't have asked.
A Nursing Progress note dated 05/16/19 at 07:15 (7:15 a.m.) included: This nurse was at resident's door at nurse cart and resident made an inappropriate request to this nurse. Resident stated Can you take your finger and put it up my butt and move it around some. This nurse made resident aware the statement was inappropriate and this nurse could not. Resident made aware that social worker, unit manger, and Director of Nursing (DON) would be made aware to statement.
During an interview on 10/04/19 with the Administrator and Director of Nursing (DON), they were asked if Resident #23's care plan had been revised to include making inappropriate sexual comments to staff. The Administrator and the DON concurred that Resident #23's care plan had not been revised to include making inappropriate sexual comments.
2. For Resident #68, the facility staff failed to include the use of tube socks to bilateral arms to prevent scratching of a wound.
Resident #68 was re-admitted to the facility on [DATE] with diagnoses that included, but not limited to, dementia, Type 2 Diabetes mellitus without complications, dementia, depression, sepsis, osteomyelitis of vertebra, sacral and sacrococcygeal region.
A Quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #68 Brief Interview for Mental Status (BIMS) a score of 6 which indicated severe cognitive impairment. In the area of Functional Status this resident was assessed in the area of Activities of Daily Living (ADL'S) as requiring total dependence of two persons for bed mobility and toileting. Extensive assistance of one person physical assist for dressing and personal hygiene. In the area of Bladder and Bowel this resident was assessed as requiring an Indwelling Catheter.
A Care Plan dated 09/16/19 indicated: Focus- Resident #68 is at risk for impaired skin integrity R/T impaired mobility, bed/chair confined, F/C (Foley catheter) use, bowel incontinence, psychotropic med use, Underlying Disease, dementia, depression, DM, PVD, COPD, H/O, CVA with left side weakness. Goal- residents skin will be free of further breakdown through next review. Resident re-admitted with open wounds to sacrum, right hip, right medical shin, and left hip. Open wounds on 09/24/19 to right lateral 3rd toe (healed 10/1/19) and right medial 4th toe. Resident noted with wound vac due to multiple areas of skin impairment with deterioration.
On 10/01/19 at 12:45 PM Resident #68 was observed in bed with a pair of tube socks on both hands extending up his arms. This resident was observed again on 10/01/19 at 2:30 PM in bed with a pair of tube socks on both hands extending up his arms. The resident was observed on 10/02/19 at 8:53 AM in bed with a pair of tube socks on both hands extending up his arms.
A review of the clinical records did not include a physician's order for the use of tube socks, nor did Resident #68's care plan include measures for the use of tube socks to reduce the resident's scratching.
During an interview on 10/03/19 at 3:20 P.M. with LPN #6 (Licence Practical Nurse) she stated, Resident #68 scratches the wound on his wound vac and some times pulls the wound vac out. During an interview on 10/04/19 at 11:15 A.M. with the Director of Nursing (DON) he was asked if Resident #68 had a physician's order for the use of the tube socks. The DON stated, Resident #68 did not have a physician's order for the use of tube socks. There was no restraint assessments for the use of the socks, no interventions for the treatment of itching or scratching behaviors and no alternate methods attempted prior to the use of the tube socks.

Based on observations, resident interview, staff interviews, and clinical record review the facility staff failed to ensure 1 of 39 residents (Resident #21), in the survey sample received fingernail care prior to his fingernails becoming long with broken edges and a brownish substance beneath them.
The findings included:
Resident #21 was originally admitted to the facility 1/16/16 and had never been discharged from the facility. The current diagnoses included rheumatoid arthritis and severe deformity of bilateral feet.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with eating, total care of two people with bed mobility and toileting and total care of one person with transfers, locomotion, dressing, personal hygiene and bathing.
On 10/1/19 at approximately 11:45 a.m., Resident #21 was interviewed in his room. The resident was seated at the bedside and his fingernails were observed to be long; approximately 1.5 inches beyond the finger tips with a brown debris beneath them. Most of he resident's fingernails also had jagged and sharp edges. Resident #21 stated it had been a while since his fingernails had been cut and he would like to have them cut and filed evenly.
Again on 10/2/19, at approximately 11:00 a.m., the resident's fingernails remained un-manicured as the day before.
An interview was conducted with Certified Nursing Assistant (CNA) #1 on 10/3/19, at approximately 11:15 a.m. CNA #1 stated she would cut the resident's fingernails, clean then and ensure the uneven edges were smooth and she did. She also stated it was their responsibility to cut and clean fingernails as needed if they were not to thick.
An interview was conducted with with Licensed Practical Nurse (LPN) #1 on 10/3/19, at approximately 2:45 p.m LPN #1 stated the CNA makes observations of fingernails and cut and keep them clean but if there is a diagnosis such as diabetes or use of certain medications the licensed nurse staff provides fingernail care.
On 10/3/19, at approximately 6:00 p.m., the above findings were shared with the Director of Nursing and the Corporate Consultant. The Director of Nursing stated fingernail care is provided by the direct care staff (CNAs and licensed nurses if indicated).

Based on observation, resident interview, and staff interviews the facility staff failed to ensure 1 of 39 residents (Resident #21), in the survey sample received foot care prior to the toe nails advancing to painful, long and curvy nails.
The findings included:
Resident #21 was originally admitted to the facility 1/16/16, and had never been discharged from the facility. The current diagnoses included; rheumatoid arthritis and severe deformity of bilateral feet.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/16/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with eating, total care of two people with bed mobility and toileting and total care of one person with transfers, locomotion, dressing, personal hygiene and bathing.
On 10/1/19 at approximately 11:45 a.m., Resident #21 was interviewed in his room. The resident was seated at the bedside and he complained of his toe nail being long and painful. The resident was wearing socks therefore his toe nails could not be observed at that time. Resident #21 stated it had been a long time since his toe nails had been cut and filed and now they hurt constantly. Again on 10/2/19, at approximately 11:00 a.m., the resident complained that his toe nails were hurting.
On 10/2/19 at approximately 2:50 p.m., the Unit Manager was notified that the resident complained of his toe nail hurting and that he would like to have his toe nails cut. The Unit Manager stated the resident resided in the facility under a Veteran's contract so their podiatrist would not be able to see him.
On 10/3/19 at approximately 11:15 a.m., Certified Nursing Assistant (CNA) #1 was observed providing care to Resident #21. CNA #1 removed the resident's socks and large flakes of dried skin fell from his feet, also very large bunions were observed bilaterally and the great toes overlapped the 2nd toe, and each toe overlapped the other. All toe nails were extremely thick, brownish and long and curvy with the appearance like a ram's horn.
An interview was conducted with with CNA #1 on 10/3/19, at approximately 11:15 a.m., she stated CNAs don't cut the resident's toenails. CNA #1 also stated if the resident complained of painful toe nails or if she felt toenails needed attention for cutting she would notify the charge nurse. Licensed Practical Nurse #1 was asked to make an observation of the Resident #21's toe nails.
An interview was conducted with on 10/3/19, at approximately 2:45 p.m., with Licensed Practical Nurse (LPN) #1. LPN stated the CNAs makes observations of toe nails during care and notifies the licensed nurses if they need to see the podiatrist. LPN #1 also stated during skin assessments she would assess the resident's feet but only for skin tears or open areas. LPN #1 further stated she asked the physician who was in the facility at the time to assess the resident's feet; the physician ordered Aquaphor to be applied to bilateral feet daily, gauze between the toes as needed and podiatry services and Tylenol was administered for the resident's complaint of painful toe nails.
On 10/3/19, at approximately 6:00 p.m., the above findings were shared with the Director of Nursing and the Corporate Consultant. The Director of Nursing stated whatever services a resident needs is provided and/or coordinated by the facility's staff. The Director of Nursing stated he should have received podiatry services before his nails reached the described state.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to practice safe bed mobility for one of 39 residents in the survey sample, Resident #26, resulting in an avoidable fall with a head laceration, that lead to an acute transfer to the hospital which constitutes harm.
The findings include:
Resident #26 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia without behavioral disturbance, high cholesterol, type two diabetes and adult failure to thrive. Resident #26's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/16/19. Resident #26 was coded as being severely impaired in cognitive function scoring 04 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Section G (functional status) coded Resident #26 as requiring extensive assistance from one staff member for bed mobility.
Review of Resident #26's clinical record revealed that she was had a fall on 9/3/19 and was transferred to the hospital. The following note was written: The CNA (certified nursing assistant) stated that she was changing her brief. The CNA stated that when she turned her, the resident fell out of bed, hitting her head on the corner of the night stand. Immediate intervention: The resident was sent out to the emergency room for evaluation. Vitals: BP (blood pressure): 139/81, Position: Lying l (left) arm. P (pulse) 81 Pulse Type: regular. Resident cooperative. Resident has full range of motion to all extremities. Neurological checks are within normal limits. Evidence of pain noted. Pain to her head. Pain is throbbing Pain level is 6 out of 10. The pain is constant Pain persistent daily. Pain medication .This writer was called down to the residents room by the CNA, the resident was observed laying on her right side side between the bed and night stand, the resident was observed bleeding from a laceration to the front of her head. 911 was called and the paramedics were here minutes later to (sic) without difficulty. The resident is complaining of pain to her head. 911 was called and paramedics were here minutes later to transport the resident to the ER (emergency room) .report was given to the ER nurse.
Review of the fall incident report dated 9/3/19 documented the following : Incident Description: The resident was observed laying on the floor in her right side, bleeding from a laceration to the front of her head. Resident was assessed and sent to the hospital. There was no additional information documented on the incident report.
Review of Resident #26's ADL (activities of daily living) care plan initiated on 5/12/16, documented Resident #26 as requiring Bathing/Hygiene assist of: 1 (one person). Resident #26 was also documented as requiring an assist of 2 with turning and repositioning/bed mobility with assist of 2.
Review of Resident #26's current nursing [NAME] (Resident care guide for nursing aides) documented Resident #26 as requiring one person physical assist with bed mobility.
Review of Resident #26's clinical record revealed the most recent fall risk assessment prior to her fall on 9/3/19 was conducted on 4/15/16. Resident #26 was coded at a level 10.0 indicating she was at high risk for falls.
Further review of Resident #26's clinical record revealed that Resident #26 arrived the same day (9/3/19) with a laceration to her forehead. The following was documented: 9/3/19 at 19:23 (7:23 p.m.) Resident returned from the hospital @ (at) 1640 (4:40 p.m.). Stitches noted to right forehead covered with dry drsg (dressing). No drainage noted. Resident has no c/o (complaints) of pain. No s/s (signs and symptoms) of acute resp (respiratory) or cardiac distress noted.
Review of Resident #26's weekly wound assessment dated [DATE] documented the following: Wound Type: Laceration .Wound Location: Forehead. Length (cm) (centimeters): 3.5 Width (cm): 0.1 .Presents with 100% granulation tissue and 5 intact sutures. Edges well approximated. No s/s (signs/symptoms) of infection or dehiscence.
Review of an IDT (interdisciplinary note) dated 9/6/19 documented the following: Par (sic) meeting [NAME] today. All I.D.T. present. Resident noted to have s (sic) laceration to forehead with 5 sutures. Resident is table (sic). No ne (sic) intervetions at this time.
Further review of Resident #26's clinical record revealed her laceration had healed on 9/17/19.
Review of Resident #26's assessments revealed that Q (every)15 (minute), Q30, Q1 (hour), Q4 hr and Q8 hr neurological checks were conducted until 9/6/19.
Further review of Resident #26's assessments revealed an updated Fall Risk assessment conducted 9/3/19. This assessment documented Resident #26 as being at high risk for falls, scoring a level 16.0.
On 10/3/19 at 9:14 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #1, the nurse who was assigned to Resident #26 at the time of her fall. When asked how many people it required to provided incontinence care to Resident #26, LPN #1 stated it only took one person. When asked what she could recall about Resident #26's fall on 9/3/19, LPN #1 stated that she was called down to the room by the CNA and found Resident #26 on the right side of the bed, laying on her right side. LPN #1 stated that the resident had fallen while the nursing aide was turning her during incontinence care. LPN #1 stated that Resident #26 was sent out to the hospital for a laceration to her head. LPN #1 stated that the nursing aide was a new employee at the time but she wasn't certain of her name. LPN #1 was asked to get this nursing aide's contact information.
On 10/3/19 at 9:31 a.m., an interview was conducted with LPN #7, the MDS nurse. When asked who was responsible for developing care plans, LPN #7 stated that she was responsible. When asked how many assist Resident #26 was with incontinence care, LPN #7 stated that Resident #26 was extensive assistance with one staff member. When asked why Resident #26's care plan documented an assist of one with bathing/hygiene but assist of two with turning and repositioning and bed mobility, LPN #7 stated that Resident #26 was an assist with one for turning but that it required to staff members to lift her up in bed (slide back up).
On 10/3/19 at 12:04 p.m., incontinence care was observed for Resident #26 with CNA #4, her assigned nursing assistant that shift. There were no concerns related to bed mobility and turning and respositioning.
On 10/3/19 at 1:12 p.m., an interview was conducted with CNA #3, the aide who was present during Resident #26's fall on 9/3/19. When asked how she provides incontinence care to a resident who is extensive assistance, CNA #3 stated that when she is providing incontinence care for a resident who is extensive assistance, she will first undo the brief, turn the resident toward her (with her standing in front of the resident), pull the brief out, wash the resident, tuck a new brief underneath, place the resident back on their back and then she will walk around the bed, turn the resident to the other side of the bed (with the aide in front of her), and then she will secure the brief. When asked how many assist Resident #26 was with incontinence care, CNA #3 stated that she extensive assist with one staff member. When asked what she could recall on 9/3/19 with Resident #26's fall, CNA #3 stated that she didn't pull Resident #26 to the center of the bed prior to turning her on her side. CNA #3 stated that she didn't realize how close Resident #26 was to the edge of the bed prior to turning her. CNA #3 stated that she tried to stop the fall but that Resident #26 was too heavy and fell off the bed. CNA #3 stated that Resident #26's head went down and hit the nightstand. When asked if any education was provided to her after this incident, CNA #3 stated that administration did an in-service with her and other staff about proper turning and respositioning.
On 10/3/19 at 2:42 p.m., a concern for harm was addressed with ASM (administrative staff member) #1, the administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional Director of Clinical Services, and RN (registered nurse) #1, the ADON (assistant director of nursing). Education that was provided to staff after the incident on 9/3/19 was requested.
On 10/3/19 at approximately 4 p.m., signature sheets dated 9/4/19 were presented. CNA #3's signature was on this sheet as well as 16 other nursing assistants. The following was documented on the signature sheet: Subject: Repositioning residents while in bed. Participants: Nursing Staff. The content of this education was requested from RN #1.
On 10/4/19 at approximately 10:00 a.m., RN #1 presented the content of the education provided on 9/4/19. The following was documented: 9/4/19 Proper positioning of resident while in bed .1. Before providing care be sure to have the appropriate amount of staff assisting, (i.e. 1 or 2 person assist, per plan of care). 2. When assisting a resident up in bed, lower the head of the bed, elevate the feet and have the resident use their legs to push up. Lowering the head of the bed and elevating the feet, will allow gravity to help. 3. When turning a resident from side to side, be sure that the resident is toward the center of the bed and using the draw sheet roll the resident on their side. Pillows or wedges can be used to maintain resident in side position. 4. Please remember that it is ok to ask for help if needed.
On 10/4/19 at 11:45 a.m., review of the facility's incident and accident log revealed no falls with major injuries since 9/3/19.
On 10/3/19 at approximately 10:45 a.m., ASM #2, the DON and ASM #3, the Regional Director of Clinical Services were made aware that this concern would be past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, and clinical record review, the facility staff failed to ensure necessary respiratory care and services were provided for 2 of 39 residents in the survey sample (Residents #97 and #10).
For Resident #97, the facility staff failed to ensure resident specific tracheostomy equipment was easily accessible in case of an emergency, failed to provide tracheostomy care without compromising the resident's respiration/airway and failed to administer oxygen (O2) as ordered. For Resident #10, the facility staff failed to administer oxygen as ordered.
The findings included:
1. Resident #97 was originally admitted to the facility 9/6/19 and had never been discharged from the facility. The current diagnoses included sarcoidosis requiring a tracheostomy.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/13/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #97's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with bed mobility and total care with locomotion, dressing, eating, toileting, personal hygiene and bathing.
Observations were made of the resident's room on 10/2/19, at approximately 11:00 a.m., with Licensed Practical Nurse (LPN) #1. An ambu bag was on the table near the foot of the bed, gauzes, an inner cannula and a trach system with an inner cannula was in the top drawer of the table near the foot of the bed. The Unit Manager stated the items in the top drawer were not the current trach equipment the resident required for the trach system the resident was currently utilizing; it didn't include an inner cannula. Further observation of the resident's room revealed a suction machine which was operational and a Yankauer oral suction tube was present however no trach catheters, sterile water or saline were in the room. A compressed oxygen machine was on the bedside table with the suction machine but and it was not delivering oxygen at 3 liter per minutes via trach collar as ordered on 9/9/19. There was no trach collar and the O2 machine wasn't on.
On 10/2/19 at 1:30 p.m., a bag with the correct tracheostomy tube and other tracheostomy supplies was observed attached to the cork board in the resident's room. An observation of LPN #1 providing trach care to Resident #97 was made; the resident was observed lying on his left side and sliding down in the bed. The tube feeding was running at 60 milliliter per hour. The resident had a large amount of secretions pooling on the right side of his neck and the trach ties appeared saturated. LPN #1 opened the supplies and placed them on an over the bed table, she opened a cotton tip applicator and swabbed around the trach opening, then she opened the gauze packets and poured saline on the gauze, wiped and the resident's neck four times until all the pooling secretions were removed from his skin. LPN #1 then removed the left side trach tie, then the right trach tie, leaving the resident's trach unsecured, not even holding it in place with her hands. LPN #1 turned to the table and began removing the new trach ties from the container and the surveyors stated I am concerned because if the resident coughs the tracheostomy tube will be dislodged and the resident will lose his ability to breath. LPN #1 continued to prepare her supplies leaving the tracheostomy tube unsecured and the resident coughed, the tube was expelled and the resident began to gasp for breath and show body restlessness. The surveyor notified staff at the nursing station there was an emergency in the resident's room and LPN #1 retrieved the tracheostomy tube and reinserted it into the resident's trachea, applied the new trach ties and clean gauze around the tracheostomy tube, obtain a pulse oximeter reading of 92%, cleaned up the unused supplies and left the resident's room. The oxygen via trach collar still wasn't provided.
On 10/2/19 at approximately 6:15 p.m., Resident #97's wife was observed seated at his bedside. She stated it was difficult seeing her husband in his current state for most of his life he was the life of a party. He always made everyone laugh and he enjoyed seeing others happy. The wife then stated her husband had sarcoidosis which progressed and required use of the tracheostomy. She added she took care of her husband at home so suctioning him wasn't a concern for her but the facility's nurses had told her they couldn't perform deep suctioning too often remove secretions. She further stated the staff does a good job keeping her husband clean but they were not doing a good job keeping his abdominal binder on and with his trach care. She stated when she entered his room earlier she had to suction him because he had a large amount of secretions pooling around his neck and there was a rattle in his trach. She also stated the facility's staff don't keep suctioning catheters in the room like she would like for them to therefore she had to ask for one and sterile water to suction him. Resident #97's wife then stated she would like for the staff to suction him before she left because he wasn't rattling again. The wife stated the resident had a large amount of scar tissue in his trachea area because he had dislodged his inner cannula and or trach tube multiple times and his current tracheostomy tube was his fourth placement.
Review of Resident #97's physician orders revealed the following orders: 9/9/19, oxygen at 3 liter per minute via trach, FIO2 28% via trach collar every shift. Suction assessment every 4 hours as needed for suctioning. Trach assessment daily every shift for trach. Trach assessment daily every shift for trach. Trach ties/collar to be changed on bath days/PRN as needed.
On 10/3/19 at approximately 3:00 p.m.,an interview was conducted with LPN #1 accompanied by the Assistant Director of Nursing. LPN #1 acknowledged she should have positioned the resident on his back and extended his neck as well as she probably should have stopped the tube feeding prior to beginning trach care. LPN #1 also answered yes when asked if she should have assessed the resident's respiratory status for: ease of breathing, respiratory rate, pulse rate, amount of secretions and appearance, and for the presence of secretions on the residents neck or trach ties. LPN #1 stated Now I understand why you stated you were concerned when the trach ties were removed but it wasn't the first time his airway had been compromised by dislodgement of the tracheostomy tube. LPN #1 stated she didn't feel the resident required suctioning but she didn't state what led her to that conclusion. LPN #1 also expressed she felt the surveyor should have offered her guidance in providing tracheostomy care.
On 10/3/19, at approximately 6:00 p.m., the above findings were shared with the Director of Nursing and the Corporate Consultant. The Director of Nursing stated the a local respiratory company had in-serviced staff on tracheostomy care. The document they provided on 10/4/19, stated the facility's staff received training 2/15/18, but a sign-in document revealing the actual participants was provided. The Director of Nursing and the Corporate Consultant were unable to state what LPN #1 should have done to fulfill the suction assessment and no information was provided to clarify what the order suction assessment meant. The Corporate Consultant stated arrangements had been made for a Respiratory Therapist to come in later in the week.2. Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to epilepsy, type two diabetes, high blood pressure, heart failure, hemiplegia (one sided paralysis) following stroke and major depressive disorder. Resident #10's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/2/19. Resident #10 was coded with moderate cognitive impairment scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam.
On 10/2/19 at 12:00 p.m., an observation was made of Resident #10. She was lying in bed with oxygen on via nasal cannula. Her oxygen flow meter was set to 4 liters of oxygen. When asked how she was breathing, Resident #10 stated she was breathing fine.
On 10/2/19 at 5:15 p.m., a second observation was made of Resident #10. She was lying in bed with oxygen on via nasal cannula. Her oxygen flow meter was set to 4 liters of oxygen.
Review of Resident #10's October 2019 POS (physician order sheet) revealed the following oxygen order initiated on 9/12/19: Oxygen at (2) LPM (liters per minute) via nasal cannula every shift for SOB (shortness of breath).
Review of Resident #10's oxygen care plan dated 9/30/19, documented the following: (Name of Resident #10) requires oxygen R/T (related to) CHF (congestive heart failure), SOB. Goal: Residents oxygen levels will be kept as desired levels per MD (medical doctor) orders through next review. Interventions: Administer oxygen as ordered.
Review of Resident #10's clinical record revealed that Resident #10 had been sent to the hospital on [DATE] for abnormal laboratory tests and elevated blood pressure. Resident #10 was admitted back to the facility on [DATE] at 4:00 a.m. There was no evidence that her oxygen was ordered to be increased to 4 liters after this hospitalization.
On 10/2/19 at 5:25 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #9, Resident #10's nurse. When asked how many liters of oxygen Resident #10 was supposed to be on, LPN #9 stated, I think it is two, I have to check. LPN #9 checked Resident #10's current physician orders and stated that her order was for two liters. When asked if she had already seen Resident #10 that shift, LPN #9 stated that she was her nurse 7-3 and 3-11 shift and had just seen Resident #10 about an hour and a half ago. When asked if she had checked Resident #10's oxygen flow meter that day, LPN #9 stated that she had not yet checked her flow meter. LPN #9 did not mention Resident #10 having any respiratory distress that shift. This writer then followed LPN #9 to Resident #10's room. LPN #9 checked Resident #10's oxygen and stated that her oxygen flow meter was set to 4 liters and that it should be set to two liters. When asked if Resident #10 was able to adjust her own oxygen, LPN #9 stated that Resident #10 could not. When asked if there could be any adverse effects from receiving too much oxygen, LPN #2 stated that receiving too much oxygen could harm her lungs. LPN #9 could not explain why receiving too much oxygen could harm her lungs.
On 10/3/19 at 6:05 p.m., an interview was conducted with ASM #2, the Director of Nursing. ASM #2 stated that on 10/1/19 Resident #10 was having respiratory distress and that he received an order from the Nurse Practitioner to increase Resident #10's oxygen up to 4 liters prn (as needed). ASM #2 stated that he had just put the new order in as a late entry on 10/3/19. ASM #2 and this writer looked at Resident #10's chart for 10/2/19. This writer showed ASM #2 that there was no evidence she was having respiratory distress on 10/2/19. ASM #2 stated that the nurse practitioner wanted Resident #10 to stay on 2 liters continuous and move up to 4 liters if needed. When asked how he would know to increase Resident #10's oxygen if it remained on 4 liters on 10/2/19, ASM #2 stated that he was not sure what happened since this writer's observation was only from 12 p.m. to 5:15 p.m. This writer explained to ASM #2 that LPN #9 (the 7-3 and 3-11 shift nurse for Resident #10 on 10/2/19) did not mention anything related to Resident #10 having respiratory distress on 10/2/19 prior to this writer's observation. This writer explained that LPN #9 had stated that she did not check Resident #10's flow meter yet that day.
On 10/4/19 at 10:46 a.m., during the pre-exit meeting, ASM (administrative staff member) #1, the Administrator, ASM #2, the Director of Nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. A policy could not be provided regarding the above concerns. No further information was presented prior to exit.

Based on observations, family interview and staff interviews the facility staff failed to ensure staff was competent in tracheostomy tube care for 1 of 39 residents (Resident #97), in the survey sample.
The findings included:
Resident #97 was originally admitted to the facility 9/6/19 and had never been discharged from the facility. The current diagnoses included sarcoidosis requiring a tracheostomy.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/13/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #97's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with bed mobility and total care with locomotion, dressing, eating, toileting, personal hygiene and bathing.
Observations were made of the resident's room on 10/2/19, at approximately 11:00 a.m., with Licensed Practical Nurse #1. An ambu bag was on the table near the foot of the bed, gauzes, an inner cannula and a trach system with an inner cannula was in the top drawer of the table near the foot of the bed. The Unit Manager stated the items in the top drawer were not the current trach equipment the resident required for the trach system the resident was currently utilizing didn't include an inner cannula. Further observation of the resident's room revealed a suction machine which was operational and a Yankauer oral suction tube was present but; no trach catheters, sterile water or saline were in the room. A compressed oxygen machine was on the bedside table with the suction machine but and it was not delivering oxygen at 3 liter per minutes via trach collar as ordered on 9/9/19. There was no trach collar and the O2 machine wasn't on.
On 10/2/19 at 1:30 p.m., a bag with the correct tracheostomy tube and other tracheostomy supplies was observed attached to the cork board in the resident's room. An observation of Licensed Practical Nurse (LPN) #1 providing trach care to Resident #97 was made; the resident was observed lying on his left side and sliding down in the bed. The tube feeding was running at 60 milliliter per hour. The resident had a large amount of secretions pooling on the right side of his neck and the trach ties appeared saturated. LPN #1 opened the supplies and placed them on an over the bed table, she opened a cotton tip applicator and swabbed around the trach opening, then she opened the gauze packets and poured saline on the gauze, wiped and the resident's neck four times until all the pooling secretions were removed from his skin. LPN #1 then removed the left side trach tie, then the right trach tie, leaving the resident's trach unsecured, not even holding it in place with her hands. LPN #1 turned to the table and began removing the new trach ties from the container and the surveyors stated I am concerned because if the resident coughs the tracheostomy tube will be dislodged and the resident will lose his ability to breath. LPN #1 continued to prepare her supplies leaving the tracheostomy tube unsecured and the resident coughed, the tube was expelled and the resident began to gasp for breath and show body restlessness. The surveyor notified staff at the nursing station there was an emergency in the resident's room and LPN #1 retrieved the tracheostomy tube and reinserted it into the resident's trachea, applied the new trach ties and clean gauze around the tracheostomy tube, obtain a pulse oximeter reading of 92%, cleaned up the unused supplies and left the resident's room. The oxygen via trach collar still wasn't provided.
On 10/2/19 at approximately 6:15 p.m., Resident #97's wife was observed seated at his bedside. She stated it was difficult seeing her husband in his current state for most of his life he was the life of a party. He always made everyone laugh and he enjoyed seeing others happy. The wife then stated her husband had sarcoidosis which progressed and required use of the tracheostomy. She added she took care of her husband at home so suctioning him wasn't a concern for her but the facility's nurses had told her they couldn't perform deep suctioning when to often remove secretions. She further stated the staff does a good job keeping her husband clean but they were not doing a good job keeping his abdominal binder on and with his trach care. She stated when she entered his room earlier she had to suction him because he had a large amount of secretions pooling around his neck and there was a rattle in his trach. She also stated the facility's staff don't keep suctioning catheters in the room like she would like for them to therefore she had to ask for one and sterile water to suction him. Resident #97's wife then stated she would like for the staff to suction him before she left because he wasn't rattling again. The wife stated the resident had a large amount of scar tissue in her trachea area because he had dislodged his inner cannula and or trach tube multiple times and his current tracheostomy tube was his fourth placement.
Review of Resident #97's physician orders revealed the following orders: 9/9/19, oxygen at 3 liter per minute via trach, FIO2 28% via trach collar every shift. Suction assessment every 4 hours as needed for suctioning. Trach assessment daily every shift for trach. Trach assessment daily every shift for trach. Trach ties/collar to be changed on bath days/PRN as needed.
On 10/3/19 at approximately 3:00 p.m.,an interview was conducted with LPN #1 accompanied by the Assistant Director of Nursing. LPN #1 acknowledged she should have positioned the resident on his back and extended his neck as well as she probably should have stopped the tube feeding prior to beginning trach care. LPN #1 also answered, yes, when asked if she should have assessed the resident's respiratory status for; ease of breathing, respiratory rate, pulse rate, amount of secretions and appearance, and for the presence of secretions on the residents neck or trach ties. LPN #1 stated now I understand why you stated you were concerned when the trach ties were removed but it wasn't the first time his airway had been compromised by dislodgement of the tracheostomy tube. LPN #1 stated she didn't feel the resident required suctioning but she didn't state what lead her to that conclusion. LPN #1 also expressed she felt the surveyor should have offered her guidance in providing tracheostomy care.
On 10/3/19, at approximately 6:00 p.m., the above findings were shared with the Director of Nursing and the Corporate Consultant. The Director of Nursing stated the a local respiratory company had in-serviced staff on tracheostomy care. The document they provided on 10/4/19, stated the facility's staff received training 2/15/18, but a sign-in document revealing the actual participants was not provided. The Director of Nursing and the Corporate Consultant were unable to state what LPN #1 should have done to fulfill the suction assessment and no information was provided to clarify what the order suction assessment meant. The Corporate Consultant stated arrangements had been made for a Respiratory Therapist to come in later in the week.

Based on staff interview and facility documentation review, the facility staff failed to ensure there was Registered Nurse (RN) coverage for eight consecutive hours in a twenty-four hour period.
The findings include:
During review of the facility's staffing for Registered Nurse coverage, the facility failed to ensure there was an RN for at least 8 consecutive hours a day seven days a week on 12/1/18, 12/2/18, 12/16/18, and 12/22/18.
On 10/4/19 at 9:49 a.m., an interview was conducted with the scheduler Other staff member (OSM) #4. When asked how long she had been creating the schedule, OSM #4 stated that she had been doing the schedule for four years. When asked if it was difficult to get RN coverage back in December of 2018, OSM #4 stated, On the weekends. Yes. OSM #4 stated that there should be an RN on shift for 8 hours in a 24 hour period. OSM #4 confirmed through review of the as worked nursing staffing schedule that there was no RN coverage 8 consecutive hours in the 24 hours on 12/1/18, 12/2/18, 12/16/18, and 12/22/18.
On 10/4/19 at 10:46 a.m., during the pre-exit meeting, ASM (administrative staff member) #1, the Administrator, ASM #2, the Director of Nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was provided by the facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based record review and staff interview the facility staff failed to ensure medications were available for administration for two residents (Resident #68 and Resident #96 ) in the survey sample of 39 residents.
The findings included:
1. Resident #68 was re-admitted to the facility on [DATE] with diagnoses which included, but not limited to, sepsis, osteomyelitis of vertebra, sacral and sacrococcygeal region, Type 2 Diabetes mellitus without complications, dementia, and chronic obstructive pulmonary disease (COPD).
A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Hearing, Speech, and Vision as having unclear speech. In the area of Cognitive Patterns this resident received a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. In the area of Functional Status this resident was assessed in the area of Activities of Daily Living (ADL) as requiring total dependence of two persons for bed mobility and toileting. Extensive assistance of one person physical assist for dressing and personal hygiene. In the area of Bladder and Bowel this resident was assessed as requiring an Indwelling Catheter. In the area of Medications this resident was assessed as receiving antibiotics during the last 7 days of reentry.
A Revised Care Plan dated 09/16/19 indicated: Resident #68 is on IV (intravenous) (ABT) antibiotic-Vancomycin IV X 35 days R/T sepsis. Goal- Resident infection will resolve without complications by Vancomycin. Interventions- Notify physician if course of treatment appears to be ineffective, medications as ordered.
A Progress Note dated 09/22/19 at (14:28) 2:28 P.M. indicated: Resident missed 18:00 dose of IV Vancomycin 1 gram on Saturday 09/21/19 due to pharmacy not delivering .sending to wrong facility. NP (Nurse Practitioner) contacted, new order to pull Vancomycin from stat tower and give now at 09:00 (9 AM) was received. LPN (Licensed Practical Nurse) used Vancomycin 1 gram from stat tower and reconstituted it and added to 250 ml of NS (normal saline) per pharmacy advice. New time for his Vancomycin is now at 09:00 AM. Pharmacy was made aware and stated that they will be sending his 09:00 AM dose of Vanco for 09/23/19 and to retake his Vanco trough 1/2 before his next dose. The nurse who did not administer the medication on 9/21/19 was not available for interview.
During an interview on 10/04/19 at 10:00 A.M. with the Director of Nursing he stated the pharmacy did not have the medication available on 09/22/19. 2. Resident #96 was originally admitted to the facility 9/4/19 and has never been discharged from the facility. The current diagnoses included; gastritis (inflammation of the stomach lining).
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/11/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #96's cognitive abilities for daily decision making were moderately impaired. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing, and total care with locomotion.
During the medication and pass and pour observation on 10/1/19, at approximately 5:53 p.m., Licensed Practical Nurse (LPN) #9 stated she didn't have Ranitidine 75 milligrams on the medication cart but she would retrieve some from the over the counter drug supply. Upon return to the medication cart she stated she had to telephone the physician for further orders because there was no Ranitidine 75 milligrams in the facility. At approximately 6:25 p.m., someone yelled down the hall to LPN #9 that the Ranitidine order had been discontinued because it was a recall medication.
Reviewed of Resident #96's physician orders revealed an order dated 10/1/19 at 6:21 p.m., to discontinue the order for Ranitidine 75 milligrams two times a day for gastritis.
An interview was conducted with the Nurse Practitioner (NP) on 10/2/19 at approximately 4:45 p.m. The NP stated the she didn't believe Resident #96 had gastritis but she had reflux disease therefore she was doing a trial discontinuation of the medication Ranitidine. The NP further stated the physician initially assessed the resident and she had not yet evaluated her but she would get back with me afterwards.
On 10/3/19 at approximately 11:20 a.m., an interview was conducted with the Supply clerk (she orders the over the counter medications) about not having Ranitidine 75 milligrams in stock. The supply clerk stated after reviewing her computer system there was no indication that she had never stocked the over the counter medication Ranitidine therefore it apparently had been obtained from some other supplier. She also stated the supplier the facility utilizes had the medication available to be ordered and if she had been notified she could have had it in the facility within one day.
On 10/3/19, the NP stated it was reported to her that Resident #96, had vomited but she wasn't certain if it was related to discontinuation of the medication Ranitidine or if it was just something the resident had consumed but she would assess the resident.
On 10/3/19 at approximately 6:00 p.m., the above findings were shared with the Director of Nursing and Corporate consultant. The Director of Nursing stated he was aware the medication Ranitidine 75 milligrams wasn't available for administration to resident #96 during the medication pass and pour and he had been planning to develop a par level for over the counter medication but he had not yet gotten around to it. The Corporate consultant stated the documentation of the NP reported episode of Resident #96 vomiting 10/2/19, was not in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interviews, clinical record review, the facility's staff failed to review food preference with the resident and provide like food alternatives for 1 of 39 residents (Resident #95), in the survey sample.
The findings included:
Resident #95 was originally admitted to the facility 9/12/19 and the resident has never been discharged from the facility. The current diagnoses included; stroke with left hemiparesis.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/18/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #95's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with locomotion, dressing, eating, toileting, and personal hygiene, extensive assistance of 2 people with bathing, bed mobility, and transfers.
On 10/1/19 at approximately 4:00 p.m., after the Resident Council meeting, Resident #95 stated I'm a young man with a wife and children. I had a stroke and am here for rehabilitation therapy. I decided while I was hospitalized that I wanted to develop a healthy lifestyle including increased exercise and eating healthier foods, preferably salads for two meals daily. Resident #95 further stated I have told the nurses almost daily that I don't want pork, gravies, or fried food or most of the foods they have been serving me, I want more vegetables and salads for lunch and dinner, but I'm still not receiving salads. The resident stated nothing has changed concerning the foods he dislikes therefore his family is bringing food in for lunch and dinner as well as leaving other food in his room for when he wants a snack. The resident stated no one had interviewed him for his food preferences or explained to him what type of diet was recommended or ordered for him and he had not met any person who identified themselves as dietary staff.
The Dietary Manager was interviewed in her office, on 10/1/19, at approximately 4:10 p.m., she stated she hadn't reviewed food preferences with Resident #95 but she had spoken with his wife and the resident was receiving foods based on the wife's information.
The Dietary Manager met with Resident #95 on 10/1/19, at approximately 4:15 p.m., to obtain preferences directly from the resident.
Review of Resident #95's Nutrition assessment dated [DATE] revealed the resident was on a regular diet with no restrictions or supplements. It also revealed the resident had no chewing or swallow problems and he fed himself. One of the interventions was to provide meals per the physician's order and to honor the resident's preferences.
An interview was conducted with Resident #95 on 10/2/19, at approximately 1: 00 p.m., the resident stated he had received a large salad for dinner on 10/1/19, and lunch 10/2/19, and the Dietary Manager stated the information was on his tray card therefore they will continue to be served until he tells the staff to stop sending them.
On 10/3/19, at approximately 6:00 p.m., the above findings were shared with the Director of Nursing and the Corporate Consultant. The Director of Nursing stated Resident #95 should not have had to wait almost three weeks for his food preferences to be obtained and honored and his request should have been passed on to dietary when they were made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility document review, the facility staff failed to provide the resident or resident's representative education regarding the benefits and potential side effects of influenza immunization for four of 39 residents in the survey sample, (Resident #33, #10, #96, #88).
The findings include:
1. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to major depressive disorder, bipolar disorder, high blood pressure, and type two diabetes. Resident #33's most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/25/19. Resident #33 was coded as being moderately impaired in cognitive function scoring 11 out of 15 on the BIMS (Brief Interview for Mental Status) exam.
Review of Resident #33's clinical record revealed that she received her last flu vaccine on 10/4/18. The following was documented in her clinical record: Immunization: Influenza: Consent confirmed date: 10/4/18 Date of Administration: 10/4/18 at 1400 (2:00 p.m.) Route of Administration: intramuscularly Amount Administered: 0.5 ml (milliliters) Location given: Right Deltoid (muscle) Manufacturer's name: Flucelvax . There was no evidence that education was provided to Resident #33 prior to the administration of the Flu vaccine.
2. Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to epilepsy, type two diabetes, high blood pressure, heart failure, hemiplegia (one sided paralysis) following stroke and major depressive disorder. Resident #10's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/2/19. Resident #10 was coded as being intact in cognitive function scoring 12 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam.
Review of Resident #10's clinical record revealed that she received her last flu vaccine on 10/30/18. The following was documented in her clinical record: Immunization: Influenza: Consent confirmed date: 10/30/18 Date of Administration: 10/8/18 at 1400 (2:00 p.m.) Route of Administration: intramuscularly Amount Administered: 0.5 ml (milliliters) Location given: Right Deltoid (muscle) Manufacturer's name: Flucelvax . There was no evidence that education was provided to Resident #10 prior to the administration of the Flu vaccine.
3. Resident #26 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia without behavioral disturbance, high cholesterol, type two diabetes and adult failure to thrive. Resident #26's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/16/19. Resident #26 was coded as being severely impaired in cognitive function scoring 04 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam.
Review of Resident #26's clinical record revealed that she received her last flu vaccine on 11/5/18. The following was documented in her clinical record: Immunization: Influenza: Consent confirmed date: 11/5/18 Date of Administration: 11/5/18 at 1330 (3:30 p.m.) Route of Administration: intramuscularly Amount Administered: 0.5 ml (milliliters) Location given: left Deltoid (muscle) Manufacturer's name: Flucelvax . There was no evidence that education was provided to Resident #26 prior to the administration of the Flu vaccine.
4. Resident #88 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to high blood pressure, dementia, and epilepsy. Resident #88's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 9/14/19. Resident #8 was coded as being severely impaired in cognitive function scoring 03 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam.
Review of Resident #88's clinical record revealed that she received her last flu vaccine on 10/22/18. The following was documented in her clinical record: Immunization: Influenza: Consent confirmed date: 10/22/18 Date of Administration: 10/22/18 at 1400 (4:00 p.m.) Route of Administration: intramuscularly Amount Administered: 0.5 ml (milliliters) Location given: Right Deltoid (muscle) Manufacturer's name: Flucelvax . There was no evidence that education was provided to Resident #88 prior to the administration of the Flu vaccine.
On 10/3/19 at 12:00 p.m., RN (Registered Nurse) #1, Assistant Director of Nursing was asked to provide evidence that education was provided to the above four residents prior to receiving the flu vaccination in 2018. RN #1 stated that she was not the nurse in charge at that time but stated that she would look for any education.
On 10/3/19 at 12:12 p.m., RN #1 presented a copy of the education sheets residents received prior to receiving the flu vaccine from the CDC (Centers for Disease Control). RN #1 stated that she could not find evidence that this education was actually provided to these residents prior to administration of the flu vaccine.
On 10/4/19 at 10:46 a.m., during the pre-exit meeting, ASM (administrative staff member) #1, the Administrator, ASM #2, the Director of Nursing and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns.
On 10/4/19 at approximately 11:45 a.m., ASM #2, Director of Nursing presented a Resident Flu Vaccine Documentation Report for three of the four residents identified above. This report documented the following: The facility will keep this record in your medical file. They will record that vaccine was given, when it was given, the name of the company that made the vaccine, the vaccine's lot number and the signature and title of the person who gave the vaccine. I have read or have had explained to me the information about influenza and influenza vaccine. I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of influenza vaccine and ask that the vaccine be given to me or the person named below for who I am authorized to make this request. I also consent to receive annual influenza vaccination from this date forward.
Review of Resident #33's Flu Vaccine Documentation Report revealed that she had signed this form on 10/3/17. There was still no evidence that she received education prior to the 10/4/18 administration of the Flu vaccine.
Review of Resident #26's Flu Vaccine Documentation Report revealed that her representative had signed this form on 10/29/14. There was still no evidence that she received education prior to the 11/5/18 administration of the Flu vaccine.
Review of Resident #88's Flu Vaccine Documentation Report revealed that his representative had signed this form on 10/29/14. There was still no evidence that the representative received education prior to the 10/22/18 administration of the Flu vaccine.
A Flu Vaccine Documentation Report could not be provided for Resident #10.
Facility policy titled, Influenza Vaccine-Resident documents in part, the following: Procedure: Consent and education for the influenza vaccine will be provided by nursing staff/designee upon the resident's admission to the facility. In the event if a weekend or after hour's admission the admitting nurse will obtain consent and provide education .C. Nursing staff (or designee) will provide the resident and/or resident's representative with information regarding the benefits and potential side effects of the influenza vaccine, every year, in the beginning of September or prior to vaccination .D. Nursing Staff will document the provision if education in the resident's medical record.

Based on observations and staff interview it was determined that the facility staff failed to maintain an effective pest control system.
The findings included:
During the kitchen inspection on 10/01/19 at 11:45 A.M. house flies were observed in the kitchen area. Drain flies were observed in the mop room and dishwasher room. Fruit flies and house flies were observed in the conference room. House flies were observed in the dining room area. Flies were observed on all units.
During an interview on 10/03/19 at 2:50 P.M. with the Maintenance Director she stated, the drain flies, fruit flies and house flies have been a concern and there is a need for pest control. The Maintenance Director stated The Pest Control company came out on 10/03/19 at 11:18 A.M. to service the facility. A copy of the work order was provided by the Maintenance Director.
A review of the Pest Management policy indicated: Mission- We shall first seek to understand the unique needs of each customer, formulate effective solutions, and implement the actions in a timely professional manner.
No further information was presented by facility staff.