Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for 1 resident, Resident #1, in a sample size of 3 residents. The findings included: For Resident #1, facility staff failed to utilize proper turning/repositioning technique while providing care. Resident #1 was discharged from the facility on 9/22/23 and therefore not available for observation and direct interview. On 11/14/23, a telephone call was placed to the last known number for Resident #1 and there was no answer. On 11/14/23, Resident #1's clinical record was reviewed in its entirety. A progress note dated 8/19/23 at 13:30 read, Resident is alert and verbally responsive and complained of pain in his right shoulder, he stated that the aid [certified nursing assistant-CNA] from last night pulled his right shoulder when she tried to turn him while doing the ADL [activities of daily living] care, upon assessment pain was rated 6/10, vital signs were stable . Resident #1 received Tylenol which relieved his pain. The physician ordered a right shoulder xray which resulted as negative for dislocations and fractures. On 11/14/23 at approximately 3:30 PM, an interview was conducted with the Facility Administrator and Director of Nursing (DON). The Facility Administrator verbalized awareness of the occurrence and stated that re-education on proper repositioning and turning of residents was conducted for all clinical staff. The Facility Administrator provided copies of the inservice education and staff sign-in sheets for verification. The DON stated, Pulling on extremities, arms or legs, is not an accepted practice for assisting with repositioning or turning, especially with the elderly, because it can cause injuries like dislocated joints or even fractures. The Facility Administrator identified CNA C as the person who was providing care to Resident #1 and additional education for CNA C was verified through the documentation provided. CNA C was not available for interview. According to an article located on MedlinePlus, an online health information resource provided by the National Library of Medicine (NLM) which is part of the National Institutes of Health (NIH), subtitle, Avoiding Injury, item 1 read, You must move or pull someone up in bed the right way to avoid injuring the patient's shoulders and skin . and item 4 read, Never move patients up by grabbing them under their arms and pulling. This can injure their shoulders. URL as follows: //medlineplus.gov/ency/patientinstructions/000429.htm On 11/15/23 at approximately 3:00 PM, the Facility Administrator and DON were updated on the findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, facility documentation and in the course of an investigation the facility staff failed to ensure the Resident's right to participate in the development and implementation of his person centered care process for one Resident (Resident #168) in a sample size of 33 Residents. The findings included: For Resident #168 the facility staff failed to allow the Resident to identify individuals or roles to be included, and failed to inform him of meeting to discuss care plan. On 1/6/23 a review of the clinical record revealed that the Resident was seen by the Psychiatrist (Employee J) on 12/1/22 and the Psychiatrist entered the following orders in Resident #168's clinical record. Physicians Progress Note 12/1/22 -Continue same meds. -PT [patient] needs to attend treatment plan with facility Administration to address behavioral concerns. -Pt will be referred to psychotherapy On 12/2/22 the following nursing note was entered: 12/2/2022 10:13 Nurses Note : Resident refused to be seen by MD [Psychiatrist name redacted] psychogeriatric services. PSG [sic] [PGS=Psychogeriatric Services] recommendation, Pt. needs to attend treatment plan meeting with facility administration to address behavioral concerns, Pt. will be referred for psychotherapy. resident self RP/mother [name redacted] notify [sic] all risk and benefit explained with verbalization of understanding consented all question answered at this time. On 12/6/22 the social worker entered the following note: 12/6/2022 4:13 PM Social Services Note : This writer made aware on Thursday 12/8 at 2pm psychogeriatric doctor requesting a IDT meeting to be held with resident. There is no documentation stating that the Resident or family member was made aware of this meeting. The next note in the Resident record is 12/8/22 was recorded in the progress note as follows: 12/8/2022 16:00 Social Services Note: This writer, psych doctor, resident, unit manager and social services assistant met with resident. Psych-doctor advise resident he don't require a 1:1 due to him not being suicidal, fall risk etc. Resident became upset stating I'll call the state. Psych-doctor suggest speaking to i.e. unit manager, social services director or the supervisor if the staff he is reaching out to are not responding timely and to not assume the staff is ignoring him. Resident proceeded to call the state and spoke to a person via phone in front of the IDT and verbalize he is being bombarded by his psych doctor, unit manager and 4 or 5 other people. Patient also verbalize he want it to be known he is being harrassed [sic] and he is willing to meet with the state and do not want the psych-doctor to be his doctor. Meeting concluded with the psych-doctor recommending the IDT to meet with resident weekly. On 1/5/23 at 11:00 AM, an interview was conducted with Resident #168 who stated that on 12/1/22 he had a meeting with the psychiatrist and they really didn't talk about much. After the meeting with the psychiatrist he told the nursing staff he did not want to see him (the psychiatrist) again. He stated he wanted talk therapy and did not need the psychiatrist for that. The nurse entered that information into the clinical record on 12/2/22. The Resident stated that on 12/8/22 the social worker told him he would be meeting with the psychiatrist that day at 2 pm. He stated that he was under the impression it would be a therapist not the psychiatrist he had told them he did not want to see. Resident #168 stated that when 6 people walked into his room he was feeling like They were ganging up on me. Resident #168 stated that he felt like it was harassment and he called the State Agency (OLC) to complain. He stated that he called the OLC while everyone was in his room. He said They look at me as a problem because I will call state and the Ombudsman. Its my life its my care; and my health should be a priority. It is my right to complain if there is a problem. On 1/6/23 a telephone interview was conducted with the Psychiatrist and he was asked about the meeting on 12/1/22 he stated that he introduced himself got background information and medication information and his history and physical, and spoke with the Resident. He told him they would be having psychotherapy services starting soon and the Resident seemed interested in those services. He stated that he did not make any changes to his medications because he seemed stable on the meds and dosages he was currently on. When asked how the second meeting came about he said, I was told by the nursing home staff that they are having a lot of challenges dealing with him, it is difficult to address all of his needs, for that reason, they have put a care giver across from his room, like 1:1 so his needs can be met. Usually 1:1 is placed when the patient is actively suicidal or may hurt someone or have physical disability that if they were to stand they would fall. [Resident name redacted] gets upset if he rings the bell and there is a delay he gets upset calls the Dept of Health and Ombudsman, so therefore my impression that the nursing home was trying their best to make sure his needs are met right away with no delay. The nursing home was feeling overwhelmed and didn't know how to meet his needs, what should be the treatment plan, etc. therefore I suggested a meeting, because I can't prescribe a medication and he will magically become pleasant. I told them it is not going to be an easy fix, I am not a magician, I can't come and immediately find a fix and everyone will be happy. He is someone you can have a meaningful conversation with, he understands what is happening around him. You have to sit down with them and have a dialogue. The nursing home admin was very apprehensive, it was like they have a [NAME] hanging on their heads, they are afraid because of the complaints, and they are very scared. I said we have to do something, we can have a treatment plan and that is why the treatment plan conference was scheduled. When I arrived the DON was there, the social worker was there, unit manager and we all went into his room, it was a scheduled meeting. After seeing us he became apprehensive and asked why we were ganging up on him. We said just a conference where we can all meet. He said he wanted to complain and asked if we were going to stop him from complaining and we said no, he picked up the phone and called and talked to someone, said he was in [the facility]; they seemed to know him by name, there was not too much introduction. He said they are all in my room I want to make this complaint. The Psychiatrist was asked if Resident #168 had bipolar disorder and he confirmed the diagnosis. He was asked if it was possible the Resident felt threatened by so many people in the room at once? The Psychiatrist said, My impression was he that he was not afraid or threatened, he might have been surprised, he might not have been expecting this conference take place. A review of the clinical record revealed the following entry by the social worker: 11/29/2022 12:07 PM -SocialServicesNote: This writer spoke with resident to remind him of his care plan meeting schedule for 11/30 at 2:30pm. Resident thanked this writer for stopping by. On the afternoon of 1/6/23 a telephone interview was conducted with the social worker, who was asked if it was usual practice to document patient notification of IDT meetings as she did on 11/29/22 and she stated that it was. She stated that she found out about the meeting on 12/6/22 and she verbally notified the Resident. When asked if she notified his mother she stated that she did not. On 1/10/22 during the end of day meeting the Administrator was made aware of concerns and no further information was provided.

Based on staff interview, clinical record review and financial record review, the facility staff failed to convey within 30 days following discharge Resident funds that were deposited within the facility for one Resident (Resident #105) in a survey sample of 33 Residents. The findings included: For Resident #105, who discharged from the facility on 2/1/22, the facility staff didn't convey the funds to the Resident within 30 days of discharge. On 1/4/23, the regional mobile business office manager (BOM) (Employee E) provided Surveyor C with a listing of Resident trust account balances on 11/13/22, and on 1/4/22. Review of this document revealed that on 11/13/22, Resident #105 had a trust fund account balance of $2,560.55. Review of the clinical record revealed Resident #105 discharged from the facility on 2/1/22. On 1/5/23, the BOM was asked to provide a transaction history of the Resident's trust fund account. Review of this document revealed that the trust account was not closed until 11/29/22. A copy of the check written revealed that the check was not written until 12/5/22. The check was then mailed to this same facility, where the Resident was no longer a Resident. On 1/5/23 at 11:51 AM, an interview was conducted with the BOM. When asked she indicated that accounts are to be closed and funds sent to the Resident or their estate within 30 days of discharge. When asked why Resident #105's account funds were not disbursed until 10 months after discharge, she said she was not aware of why the delay. The Regional Business office manager was able to confirm that the check was initially mailed to this facility and then had to be forwarded to the facility where he was a current resident. The envelope was post marked 12/14/22. When the facility mailed it to the other nursing facility where the Resident was, it got returned to this facility. As a result, as of 1/5/23, the Resident was still not in receipt of the funds. On 1/5/23 at approximately 2:30 PM, the business office manager reported to Surveyor C that she had called the other nursing facility and confirmed that the Resident lives there and would be mailing the check out again. On 1/10/23 at 9:45 AM, an interview was conducted with the Regional Business office manager. She stated, When residents leave we should be closing their account within 30 days of their discharge. Review of the facility policy titled Resident Trust Fund was reviewed. This policy did not address the timing of closing a Resident's account following their discharge from the facility. On the morning of 1/10/23, the facility Administrator was made aware of the findings. No further information was provided.

Based on staff interview, Resident record review, financial record review and facility documentation review, the facility staff charged the Resident and deducted from their patient trust account funds more than what were due to the facility for two Residents (Resident #170 and #1111), in a survey sample of 33 Residents. The findings included: 1. For Resident #170 the facility staff withdrew $82 more than what was due towards the cost of care for January 2023. On 1/4/23, Surveyor C met with the regional business office manager and obtained a trust account transaction history and the patient liability verifications for Resident #170 dating November 2022-January 2023. Review of these documents revealed the following: On 1/3/23, the facility withdrew funds in the amount of $920 and indicated this was a Care Cost withdrawal. The Virginia Medicaid Web Portal had indicated Resident #170 owed $838 towards the cost of care for the month of January. This was $82 more than the owed amount that the facility withdrew. 2. For Resident #1111, the facility staff withdrew more than what was due to the facility for the cost of care and services for December and January. Review of the patient trust account transaction history revealed the following: On 12/2/22, the facility staff withdrew $1,436 from Resident #1111's trust account. On 12/5/22, an additional withdrawal in the amount of $54 was made. Review of the Virginia Medicaid Web Portal for December 2022, Resident #1111 only owed $1,463 for the month of December and a total of $1,490, was taken from Resident #1111's trust account, which was an overpayment of $27. On 12/7/22, Resident #1111 received a refund check from the facility in the amount of $4,041, for prior instances where the facility withdrew funds more than what was due for the cost of care. On 1/3/23, the facility staff withdrew funds in the amount of $1,597 from Resident #1111's trust account and noted with transaction as a Care Cost Auto Withdrawal. The Medicaid web portal showed Resident #1111 only owed $1,463 for the month of January, therefore the facility withdrew an excess of $134. On 1/4/22, in the afternoon an interview was conducted with the Regional Business office manager. She was asked about the above transactions and said, Per the Medicaid portal he should have paid $1,463 for December and when I made the withdrawal, I transposed the numbers and only took $1,436. So, we went back and took the balance which is where the $54 withdrawal on 12/5/22, came in. On the afternoon of 1/4/22, the Regional Business Office manager was asked about the money that was withdrawn from Resident #170 and #1111's trust accounts in the month of January that were more than what was due to the facility. The business office manager said, I will have to do a refund back for January and everyone will have to be reviewed because of the cost-of-living increase in January, I'm sure they are all wrong. On 1/10/23 at 9:45 AM, an interview was conducted with the Regional business office manager. When asked to explain the process regarding trust funds and payments to the facility the following explanation was given. When a resident sets up a RFMS (Resident Fund Management System) agreement we set up for it to transfer their PL (patient liability). We look at their deposit and make sure what we transfer matches the Medicaid portal. Review of the facility policy titled; Resident Trust Fund was conducted. This policy read, Purpose: To hold, safeguard, manage, control and reconcile the personal needs funds deposited with the facility by the residents, as authorized, in a manner and in compliance with all laws and regulations to provide the residents with accurate and timely information regarding their personal funds .B. Withdrawals .8. Withdrawals are not made from a resident trust funds account for items or services that are reimbursed by Medicare and/or Medicaid. On the morning of 1/11/23, the facility Administrator was made aware of the above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility documentation review, the facility staff failed to provide a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) to 2 Residents (Resident #109, 110) in a survey sample of 2 Residents reviewed for such notices. The findings included: On 1/4/23, the facility Administrator was asked to provide a listing of Residents who were discharged from Medicare Part A services. From this listing a sample was selected which consisted of Resident #109 and 110. The notices issued to these Residents were reviewed and revealed the following: 1. For Resident #109, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending. Resident #109 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. Review of the clinical record revealed that Resident #109 was readmitted to the facility on [DATE], for skilled care, Medicare part A services. When skilled services were scheduled to end on 12/25/22, the Resident remained in the facility. The facility staff issued a NOMNC (Notice of Medicare Non-Coverage) form on 12/23/22. The facility staff failed to provide Resident #109 with the second required notice, a SNF ABN, which allows the resident an option to continue to receive services, be notified of the expected cost, and have Medicare make the coverage determination once a bill is submitted to Medicare. 2. For Resident #110, the facility staff failed to provide a SNF ABN notice prior to skilled care services ending, therefore eliminating the Resident's opportunity to have Medicare make the coverage determination. Review of the clinical record for Resident #110 revealed that the Resident was readmitted to the facility on [DATE], under skilled care/Medicare part A benefits. Skilled care ended on 12/23/22, and the Resident remained in the facility for long-term care. The facility staff issued Resident #110 a NOMNC on 12/21/22 but had no evidence that the SNF ABN was issued. 1/9/23 at 9:38 AM, an interview was conducted with Employee M, a facility social worker. Employee M was asked to explain the NOMNC and ABN forms and explain when they are issued. Employee M stated, The ABN is a waiver of liability. The provider gives it to let them know Medicare coverage rules. It lets them know where expenses will incur. Our policy is that we issue it 2 days prior that way if they appeal, they can do that. The social work department issues the notices, but the business office tells us which form to provide. The facility policy titled, Non-coverage and Advanced Beneficiary Notices Policy was reviewed. It read, .4) SNFABN (Part A Traditional Medicare only). a) Regulations mandate that Medicare Part A beneficiaries be notified in advance when the Skilled Nursing Facility (SNF) makes a determination that the SNF stay may not be covered by Medicare. b) This usually happens on two occasions, either upon admission, or at the end of a Medicare covered stay. c) The SNFABN is based on not meeting the skilled level of care criteria. d) The SNFABN is not REQUIRED (but recommended) if noncoverage is related to a technical denial (no 3-day hospital stay, no benefits available). e) The facility will issue the SNFABN prior to Medicare A services ending to inform them that there will potentially be a cost incurred to the resident as a result of the Med A coverage ending. i) Typically, the facility will make every effort to issue this notice at the same time as the NOMNC . CMS gives the following guidance to skilled nursing facilities regarding ABN notices in the Medicare Claims Processing Manual Chapter 30 - Financial Liability Protections. An excerpt from Page 72 read, .70.2 - Situations in Which a SNF ABN Should Be Given .In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services . Accessed online at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c30.pdf On 1/11/23 at approximately 9 AM, the facility administrator was made aware of the above findings. No further information was provided.

Based on observation, staff interview and facility documentation review, the facility staff failed to provide a clean and homelike environment for two Residents (Resident #103, 1111) in a survey sample of 33 Residents. The findings included: 1. For Resident #103 the facility staff failed to provide a clean and homelike environment as evidenced by a significant amount of splatters and drips of a tan colored substance on the wall behind the head of the bed. On 1/5/23 at 2:23 PM, Surveyor C made observations of Resident #103's room. The wall behind the head of the bed had a tan colored substance splattered all over the wall with drips running from the over bed light to the baseboard. The splattered substance was on a photo that was hanging on the wall over the Resident's head of the bed. There was a tube feeding pole that had the same-colored substance with drips on the entire length of the pole. Resident #103 was non-verbal and unable to be interviewed about the findings or with regards to the cleaning frequency of her room. On 1/6/23 at approximately 11:40 AM, an additional observation was made of Resident #103's room with the same findings noted. On the afternoon of 1/9/23, Surveyor G made observations of the same in Resident #103's room. On 1/9/23 at 9:47 AM, an interview was conducted with Employee L, the housekeeping supervisor. The housekeeping supervisor described the facility housekeeping process to be that Resident rooms are checked three times daily. Employee L said, in the morning they prepare their carts, go to every Resident room and get trash and sweep the floor. After breakfast, we start a full cleaning of every room. He described this process to be, cleaning the floor, sweeping and mopping, wiping down all surfaces, and cleaning the bathroom. Employee L then went on to say, After lunch we go back to every Resident room and sweep, mop and clean the room again. When asked about cleaning of the entire room and walls, the housekeeping supervisor said, We call that a terminal clean, we do 5 rooms a day, so that all rooms are done monthly. On 1/10/23 at 9:30 AM, a video call was held with the facility Administrator. The Administrator was made aware of the observations. The Administrator stated that Resident #103's room had been brought to her attention that morning and had been cleaned. The Administrator went to the room and showed Surveyor C that it had been cleaned. The Administrator confirmed the Surveyor's prior observations and stated she was very upset when she saw the condition of the room prior to the cleaning. Review of the Terminal Cleaning Schedule provided by the facility staff revealed that Resident #103's room was scheduled for a terminal cleaning on 11/4/22, 12/8/22, 1/5/23. The facility policy titled Occupied Patient/Resident Room Cleaning was reviewed. This policy read, .5. Disinfecting: Beginning at the door, using a germicide-soaked microfiber cloth, disinfect all touch points and areas that have a high probability of carrying infections including: doorknobs, edges of furniture, bed rails, the phone, nurse call button, needle box, and sink by the patient/resident, not in the bathroom. Work in a single direction around the room to ensure that no key areas are missed. Fold your cloth using a clean surface as needed . On 1/11/23 at 9:00 AM, the facility administrator was made aware of the above findings. No further information was provided. 2. For Resident #1111, the facility staff failed to provide a homelike environment as evidenced by missing sections of wallpaper and peeling wallpaper in the Resident's bathroom. On 1/5/23 at 2:20 PM, observations were made of Resident #1111's bathroom. The observation revealed there was a large section of wallpaper missing below the paper towel dispenser. The missing area measured approximately 6 inches long and approximately 16 inches wide. Additionally, there was a significant amount of wallpaper throughout the bathroom which was peeling and was not adhered to the wall. On 1/6/23 at approximately 11:40 AM, observations revealed the same findings in Resident #1111's bathroom. Resident #1111 was interviewed and had no knowledge as to how long the bathroom had been in this condition. On 1/9/23 at 3:40 PM, Surveyor G observed the same findings in Resident #1111's bathroom, which included the missing wallpaper and peeling wallpaper. Review of the maintenance work orders from November 13, 2022, until the time of survey revealed no listing of Resident #1111's room being communicated to maintenance. On 1/10/23 at 9:40 AM, during a video call with the facility Administrator, the Administrator was made aware of the observations. The Administrator went to Resident #1111's room and confirmed the findings. No further information was provided prior to the conclusion of the survey. Complaint related deficiency.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to provide evidence of an investigation being conducted when an allegation of misappropriation was reported for 1 Resident (Resident #147) in a survey sample of 33 Residents. The finding included: On 1/5/23 at 2:03 PM, Resident #147 was visited in his room. Resident #147 was in bed resting and when asked about a check that had been left at the facility for payment that went missing the Resident's response was non-sensical. The Resident interview was not continued as there was noted confusion. On 1/6/23 at 11:14 AM, an interview was conducted with the spouse of Resident #147. The spouse stated that she had dropped off a check to the facility to pay for her husband's care at the facility and the check got lost. She reported she went to her bank and stopped payment on the check. She reports she notified the facility administration of this. On 1/6/23, the facility Administrator provided the survey team with an investigation file that contained some documents with regards to the above allegation. The file contained a copy of the stop payment request that the spouse of Resident #147 initiated at her bank. There was also a document dated 11/11/22, where the facility Administrator reported this allegation to the state survey agency and law enforcement. There was no supporting evidence that a thorough investigation had been conducted. On the afternoon of 1/6/23, the facility Administrator was given the investigation file back and asked to provide Surveyor C with a copy of the documents. The Administrator was made aware that evidence of the investigation was missing. On 1/9/23, the facility Administrator provided 2 written statements from facility staff that were dated 1/5/23. Review of the facility abuse policy revealed the following statement, .V. Investigation of Incidents. 1. In the event a situation is identified as abuse, neglect or misappropriation, an investigation by the executive leadership will immediately follow. This policy went on to read, 2. A suspected abuse. a. Neglect or Misappropriation Investigation report will be initiated by the Director of Nursing or designee. b. Initial findings will be reported to the Executive Director, the physician (except in case of misappropriation of funds/property) and the resident representative d. Statements will be obtained from staff related to the incident, including victim, person reporting incident, accused perpetrator and witnesses. This statement should be in writing, signed, and dated at the time it is written .e. Statements should include the following: i. First-hand knowledge of the incident. ii. A description of what was witnessed, seen, or heard. f. Findings/conclusion of the investigation are then reported to the physician and Resident representative and documented on the investigation form. g. By the fifth day, the alleged abuse investigation form is completed and reviewed for completeness and accuracy by the Executive Director or designee and submitted to the state. h. Investigation files are kept in a confidential file located in the Executive Director's office. i. This file will be accessible for follow-up and state or local police review of the investigation. On 1/11/23, the facility Administrator was made aware of the lack of evidence of an investigation being conducted. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility failed to issue a written bed hold notice for 1 resident (Resident # 109) of 33 residents in the survey sample. Findings included: For Resident # 109, there was no Bed Hold Authorization form at discharge on [DATE]. Resident # 109 was discharged from the facility on 12/21/2022. Review of the electronic clinical record was conducted 1/10/2023-1/11/2023. Review of the miscellaneous forms revealed no documentation of a Bed Hold Authorization Form Thorough review of the clinical record revealed no Bed Hold Authorization Form. Resident # 109 was readmitted to the facility on [DATE]. On 1/10/2023 at 12:30 p.m., an interview was conducted with the Social Services Director (Employee K) who stated written Bed Hold Authorization Forms should be completed at the time of discharge. Employee K stated her Assistant (Employee M) had a access to Bed Holds from December. Employee M was asked to show the surveyors the signed Bed Hold Authorization Form. During the end of day debriefing on 1/10/2023, the Administrator stated we have it. I will give it to you. The Administrator did not present a copy of a Bed Hold Authorization Form for Resident # 109. During the end of day debriefing on 1/11/2023, the facility Administrator, Director of Nursing, and Regional Nurse Consultant were informed of the findings. The Administrator and Regional Nurse stated the Bed Hold forms should be completed at the time of discharge. No further information was provided.

Based on interview, clinical record review, facility documentation and in the course of a complaint investigation, the facility staff failed to review and revise care plans for 2 Residents (#168 & 102 ) in a survey sample of 33 Residents. The findings included: 1. For Resident #168 the facility staff failed to revise and update the care plan to reflect psychiatrist recommendations during IDT (Inter-Disciplinary Team) meeting. A Social Services note read: 12/8/22 5:52 PM - Resident was agreeable with the psychiatrist recommendation smiling and thanking him for the suggestion of weekly IDT meeting. On 1/5/22 during clinical record review it was found that the behavior section of the care plan for Resident # 168 did not mention weekly IDT meetings. On 1/9/23 during the end of day meeting the Administrator was asked if the outcomes of care plan meetings are used in updating the care plans and she stated that they were. When asked about the meeting on 12/8/22 she stated that was not a care plan meeting it was an Interdisciplinary Meeting that the psychiatrist requested. The Administrator was asked if the care plan should be updated if a physician makes a recommendation as to the care of modality of treatment. She stated that it should. When asked if the care plan was updated after that meeting the clinical consultant stated that it was not a care plan meeting and no recommendations were made. When asked if they had read the notes of the social worker she indicated that she had not. On 1/10/23 at approximately 2:50 PM an interview was conducted with the DON who stated that IDT meetings are usually conducted in the patient rooms. She stated that the patients and the family or RP are notified and told of who will attend. She was asked about the meeting on 12/8/22 and stated that it was an IDT meeting the psychiatrist (Employee ) had called the meeting. She stated that it was about how the facility could meet the Resident needs so that he would not continue to phone police or state. When asked if the care plan should be updated with new treatments or physician recommendations she stated that it should. When asked if the care plan was updated after the IDT meeting on 12/8/22 she stated that it wasn't because there was no new recommendations. The DON was shown the Social Services note read: 12/8/22 5:52 PM - Resident was agreeable with the psychiatrist recommendation smiling and thanking him for the suggestion of weekly IDT meeting. She was then asked if the care plan should have been updated to include the weekly IDT meetings and she stated that it should have been. A review of the facility care plan policy read: Page 1 Procedure 1. C c. Resident / representative will have the right to participate in the development and implementation of his/her own POC [plan of care] including but not limited to: i. Right to request meeting ii. Right to identify individuals or roles to be included in the planning process. On 1/11/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #102, the facility staff failed to revise the comprehensive care plan to include interventions for episodes of hypotension. Review of Resident # 102's closed electronic clinical record was conducted on 01/04/2023-01/06/2023 and 01/09/2023-01/11/2023. Review of the progress notes revealed a note written on 8/19/22 regarding episodes of hypotension with physician's orders given to hold Amlodipine, check blood pressures every shift . Resident #102's care plan was reviewed and revealed none of the physician recommendations from 8-19-22 were placed on the care plan to guide treatment. At the end of day meeting on 1/10/23, the Administrator, and DON were notified of the concerns regarding the lack of implementing revisions to the careplan to address the management of hypotension. They were asked if it was the facility's policy to review and revise care plans and both agreed it was their policy to do so. During the end of day debriefing on 1/11/2023, the corporate nurse stated the changes in the care plan to reflect hypotension did not exist. No further information was provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility physician staff failed to complete a discharge summary to include recapitulation of stay for 1 resident (Resident #101) in the survey sample of 33 residents. The findings included: For Resident #101, the facility staff failed to complete a recapitulation (discharge summary) of care, upon discharge from the facility. Resident #101 was discharged home on [DATE]. The Resident's closed record was reviewed on 1-4-23. No discharge summary, nor recapitulation of stay was included in the closed record. There was a discharge assessment by an Licensed Practical Nurse in the facility, however, no recapitulation of stay from the doctor. The Administrator and Director of Nursing (DON) were notified of the missing discharge summary at the end of day meeting on 1-9-23. On 1-11-23 at 1:30 p.m. the Administrator stated that they could not locate a discharge summary in the clinical record for Resident #101. No further information was provided by the facility.

Based on resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation the facility staff failed to provide services to maintain personal hygiene for 1 Resident (#101) in a survey sample of 33 Residents. The Findings included: For Resident #101, the Resident did not receive hygiene care on multiple days. Resident #101 had an admission minimum data set assessment which coded the Resident with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment. The Resident was coded as incontinent of bladder and bowel, and coded as requiring extensive to total dependence on staff for all activities of daily living, with the exception of eating and was able to feed herself. Resident #101 was discharged home. On 1-9-23 Resident #101 was interviewed and stated she had not received incontinence care frequently while in the facility. Resident #101's care plan was reviewed and revealed that the Resident was incontinent of bladder and bowel. The Resident's closed record point of Care certified nursing assistant documentation record for ADL care was reviewed on 1-4-23. No ADL (activities of daily living) hygiene care was documented as being provided for the Resident on the following days and shifts. 7a.m. to 3p.m. shift - 8-1-22, 9-16-22, 9-29-22, 10-10-22, and 11-11-22. 3p.m. to 11p.m. shift - 7-28-22, 7-29-22, 8-1-22, 8-18-22, 9-2-22, 9-5-22, 9-10-22, 9-11-22, 9-30-22, 10-5-22, 10-6-22, 10-9-22, 10-12-22, 10-28-22, 11-3-22, 11-6-22, and 11-11-22. 11p.m. to 7a.m. shift - 14 times in July 2022, 21 times in August 2022, 23 times in September 2022, 21 times in October 2022, 9 times in November 2022, On multiple occasions 2 shifts (16 hours) were skipped before the Resident was given hygiene care. On 1-6-23 The Director of Nursing was asked if the point of care documents should be signed correctly indicating care was given, and she stated if it's not documented, it's not done. The DON stated that the facility policy is to provide incontinence care hygiene when getting out of bed, or waking in the morning, before and after meals, before bed time, and whenever residents are soiled. The Administrator and Director of Nursing (DON) were notified of the missing documentation and the complaint allegation, at the end of day meeting on 1-10-23. No further information was provided by the facility. Complaint deficiency.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents are free from accidents and hazards for 1 Resident ( #131) in a survey sample of 33 Residents. The findings included: 1. For Resident #131 the facility staff failed to ensure the mechanical lift was properly secured and that all of the pieces of the equipment were present and in working order. On 1/6/22 at 10:30 AM Surveyor C went to Resident #131's room and did not find her in the room. She observed a mechanical lift was positioned over the bed on closer inspection the lift was found to be missing one of the safety clips that prevents the sling from backing off of the hook during lifting. Surveyor C stepped in the hall and conducted an interview with CNA D who stated that she just gotten Resident #131 out of bed and into her wheelchair. Surveyor C inquired about the transfer and CNA D stated she used the mechanical lift located in Resident #131's room. She stated that another CNA assisted her with the lift. Surveyor C & D then went to the room of Resident #116 and observed CNA E and F using the mechanical lift. When asked what the clip on the hook was for the CNA stated it was so that the sling doesn't back up and slip off the hook during transfer. When asked if it was ok to use the lift with the clip missing CNA E stated that the slings never back up its safe to use. Surveyors C & D then inspected a total of three (3) mechanical lifts. Of the three lifts inspected, one of them had one (1) clip missing and the other had two (2) clips missing the third lift was intact. A review of the mechanical lift manual provided to surveyors by the facility read: Before lifting the patient, perform safety check: Examine all hooks and fasteners to ensure they will not unhook during use. Double-check position and stability of straps and other equipment before lifting patient. Ensure clips, latches and bars are securely fastened and structurally sound. On 1/6/23 at approximately 4:00 PM the Administrator was interviewed and the concern with the lifts was explained and she stated that the staff should not be using any equipment that is not fully operational and in good repair. She stated that she was going to pull the lifts from use until they are repaired. On 1/6/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility record review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure 1 Resident was free from unnecessary medications (Resident #101) in a survey sample of 33 Residents. The findings included: Resident #101 received Atenolol anti-hypertensive medication, Dexamethasone anti-inflammatory steroid medication, and Metronidazole antibiotic medication against physician ordered parameters. Resident #101 was admitted to the facility on [DATE]. Diagnoses included but were not limited to; hypertension. Resident #101's most recent Minimum Data Set assessment (a federal assessment protocol) was a discharge assessment dated [DATE]. Review of the physician's orders and Medication Administration Record (MAR), in the clinical record, revealed the following; 1. Ordered 7-10-22 - Atenolol for high blood pressure - 100 MG (milligrams) in the morning, hold for systolic blood pressure (SBP) less than 110. The Atenolol unnecessary medication was given on the following days; On 7-22-22 with an SBP of 105, On 8-10-22 SBP of 104, On 8-14-22 SBP of 100, On 8-28-22 SBP of 102, On 10-29-22 SBP of 101. 2. Ordered 7-11-22 - Dexamethasone for diverticulitis inflammation - 1 MG in the morning for 3 days. However, the Dexamethasone medication was given for 7 days. 3. Ordered 7-10-22 - Metronidazole antibiotic for diverticulosis - 500 MG once per day, and the next day on 7-11-22 the order changed to - Metronidazole antibiotic for diverticulitis - 500 MG every 8 hours (3 times per day) for 7 days. There were 2 extra does of Metronidazole given. On 1-10-23 an interview was conducted with LPN D who stated about the Atenolol medications being administered unnecessarily, she stated we don't want to give Antihypertensives outside of parameters because we don't want them to bottom out. (become Hypotension), and antibiotics and steroids should only be given for a short time and per orders. The facility policy for Medication Administration was reviewed, and documented that medications must be given according to the physician's orders. On 1-10-23 at 12:00 p.m., the Administrator and Director of Nursing (DON) were made aware of the findings. At the time of exit the DON stated there was no further information available to submit to surveyors. Complaint Deficiency

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility record review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure 1 Resident was free from significant medication errors (Resident #101) in a survey sample of 33 Residents. The findings included: Resident #101 received Atenolol anti-hypertensive medication, Dexamethasone anti-inflammatory steroid medication, and Metronidazole antibiotic medication outside of physician ordered parameters. Resident #101 was admitted to the facility on [DATE]. Diagnoses included but were not limited to; diverticulosis, sciatica, spinal stenosis, stroke, hypertension, type 2 diabetes, and morbid obesity. Resident #101's most recent Minimum Data Set assessment (a federal assessment protocol) was a discharge assessment dated [DATE]. The document denoted the Resident as fully cognitively intact, no mood or behavior disorders, and requiring extensive assistance with dressing toileting and hygiene. Review of the physician's orders and Medication Administration Record (MAR), in the clinical record, revealed the following 3 significant medication errors; 1. Ordered 7-10-22 - Atenolol for high blood pressure - 100 MG (milligrams) in the morning, hold for systolic blood pressure (SBP) less than 110. The Atenolol was given on the following days when it was not supposed to be given; On 7-22-22 with an SBP of 105, On 8-10-22 SBP of 104, On 8-14-22 SBP of 100, On 8-28-22 SBP of 102, On 10-29-22 SBP of 101. 2. Ordered 7-11-22 - Dexamethasone for diverticulitis inflammation - 1 MG in the morning for 3 days. However, the Dexamethasone was given for 7 days. 3. Ordered 7-10-22 - Metronidazole antibiotic for diverticulosis - 500 MG once per day, and the next day on 7-11-22 the order changed to - Metronidazole antibiotic for diverticulitis - 500 MG every 8 hours (3 times per day) for 7 days. The Metronidazole was given an 2 extra doses. On 1-10-23 an interview was conducted with LPN D who stated about the Atenolol medications being administered unnecessarily, she stated we don't want to give Antihypertensives outside of parameters because we don't want them to bottom out. (become hypotensive), and antibiotics and steroids should only be given for a short time and per orders. The facility policy for Medication Administration was reviewed, and documented that medications must be given according to the physician's orders. On 1-10-23 at 12:00 p.m., the Administrator and Director of Nursing (DON) were made aware of the findings. At the time of exit the DON stated there was no further information available to submit to surveyors. Complaint Deficiency

Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to provide rehab services as ordered to one Resident (Resident #103) in a survey sample of 33 Residents. The findings included: On 1/5/23 at 2:23 PM, Resident #103 was observed in bed. Resident #103 was noted to be non-verbal and not able to be interviewed. Resident #103 was noted to have bilateral hand contractures with splints/palm protectors on both hands. Review of the clinical record revealed a current and active physician order dated 12/13/22, that read, Skilled OT [occupational therapy] indicated 3x/wk. x 4wks for self-care training, therapeutic activities, therapeutic exercises, neuromuscular re-education, manual techniques, and orthotic management. Review of the care plan for Resident #103 revealed the following focus areas, [Resident name redacted] ADL [activities of daily living] Self Care Performance deficit, requires assistance with ADL Cognitive deficit, Disease Process, Functional Deficit. BL [bilateral/both] Hand Splints to be worn as tolerated and one that read, [Resident #103's name redacted] has rehab oriented nursing program as related to physical limitations identified in therapy R/T [related to] acute respiratory failure, COPD, CVA. Review of the nursing notes revealed that Resident #103 was readmitted to this facility following a hospitalization on 12/12/22 at 10:05 PM. On 12/13/22, a wound nurse practitioner saw the Resident and noted the following in the progress note: .Chief Complaint: Comprehensive skin and wound evaluation for readmission to facility for Multiple DTI [deep tissue injuries] to fingers of both hands . Musculoskeletal - Patient has decreased ROM. Patient has contractures. Dermatologic - Wound(s)present; Please see wound assessment below. Wounds - Hands are contracted. Fingernails are long. Not wearing hand braces. DTI [deep tissue injury] with scabbing to bilateral hands/fingers .PLAN OF CARE: Wound plan of care: Stressed importance of needing nails cut short and file sharp edges. Need to obtain patient's hand braces and needs to wear them per OT recommendation . There were additional notes within the chart dated 12/13/22, that indicated wounds/skin impairments. The areas included but were not limited to: Right thumb, right third finger, left third finger, right inner thumb, right fourth finger, right fifth finger. The listing of Resident's currently on therapy case load was reviewed and Resident #103 was not noted to be listed as being on active therapy caseload. On 1/4/23 at 3:42 PM, an interview was conducted with Employee C, the therapy director. Employee C accessed Resident #103's electronic chart and confirmed the active physician order for occupational therapy services. Employee C stated, She is on hospice now so it wasn't dc 'ed [discontinued] and it should have been. Employee C went on to say, My OT put the order in, we had planned to pick her up and she came in with orders, so we did the evaluation. Employee O, the evaluating occupational therapist/OTR then came to talk with Surveyor C. The OTR confirmed that she had evaluated Resident #103 upon her readmission. The OTR went on to say that she felt therapy services were necessary to help with the contractures in her hands to maintain skin integrity and hygiene of her hands and for splints. She said that she had initially ordered for therapy services three times per week for four weeks. However, after her evaluation she, the OTR, learned that Resident #103 had went on hospice care and so she revised the evaluation to indicate it was an evaluation only with no treatment but had not discontinued the order. During the above interview with the therapy manager and OTR, the manager confirmed that while it is not a common occurrence there are times that a Resident can and does receive therapy services while under hospice care. The OTR said she had not experienced this in her tenure as a therapist. When asked if the need for therapy was discussed with hospice to see if they would agree to and permit therapy to continue both confirmed that this had not been discussed as an option and was not initiated. Review of the OT evaluation and Plan of Treatment with a start of care date of 12/13/22, was conducted. This document noted: Caregiver goals: improve condition of B [bilateral] hands. Potential for achieving goals: fair due to previous success with B orthotics . Reason for Referral: Patient is a 72 y/o [year old] F [female] resident of this LTC [long term care] referred to skilled OT eval following hospitalization for UTI and hypernatremia . Page 4 of the above referenced document read, Clinical Impressions: Current Value changed from Patient currently positioned well in semi-Fowler's with B offloading boots. Because of significant ulnar deviation of R D2, patient with moist skin and re-design of the palm protector to include finger spacing/more appropriate fit warranted, L palm protector to be changed accordingly as well. Nursing has voiced concern for skin breakdown and contracture; however, flexor tone is very tight; this paired with lack of consistent hand hygiene has resulted in skin softening, redness, and unpleasant smell. Skilled OT indicated to re-address current splints in place. to: Patient with previous success with placement of B palm protectors, soft type (Rolyan Palm Shield for severe hand tightness) which took multiple visits and collaboration with nursing due to severity. Patient is s/p [status post] hospitalization with B orthotics removed and B hands with 2+ edema and back into flexor tone. Skilled OT indicated to re-address current splints in place and ensure proper fit to maintain gains made by previous therapy included: decreased moisture, healed wounds, decreased skin-to-skin contact, and increased PROM [passive range of motion] for adequate hand hygiene. On 1/4/23 at 4:01 PM, the therapy manager provided Surveyor C with a copy of the physician order that discontinued to OT evaluation. When the therapy manager was asked to explain the document she stated, They dc 'ed the evaluation only order but didn't discontinue the other one. On 1/9/23 at 1:40 PM, a follow-up interview was conducted with Employee C, the therapy director and Employee O, the OTR. They stated that the benefits of therapy services for a resident like Resident #103 with hand contractures is to decrease the risk of infection, sores on the fingers, pressure sores between the fingers, and to maintain skin integrity. Additionally, to improve quality of life by decreasing pain and improve hand hygiene. Prior to hospitalization she [Resident #103 was on case load, when she came back, I wanted to schedule to continue to make sure the splints were appropriate, and I spent a lot of time placing the splints slowing to prevent pain. My focus was also to decrease the overgrowth of bacteria in her hands due to the moisture. The facility policy titled Order Guidelines was reviewed. This policy read, .Clarification Orders: Clarification orders are to be written on the same day the evaluation is completed. The evaluating therapist is responsible for writing the clarification order. Clarification orders should contain the following: Discipline type, frequency, duration- must match the certification period of the evaluation, which is typically 30 days, therapy services- treatments listed must match the CPT [billing codes] codes listed on the evaluation . On the morning of 1/11/23, the facility Administrator was made aware of the above noted concern. No additional information was provided.

Based on observation, resident interview, staff interview and facility documentation review, the facility staff failed to maintain a sanitary and comfortable environment for 1 Resident (Resident #1111) in a survey sample of 33 Residents. The findings included: On 1/5/23 at 2:20 PM, observations were made of Resident #1111's bathroom. The observation revealed there was a brown substance on the wall that appeared to be feces. There was also a copious amount of a brown substance on the floor of the bathroom, that appeared to be feces as well. On 1/6/23 at approximately 11:40 AM, observations revealed the same findings in Resident #1111's bathroom. Resident #1111 was interviewed and had no knowledge as to how long the substance had been in the bathroom. On 1/9/23 at 9:47 AM, an interview was conducted with Employee L, the housekeeping supervisor. The housekeeping supervisor during interview described the facility housekeeping process to be that Resident rooms are checked three times daily. Employee L said, in the morning they prepare their carts, go to every Resident room and get trash and sweep the floor. After breakfast, we start a full cleaning of every room. He described this process to be, cleaning the floor, sweeping and mopping, wiping down all surfaces, and cleaning the bathroom. Employee L then went on to say, After lunch we go back to every Resident room and sweep, mop and clean the room again. When asked about cleaning of the entire room and walls, the housekeeping supervisor said, We call that a terminal clean, we do 5 rooms a day, so that all rooms are done monthly. On 1/9/23 at 3:40 PM, Surveyor G observed the same findings in Resident #1111's bathroom, which included the brown substance on the wall and on the floor. On 1/10/23 at 9:30 AM, a video call was held with the facility Administrator. The Administrator was made aware of the observations. The Administrator then went to Resident #1111's room and observed the bathroom and confirmed the brown substance was present. The Administrator stated that she would have this cleaned immediately. On 1/10/23, during mid-late morning the facility Administrator notified the survey team that Resident #1111's bathroom had been cleaned. Review of the Terminal Cleaning Schedule provided by the facility staff revealed that Resident #1111's room was scheduled for a terminal cleaning on 1/4/23. The facility provided a policy titled, Restroom Cleaning. This policy read, .6. Check the wall for spots and clean if necessary . The facility policy titled, Occupied Patient/Resident Room Cleaning- Individual Cleaning, was reviewed. This policy stated, .6. Restroom disinfecting: Return to the room with germicide-soaked microfiber cloths. Disinfect all fixtures in the restroom, paying special attention to soap dispensers, underneath the sink, and grab rails. Clean the toilet last 10. Use a microfiber mop from your charging bucket on the cart, soaked in stride neutral cleaner, to damp mop the patient room floor .Include the restroom when mopping the floor. No further information was provided prior to the conclusion of the survey. Complaint related deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #116, the facility allowed disclosure of PPI, and PHI by way of access to the electronic clinical record. During the survey, Resident #116's clinical record was reviewed. There were three progress notes (05/26/2020, 06/02/2020, and 06/09/2020) written by Employee G, an alleged physiatrist (in sports medicine) who was not in contract with the facility to provide services. All three progress notes were written as late entries over two months after the dates of service. All three progress notes were identical and included the following excerpt: Patient is in therapies working towards functional goals as noted in the functional status updates in the chart. Plan is to continue intensive skilled nursing rehabilitation including PT/OT [Physical Therapy/Occupational Therapy] and if needed SLP [Speech Language Pathology] to work toward functional goals which include improvement in mobility, ADLs [Activities of Daily Living], transfers, cognition, safety awareness, balance, selfcare, and hygiene. Continue 5-6 days a week of therapy to achieve the above-mentioned goals. A review of the physician orders revealed that there were no therapy orders nor a physiatry consult in 2020. On 01/11/2023 at 4:20 P.M., the Therapy Manager was interviewed. The Therapy Manager verified that Resident #116 did not receive any therapy services in 2020. On 01/11/2023 at approximately 4:45 P.M., the Administrator was notified of findings. The Administrator stated she would be launching a formal investigation into the matter. 3. For Resident #188 the facility staff failed to ensure privacy of Protected Health and Protected Private Information For Resident #188 the facility staff failed to ensure privacy of Protected Health and Protected Private Information by physiatrist, who did not have contract, or agreement with the facility or rehab department and who was not referred by the medical director or Nurse practitioner working under him. Resident #188 was not available for interview as he was out of the facility. On 1/11/23 during clinical record review it was discovered that Employee G (a physiatrist) had entered progress notes in the Residents chart including the time period when the Resident was not receiving therapy. Many of the physiatrist notes were identical as if copied and pasted to include typos. The notes do not reflect any services provided by the physiatrist they only give history and physical as input by the medical director and list of diagnoses the notes do not reflect any changes in patient status, any recommendations for patient care or therapy modalities. All progress notes placed in the system were at minimum 1 month after the alleged visit and maximum 2 1/2 months after the alleged visit. All of the notes from 9/24/22 - 10/7/2 (4 in total) were while this Resident was not receiving therapy. On 1/11/23 at approximately 3:00 PM an interview was conducted with employee C (Physical Therapy Manager) who stated that she did not know who this doctor was and she had asked around in the department and no one was aware of him working with therapy patients. On 1/11/23 at approximately 4:30 PM an interview was conducted with the Administrator who stated that she was not aware of the physiatrist but stated that she had suspended services in the building and had spoken to the medical director about him. She stated that some of the nurses recall him but said They have not seen him lately. When asked if the facility has a contract with this physiatrist or if the medical director has consulted him to see residents she stated that he had not. On 1/11/23 at approximately 2:00 PM an interview was conducted with the business office manager who stated that she does not bill for the physiatrist she bills for in house therapy providers. On 1/11/23 during the end of day meeting the Administrator was made aware of the concerns and she stated that she was going to launch a formal investigation. The Administrator then submitted a copy of the document she sent to the state agency reporting the investigation of the physiatrist. No further information was provided. 2. For Resident #102, the facility failed to protect the resident's right to privacy and confidentiality of personal, health and medical records. For Resident #102, the facility failed to protect the resident's right to privacy and confidentiality of personal, health and medical records. The facility allowed access of PPI (Protected Personal Information) and PHI (Protected Health Information) through the electronic clinical record Resident # 102 most recent Minimum Data Set (MDS) was an admission assessment with an Assessment Reference Date (ARD) of 7/13/2022. The MDS coded Resident # 102 with a BIMS (Brief Interview for Mental Status) Score of 14 out of 15 indicating no cognitive impairment. Review of the closed electronic clinical record was conducted on 01/04/2023-01/06/2023 and 01/09/2023-01/11/2023. Thorough review revealed no Physician's Order for a Rehab Consultation by the Physiatrist. The dates of the alleged Physiatrist encounters and the dates the note were created were documented as follows: 7/12/2022 15:01:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/15/2022 13:02:24 7/14/2022 15:05:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/17/2022 13:05:26 7/16/2022 15:29:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/19/2022 13:30:12 7/21/2022 15:39:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/24/2022 13:39:53 7/23/2022 15:01:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/26/2022 14:02:11 7/26/2022 15:15:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/29/2022 13:15:27 7/28/2022 15:14:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 8/31/2022 13:14:15 7/30/2022 15:23:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/2/2022 09:23:53 8/2/2022 15:21:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/5/2022 15:21:16 8/4/2022 16:31:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/7/2022 16:31:38 8/6/2022 14:20:00 Department: Physician Position: Physician Created By: (name redacted)Created Date : 9/9/2022 14:20:25 8/9/2022 15:01:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/12/2022 12:01:46 8/11/2022 15:49:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/14/2022 12:49:14 8/13/2022 15:19:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/16/2022 13:19:18 8/18/2022 15:26:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/21/2022 12:26:22 8/20/2022 15:22:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/23/2022 12:23:03 8/23/2022 15:16:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/26/2022 15:17:00 8/25/2022 15:55:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/28/2022 15:55:34 8/27/2022 17:11:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 9/30/2022 17:11:32 8/30/2022 15:59:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 10/3/2022 07:00:15 9/1/2022 13:39:00 Department: Physician Position: Physician Created By: (name redacted) Created Date : 10/5/2022 13:40:05 9/3/2022 14:19:00 Department: Physician Position: Physician Created By: (name redacted)Created Date : 10/7/2022 14:19:27 Review of the Progress notes revealed the notes appeared to be essentially the same verbiage during every encounter. The Assessment and Plan section addressed 8 areas. All of the notes had the narratives written in the 8 areas. On 1/5/2023 at 4:01 p.m., an interview was conducted with Resident #102's family member who stated she visited Resident # 102 daily and stayed for all waking hours for weeks. The family member stated she did not see a Rehab doctor visit Resident # 102. Interviews by another surveyor with another alert resident (with a BIMS score of 15/15 indicating no cognitive impairment) in the survey sample revealed that particular Resident stated she had never met the Physiatrist, never consented to receive services from the Physiatrist and was certain to not have ever heard that name (when asked about the name of the Physiatrist). The interviews with the therapy department continued throughout the course of the survey from 1-4-23 through 1-11-23. Both employees C, and F, stated that no one in the Rehab department knew the alleged physiatrist. They also stated they never met the Physiatrist and were unaware if [Physiatrist] is a woman or a man. Employees C and F stated that the therapy department (Rehab) did not have any contract nor any business agreement with the Physiatrist, nor was the Physiatrist consulted by them to see the Residents on their case load. They stated that the rehabilitation department (Rehab) did not bill the residents for the Physiatrist alleged visits. They stated the Physiatrist would not have been needed as the medical doctor saw the residents for their medical needs and for orders to be issued for therapy, then they treated the residents. Employee C and Employee F stated that the operating standard for therapy was for the Medical Doctor to give the order for OT, PT, and Speech Therapy (ST), to evaluate the Residents first, then make recommendations to the doctor for treatment needs. After the doctor received the evaluations, the doctor would issue therapy orders, and finally, they as therapists would follow the doctor's orders to treat the residents, document and report to the doctor the Residents progress, or lack thereof. Licensed Practical Nurses (LPN) B unit 2, and (LPN) D unit 1 manager, were interviewed and stated they had not seen, and did not know the Physiatrist. Progress notes were reviewed and revealed that the Physiatrist had documented in the clinical record as type of note Rehab progress note. The physiatrist documented 22 notes stating he was providing Physiatry follow up and seeing the Resident approximately every two days, with weekends off. The notes revealed that all of them were late entry notes and were placed in the medical record 4-5 weeks after alleging to have seen the Resident. The notes would not have been available to the physician nor the rehab department for 4-5 weeks which made them unnecessary to the facility for use in care of the Resident. The notes were all essentially identical as though they were copied and pasted into the record with only 1 or 2 words changed of no significance to findings. All of the notes indicated that the physiatrist documented the visits had occurred during daytime business hours. According to the Physical Therapy records, Resident # 102 was discharged from therapy on 9/2/20222. The last note from the Physiatrist on 9/3/22 was put into the clinical record by the physiatrist on 10/16/22, (over 5 weeks late) and 6 weeks after the Resident was discharged on 9-4-22. There were a total of 14 late entry notes entered into the clinical record by the Physiatrist after Resident # 102 was discharged . On 1/9/23 at 11:00 a.m., the survey team conducted interviews with the Administrator and Director of Nursing (DON) who both stated the physiatrist was unknown to them, and they had no contract with him to provide services in the facility. They stated they would check with their corporate office and get back to surveyors if one could be found. Further, they could not say if he was an MD (medical doctor), DO (Doctor of Osteopathic Medicine) or a PHD (Doctor of Philosophy.) The Administrator stated she would check and let the survey team know the next day On 1/9/23 at 4:00 p.m., the Administrator stated there was no corporate contract with the physiatrist, and that the facility did not bill for him. The Administrator had no contact information for the physiatrist, and she was not aware of how the physiatrist was able to access the clinical record. The Administrator stated she did not know the credentials of the individual and that she talked with the Medical Director who stated he knew him and that he was a Physiatrist. She stated the medical director and he said he would call and talk to the physiatrist and tell him that he was revoked from the building, and was not to enter. The Administrator stated she deactivated him from seeing residents and was going to launch an investigation. The Administrator stated she asked the therapy staff if they knew the Physiatrist and they did not. The Administrator stated she did not know how this happened and how the Physiatrist was able to see so many residents. When asked exactly how many residents were being seen by the Physiatrist, the Administrator stated she did not know for sure but would check. The Administrator was informed that the Electronic Medical Record System had two specific tabs designated for documentation by this particular Physiatrist. One tab was for (Dr. name redacted) initial Rehab consultation and the other was for (Dr. name redacted) Rehab progress notes. The Administrator stated she did not know how it happened that this Physiatrist had access to electronic health records. On 1/10/23 at 10:00 a.m., the Administrator told surveyors that she had spoken to the physiatrist and notified him she was conducting an investigation into the matter and that state surveyors were conducting an investigating as well. Surveyors asked for the contact information of the physiatrist and she stated that she didn't have a number for him as he had contacted her and told her he had been coming there for more than 6 years. She stated his business office was in Florida and he billed through his own office. She further stated his office was listed as a Post Office box. The Administrator was notified at that time that online research had proven the Physiatrist had listed his business office as this facility, and at this facility address, and that he did bill insurances to include Medicare. Surveyors also notified her that his license to practice was only 5 years old. Policy and procedure was requested for a physiatry program, and the DON stated we don't have a physiatry program. Facility billing records were reviewed and revealed that no resident billing for this physiatrist had been conducted from this facility. During the end of day meeting on 1/10/23, the Administrator, and DON were made aware of the failure of staff to protect residents from access to their person and protected records. This was in regard to the potential for unsupervised visits in the private rooms of vulnerable Residents by a person who was unknown by staff, Residents, and Residents' responsible parties. Resident #102 was not afforded the right to privacy nor the right to deny the Physiatrist access to confidential personal and medical records. The protected health and private information was disclosed to the Physiatrist without Resident # 102's knowledge or consent. For Resident # 102, the facility failed to ensure protected health and protected private information. According to the facility staff including administrative staff, the facility had no business relationship with the physiatrist who was allowed to view the personal and protected information for every resident in the facility. On 1/11/23 at the end of day meeting at 5:00 p.m., the facility Administrator and DON were again notified by the survey team of the findings and they stated they had no further information to provide the survey team. Based on Resident interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to protect Resident's confidential records, to include Protected Health Information (PHI) and Protected Private Information (PPI), for 4 Residents (#101, 102, 188, and 116) in a survey sample of 33 Residents. The findings included; This access was given to an individual who was an alleged physiatrist (in sports medicine) who was not in contract with the facility to provide services. The individual was not in contract nor known by the Rehab Department for services, and not ordered to consult with the Residents by the physician. The individual was not known by the Residents nor their responsible parties, and had not received consent to this access the medical record from them. 1. For Resident #101, the facility allowed disclosure of PPI, and PHI, by way of access to the electronic clinical record. Resident #101's most recent Minimum Data Set assessment (a federal assessment protocol) was a discharge assessment dated [DATE]. The document denoted the Resident as fully cognitively intact. A review Resident #101's physician's orders in the clinical record, revealed Physical Therapy (PT), and Occupational Therapy (OT) orders but there were no orders for Physiatry consult. Resident #101 was interviewed via telephone on 1-9-23 and stated that she had never met, nor been seen by the alleged Physiatrist. Resident #101 further stated the medical doctor's name, the nurse practitioners name, the OT staff names, and the PT staff names, indicating she had seen all of them and could describe them. The Resident was oriented, and a good historian to include dates given during the interview. Research in the clinical record revealed that the Resident's account of her stay was exactly accurate. On 1-9-23 initially multiple interviews, with multiple surveyors present for each interview, were conducted with Employee C (Therapy manager), and Employee F (OT) in regard to the physiatrist specifically. The interviews with the therapy department continued throughout the course of the survey from 1-4-23 through 1-11-23. Both employees C, and F, stated that no one in the Rehab department knew the alleged physiatrist and further never met and am unaware if (name) is a woman or a man. Employees C and F stated that the therapy department (Rehab) did not have any contract nor any business agreement with the physiatrist, nor was the physiatrist consulted by them to see the Residents on their case load. They stated that the rehabilitation department (Rehab) did not bill the residents for the physiatrist alleged visits. They stated the physiatrist would not have been needed as the medical doctor saw the residents for their medical needs and for orders to be issued for therapy, then they treated the residents. Employee C, and F, stated that the operating standard for therapy was for OT, PT, and Speech Therapy (ST), to evaluate the Residents first, then make recommendations to the doctor for treatment needs. After the doctor received the evaluations, the doctor would issue therapy orders, and finally, they as therapists would follow the doctors orders to treat the residents, document and report to the doctor the Residents progress, or lack thereof. Licensed Practical Nurses (LPN) B unit 2, and (LPN) D unit 1 manager, were interviewed and stated they had not seen, and did not know the physiatrist. Progress notes were reviewed and revealed that the physiatrist had documented in the clinical record as type of note Rehab progress note. The physiatrist documented 40 notes stating he was providing Physiatry follow up and seeing the Resident approximately every two days, with weekends off, in a 124 day stay. The notes revealed that all of them were late entry notes and were placed in the medical record 4-5 weeks after alleging to have seen the Resident. The notes would not have been available to the physician nor the rehab department for 4-5 weeks which made them unnecessary to the facility for use in care of the Resident. The notes were all essentially identical as though they were copied and pasted into the record with only 1 or 2 words changed of no significance to findings. All of the notes indicated that the physiatrist documented the visits had occurred during daytime business hours. The National Institutes of Health define a physiatrist as Physical Medicine and Rehabilitation physicians. The Resident was discontinued from Physical Therapy on 9-28-22, as having plateaued and not a further candidate for therapy services, however, the physiatrist continued to write Rehab progress notes as having seen the Resident, on 9-29-22, 10-1-22, 10-4-22, 10-6-22, 10-8-22, and 10-11-22. The last note on 10-11-22 was put into the clinical record by the physiatrist on 11-16-22, (5 weeks late) and 2 days after the Resident was discharged . On 1-9-23 at 11:00 a.m., the Administrator and Director of Nursing (DON) were interviewed and stated the physiatrist was unknown to them, and they had no contract with him to provide services in the facility. They further stated they would check with corporate and get back to surveyors if one could be found. On 1-9-23 at 4:00 p.m., the Administrator stated there was no corporate contract with the physiatrist, and that the facility did not bill for him. She stated she had contacted the medical director and he said he would call and talk to the physiatrist and tell him that he was revoked from the building, and was not to enter. The Administrator had no contact information for the physiatrist, and she was not aware of how the physiatrist was able to access the clinical record. She stated that she was investigating. On 1-10-23 at 10:00 a.m., the Administrator told surveyors that she had spoken to the physiatrist and notified him she was conducting an investigation into the matter and that state surveyors were conducting an investigating as well. Surveyors asked for the contact information of the physiatrist and she stated that she didn't have a number for him as he had contacted her and told her he had been coming there for more than 6 years. She stated his business office was in Florida and he billed through his own office. She further stated his office was listed as a Post Office box. The Administrator was notified at that time that online search had proven he had listed his business office as this facility, and at this facility address, and that he did bill insurances to include Medicare. Policy and procedure was requested for a physiatry program, and the DON stated we don't have a physiatry program. Facility billing records were reviewed and revealed that no resident billing for this physiatrist had been conducted from this facility. At an end of day meeting on 1-10-23 the Administrator, and DON were made aware of the failure of staff to protect residents records. The alleged physiatrist accessed Resident protected private information (PPI), and protected health information (PHI) without Resident nor responsible party consent. On 1-11-23 at the end of day meeting at 5:00 p.m., the facility Administrator and DON were again notified by the survey team of the deficient practice, and they stated they had no further information to provide the survey team.

On 09/13/2022 at 9:30 A.M., Resident #90 was observed asleep in her bed with the head of the bed elevated approximately 60 degrees. Resident #90 had a plaid clothing protector on with food particles on it. The tray table with the breakfast tray was positioned over the bed and in front of Resident #90. All the food had been eaten off the plate. There was no staff in the room. At 9:36 A.M., Certified Nursing Assistant N (CNA N) entered Resident #90's room, took the tray off the tray table, exited the room, and placed the tray on the cart in the hall. CNA N then re-entered Resident #90's room, walked past Resident #90, and took the roommate's tray to the cart in the hall. CNA N then proceeded to the adjacent room and removed those breakfast trays. At 9:50 A.M., Resident #90 was observed still sleeping with the head of the bed elevated approximately 60 degrees, and the plaid clothing protector on with food particles on it. At 10:00 A.M., CNA N was interviewed. When asked about the process of assisting a Resident after mealtime, CNA N stated that afterwards, she would assist the resident to clean their face, hands, and mouth. When asked why Resident #90 still had a clothing protector on, CNA N stated that she should have taken it off after the meal. When asked why, CNA N stated it's for dignity and make sure she's clean. CNA N then entered Resident #90's room, observed Resident #90 with the clothing protector on, and left the room and headed down the hall stating she was going to get help so Resident #90 could be toileted. CNA N did not remove the clothing protector at that time. On 09/14/2022, Resident #90's clinical record was reviewed. Resident #90's quarterly Minimum Data Set with an Assessment Reference Date of 08/23/2022 coded the functional status for eating as requiring extensive assistance from staff. The Brief Interview for Mental Status was coded as 3 out of 15 indicative of severe cognitive impairment. The care plan was reviewed. There was not a focus, goals, or interventions on the care plan associated with Activities of Daily Living. On 09/13/2022 at approximately 5:30 P.M., the Administrator and Director of Nursing (DON) were notified of findings. When asked about the expectation, the DON stated that if a resident is assisted with eating, the staff should clean up the resident and make sure they are comfortable The DON then stated she would retrain the staff on the topic of resident dignity. Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure the Resident's right to a dignified existence for 2 Residents (#'s 269 & 90) in a survey sample of 60 Residents. For Resident #269 the facility staff failed to ensure the Resident's right to dignity and privacy by using his photo and diagnoses on a marketing flyer that they posted in the elevator. On 9/12/22 at approximately 2:00 PM Surveyor D observed a marketing flyer in the elevator that read: [Company name and logo redacted] Celebrating Success We are pleased to share another wonderful rehab success story from: [Address and phone number of facility redacted [Resident #269 name redacted] came to [Facility name redacted] from [hospital name redacted]. [Resident #269 name redacted] experienced a fall at home due to a Urinary Tract Infection, luckily no injuries sustained from the fall. [Resident #269 name redacted] had difficulty with walking and performing steps so he could return home. [Resident #269 name redacted] required help with his bathing, dressing, and toileting. [Resident # 269 name redacted] family was very supportive and very involved with his care. While at [facility name redacted], [Resident # 269's name redacted] made significant gains with his therapy plan of care, he was able to increase his walking abilities to over 350 ft., and was able to successfully navigate steps with no increased pain or assistance. [Resident #269 name redacted] was able to bathe, dress, and complete his toileting with little to no assistance. Name: [redacted] Admitting Diagnosis: UTI with a fall LOS: [length of stay] 34 days Discharge Location: Home [There was a graph on the page that showed his Functional Outcome Measures from admission to Discharge for Bathing, Bed mobility, Grooming, Toileting, Upper body Dressing, Lower Body Dressing, Gait, Stairs, Transfers.] On 9/12/22 during the end of day meeting Surveyor D requested that the Administrator show documentation that Resident #269 approved or gave consent to disclose his protected health information (diagnosis of UTI and fall) that was used in the marketing flyer posted in the elevator, Surveyor D requested again on 9/13/22 and was told that the Administrator was awaiting for regional manager to get back to him. On 9/15/22 at 1:02 PM an interview was conducted with the Administrator and Employee D (the Regional Nurse Consultant) On 9/16/22 when the admission package was reviewed it was found that the resident signed giving to use his photo however nothing was mentioned about using his protected health information along with his photo. The Administrator and Employee D (Regional Nurse Consultant) were both asked about permission to use his diagnosis and both stated that all they have is what is in the contract. On 9/16/22 a review of the facility's HIPAA policy read as follows: 1 - To respect the privacy and confidentiality of any information you may have access to through our computer system or network and that you will access or use only that information necessary to perform your job. 3 - To disclose confidential resident, business, financial or employee information ONLY to those authorized to receive it. 7 - Not to release or disclose the contents of a resident or facility record except to fulfill your work. On 9/16/22 an excerpt of the facility's Routine Resident Care Policy read: h. Maintains confidentiality of resident information at all times including but not limited to: i. photographs . ii. social media . iii. unauthorized email, fax, texting or telephone communication . iv. unauthorized communication in inappropriate environments such as open hallways, within the immediate vicinity of other residents/family or outside of the facility. On 9/16/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident #90, the facility staff failed to maintain dignity and assist Resident #90 getting cleaned after her meal, resulting in Resident #90 sitting up in bed sleeping in front of her meal tray with a soiled clothing protector in place on 09/13/2022.

Based on observation, resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to assess and determine if a Resident was safe to self-administer medications, for one Resident (Resident #35) in a survey sample of 60 Residents. The findings included: For Resident #35, who had medications stored in his room, the facility staff failed to assess if Resident #35 was safe to self-administer medications and removed the medications, stating it was not permitted. On 9/13/22 at 9:28 PM, Resident #35 was observed awake and sitting on the edge of his bed. A Resident interview was conducted and during this interview Resident #35 was observed with a bottle of Tums/antacid tablets on his bed and in the bottom of his bed side table several prescription bottles were observed. On 9/13/22 at 9:31 PM, an interview was conducted with LPN D. When asked if she has any Residents that self-administer medications and are permitted to keep them in their room, she said, No, we have to keep all medications in the medication cart, we don't allow them to keep any in their rooms. On 9/14/22 at 9:30 AM, Resident #35 was visited in his room. Resident #35 showed Surveyor B that he had a bottle of Tums, bottle of Tylenol, 2 pill bottles that the label was worn on and the contents were unable to be identified. Resident #35 reported that one bottle had anti-diarrhea medication and the other was Tylenol. There was a box of refresh eye drops. Resident #35 reported, They confiscated them for a while but then put it on their list and said I could keep them, referring to the eye drops. On 9/15/22 at 4 PM, during an interview with Resident #35, the Resident said, Someone came and took my medicines, they got gone yesterday. He continued, The refresh plus is for my eyes and the Tylenol is for my aching back versus going to the nurse and waiting forever to get it. My wife called the police because they were stolen. The question is who took them and second, were they destroyed. They are over the counter medicines and I would like them back. On 9/15/22 at 5 PM, an interview was conducted with LPN J, the Unit Manager for the second floor. When asked about Resident #35's medications, LPN J said, When I made my rounds yesterday I saw medications under his pillow and in the drawer, they were eye drops and Tums, I called the wife and explained he is not allowed to keep medications in his room. We have scheduled the eye drops every 12 hours and the Tums is every 4 hours as needed, we will use his supply. When asked why he is not permitted to keep them in his room she said, It is not safe. When asked if Residents are able to self-medicate, LPN J said, No, we don't allow that here. On 9/15/22 at 5:25 PM, during the end of day meeting, the facility Director of Nursing (DON) was asked if they have any Resident who self-administer medications. The DON said, No, we don't have any Residents that self-administer medications. When asked if this is permitted, the DON said, I will check. On 9/14/22 and on 9/15/22, the facility staff were asked to provide a self-administration of medication assessment for Resident #35. This was never received prior to the survey team's exit. Review of Resident #35's entire clinical record, to include but not limited to: physician orders, care plan, nursing notes, assessments, and interdisciplinary team meeting notes there was no indication that Resident #35 had been assessed for his ability to self-administer medications. On 9/21/22, during an end of day meeting the facility Administrator, Director of Nursing and Corporate staff were made aware that Resident #35 was not assessed for, nor afforded the opportunity to self-administer medications. A review was conducted of the facility policy titled, Resident Self-Administration of Medications. This policy read, It is the policy of this facility to provide resident centered care that safeguards the Resident's right for self-administration of their own medication that supports resident dignity and self-determination . The facility will periodically review the ability to self-administer medication based upon change in status .On admission, the facility will assess the resident for safety through the IDT (Interdisciplinary Team) care planning team prior to the resident exercising their right of self-administration of drugs within 7 days after the comprehensive assessment is completed as required by regulations . The policy continued to read, Procedure: 1. Determine if the resident desires to self-administer their own medication. a. Resident may not self-administer medication until the assessment is completed by the IDT team and determined safe to do so .2. Resident may self-administer some or all of their medications . No further information was provided. .

Based on observation, interview, facility record review and clinical record review the facility staff failed to ensure the right of self-determination for 1 Resident (#31) in a survey sample of 60 Residents. The findings included: For Resident #31, the Resident had made it clear to staff she wanted only female CNA's to work with her, as evidenced by the care plan entry dated 6/10/22, however, they continued to schedule male CNA's to be assigned to her. On 9/21/22 at approximately 10:30 AM an interview was conducted with Resident #31 who stated, I don't want none of those men undressing me. Resident #31 stated, I told him No and he got angry and banged his fist on the table it was threatening. I was afraid he would come back. On 9/20/21 an interview with the DON was conducted and she was informed of the Resident's complaint she stated she was aware and they had addressed it in the care plan meeting in June. When told that the Resident stated it had happened a few days ago, the DON stated that Resident #31 has dementia and is confused about the time. A review of the Concern Forms (grievance log) revealed that on June Social worker had filled out a Concern Form for Resident #31 that read: [Resident #31 name redacted] reported that her CNA [CNA Q name redacted] is rough during ADL's and keeps washing and washing her and it is rough on her skin. Resident requested to have female CNA's who are gentle her the skin. Attached to the concern form was a sign off sheet where CNA Q was provided education and signed off. On 9/21/22 a review of the care plan revealed that on 6/10/22 during the care plan meeting this topic was addressed and the care plan read: FOCUS- [Resident #31 name redacted] is at risk for Self Care Performance deficit and requires assistance with ADL care GOAL- 06/10/2022- resident requested to have a female CNA perform her ADL's. Resident will maintain current level of function. INTERVENTION- Female CNA to perform ADL's care. On 9/16 a review of the clinical record revealed that Resident #31 had male CNA's signing off on the POC (Point of Care) system the Resident had continued to have male CNA's as recently as 9/18/22 and 9/19/22. On 9/16/22 the DON was asked about Resident #31 having male CNA's she stated that they had a care plan meeting and updated the care plan for no male CNA's. When asked why this was done she stated the Resident does not want male CNA's, and it's her right to have this choice On 9/17/22 the Administrator was made aware of the concerns and no further information was provided.

Based on Resident interview, staff interviews and facility documentation review, the facility staff failed to permit Residents to access their personal funds/trust accounts on weekends and evenings, for Residents with trust accounts. The findings included: On 9/13/22 at 10:20 AM, an interview was conducted with the receptionist/Employee G. Employee G confirmed that a staff member is at the receptionist desk from 7 AM until 8 PM, Monday through Friday and on weekends from 8 AM until 8 PM. On 9/15/22, Resident #2 was interviewed regarding his access to his trust account. Resident #2 said he had to go downstairs to the business office to make withdrawals and they are only open Monday-Friday. On 9/19/22 at 3:15 PM, an interview was held with Employees CC/the assistant regional director of finance and Employee J, the divisional director of revenue cycle. They reported, We have banking hours. On 9/19/22 at 4:40 PM, an interview was conducted with Employee G/the receptionist. Employee G was asked how Residents access or withdraw money from their trust account. Employee G said, They go to the business office. When asked what they do on the weekends when the business office is closed, Employee G said, They would have to call him [referring to the business office manager]. On 9/19/22 at 4:43 PM, CNA J was asked how Residents access their money. CNA J said, They go to the social worker. On 9/19/22 at 4:45 PM, an interview was conducted with Employee E, the social worker. The social worker was asked how Residents access their trust account. Employee E said, They come to the business office. When asked what happens on weekends, Employee E said, I don't know the process, I haven't had anyone complain that they didn't have access on weekends. On 9/19/22 at 5:10 PM, an interview was conducted with Resident #88, the Resident Council President. When asked how Residents access their money, Resident #88 said, They have to go to the business office. The Resident confirmed that the business office is open Monday through Friday. When asked if someone wants money on the weekends, what they do, Resident #88 said he was not aware and suggested I talk with Resident #70. On 9/19/22 at approximately 5:20 PM, an interview was conducted with Resident #70. When asked about accessing money from his trust account, Resident #70 said that he has to go to the business office during their work hours to access his money or make withdrawals. When asked what happens if it is a weekend, Resident #70 said, You are out of luck. On 9/19/22 at 5:27 PM, an interview was conducted with Employee DD, the admissions director. When asked, how do Residents withdraw money from their trust account? Employee DD said, They go to the business office. When asked what happens when the business office isn't here, she said, They have [Employee J's name redacted] who comes and they let [Administrator's name redacted] know. When asked about accessing funds on weekends, Employee DD said, On weekends it should be activities that assists with that. On 9/19/22 at 5:30 PM, an interview was conducted with Employee EE, the activity leader. Employee EE was asked how Resident's get money from their bank/trust account, Employee EE said, They go through the business office. On 9/20/22 at 2:40 PM, an interview was conducted with the facility Administrator. The Administrator was asked how Residents access money from their trust account and he said, After hours they come to the reception desk to get money. Following the response from the Administrator, Employee G, the receptionist was again asked if she has funds available to distribute to Residents. Employee G said, I was just told about this process and confirmed that this will be a new process implemented and that currently she has no funds available to distribute. The facility policy titled, Resident Trust Fund, was reviewed. The policy did not address when Residents can access money from their trust fund. During the survey there were two days the survey team observed that the business office was closed and no staff were able. The facility Administrator confirmed no one was available in-house on those days and someone from Corporate would be coming the following day. On 9/21/22, during an end of day meeting the facility Administrator, Director of Nursing and Corporate staff were made aware that Residents do not have access to their funds when the business office is closed. No additional information was available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, family interview, clinical record review and during the course of a complaint investigation, the facility staff failed to provide one resident ( Resident # 217) with a conveyance of funds within 30 days. Findings included: For Resident # 217, the facility staff did not convey funds within 30 days. Resident # 217 was admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Resident # 217 did not return to the facility. Review of the Personal Funds account for Resident # 217 revealed documentation that the account was not reconciled until [DATE]. Resident # 217 transferred from the facility on [DATE]. A check was written on [DATE] but was not cashed. An audit in [DATE] revealed the check had not been cashed. The facility staff voided the check and wrote another check in [DATE]. The final check was written on [DATE] and cashed on [DATE]. On [DATE] at 2 p.m., an interview was conducted with the Regional Business Office Consultant (Employee J) who stated that the facility staff should reconcile the accounts within 30 days once we [the facility] receives all payments due. Regarding the Trust Funds, Employee J stated once discharges or the resident expires, then it is 30 days after discharges or expiration, assuming they are not returning. Employee J was asked to review Resident # 217's fund accounts to determine the date the account was reconciled. Employee J stated according to the documentation, the resident expired on [DATE]. There was a check written on [DATE] to close the account. The check number was # 1071 for the amount of $1549.56. The check # 1071 was voided and reissued on [DATE] as check # 1076 for the amount of $ 1549.56. Employee J stated the she actually audited this account in May. The National Data Care System was set up that checks could be left open indefinitely. Employee J stated the issue was that the check # 1071 was not cashed originally. When I came in May, I audited records and found the check not cashed, another check was written after voiding the first check. Review of the Patient Funds account and Trust Funds account revealed lack of sufficient evidence of funds being misappropriated. However, the facility staff failed to reconcile the account timely within 30 days as per the regulation and facility policy. During the end of day debriefing on [DATE], the facility Administrator, Director of Nursing and Corporate Consultants were informed of the findings that for Resident # 217, the facility staff failed to reconcile the account timely. The Corporate Consultant stated the funds should have been rectified within 30 days. No further information was provided. COMPLAINT DEFICIENCY

Based on Resident interview, staff interviews and facility documentation review, the facility staff failed to only withdraw funds authorized for the cost of care for one Resident (Resident #70) in a sample of 3 Residents reviewed for trust fund transactions. The findings included: For Resident #70, the facility withdrew funds monthly in excess of what was due to the facility for the Resident's cost of care as directed by Medicaid. On 9/19/22, Resident #70 disclosed during an interview concerns about money received not being deposited into his bank account/trust fund. On 9/19/22, Surveyor B asked for a transaction history of Resident #70's account and the patient liability (amount Resident is responsible to pay towards cost of care when on Medicaid) from the Virginia Medicaid web portal. The requested items were received and reviewed. The findings were as follows: 1. August 2021-September 2022, Medicaid indicated that Resident #70 was responsible to pay $838.00 per month as his patient liability. 2. For the months of August, September, October, November, and December 2021, the facility deducted $849.00 from the trust account monthly, which was an overpayment of $11 per month. This totaled an overpayment of $55 for the year of 2021. 3. For the months of January-September 2022, the facility withdrew $901 per month to apply towards cost of care. This was a monthly overpayment of $52 per month, which equaled a total overpayment in 2022 of $468. On 9/20/22, an interview was conducted with Employee J, the Regional Director of Revenue Cycle who was present in the absence of the facility business office manager. Employee J was asked if she had any significant findings from the review of the documents Surveyor B had requested for Resident #70. Employee J said, yes, she had identified that they were deducting the wrong amount from Resident #70's account for the cost of care and was not certain why this had been done. Review of the facility policy titled, Resident Trust Fund was conducted. This policy read, Purpose: To hold, safeguard, manage, control and reconcile the personal needs funds deposited with the facility by residents, as authorized, in a manner and in compliance with all laws and regulations to provide the residents with accurate and timely information regarding their personal funds . On 9/21/22, the facility Administrator was made aware of the above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to offer and/or provide Advance Directive planning for 2 residents, Resident #35 and Resident #111, out of a sample of 10 residents reviewed for Advance Directives. The findings included: The facility staff failed to offer and/or provide Resident #35 or their Responsible Party (RP) with Advance Directive planning. On 9/14/22, clinical record review was performed for Resident #35 and Resident #111 which revealed the following: 1. Resident #35 was re-admitted to the facility on [DATE] following a hospital admission on [DATE]. Physician orders and patient profile read, Full Code status which indicated that Cardiopulmonary Resuscitation would be initiated in the event of cardiac and/or respiratory arrest. The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) on 7/13/22 indicated that Resident #35 had a Brief Interview for Mental Status (BIMS) of 13, cognitively intact. 2. The facility staff failed to offer and/or provide Resident #111 and/or their Responsible Party (RP) with Advance Directive planning. Resident #111 was re-admitted to the facility on [DATE] following a hospital admission on [DATE]. Physician orders and patient profile read, Full Code status which indicated that Cardiopulmonary Resuscitation would be initiated in the event of cardiac and/or respiratory arrest. The MDS, Assessment Reference Date on 9/5/22 indicated that Resident #111 had a BIMS of 04, severe cognitive impairment. There was no documentation in the clinical record, for either Resident, that the facility staff offered or provided Advance Directive planning with Resident #35 and with Resident #111's Responsible Party (RP). On 9/15/22, an interview was conducted with the Director of Social Services (DSS) who confirmed the findings and stated that she was responsible for Advance Directive planning with residents and their families. She stated that for Residents #35 and #111, since they had no prior Advance Directives, they, or their RP, would have been given an Advance Directive booklet and offered assistance with planning. The DSS stated the Advance Directive conversations and provision of the booklet would have been documented in the Progress Notes, however she acknowledged the lack of documentation for Resident #35 and #111, stating, It must have been an oversight. Review of the facility policy titled, Advance Care Planning, effective date 9/18/20, read, .[name redacted] affirms the resident's right to make decisions regarding his/her medical care, including the decision to appoint a surrogate decision maker, make end of life wishes known, discontinue treatment, to the extent permitted by law while acknowledging the psychosocial and spiritual concerns of the resident and the family regarding the dying and the expression of grief by the resident and family. The same policy, subheading Procedure, item 7, read, The social services department is responsible for follow-up with the patient or representative for education and communication regarding Advance Care Planning. Item 8-b-2 read, Document in the electronic medical record using the specific record Advance Care Planning note whether or not a resident has executed an Advance Directive .A progress note regarding the conversation must also be documented. The Facility Administrator was informed of the findings on 9/15/22. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF (skilled nursing facility) NOMNC (notice of Medicare non-coverage) and ABN (advance beneficiary notice) timely and accurately for 2 Residents (Resident #417 and #35) in a survey sample of 3 Residents reviewed for Beneficiary Notifications. The findings included: 1. For Resident # 417, the facility staff failed to issue a NOMNC timely, therefore the Resident was not afforded the opportunity to file an appeal if she so desired. Resident #417, was admitted to the facility on [DATE], for skilled care. Resident #417 was issued a NOMNC on 3/31/21, which notified her that her skilled stay would end on 4/1/22. This notice did not afford the Resident adequate time to file an appeal if she chose to. Per the NOMNC, it read, Your request for an immediate appeal should be made as soon as possible, but no later than noon the day before the effective date indicated above. The appeal would have had to be filed by noon on 3/31/21, if she chose to appeal the decision. On 09/15/22 at 10:27 AM, an interview was conducted with the social worker (SW). The SW stated that with regards to timing of the notice, A NOMNC has to be issued with 48-72 hours' notice. She confirmed the purpose of the NOMNC is To help them understand their insurance will no longer be billed. When shown the NOMNC issued to Resident #417, the SW confirmed that the Resident was not issued the notice timely and did not have adequate opportunity to file an appeal. 2. For Resident #35, the facility staff failed to issue an accurate and timely ABN and NOMNC. Resident #35 was hospitalized and readmitted to the facility on [DATE], under Medicare Part A benefit/skilled care for therapy services. On 7/11/22, the facility staff contacted Resident #35's spouse and discussed that skilled care would end on 7/13/22. As per the NOMNC, Beginning on 7/14/22, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. According to the census tab of the electronic health record, Resident #35 began paying privately for his stay on 7/13/22, not 7/14/22. Therefore, his last day of Medicare Part A services was 7/12/22, and the NOMNC and ABN were not issued 2 days prior to services ending, nor were they accurate with regard to the date services would end. Therefore, he was not afforded the time required to make a decision if he wanted to appeal the decision. A review of the facility Non-coverage and Advance Beneficiary Notices Policy, was conducted. It read, .3) NOMNC a) Regulations state that we must notify residents, currently covered under Medicare that their coverage is ending. b) This is accomplished through the use of the NOMNC. i) This notice will be provided at least 2 days in advance of the last covered day to allow for adequate time to appeal, if the beneficiary so chooses . This above referenced policy also read, .6) SNF ABN- End of Covered Stay. a) If a resident is currently covered under Medicare and coverage is ending and the resident will remain in the SNF, the SNF ABN must be provided to the resident notifying them that someone else will need to pay for the SNF stay after Medicare ends. b) This could be private, Medicaid other insurance. c) This would be in addition to the NOMNC you already provided . According to Medicare, While you're getting SNF [skilled nursing facility] ., you should get a notice called Notice of Medicare Non-Coverage at least 2 days before covered services end. Accessed online at: https://www.medicare.gov/claims-appeals/your-right-to-a-fast-appeal/getting-a-fast-appeal-from-non-hospital-settings CMS identifies when the ABN is required to be issued in their document titled Form - Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) read, Medicare requires SNFs to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: Not medically reasonable and necessary; or Considered custodial. The Administrator was informed on 5/21/22, of the above findings. No further information was provided.

Based on observations, Resident interviews, staff interviews, clinical record reviews, facility documentation review, and in the course of a complaint investigation, the facility staff failed to promptly respond to grievances for 2 Residents (Resident #46, Resident #68) in a sample size of 60 Residents. The findings included: 1. For Resident #46, the facility staff failed to promptly respond after being notified of baseboards loose/missing in room as well as extensive scuff marks and stains on floor, baseboards, and walls. For Resident #46, the facility staff failed to maintain a comfortable homelike environment as evidenced by scuff marks and stains on the floor, baseboards, and walls. Also, there were strips of scotch tape on wall across from Resident #46's bed with ripped paper attached. Also, the baseboard next to Resident #46's bed was separating from the wall and the baseboard to the right of the bathroom door was gone, revealing a small hole in the wall and ripped drywall. On 09/13/2022 at 9:20 A.M., Resident #46 was observed lying in his bed. When asked about concerns with the facility, Resident #46 said everything was alright. When asked how he felt about the extensive amount of scuff marks, stains, and tape on the floor and walls, Resident #46 then pointed to the baseboard on the right side of his bed. This surveyor observed that the entire strip of baseboard was not tightly secured to the wall. Furthermore, the baseboard from the right side of the bathroom to the end of the wall was gone revealing a small hole in the wall and ripped drywall. On 09/13/2022, Resident #46's clinical record was reviewed. Resident #46's quarterly Minimum Data Set with an Assessment Reference Date of 07/22/2022 coded the Brief Interview for Mental Status as 6 out of 15 indicative of severe cognitive impairment. On 09/13/2022 at approximately 5:30 P.M., the Administrator and Director of Nursing were notified of findings. On 09/20/2022 at approximately 2:45 P.M., Resident #46's room still had extensive scuff marks, stains, and tape on the floor and walls as well as loose/missing baseboards as observed on 09/13/2022. On 09/20/2022 at 3:20 P.M., the Maintenance Director, Employee F, and Employee U, maintenance staff, were interviewed. When asked about the process for work orders, the Maintenance Director stated that some requests are by word-of-mouth and some are put into the system. When asked about current work orders needing to be done, the Maintenance Director stated there were two work orders in the system. This surveyor and the Maintenance Director observed the work order screen and there was not a work order for Resident #46's room. When asked about any requests made for Resident #46's room, the Maintenance Director and Employee U both stated they were unaware of any work orders for Resident #46's room. At approximately 3:25 P.M., this surveyor, the Maintenance Director, and Employee U entered Resident #46's room for an observation of the loose/missing baseboard and hole in the wall. The Maintenance Director stated he was not aware of this and would fix it. The facility staff provided a copy of their policy entitled, Resident Grievance. Under the header Policy an excerpt documented, The facility recognizes that residents have a right to voice grievances to the facility, or other agencies or entities that hear grievances, without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment that has been furnished, the behavior of staff and other residents and any other concern regarding the resident's stay. 2. For Resident #68, the Administrator failed to respond to Resident #68's multiple messages and urgent requests to speak with him over a 4-month period (May-September 2022). On 09/12/2022 at approximately 12:35 P.M., Resident #68 was interviewed. When asked if he had any concerns about the care he receives at the facility, Resident #68 stated that he has asked to speak with the Administrator multiple times but the Administrator never shows up. When asked what he would like to talk with the Administrator about, Resident #68 stated that he is supposed to be receiving physical therapy but not getting it. Resident #68 also stated it takes staff up to 45 minutes to answer the call light sometimes. Resident #68 stated that he has epilepsy and may be alone having a seizure by the time staff respond to the call light. Resident #68 also stated that he has had a stroke before and I could've had a stroke but I would be dead by the time I get a medical response. When asked if he filed a grievance, Resident #68 nodded his head yes. Resident #68 stated he calls the front desk and leaves messages for the Administrator. Resident #68 stated that the secretary at the front desk has a call log to show how many times he has called. When asked if he was informed of the facility's process for filing a grievance, Resident #68 stated, No. On 09/13/2022 at 11:00 A.M., the receptionist, Employee G, was interviewed. When asked about Resident #68 calling to ask to speak with the Administrator, the receptionist stated that [Resident #68] calls all the time. The receptionist verified she has a call log and provided a copy of the call logs for June, July and August 2022. There were 12 messages from Resident #68 for the Administrator. The dates, times, and messages were as follows: 06/14/2022 at 1:50 P.M. Would like for you to call him when you get the chance. 06/28/2022 (not timed) Please call-it is urgent. 07/12/2022 at 4:32 P.M. Calling in regards to a missed meeting you guy had set up. 07/13/2022 (not timed) Please see him re: [regarding] the conditions of his living condition. 07/21/2022 (not timed) Would like to speak with you. 07/28/2022 at 11:26 A.M. Please call [Resident #68]. He said he has been trying to speak to you for about 6 weeks. 08/09/2022 at 4:26 P.M. His 14th time trying to reach you - if you don't contact him, he will call corporate office. 08/09/2022 at 4:36 P.M. This is his 14th time trying to contact you. He will call corporate office. 08/12/2022 at 6:00 P.M. Would like to speak with you about why the 2 meetings he had scheduled with you didn't occur. 08/15/2022 at 12:46 P.M. Called and would like to speak with you. 08/16/2022 (not timed) Would like to speak with you regarding his treatment. On 09/21/2022 at approximately 4:15 P.M., the Administrator was notified of findings. When asked how Residents are made aware of grievance policy, the Administrator stated there are grievance forms at every nursing station and staff let them know they can complain to any of us. When asked if the multiple messages left by Resident #68 were addressed, the Administrator stated that he goes and meets with [Resident #68] and many times, makes appointments. When asked for evidence that the Administrator addressed Resident #68's concerns, the Administrator confirmed there is no documentation to support that Resident #68's messages were answered and addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed implement their policy with regards to reporting crimes affecting 3 Residents (Resident #35, #368, and 217) in a survey sample of 60 Residents. The findings included: 1. For Resident #35, whose wife was a former Resident #368, reported that money was missing from their joint bank account, the facility staff failed to report timely an allegation of misappropriation and exploitation in excess of $50,000. On 9/12/22 at 3:07 PM, an interview was conducted with Resident #35. Resident #35 said, I had trouble when I first came here, thieves got hold of the books and it was a minor thing to them. I woke up one morning and the checking account was down to zero. It was an inside job, no one cared about how the books were managed. On 9/15/22 at 4 PM, a follow-up interview was conducted with Resident #35. He stated, $70,000 was taken. We used a check to pay the facility because it wasn't covered by Medicare, we wrote a check for the amount due and they never paid the business office. Another check was written and they went to a young teller and got the money and we were down to zero. When asked how did this make him feel, Resident #35 said, [Expletive], I will be blunt. My wife is starting to get tarnished in her trust in people. I want to get out of here because of how they run their accounting and they see nothing wrong with it. It all started here, $4,000 my wife paid was charged to us again, and then another $5,000, looks like the hands of thieves are in it again. On 9/21/22 at 9:54 AM, an interview was conducted with Resident #368. When asked about the incident, Resident #368 said, I'm not sure who took it. A lady there released me and she wanted over $5,000 from me and never took it to the business office. They stole all our money. I'm having so much trouble with that business office. Resident #368 confirmed she feels taken advantage of. The interview was terminated because Resident #368 became very tearful and said, I don't like what is going on. A lot of night I lay awake and can't sleep, it's awful I sit here and cry a lot and worry about money all the time. On 9/15/22, an interview was conducted with Adult Protective Services (APS). They were able to provide information regarding their investigation which revealed a preponderance of evidence to substantiate that Residents #35 and 368 were victims of financial exploitation by a facility employee in excess of $50,000. On 9/15/22, during an interview with Adult Protective Services (APS), Surveyor B was notified that APS had called the facility and made an on-site visit on 4/29/22, and reported the allegation of misappropriation to the facility's Director of Nursing (DON). The facility provided the survey team with a Facility Reported Incident (FRI) regarding this allegation of misappropriation. It was dated 5/2/22. The facility didn't report the allegation to the state survey agency or law enforcement until 4 days after they were made aware of the allegation. On 9/15/22 at 12:06 PM, an interview was conducted with the DON. During this interview the DON confirmed that APS had notified her of the allegation. The DON stated, I was here and the lady from APS wanted to see me, she said she had an allegation that one of our staff was involved with Resident's money going missing. She had a list of documents she wanted, I gave her those documents and she left. I called the Administrator and when she came back she took over the investigation. The DON was shown the Facility Reported Incident (FRI) that was dated 5/2/22. The DON said, I am aware of the FRI reporting requirements and we have to report abuse but the ED [executive director/administrator] handles that. When asked who is in charge in the absence of the Administrator, the DON said, If the ED is on vacation I can assume that role. If they are just out for the day, I called them and they do it. On 9/13/22, 9/15/22, and again on 9/16/22, the facility Administrator was asked to provide all documentation regarding this FRI, investigation, etc. On 9/15/22 at 6 PM, during an end of day meeting, the facility Administrator was interviewed. The Administrator stated that a FRI (Facility Reported Incident) is completed for anything causing harm, potential harm, or when something happens to a patient, a patient to patient situation or staff to patient. We report the FRI and send to the OLC and APS via fax and the Ombudsman. The initial notification is within 2 hours, we make sure the Resident is safe and start an investigation. Within 5 days we report to the OLC our investigation and what we found out as well as the resolution. On 9/22/22 at 9:39 AM, an interview was conducted with Employee E, the social worker. Employee E stated, If you have an allegation of abuse you have to report it immediately because it has to be reported to the state, APS, and Ombudsman within 2 hours. Also, you need to make sure the Resident is safe during that time, if you don't report immediately you can put the Resident at risk. When asked about the timing of the investigation, Employee E said, Everything has to be done in 5 days. The facility policy titled, Abuse, Neglect and Exploitation Policy was received and reviewed. This policy read, .VII. Reporting and Response: VIRGINIA. i. Within 24 hours of learning of an incident the facility must report it to the OLC unless the incident is an allegation of abuse or involves serious bodily injury and then the facility must report to the OLC within 2 hours. Incidents shall be submitted to the OLC Complaint Department via fax at [fax number redacted]. ii. Any incident or event with a suspicion of a crime is to be reported to the local police department within 2 hours NOTE: Absence of the facility administrator, or designated alternate, from the facility cannot be used to delay implementation of the facility investigation protocols . On 9/15/22 at 6 PM, and again on 9/21/22, during end of day meetings the facility Administrator, Director of Nursing and Corporate staff were made aware the survey team had identified concerns regarding the timing of FRI reporting. No further information was received. 2. For Resident # 217, the facility staff failed to report an allegation of neglect to the State Agency timely. Resident # 217 was admitted to the facility on [DATE] for skilled services in nursing and therapy with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism and Morbid Obesity with BMI (Body Mass Index) 60-69. Review of the Resident # 217's closed clinical record revealed the most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 9/16/2021. The MDS coded Resident #217 as requiring extensive to total assistance of one to two staff persons with activities of daily living and frequently incontinent of bowel and bladder. Review of the clinical record was conducted on 9/12/2022-9/22/2022. Review of the Progress Notes revealed documentation of a nurses note dated 5/28/2020 at 8:19 a.m. which stated: Resident The CNA (Certified Nursing Assistant) and I transferred (gender redacted) to the wheelchair. At around 10:30 p.m., I asked the CNA to help put (gender redacted) back to bed because it would be difficult if nobody is around to put (gender redacted) to bed. Resident refused to go to bed. (gender redacted) later on asked to be put to bed and I said (Resident # 217's name redacted) not by myself. I will need someone to help me. There was nobody at the moment and (gender redacted) was in the wheelchair for a while until when (Name of CNA redacted) came to help with (name of another resident redacted), then we put (gender redacted) to bed. On 9/20/2022, an interview was conducted with the Regional Nurse Consultant who read the Progress note and stated That's abuse. The Regional Nurse Consultant stated the nurse should have assisted the resident back to bed upon request. Resident # 217 should not have had to wait in the wheelchair for an extended time as documented by the Licensed Practical Nurse (LPN K). The facility Administrator submitted a FRI report to the State Agency on 9/21/2022. During the end of day debriefing on 9/21/2022, the facility Administrator, Director of Nursing and Corporate Consultants were informed of the findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility record review, the facility staff failed for 1 resident (Resident #119) to provide the resident with a necessary and safe discharge, in a survey sample of 60 Residents. The Findings included: The facility unnecessarily, and unsafely discharged Resident #119, did not apply for timely insurance coverage for a needed continuance of stay, and further failed to involve, evaluate, and provide Resident #119 with an interdisciplinary discharge plan. No community services were planned, no written discharge instructions were planned, nor given to the Resident, no medical equipment was obtained for discharge home, and the facility did not document a recapitulation of the Resident's stay in the clinical record. Resident #119 was admitted to the facility on [DATE] and discharged home on 7-8-22 (6 weeks later). Resident #119's diagnosis included; Heart disease, Heart Failure, Diabetes, chronic kidney disease, stroke, obesity, a sacral pressure sore, and hypertension. The most recent Minimum Data Set (MDS), which was a 30-Day Assessment was reviewed and coded Resident #119 as having intact cognition. The Resident was his own responsible party. On 9-21-22, a review was conducted of Resident #119's clinical record. The Resident discharged home on 7-8-22. There was no record of discharge planning, no discharge plan completed in the care plan nor in the therapy notes, and the doctor and therapists were notified after the Resident was discharged that he had been discharged . The last nursing progress note prior to discharge was written by the day shift nurses on 7-7-22 at 1:40 PM, and 2:30 p.m., stating that the Resident had changed rooms (no documented reason was given), and that no new skin issues were assessed, and healed. The Resident had 2 pressure areas which were not healed. No location for the nursing assessment of healed, was given. On 9-21-22 Physical therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) notes were reviewed and revealed that on 7-7-22 Resident #119 has progressed with all 3 therapies and improvements were noted, however, the Resident required more time in therapy to reach the goals to move home safely. The Resident required minimal assistance with dressing, moderate assistance with toileting, contact guard assist with transferring to a toilet from a wheel chair using a scooting/bridging/sliding technique with a walker. The Resident was receiving therapy instruction on safe techniques with adaptive equipment for bed mobility, balance, energy conservation, safety in transitional movements, and safe use of durable medical equipment that would be needed/ordered upon discharge. The Resident was documented as continuing to have difficulty with peri care (incontinence care). On 7-7-22 the therapy evaluations stated that continued therapy was needed to reach goals of limited assistance needed at home, and were recommended to be continued 5 times per week, for 4 more weeks to meet goals to return home. The Resident lived alone and had only Friends who lived 30-35 minutes away from the Resident and would only be Stopping by at times to assist. The Resident was documented as stating that when a date for discharge was planned he would contact his middle son to fly in from California to assist him upon his discharge. This indicated that home health would also be necessary upon discharge. The projected insurance date for discharge at that time was 7-14-22, and another application to the Resident's insurance would be needed to extend his Rehab time. No further therapy nor insurance communication was documented by the facility regarding this Resident and an interview with the Social Worker was requested by surveyors. On 9-21-22 an interview with the Social worker was conducted and revealed that the Regional Insurance Case Manager for the facility's parent company did not submit for further stay insurance authorization for Resident #119, and he was notified on 7-7-22 that his room would change and he would need to pay for the stay out of pocket as his insurance coverage would end on that very day (7-7-22). The Resident stated he needed home health and medical equipment and he would have to discharge as he was unable to pay out of pocket for the stay. Resident #119 discharged in a Taxi cab he called for himself, without a discharge plan, or home health services, or medical equipment to travel from [NAME] Virginia to Maryland alone on 7-8-22. Facility documents were reviewed and revealed that on 6-30-22 the Regional Insurance Case Manager for the facility's parent company corresponded via email with the Rehabilitation Director, and asked what support the Resident would require as to home health upon discharge. The email was forwarded to the Social Services Assistant who replied that Resident #119 would be moving home alone to Maryland and would need home health services. The Resident stated he would need to be ambulating well so that he could do his stairs safely at home. The resident required (2) 2 wheeled walkers, one for upstairs and 1 for downstairs, a raised toilet seat, a hospital bed, and a wheelchair. The final documentation in the clinical record was written on 7-12-22 (4 days after the Resident discharged ) by the Social worker in a progress note which stated the Resident left AMA (against medical advice). The facility policy on discharge (D/C) planning was requested and received. The policy stated the following; The discharge process will begin with 72 hours of admission, planning will involve residents needs for assistance with activities of daily living, meals, ambulation, transportation medications, primary care physician follow up, home health, home care, outpatient/community outreach services. The resident and or their representative will be active participants in the D/C planning process. The plan will be reviewed by the Resident or representative weekly and Social services will update the plan. Within 6 days of discharge the Social Services Department will ensure all portions of the plan are completed, and after completion the plan will be printed and signed by the Resident or representative. A copy of the signed plan will be kept in the medical chart and a copy will be given to the Resident or Resident representative. There was no discharge plan completed in the clinical record, there was no discharge plan in the care plan, and no discharge recapitulation of stay was in the clinical record from the physician. The Administrator and Director of nursing were asked for these documents, and stated there are none. On 9-21-22 at the end of day debriefing the facility administration was made aware of the deficient practice. They stated they had nothing further to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and in the course of a complaint investigation, the facility staff failed to notify the Long Term Care ombudsman of the discharge of one Resident (Resident # 217) in a survey sample of 60 residents and the facility staff failed to notify the Ombudsman of any discharges during a 4 month period of time (October 2021-January 2022). Findings included: 1. For Resident # 217, the facility staff failed to notify the Ombudsman of the transfer to the hospital on [DATE]. The facility staff did not notify the Ombudsman of any discharges in October 2021 to January 2022. Resident # 217 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism and Morbid Obesity with BMI (Body Mass Index) 60-69. The MDS coded Resident #217 as requiring extensive to total assistance of one to two staff persons with activities of daily living and frequently incontinent of bowel and bladder. On 9/ 14/2022 an interview was conducted with the Social Services Director who stated Notices of discharges should be sent to the Ombudsman's office at least monthly. The Social Services Director stated that she usually would send the notices a least once a month but sent them more often depending upon how many discharges there were during that month. She stated sometimes I send them every two weeks. When asked for a copy of the Ombudsman notification informing the Ombudsman of Resident # 217 being transferred in November 2017, the Social Worker stated she did not see any verification that the information was sent. When asked for copies of the Ombudsman notifications for October, November and December 2021, the Social Services Director stated she did not see any verification that notices were sent. The Social Services Director stated she started working at the facility in December 2021. A copy of the January 2022 notice was requested. On 9/21/2022 during the end of day debriefing, the facility administrator, Director of Nursing, Social Services Director and Regional Consultants were informed of the findings of no documentation of notices being sent to the Ombudsman during October, November and December 2021 and none for January 2022. The Regional Consultant stated we do not have them. They were not done. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and in the course of a complaint investigation, the facility failed to issue an accurate written bed hold notice for 1 resident (Resident #217) of 60 residents in the survey sample. Findings included: For Resident # 217, the Bed Hold Authorization form was signed but incomplete. There were blanks in the documents. Resident # 217 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism, and Morbid Obesity with BMI (Body Mass Index) 60-69. The MDS coded Resident #217 as requiring extensive to total assistance of one to two staff persons with activities of daily living and frequently incontinent of bowel and bladder. Review of the electronic clinical record was conducted 9/12/2022 - 9/22/2022, including a review of the miscellaneous forms, revealed a document entitled Bed Hold Authorization Form. The document dated 11/16/2021 revealed signatures of the Responsible Party and the facility Social Worker. The form was not completed. There were blank spaces where the amount of the daily rate. An excerpt read: The rate for holding a bed is equal to the prevailing daily rate of ______. This serves as a notice of bed hold days the resident currently has remaining that will be paid by Medicaid:___days . If the resident does not return to the facility within that tine period, you may choose to guarantee the availability of an accommodation by paying privately the daily rate for that accommodation, which is listed above. Otherwise admission to the facility will be on a first available basis. On 9/20/2022 at 11:15 a.m., an interview was conducted with the Regional Nurse Consultant who stated the facility staff should have completed the information informing the resident/responsible party of the amount of the daily rate and the remaining days that would be paid by Medicaid. The Regional Nurse Consultant stated the resident and/or Responsible party should not be asked to sign forms that are not complete. During the end of day debriefing on 9/21/2022, the facility Administrator, Director of Nursing, Regional Nurse Consultant and Corporate vice President were informed of the findings. The Administrator and Regional Nurse stated the Bed Hold forms should be completed properly prior to having the Resident and/or Responsible Party sign so they would know their responsibility. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, clinical record review,and in the course of a complaint investigation, the facility staff failed to ensure an accurate MDS/RAI assessment was completed for one resident (Resident #217) in a survey sample of 60 residents. Findings included: 1. For Resident # 217, the facility staff failed to complete Section C: Cognitive Patterns in a Quarterly assessment dated [DATE]. Resident # 217 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism, and Morbid Obesity with BMI (Body Mass Index) 60-69. Review of the clinical record was conducted on 9/12/2022-9/22/2022. Review revealed the most recent MDS (Minimum Data Set) assessment was a Quarterly Assessment with an ARD of 9/16/2021. Review of Section C for Cognitive Patterns revealed Section C0100 asked the question if a Brief Interview for Mental Status (Section C0200-C0500) be conducted. The facility staff answered yes. Further review of the MDS revealed dashes in several sections in Section C for Cognitive Patterns. Sections C0200-C0500 were documented as not assessed. The next section C0600- Should staff assessment be conducted? not assessed. C0700-Short Term Memory- not assessed. C0800-Long Term Memory-not assessed. C0900- Memory Recall Ability- Staff answered no to all of the questions regarding A. Current Season, B. location of own room, C. staff names and faces, and D. that he or she is in a nursing home . and Z. none of the above recalled. C1000- Cognitive Skills for Daily Decision Making-not assessed. Review of the MDS Annual Assessment with an ARD of 12/24/2020 revealed Section C was completed and Resident # 217 was coded with a BIMS score of 15 indicating no cognitive impairment. Throughout the clinical record in the nurses progress notes and physicians progress notes, there was documentation that Resident # 217 was alert and oriented x 3 (person, place and time). On 9/14/2022 at 2:10 p.m., an interview was conducted with the Regional Nurse Consultant who stated the entire MDS should be completed. The Regional Nurse Consultant stated the MDS was an important assessment tool. She stated the section on Cognition was important to determine if there was any cognitive impairment and would help to guide the care plan. On 9/14/2022 at 2:20 p.m., an interview was conducted with the MDS Coordinator who stated it was important to complete all sections of the MDS. She stated she did not know why the Section C had not been completed. The MDS Coordinator stated she would review Resident # 217's record to determine what happened. There was no BIMS (Brief Interview for Mental Status Score) calculated due to the assessment not being completed as indicated by the dashes. Guidance was provided in Long Term Care Facility Resident Assessment User's Manual Version 3.0 May 2013, p. C-3. An excerpt read: Steps for Assessment 1. Determine if the resident is rarely/never understood verbally or in writing. If rarely/never understood, skip to C0700 - C1000, Staff Assessment of Mental Status. 2. Review Language item (A1100), to determine if the resident needs or wants an interpreter. If the resident needs or wants an interpreter, complete the interview with an interpreter . Coding Instructions Record whether the cognitive interview should be attempted with the resident. Code 0, no: if the interview should not be attempted because the resident is rarely/never understood, cannot respond verbally or in writing, or an interpreter is needed but not available. Skip to C0700, Staff Assessment of Mental Status . Code 1, yes: if the interview should be attempted because the resident is at least sometimes understood verbally or in writing, and if an interpreter is needed, one is available . Proceed to C0200, Repetition of Three Words. CMS's RAI Version 3.0 Manual CH 3: MDS Items [C] May 2013 Page C-2 . C0100: Should Brief Interview for Mental Status Be Conducted? (cont.) Coding Tips . If the resident needs an interpreter, every effort should be made to have an interpreter present for the BIMS. If it is not possible for a needed interpreter to participate on the day of the interview, code C0100 = 0 to indicate interview not attempted and complete C0700-C1000, Staff Assessment of Mental Status, instead of C0200-C0500, Brief Interview for Mental Status. Includes residents who use American Sign Language (ASL). C0200-C0500: Brief Interview for Mental Status (BIMS) . Almost all MDS 3.0 items allow a dash (-) value to be entered and submitted to the MDS QIES ASAP system. - A dash value indicates that an item was not assessed. This most often occurs when a resident is discharged before the item could be assessed. - Dash values allow a partial assessment to be submitted when an assessment is required for payment purposes . All items for which a dash is not an acceptable value can be found on the CMS MDS 3.0 Technical Information web page at the following link: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html The Administrator, DON (Director of Nursing), and Corporate Consultants were informed of the failure of the staff to complete Section C100-C1000 accurately for a quarterly MDS during the end of day debriefing on 9/21/2022. No further information was provided. COMPLAINT DEFICIENCY .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations, Staff interview, and clinical record review, facility staff failed to refer 1 Resident (Resident #77) with a serious mental illness for a level 2 PASARR, in a survey sample of 60 Residents. The findings included: For Resident #77 a PASARR II was not completed despite diagnoses of serious Mental Illness, schizophrenia, Bipolar I & II, delusions, psychosis, Cyclothymic disorder, psychotic disorder, behaviors, and behavior management. Resident #77 was readmitted on [DATE]. Diagnoses included the above, as well as, Diabetes, Hyperlipidemia, anemia, heart failure and renal insufficiency. The most recent Minimum Data Set (MDS) Assessment was a quarterly Assessment with an Assessment Reference Date (ARD) of 8-12-2020. The Brief Interview for Mental Status scored as 11 of a possible 15, indicating mild cognitive impairment. On 9-15-22, a review of Resident #77's record was conducted. The diagnoses associated with the Resident's serious mental illness were noted. The Director of Nursing (DON) was asked to located Resident #77's Pre-admission Screening and Resident Review (PASARR) Level I and/or Level II. The DON returned with a PASARR I which was incomplete, and stated that a Level II should have been completed, however, had not been completed. On 9-16-22 at the end of day debrief the Administrator and Director of Nursing were informed of the findings, and stated they had nothing further to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility documentation, facility staff failed to ensure PASRR (Pre-admission Screening and Resident Review) prior to admission, for 1 Resident (#34) in a survey sample of 60 Residents. The findings included: For Resident #34 the facility staff failed to ensure a PASRR was completed prior to his admission on [DATE]. On 9/13/22 a review of the clinical record revealed that Resident #34 did not have a completed PASRR on admission. The Social Worker at the facility completed the PASRR after he arrived at the facility, however, she did not complete the PASRR. The Social Worker completed boxes 1-4 however she did not complete box #5 which is the box that read: Recommendation (either a or b must be checked) She did not check either a (recommending a level 2) or b (stating why a level 2 was not appropriate for this resident). On the morning of 9/15/22 the Social Worker was interviewed and she was asked if the PASRR is complete and she stated that it was not. When asked why it was not filled out completely she stated that she did not know why it was blank. When asked if she signed it she stated that she had. On 9/16/22 during the end of day meeting the Administrator was made aware of the findings and no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation the facility staff failed to develop and implement a baseline care plan that includes instructions needed to provide and effective person-centered care for 1 Resident (#34) in a survey sample of 60 Residents. The Findings included; For Resident # 34 the facility staff failed to address the Resident's lack of communication as he does not speak English. On 9/12/22 at approximately 2:00 PM an interview was conducted with Resident #34's son. Resident #34's son stated that his father did not speak English. When asked how he communicates with the facility staff he stated, he doesn't. He stated that he has to speak for his father because his father cannot speak English. When asked if they had given the Resident some kind of pictures to show what he needs like food, drink, or toilet. He stated that he has been in the facility every day and has not seen anyone use communication board since his admission on [DATE]. On 9/14/22 an interview was conducted with CNA F who stated that she knows the Resident doesn't speak English but she goes in and cleans him up and feeds him. When asked how they know what he wants or if he needs a nurse she stated she has not come upon that situation, but if he were in distress or pain she would notify the nurse. On the morning of 9/15/22 an interview was conducted with the DON stated that all departments were represented in the care plan. When asked what should be addressed in the care plan she stated that anything the Resident required to care for him should be in the care plan. When asked if language and communication should be addressed for a Resident who is unable to speak English or unable to speak at all and she stated that it should. When asked for a facility policy on Communication she stated we don't have one, however the Resident Rights Policy read: Page 3 Residents have the right to: vii. Receive proper medical care including but not limited to: 1. To be fully informed about their total health status in a language the resident understands A review of the care plan revealed that communication was not addressed at all. It was not in the care plan that the Resident did not speak English. They did not initiate the use of a communication board until after 9/16/22 when it was addressed to the facility DON. On 9/16/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was made available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and/or implement a comprehensive care plan for 3 Residents (Resident #90, Resident #23, Resident #34) in a sample size of 60 Residents. The findings included: 1. For Resident #90, the facility staff failed to include Activities of Daily Living on the comprehensive care plan. On 09/13/2022 at 9:30 A.M., Resident #90 was observed asleep in her bed with the head of the bed elevated approximately 60 degrees. Resident #90 had a plaid clothing protector on with food particles on it. The tray table with the breakfast tray was positioned over the bed and in front of Resident #90. All the food had been eaten off the plate. There was no staff in the room. At 9:36 A.M., Certified Nursing Assistant N (CNA N) entered Resident #90's room, took the tray off the tray table, exited the room, and placed the tray on the cart in the hall. CNA N then re-entered Resident #90's room, walked past Resident #90, and took the roommate's tray to the cart in the hall. CNA N then proceeded to the adjacent room and removed those breakfast trays. At 9:50 A.M., Resident #90 was observed still sleeping with the head of the bed elevated approximately 60 degrees, and the plaid clothing protector on with food particles on it. At 10:00 A.M., CNA N was interviewed. When asked about the process of assisting a Resident after mealtime, CNA N stated that afterwards, she would assist the resident to clean their face, hands, and mouth. When asked why Resident #90 still had a clothing protector on, CNA N stated that she should have taken it off after the meal. When asked why, CNA N stated it's for dignity and make sure she's clean. CNA N then entered Resident #90's room, observed Resident #90 with the clothing protector on, and left the room and headed down the hall stating she was going to get help so Resident #90 could be toileted. CNA N did not remove the clothing protector at that time. On 09/14/2022, Resident #90's clinical record was reviewed. Resident #90's quarterly Minimum Data Set with an Assessment Reference Date of 08/23/2022 coded the functional status for eating as requiring extensive assistance from staff. The Brief Interview for Mental Status was coded as 3 out of 15 indicative of severe cognitive impairment. The care plan was reviewed. There was not a focus, goals, or interventions on the care plan associated with Activities of Daily Living. On 09/13/2022 at approximately 5:30 P.M., the Administrator and Director of Nursing (DON) were notified of findings. When asked about the expectation, the DON stated that if a resident is assisted with eating, the staff should clean up the resident and make sure they are comfortable. The facility staff provided a copy of their policy entitled, Plan of Care Overview. Under the header Policy, an excerpt documented, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. 2. For Resident #23, the facility staff failed to address her contracture on the comprehensive care plan. On 09/20/2022 at 2:55 P.M., Resident #23 was observed in her bed. Resident #23 had a contracture of her left upper extremity and there was no positional device observed. At approximately 2:57 P.M., Certified Nursing Assistant Q (CNA Q) was interviewed. When asked about a positional device for Resident #23, CNA Q stated that Resident #23 has one but she hates it and she always throws it away. When asked where the device was located, CNA Q looked around the room and found it in the closet. CNA Q did not attempt to apply the device but put it back in the closet. On 09/20/2022 at 3:02 P.M., the Director of Rehab was interviewed. When asked about the dates of service for therapy for Resident #23, the Director of Rehab referred to Resident #23's clinical record and stated the dates of service were 06/28/22 to 09/15/2022. When asked about therapy recommendations at the conclusion of her therapy care, the Director of Rehab stated that therapy recommended a positional device for her left upper extremity. When asked if Resident #23 tolerates the device, the Director of Rehab stated that She tolerated it really well, some days better than others. At 3:09 P.M., this surveyor and the Director of Rehab entered Resident #23's room to do an observation. The Director of Rehab retrieved the positional device from the closet and positioned it on Resident #23's left upper extremity. Resident #23 tolerated the application of the positional device. At 3:19 P.M., Resident #23 was observed awake in bed still wearing the device. On 09/20/2022, the facility staff provided a copy of Resident #23's Occupational Therapy notes. On the Occupational Therapy Discharge summary dated [DATE] under the header Patient Response an excerpt documented, Patient tolerating orthotics well. No large gains in ROM [range of motion] however decreased skin to skin contact and risk of skin breakdown and further contracture. Under the header, D/C Recs [discharge recommendations] an excerpt documented, placement of LUE [left upper extremity] orthotics (UE [upper extremity] device and palm protector . On 09/21/2022, Resident #23's clinical record was reviewed. There were no physician's orders for a positional device for Resident #23's left upper extremity. The care plan was reviewed. There was no focus, goals, or interventions pertaining to Resident #23's left upper extremity contracture. On 09/21/2022 at approximately 4:15 P.M., the Administrator and Director of Nursing were notified of findings. When asked about the expectation, the Director of Nursing indicated contracture management should be on the care plan. On 09/22/2022 at 10:45 A.M., the Director of Rehab was interviewed. When asked about the process for therapy recommendations upon discharge from services, the Director of Rehab stated that therapy staff will enter the orders into the electronic health record. When asked why Resident #23 did not have orders for the therapy-recommended orthotic, the Director of Rehab stated, It just got missed. The facility staff provided a copy of their policy entitled, Plan of Care Overview. Under the header Policy, an excerpt documented, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. 3. For Resident #34 the facility failed to develop and implement a comprehensive person-centered care plan that includes methods of communication for non-English speaking Resident who has also had a stroke. On 9/12/22 during initial tour of the facility an interview was conducted with Resident #34's son. Resident #34's son stated that his father did not speak English. When asked how he communicates with the facility staff he stated, he doesn't. He stated that he has to speak for his father because his father cannot speak English. When asked if they had given the Resident some kind of pictures to show what he needs like food, drink, or toilet. He stated that he has been in the facility every day and has not seen anyone use communication board since his admission on [DATE]. On 9/14/22 an interview was conducted with CNA F who stated that she knows the Resident doesn't speak English but she goes in and cleans him up and feeds him. When asked how they know what he wants or if he needs a nurse she stated she has not come upon that situation, but if he were in distress or pain she would notify the nurse. On 9/14/22 at approximately 2:30 PM an interview was conducted with LPN D who stated that if she had a patient that could not speak English, she would use translator phone number. When asked how she would know what language the Resident spoke she said it's in the admission paperwork and it should be in is care plan. A review of the comprehensive care plan revealed that the Communication needs of Resident #34 were not addressed in the comprehensive care plan. On 9/14/22 a review of the clinical record was conducted the following are excerpts from the record: A review of the admission Assessment page 2 read: 2. Cognitive Status / Orientation 1. Able to report correct year (box checked) x Not assessed 2. Able to report correct month (box checked) x Not assessed 3. Able to report correct day of the week (box checked) x Not assessed 4. Verbalizes or demonstrates use of (select all that apply) (Box checked) x Call bell/light 5. Is English primary language? (Box checked) x NO 6. Primary language (No box checked area left blank) On 9/16/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was made available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility record review, the facility staff failed for 1 resident (Resident #119) to provide the resident with a discharge plan that met the needs of the Resident, in a survey sample of 60 Residents. The facility failed to involve, evaluate, and provide Resident #119 with an interdisciplinary discharge plan. No community services were planned, no written discharge instructions were planned, nor given to the Resident, and no medical equipment was obtained for discharge home. The Findings included: Resident #119 was admitted to the facility on [DATE] and discharged home on 7-8-22 (6 weeks later). Resident #119's diagnosis included; Heart disease, Heart Failure, Diabetes, chronic kidney disease, stroke, obesity, a sacral pressure sore, and hypertension. The most recent Minimum Data Set (MDS), which was a 30-Day Assessment was reviewed and coded Resident #119 as having intact cognition. The Resident was his own responsible party. On 9-21-22, a review was conducted of Resident #119's clinical record. The Resident discharged home on 7-8-22. There was no record of discharge planning, no discharge plan completed in the care plan nor in the therapy notes, and the doctor and therapists were notified after the Resident was discharged that he had been discharged . The last nursing progress note prior to discharge was written by the day shift nurses on 7-7-22 at 1:40 PM, and 2:30 p.m., stating that the Resident had changed rooms (no documented reason was given), and that no new skin issues were assessed, and healed. The Resident had 2 pressure areas which were not healed. No location for the nursing assessment of healed, was given. On 9-21-22 Physical therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) notes were reviewed and revealed that on 7-7-22 Resident #119 has progressed with all 3 therapies and improvements were noted, however, the Resident required more time in therapy to reach the goals to move home safely. The Resident required minimal assistance with dressing, moderate assistance with toileting, contact guard assist with transfering to a toilet from a wheel chair using a scooting/bridging/sliding technique with a walker. The Resident was receiving therapy instruction on safe techniques with adaptive equipment for bed mobility, balance, energy conservation, safety in transitional movements, and safe use of durable medical equipment that would be needed/ordered upon discharge. The Resident was documented as continuing to have difficulty with peri care (incontinence care). On 7-7-22 the therapy evaluations stated that continued therapy was needed to reach goals of limited assistance needed at home, and were recommended to be continued 5 times per week, for 4 more weeks to meet goals to return home. The Resident lived alone and had only Friends who lived 30-35 minutes away from the Resident and would only be Stopping by at times to assist. The Resident was documented as stating that when a date for discharge was planned he would contact his middle son to fly in from California to assist him upon his discharge. This indicated that home health would also be necessary upon discharge. The projected insurance date for discharge at that time was 7-14-22, and another application to the Resident's insurance would be needed to extend his Rehab time. No further therapy nor insurance communication was documented by the facility regarding this Resident and an interview with the Social Worker was requested by surveyors. On 9-21-22 an interview with the Social worker was conducted and revealed that the Regional Insurance Case Manager for the facility's parent company did not submit for further stay insurance authorization for Resident #119, and he was notified on 7-7-22 that his room would change and he would need to pay for the stay out of pocket as his insurance coverage would end on that very day (7-7-22). The Resident stated he needed home health and medical equipment and he would have to discharge as he was unable to pay out of pocket for the stay. Resident #119 discharged in a Taxi cab he called for himself, without a discharge plan, or home health services, or medical equipment to travel from [NAME] Virginia to Maryland alone on 7-8-22. Facility documents were reviewed and revealed that on 6-30-22 the Regional Insurance Case Manager for the facility's parent company corresponded via email with the Rehabilitation Director, and asked what support the Resident would require as to home health upon discharge. The email was forwarded to the Social Services Assistant who replied that Resident #119 would be moving home alone to Maryland and would need home health services. The Resident stated he would need to be ambulating well so that he could do his stairs safely at home. The resident required (2) 2 wheeled walkers, one for upstairs and 1 for downstairs, a raised toilet seat, a hospital bed, and a wheelchair. The final documentation in the clinical record was written on 7-12-22 (4 days after the Resident discharged ) by the Social worker in a progress note which stated the Resident left AMA (against medical advice). The facility policy on discharge (D/C) planning was requested and received. The policy stated the following; The discharge process will begin with 72 hours of admission, planning will involve residents needs for assistance with activities of daily living, meals, ambulation, transportation medications, primary care physician follow up, home health, home care, outpatient/community outreach services. The resident and or their representative will be active participants in the D/C planning process. The plan will be reviewed by the Resident or representative weekly and Social services will update the plan. Within 6 days of discharge the Social Services Department will ensure all portions of the plan are completed, and after completion the plan will be printed and signed by the Resident or representative. A copy of the signed plan will be kept in the medical chart and a copy will be given to the Resident or Resident representative. There was no discharge plan completed in the clinical record, there was no discharge plan in the care plan, and no discharge recapitulation of stay was in the clinical record from the physician. The Administrator and Director of nursing were asked for these documents, and stated there are none. On 9-21-22 at the end of day debriefing the facility administration was made aware of the deficient practice. They stated they had nothing further to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility record review, the facility staff failed for 1 resident (Resident #119) to provide a recapitulation of the Resident's stay upon discharge, in a survey sample of 60 Residents. The facility failed to document a recapitulation of the Resident's stay in the clinical record after his discharge. The Findings included: Resident #119 was admitted to the facility on [DATE] and discharged home on 7-8-22 (6 weeks later). Resident #119's diagnosis included; Heart disease, Heart Failure, Diabetes, chronic kidney disease, stroke, obesity, a sacral pressure sore, and hypertension. The most recent Minimum Data Set (MDS), which was a 30-Day Assessment was reviewed and coded Resident #119 as having intact cognition. The Resident was his own responsible party. On 9-21-22, a review was conducted of Resident #119's clinical record. The Resident discharged home on 7-8-22. There was no record of discharge planning, no discharge plan completed in the care plan nor in the therapy notes, and the doctor and therapists were notified after the Resident was discharged that he had been discharged . On 9-21-22 Physical therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) notes were reviewed and revealed that on 7-7-22 Resident #119 has progressed with all 3 therapies and improvements were noted, however, the Resident required more time in therapy to reach the goals to move home safely. The Resident was receiving therapy instruction on safe techniques with adaptive equipment for bed mobility, balance, energy conservation, safety in transitional movements, and safe use of durable medical equipment that would be needed/ordered upon discharge. The Resident was documented as continuing to have difficulty with peri care (incontinence care). On 7-7-22 the therapy evaluations stated that continued therapy was needed to reach goals of limited assistance needed at home, and were recommended to be continued 5 times per week, for 4 more weeks to meet goals to return home. Therapists also indicated that home health would also be necessary upon discharge. On 9-21-22 an interview with the Social worker was conducted and revealed that the Regional Insurance Case Manager for the facility's parent company did not submit for further stay insurance authorization for Resident #119, and he was notified on 7-7-22 that his room would change and he would need to pay for the stay out of pocket as his insurance coverage would end on that very day (7-7-22). The Resident stated he needed home health and medical equipment and he would have to discharge as he was unable to pay out of pocket for the stay. Resident #119 discharged in a Taxi cab he called for himself, without a discharge plan, or home health services, or medical equipment to travel from [NAME] Virginia to Maryland alone on 7-8-22. Facility documents were reviewed and revealed that on 6-30-22 the Regional Insurance Case Manager for the facility's parent company corresponded via email with the Rehabilitation Director, and asked what support the Resident would require as to home health upon discharge. The email was forwarded to the Social Services Assistant who replied that Resident #119 would be moving home alone to Maryland and would need home health services. The Resident stated he would need to be ambulating well so that he could do his stairs safely at home. The resident required (2) 2 wheeled walkers, one for upstairs and 1 for downstairs, a raised toilet seat, a hospital bed, and a wheelchair. The final documentation in the clinical record was written on 7-12-22 (4 days after the Resident discharged ) by the Social worker in a progress note which stated the Resident left AMA (against medical advice). The facility policy on discharge (D/C) planning was requested and received. The policy stated the following; The discharge process will begin with 72 hours of admission, planning will involve residents needs for assistance with activities of daily living, meals, ambulation, transportation medications, primary care physician follow up, home health, home care, outpatient/community outreach services. The resident and or their representative will be active participants in the D/C planning process. The plan will be reviewed by the Resident or representative weekly and Social services will update the plan. Within 6 days of discharge the Social Services Department will ensure all portions of the plan are completed, and after completion the plan will be printed and signed by the Resident or representative. A copy of the signed plan will be kept in the medical chart and a copy will be given to the Resident or Resident representative. A recapitulation of the stay would be documented in the medical record. There was no discharge plan completed in the clinical record, there was no discharge plan in the care plan, and no discharge recapitulation of stay was in the clinical record from the physician. The Administrator and Director of nursing were asked for these documents, and stated there are none. On 9-21-22 at the end of day debriefing the facility administration was made aware of the deficient practice. They stated they had nothing further to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide necessary care and services to ensure Residents have the means to communicate with others for 3 Residents (Resident #78, Resident #318, Resident #34) in a sample size of 60 Residents. The findings included: 1. For Resident #78 (whose primary language is not English), the facility staff failed to provide interpretive services as a means to effectively communicate. On 09/12/2022 at 12:45 P.M., Resident #78 was observed in bed awake. When I asked if she had any concerns about the care received at the facility, Resident #78 motioned to their neck and pointed to her roommate, Resident #38. Roommate (Resident #38) stated that [Resident #78] cannot speak but responds to yes/no questions. The Roommate (Resident #38) also stated that [Resident #78]'s primary language is not English. This surveyor observed there were no communication aids in the room and no information about a language line was observed. The roommate (Resident #38) was asked if staff used interpreter to communicate with Resident #78, and the roommate stated staff sometimes ask her to interpret because she can also speak Resident #78's primary language. When asked what she is asked to interpret, the roommate Resident #38 stated, I let them know what food she doesn't like or I let them know when she has an upset stomach. On 09/13/2022, Resident #78 clinical record was reviewed. Under the Assessment tab in the electronic health record, there was no evidence Resident #78's understanding of the English language was assessed. According to the Face Sheet under the section Primary Language, it was documented, English. According to the admission Evaluation dated 09/13/2017 under the section entitled, Communication, the choices were English or Other. The option Other was selected and Spanish was written in the text box. A focus on the care plan initiated on 09/20/2017 entitled, [Resident #78] has a communication problem r/t Expressive Aphasia, Language barrier, Anarthria and dysarthria documented the following interventions: Anticipate and meet needs. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Ensure/provide a safe environment: Call light in reach, adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Another focus on the care plan was entitled, [Resident #78] is a native (Chilies, Mexican, etc.) and English is the her [sic] second language. The language barrier may limit participation during programs. Interventions associated with this focus were the following: Assess previous and current leisure interests and lifelong routines. [Resident #78] enjoys attending religious services and will be added to church list .Invite, remind and encourage to activities of stated interests as requested and tolerated. Offer and support according to needs and preferences: (life review activities, quality time with chosen relatives, friends, staff, other residents, spiritual support, touch, massage, music of preference, reading aloud, reading of preference, etc.). Offer social, recreational and volunteer visits within her tolerance and preferences. Provide and review monthly calendar with resident, offer alternatives that can be done individually. Provide one-on-one visits (in the room, at bedside, etc.) to stimulate senses and provide contact, target supportive programs such as (listening to relaxing music, hand massage, relaxation techniques). Respect her right to refuse groups and set own leisure routine. Staff will invite, remind and escort to programs of interests. Another focus on the care plan dated 04/25/2022 entitled, [Resident #78] has a communication problem r/t [related to] other disease process / condition had the following interventions: Observe effectiveness of communication strategies and assistive devices. Observe for declines in communication. Observe/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. There were no interventions on the care plan addressing how to effectively communicate with Resident #78. On 09/14/2022 at 9:30 A.M., this surveyor observed Licensed Practical Nurse H (LPN H) administer medications to Resident #78. As this surveyor and LPN H entered the room, Resident #78 grimaced, held up 2 fingers, then pointed to her abdomen. As LPN H offered the Colace (a laxative), Resident #78 motioned with her hand and shook her head no. LPN H spoke to Resident #78 in English and asked Resident #78 if she was having loose stools and Resident #78 nodded her head yes and held up 2 fingers. LPN H asked Resident #78 if she had 2 loose stools and Resident #78 nodded her head yes. LPN H returned to the medication cart after the med pass and stated to this surveyor that Resident #78 had anti-diarrheal available to administer as needed. When asked how staff communicate with Resident #78, LPN H stated that staff don't use an interpreter because [Resident #78] cannot speak and she understands English. LPN H then approached Certified Nursing Assistant H (CNA H) and asked if Resident #78 had loose stools this day. CNA H stated that Resident #78 has not had a bowel movement this day. When asked how staff communicate with Resident #78, CNA H stated, We've been around her a long time; we just know what she is saying. LPN H then saw the nurse practitioner (Employee FF) in the hall and informed her of the loose stools. The nurse practitioner then started walking toward Resident #78's room. This surveyor asked to observe the nurse practitioner interact with Resident #78. The nurse practitioner stated, Do you have to be there? I'll be asking [Resident #78] a lot of questions. The nurse practitioner then turned to the nurse (LPN H) and stated she would need an interpreter. LPN H walked down to the nurse's station to ask the unit manager about an interpreter. LPN H returned and stated that the unit manager, Registered Nurse C (RN C), went to the basement to get an interpreter. On 09/14/2022 at 10:15 A.M., the Assistant Director of Nursing, RN E, was interviewed. When asked how staff communicate with Resident #78, the Assistant Director of Nursing (ADON) indicated she didn't know and stated Let me get that information for you. The ADON then stated that she would go to an interpretation site on the internet. At approximately 10:18 A.M., CNA O was asked how staff communicate with Resident #78 and CNA O stated that there are two housekeepers that speak the same language as Resident #78. The staff were identified and placed in staff identifier as Employee Q, a laundry aide and Employee R, a housekeeper. On 09/14/2022 at 10:21 A.M., LPN H provided a document entitled, Language Line with a phone number and PIN. On 09/14/2022 at 10:30 A.M., the ADON provided a copy of another document entitled, Language Line with a different phone number and PIN. The ADON stated that this was the correct one because she got it from the social worker. On 09/15/2022 at 9:20 A.M., Employee Q was interviewed. When asked if the staff ask her to interpret for Residents, Employee Q stated that sometimes she would interpret but I only speak alittle bit of English. When asked how often she serves as interpreter, Employee Q indicated she didn't understand the question and wanted to get her supervisor to interpret the question. On 09/15/2022 at 9:30 A.M., Employee R was interviewed. When asked if staff ask her to interpret, Employee R stated that the nurses ask her to interpret. Employee R also stated that she is not fluent in English but understands a little bit. When asked which Residents she serves as interpreter, Employee R stated Resident #78's name and Resident #6 in the sample. Employee R stated that sometimes Resident #6 will say she has pain in her leg or hip. Employee R stated Resident #6 speaks no English. When asked about Resident #78, Employee R stated that when she is interpreting for Resident #78, sometimes she will need medication. Employee R stated that Resident #78 Doesn't talk, only answers yes/no questions. I will ask her questions and she will answer. Employee R stated that she interprets when the doctor is seeing her and sometimes the nurses will ask me to go in there and check on her. On 09/15/2022 at approximately 6:45 P.M., the Administrator and Director of Nursing were notified of findings. On 09/20/2022 at approximately 10:35 A.M., Employee T, a physician, was interviewed. When asked how she communicates with Resident #78, the physician stated she asks the roommate to interpret sometimes or usually a maintenance person will do it. The physician also stated that she can speak a little bit of Resident #78's language but it was more difficult to understand her. The physician stated that Resident #78 points things out .points to things. When asked how long she had been caring for Resident #78, the physician indicated she has been seeing Resident #78 for 2 years. On 09/21/2022 at approximately 3:45 P.M., a copy of the facility's communication policy was requested and the Corporate Clinical Registered Nurse, Employee D, stated that they do not have a communication policy. The facility staff provided a copy of their policy entitled, Resident Rights. In Section (II)(a)(vii), it was documented, Residents have a right to: receive proper medical care including but not limited to: To be fully informed about their total health status in a language the resident understands. 2. For Resident #318 (whose primary language is not English), the facility staff failed to provide interpretive services as a means to effectively communicate. On 09/12/2022 at 3:50 P.M., Resident #318 was observed awake in her bed. When asked if she had any concerns about the care received at the facility, Resident #318 spoke in a foreign language. There were no communication aids or language line number observed at the bedside. On 09/13/2022, Resident #318's clinical record was reviewed. Under the Assessment tab in the electronic health record, there was no evidence Resident #318's understanding of the English language was assessed. According to the Face Sheet under the section Primary Language, it was documented, Hindi. According to the admission Evaluation dated 08/31/2022 under Section 5 entitled, Is English primary language? the answer no was selected. In Section 5a entitled, Primary Language it was documented, Paru. Under the Miscellaneous tab in the electronic health record, there was a scan entitled, admission info. A document form another facility entitled, admission Record Report documented that Resident #318's primary language was Farsi. Resident #318's care plan did not have a focus, goals, or interventions addressing Resident #318's primary language and communication management to effectively communicate with Resident #318. On 09/21/2022 at 9:55 A.M., Resident #318 was observed with a visitor at the bedside. The visitor indicated she was a family friend and visits often in the morning-time. When asked about Resident #318's primary language, the family friend stated Urdu. When asked about Resident #318's ability to understand/communicate in English, the family friend stated that Resident #318 understands some English, but not everything. The family friend also stated that Resident #318 can speak a few words in English. When asked how the staff communicated with Resident #318, the family friend stated she didn't know because they're not here when I'm here. On 09/21/2022 at approximately 10:00 A.M., Certified Nursing Assistant W (CNA W) was interviewed. CNA W verified she was assigned to care for Resident #318. When asked for Resident #318's primary language, CNA W indicated she didn't know. CNA W then stated that Resident #318 sometimes speak English but she is not fluent. On 09/21/2022 at approximately 10:05 A.M., Registered Nurse D (RN D) was interviewed. RN D verified she was assigned to care for Resident #318 this day. When asked for Resident #318's primary language, RN D stated that she didn't know and added that she doesn't speak much English. When asked how she communicates with Resident #318, RN D stated that she understands when we talk with her. RN D also stated that the family friend that visits in the morning will help as well. On 09/21/2022 at approximately 4:15 P.M., the Administrator and Director of Nursing were notified of findings. 3. For Resident #34 the facility staff failed to provide adequate means for communication for a non-English speaking Resident who has suffered a stroke. On 9/12/22 at approximately 2:00 PM an interview was conducted with Resident #34's son. Resident #34's son stated that his father did not speak English. When asked how he communicates with the facility staff he stated, he doesn't. He stated that he has to speak for his father because his father cannot speak English. When asked if they had given the Resident some kind of pictures to show what he needs like food, drink, or toilet. He stated that he has been in the facility every day and has not seen anyone use communication board since his admission on [DATE]. On 9/14/22 an interview was conducted with CNA F who stated that she knows the Resident doesn't speak English but she goes in and cleans him up and feeds him. When asked how they know what he wants or if he needs a nurse she stated she has not come upon that situation, but if he were in distress or pain she would notify the nurse. On 9/14/22 at approximately 2:30 PM an interview was conducted with LPN D who stated that if she had a patient that could not speak English, she would use translator phone number. When asked how she would know what language the Resident spoke she said it's in the admission paperwork and it should be in is care plan. On the morning of 9/15/22 an interview was conducted with the DON who was asked what they would do if a Resident did not speak she stated they would use a communication board with pictures to identify needs such as water, toilet, and food. When asked if Resident #34 was provided such she stated that she did not know. When asked for a facility policy on Communication she stated we don't have one, however the Resident Rights Policy read: Page 3 Residents have the right to: vii. Receive proper medical care including but not limited to: 1. To be fully informed about their total health status in a language the resident understands On 9/15/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided

3. Resident #35, who required staff assistance, was not assisted by facility staff to shave following his request. On 9/13/22 at 8:15 AM, during an interview with Resident #35, the Resident asked, What do you have to do to get a shave around here, do I need to arrange for my wife to take me to the barber? Surveyor B let LPN B know of Resident #35's request to be shaved. LPN B said she would let the CNA know. Surveyor B then saw the assigned CNA, CNA H and let her know of Resident #35's request to be shaved. On 9/13/22, at 9:28 PM, Resident #35 was observed sitting on the edge of his bed. Surveyor B went in and talked with Resident #35 and observed that he had not been shaved as he had previously requested. On 9/14/22 at 9:30 AM, Resident #35 was visited in his room. Resident #35 identified CNA D by first name and said she had shaved him that morning. On 9/14/22 at approximately 9:40 AM, an interview was conducted with LPN B. When asked when Residents are shaved, LPN B said, During their shower, upon request or as needed. On 9/14/22 at approximately 9:45 AM, an interview was conducted with CNA E. CNA E was asked about the schedule for shaving Residents. CNA E said, There is no schedule, we shave everyday. The facility policy titled, Routine Resident Care was reviewed. This policy read, It is the policy of this facility to promote resident centered care by attending to the physical emotional, social, and spiritual needs and honor resident lifestyle preferences while in the care of this facility .3. b. Routine care by a nursing assistant includes but is not limited to the following: i. Assisting or provides for personal care . On 9/14/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the facility staff not assisting Resident #35 with shaving after his request was made known to two nursing staff. The DON stated, When they give a shower they shave them or as needed. Upon request if they request it, the CNA would finish what they are doing and then shave the Resident or at least on that shift. This is not acceptable at all, I'm starting to hold people accountable right now! No additional information was provided. Based on observations, Resident interviews, staff interviews, clinical record reviews, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide necessary services to maintain grooming and personal hygiene for 3 Residents (Resident #38, Resident #34 and Resident #35) in a sample size of 60 Residents. The findings included: 1. For Resident #38, the facility staff to provide showers for her in August and September 2022 which was her personal preference. On 09/13/2022, the facility staff provided a copy of their policy entitled, Routine Resident Care. In Section (3)(a)(b)(i)(1) documented, Provide routine daily care by a certified nursing assistant under the supervision of a licensed nurse. (b) Routine care by a nursing assistant includes but is not limited to the following (i) assisting or provides for personal care (1) bathing. On 09/20/2022 at 11:30 A.M., Resident #38 was interviewed. When asked about receiving assistance with bathing, Resident #38 stated she gets bed baths but would really prefer a shower. Resident #38 stated she had not received a shower in a long time. Resident #38 pointed to the sign on the wall which indicated her shower days should be Monday and Thursday in the afternoon but they don't do it. On 09/21/2022, Resident #38's clinical record was reviewed. Resident #38's quarterly Minimum Data Set with an Assessment Reference Date of 07/16/2022 coded the Brief Interview for Mental Status as 13 out of 15 indicative of intact cognition. Resident #38's care plan was reviewed. A focus entitled, [Resident #38] ADL Self Care Performance deficit, requires assistance with ADL Function Deficit included was not limited to the following intervention: Resident requires assistance with bathing, shower, bed bath. The care plan did not address Resident #38's preference or schedule for showers. According the Activities of Daily Living (ADL) flowsheet for the month of August 2022, Resident #38 received 6 bed baths and one shower. For the month of September 2022 up through 09/19/2022, Resident #38 received 5 bed baths and no showers. On 09/21/2022 at approximately 4:15 P.M., the Administrator and Director of Nursing (DON) were notified of findings. The DON stated the expectation is that residents would receive a bed bath daily and she would look into Resident #38 receiving showers. 2. For Resident #34 the facility staff failed to provide adequate and timely feeding assistance and incontinence care. On 9/12/22 at approximately 2:00 PM Resident #34 was observed in bed resting with his eyes closed he was dressed in a hospital gown and his hair appeared greasy, the head of bed was elevated and a family member at his bedside. At that time an interview was conducted with Resident #34's son. Resident #34's son stated that his father did not speak English. When asked how he communicates with the facility staff he stated, he doesn't. He stated that he has to speak for his father because his father only speaks Korean. He stated his father was completely dependent on staff for all aspects of his daily care. Resident #34's son stated that on more than one occasion he has come in to find his father soaking wet including the sheets. He stated that on many occasions he has come in hours after the meal to find the food tray sitting on the bedside table untouched because his father cannot feed himself. He further stated that he once found the call bell draped over the light above his bed out of his reach. He stated that he reported this to the DON who came in and yelled at the CNA responsible. Resident #34's son stated this made him feel uncomfortable about leaving his father alone at the facility, and is currently seeking out another facility for his father due to the lack of adequate care. On 9/20/22 at approximately 3:00 PM an interview was conducted with CNA D who was asked how often residents receive showers she stated twice a week. When asked how this was documented she stated in Point of Care (electronic health record). When asked what about if a Resident does not get shower just a bed bath, is that only twice a week as well, she stated if a shower is not given twice a week the Resident should be given a daily bed bath. On 9/20/22 a review of the ADL record revealed that Resident had 3 bed baths in last 30 days. On the afternoon of 9/15/22 the Ombudsman met with the Survey Team and she discussed her observations of the lack of cleanliness of the facility and her observations of Residents receiving inadequate incontinent care. The following are some excerpts from that interview: Yesterday I was in visiting [Resident # 57 name redacted], she was uncomfortable, she was laying on a blanket all crumpled up. Someone had thrown a fitted sheet on top of the soiled sheet and the fitted sheet was also soiled. This was about 4:30 PM. I stayed while they fixed it. When asked if she sees that kind of thing frequently at this facility she said Yes, unfortunately I do. On 9/20/22, during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure an environment free from accident hazards for one Resident (Resident #27) of 60 residents in the survey sample. The findings included: For Resident #27 the facility staff failed to supervise a confused known fall risk resident who recently suffered facial fractures as the result of an unwitnessed fall. The Resident was in his room in a geri (reclining) chair with the bedside curtain closed obscuring the Resident from view, no fall mats in place, and his helmet off. Resident #27 was admitted to the facility on [DATE] with diagnoses including; Covid-19, Rhabdomyolysis, Dementia, psychotic disturbance, anxiety, and history of multiple falls. The Resident required total dependence on staff for all activities of daily living. The Resident was able to stand independently. On 9-15-22 at 4:00 p.m. Resident #27 was observed by 2 surveyors alone in his room. The privacy curtain had been closed and the Resident was found behind the curtain obscured from view of the hallway, between the 2 beds in the semi-private room alone. The Resident was sitting in a geri reclining chair, reclined at a 45 degree angle. There were no fall mats on the floor on either side of the chair/bed, and his helmet was on the floor beside him. The call bell was tied on the back of the chair out of his reach, and his bed was in high position beside him. The nurse at the nursing station approached the room and stated, when asked, if it was safe for the Resident to be left here alone in this way, This should absolutely not happen. Resident #27's physician orders, progress notes, and care plan were reviewed. The review revealed that Resident #27 had active physician orders for the following; 1. A sitter 1:1 for safety precautions ordered 6-22-22. 2. Wear protective helmet at all times when out of bed for safety precautions ordered 6-22-22. 3. Hospice ordered 6-29-22. Review of the Care Plan revealed documented falls in 2022 (including 3 with serious injury) on; 1-3-22, 1-8-22, 5-3-22, 6-18-22, and 8-9-22. The Resident sustained a lacerated left eyebrow on 5-3-22, and fractured zygomatic (broken nose) arch on 6-18-22, and hematomas/black right eye, bruised scalp and cheek on 8-9-22. The care plan active treatment modalities included the following active interventions to be carried out by staff; 1. Call bell within reach, instituted 2-22-22. 2. Monitor closely when in wheel chair with other fall risk residents, instituted 3-26-22. 3. Mattress on floor to prevent falling out of bed, instituted 3-28-22. 4. At nursing station when out of bed in wheel chair, and anti lock device to wheel chair, instituted 5-2-22. 5. Place in close observation and monitoring every shift, instituted 6-18-22. 6. 1:1 observation (sitter at all times within sight), instituted 6-19-22. 7. Apply helmet to prevent head injury related to fall, instituted 6-22-22. 8. Floor mats beside bed, non-skid foot wear, to group activities to prevent further falls, instituted 6-23-22. Upon observation of the Resident on 9-15-22 during survey none of the interventions listed were being implemented by staff for a known fall risk Resident who had sustained serious injury due to falls. Supervision was inadequate, and the Resident was at risk for an accident because of known hazards. On 9-15-22 at the end of day debrief, the Administrator and DON were notified of the above findings. The DON stated their was no further evidence to present, and stated that the Resident should not have been left alone.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure services for care of a suprapubic catheter consistent with professional standards of care, the comprehensive care plan and Resident preferences for 1 Resident (#88) in a survey sample of 60 Residents. The findings included: For Resident #88 the facility staff failed to ensure proper and timely care for a suprapubic catheter (a suprapubic catheter is a tube inserted into the bladder through an incision in the abdomen, to drain urine into a collection bag.) On 9/12/22 at 12:00 PM and again on the morning of 9/13/22 Resident # 88 was observed with this suprapubic catheter collection bag hanging from the back of his wheel chair near the handle above his waist height. On 9/13/22 at approximately 10 AM an interview was conducted with Resident #88 and he was asked if it was usual practice for the staff to hang his collection bag for his catheter on the wheel chair handle and he stated that it was. On 9/13/22 at approximately 11:00 AM, during a Resident Council meeting, Resident #88 stated that call bell answer times are still an issue. He further elaborated that what the staff are doing is come by and shut light off and say they'll get your aide or say someone is coming but no one comes. If they do show up it takes a long time for them to come take care of your needs. He indicated this has been an ongoing problem. A review of the facility documentation revealed that on 8/27/22 a Training Sign-In Log was signed by 17 staff members both CNA's and Nurses, on the topics of timely answering of call bells, Perineal Care and ADL care. On 9/12/22 at approximately 12:15 PM CNA E was asked if his bag was hanging correctly and she stated it has got to be up here so it doesn't hit the floor. The following are excerpts from the NIH online article Strategies for Preventing Catheter-associated Urinary Tract Infections. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5998608/] Strict handwashing with soap and water should be done immediately before and after any manipulation of the catheter site or device. Unobstructed flow of urine should be maintained at all times. Indwelling catheter must be properly secured to the patient's thigh to prevent urethral meatus injury. The skin condition around the catheter should be checked regularly and if skin irritation is noted the site must be changed. A sterile, closed unobstructed urinary drainage should be used with indwelling catheters. The collecting bag should be placed below the level of the bladder and off the floor and should be kept and emptied regularly. National Institutes of Health website (https://medlineplus.gov/ency/patientinstructions/000145.htm) read: Check the catheter site a few times a day. Check for redness, pain, swelling, or pus. Wash the area around catheter every day with mild soap and water. Gently pat it dry. Showers are fine. The collecting bag should be placed below the level of the bladder and off the floor and should be kept and emptied regularly. Make sure your bag is always below your waist. This will keep urine from going back into your bladder. Try not to disconnect the catheter more than you need to. Keeping it connected will make it work better. Check for kinks, and move the tubing around if it is not draining. On the afternoon of 9/15/22 the Ombudsman met with the Survey Team and she discussed her observations of the lack of cleanliness of the facility and her observations of Residents receiving inadequate incontinent care. The following are some excerpts from that interview: Yesterday I was in visiting [Resident # 57 name redacted], she was uncomfortable, she was laying on a blanket all crumpled up. Someone had thrown a fitted sheet on top of the soiled sheet and the fitted sheet was also soiled. This was about 4:30 PM. I stayed while they fixed it. When asked if she sees that kind of thing frequently at this facility she said Yes, unfortunately I do. On 9/14/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide comprehensive behavioral health services for one Resident (Resident #68) in a sample of 60 Residents. The findings included: Resident #68 was not receiving supportive therapy as recommended by the Mental Health Nurse Practitioner. Resident #68's clinical record was reviewed. According to Resident #68's quarterly Minimum Data Set with an Assessment Reference Date of 08/02/2022, Resident #68's medical diagnoses included but were not limited to Bipolar disorder. A nurse's note dated 06/01/2022 at 4:53 P.M. documented, Note Text: Writer was called to resident [#68] room by activity staff that the resident pushed his roommate's [Resident #70] face. Immediately writer went to the resident's room and the activity staff said she came to the resident's room to do an assessment on the resident's roommate at about 10:20 am. While the activity staff was conducting her UDA assessment on the resident's roommate who was lying on his bed, the activity staff asked the roommate about the resident, meanwhile, the resident was in the bathroom and he heard the activity staff asking about him. The resident's roommate then said to the activity staff Resident was in the bathroom and he's been there for too long. The resident while in the bathroom came out of the bathroom and started saying he is tired of his roommate and rushed toward roommate and pushed his face. The activity staff tried to stop him and resident rushed to the roommate who was lying on the bed and pushed his face. The resident was accompanied out of the room by the nurse. Head to toe assessment done on the resident's roommate and upon assessment, no bruises, no swelling, no skin tear, no discoloration, no injury, no s/s [signs/symptoms] of trauma noted. The resident also was assessed and no s/s of trauma noted and denies pain. The resident was immediately moved to another room and was separated from the roommate. The resident was asked why he pushed the roommate's face and the resident said 'I am tired of my roommate talking about me.' Resident was calmed at this time and was educated not to put his hand on any resident. Resident [#68] with history and diagnoses of Behavioral with major depressive disorder, bipolar disorder, yelling, complaining and using abusive language. MD [medical doctor] and RP [responsible party] made aware, new ordered [sic] for psych consult and evaluation. 911 was called spoke with officer [name], case number [number] Resident was separated and room changed to another wing on same unit. Resident is been monitored closely for any further behavior. The social worker was called and also spoke with the resident regarding his behavior. The resident remain calmed [sic] and in his new [sic] adjusting well with no complaints at this time. Resident was moved with all his belongings and the resident checked and made sure all his belongings were moved. We will continue with the plan of care. The facility staff provided a copy of three Resident-to-Resident Facility-Reported Incidents (FRI) involving Resident #68 and his roommates: FRI #1) Incident date 09/13/2020 with Resident #322. According to the incident description, there was a loud exchange of words heard by staff between Resident #68 and Resident #322 about whether or not to close the room door resulting in Resident #68 hitting Resident #322 on the back of his head. According to the 5-day follow-up report dated 09/17/2020, an excerpt documented, Education was provided to each resident about respecting other individuals' space and no physical contact without consent from the other individual. FRI #2) Incident date 08/13/2021 with Resident #321. According to the incident description, staff heard Resident #321 shouting that Resident #68 had hit him. Resident #321 was then treated for injury to eye and moved to room on adjacent hall. There were no supporting investigation documents such as written statements from staff, other potential witnesses, or interviews with other Residents. According to the FRI Investigation Summary under the header Summary of Investigation, an excerpt documented, Resident [#68] reported that he went to assist Resident [#321] who was eating from his wheelchair and had some food particles on his shirt. When he bent down to assist him, [Resident #321] hit him in the face, at which time he struck [Resident #321] in the face. The Summary also documented that Resident #321 had significantly impaired vision secondary to glaucoma. The Summary did not include Resident #321's version of events. According to a nurse's note in Resident #321's clinical record dated 08/13/2021 at 2:45 P.M., an excerpt documented, The resident stated, 'My roommate [Resident #68] came too close to my face and I punch him in his face and he also punch me in my face.' FRI #3) Incident date 06/01/2022 with Resident #70. An excerpt of an Activity staff member handwritten statement documented, I went into [room number] to see [Resident #68]. I asked [Resident #70] who was in (Bed A) where is [Resident #68] and [Resident #70] stated that he was in the bathroom-he always in the bathroom. I asked [Resident #68] how long will he be in the bathroom so [Resident #68] came flying out of the bathroom and rushed toward [Resident #70] saying I'm sick and tired of him. I tried to hold [Resident #68] back and he pushed me out of the way and put his hands in [Resident #70]'s face and then pushed his face and [Resident #70]'s head went to the edge of the bed. An excerpt of the Follow-Up Report written by the Director of Nursing dated 06/03/2022 under the section entitled Conclusion documented the following excerpt pertaining to Resident #68: behavior problems of being verbally abusive to staff and other residents, and he is receiving treatment to manage his health conditions. Resident has also been seen by the psychiatric NP [nurse practitioner] related to this behavior problems [sic]. Staffs [sic] will continue to monitor him closely, assist with care as needed, assess for pain, skin and will report any abnormal findings or behavior symptoms to the MD/NP. On 09/15/2022 at 5:30 P.M., the Ombudsman reported to the survey team that she heard Resident #68 verbally abuse his roommate with threat of physical harm at approximately 5:10 P.M. on 09/15/2022. On 09/15/2022 at 6:15 P.M., the Administrator, the Director of Nursing, and the Social Worker were notified of the Ombudsman's observation and the Administrator stated he had not been notified of the incident. When asked about Resident #68's altercations with roommates, the Social Worker stated the first altercation was with (Resident #321) and afterwards, Resident #68 was moved into a room with (Resident #77). The Social Worker then stated that staff started to see that they were not compatible and proactively moved (Resident #68) into a room with (Resident #70). The social worker stated that there was an altercation between Resident #68 and Resident #70 so Resident #68 was then moved into a room with (Resident #63).When asked how the facility staff determines which Resident would be a compatible roommate with (Resident #68), the social worker stated that (Resident #68) prefers to have a bathroom to himself so they opted to pair him with a roommate that is non-ambulatory and does not use the bathroom. In Resident #68's electronic health record under the Miscellaneous tab, there were 4 scanned documents pertaining to mental health evaluations by mental health providers from one mental health company. There were three visits in 2020. One visit dated 09/16/2020 (following FRI #1) written by Employee S, a Mental Health Nurse Practitioner (MH-NP), under the header Chief Complaint documented, Staff reports patients had a physical altercations [sic] with former roommate. Request follow up to assess mood. Under the header Recommendations an excerpt documented, Will continue to provide supportive therapy to improve mood and physiological well-being. There was not another visit from the MH-NP until 06/02/2022 following another altercation between Resident #68 and his roommate 06/01/2022. On 09/20/2022 at 3:52 P.M., Employee S, MH-NP, was interviewed via telephone. When asked about Resident #68, the MH-NP explained that she saw Resident #68 back in June 2022 and again recently on 09/16/2022. The MH-NP stated that Resident #68 wants to have his own way with certain things; he wants to be in a room by himself so he picks fights because he knows they will remove the roommate. The MH-NP stated that there is an awareness of what he does and it doesn't fit behavior for medication; it's not fair to manage his condition with medications but more talking with him and how his behavior impacts others and his behavior may be traumatic to others. The MH-NP explained that she manages Resident #68's bipolar disorder with medication and does not see him routinely. The MH-NP stated that she primarily does medication management and a talk therapist used to go to the facility as well but was unsure if the talk therapist worked with Resident #68. The MH-NP stated that back in 2020, she told an in-house therapist that Resident #68 would benefit from talk therapy. In the course of the interview, the MH-NP Company Manager joined the call. When asked about referrals for talk therapy, the Manager stated that they currently don't have a provider but are actively recruiting for one. The Manager also stated that the facility is aware we don't have a provider. On 09/22/2022 at 12:07 P.M., the Social Worker, Employee E, was interviewed. When asked about mental health services offered at the facility, the Social Worker stated that residents with mental illness or any resident that requests mental health services can let the nurse know, and the nurse will get an order for mental health services. The Social Worker stated that she herself utilizes a tool to identify if someone is depressed. The Social Worker stated that if behavior modification is needed, the resident could be referred to a psychologist onsite named [Employee S] who does talk therapy. When informed Employee S is a nurse practitioner that primarily does medication management, the Social Worker stated she didn't know that. The Social Worker stated that she hasn't asked Resident #68 if he would like supportive therapy because, to be honest, he doesn't want to be here and I'm trying to find him placement somewhere else. When asked what is being done to help Resident #68 with his mental health, the Social Worker stated, Medications, that's it. The Social Worker stated that Resident #68 would definitely benefit from one-on-one therapy sessions and stated I will get that ball rolling. The facility staff provided a copy of their policy entitled, Social Services. In Section 7, it was documented, The social services staff shall be responsible for making referrals to community social service agencies, should a resident require a service that cannot readily be provided by the facility.

2. For Resident #68, the facility staff failed to provide safekeeping of hard scripts for controlled drugs, to prevent drug diversion. On 9/13/22 at 8:46 AM, during an interview with the facility Administrator and while he was looking for a document, it was observed at the nursing station on the first floor a drawer would not close and was open. An original hard script for Hydrocodone-Acetaminophen 5 mg-325 mg tablets, with a quantity of 90 tablets to be filled, was noted. The prescription was dated 2/15/22, and had not been voided. On 9/13/22, the unit manager/RN C approached the nursing station and was shown the prescription. RN C said, It is supposed to be put in an envelope and sent to the pharmacy. When asked what the risk of having prescriptions that were not voided, RN C said, There are a lot of risks, someone can take this and go get the prescription filled, and it is not safe. On 9/13/22 at 10:12 AM, RN C was observed at the first floor nursing station going through all of the drawers at the station and stated, I am working my plan of correction. RN C acknowledged she had found quite a few other original prescriptions that had been left at the desk and were not voided, which were available to be filled. On 9/15/22 at 12:20 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked to explain the process when the doctor writes and provides a prescription for a narcotic medication. The DON said, They fax it to the pharmacy. The DON was unable to explain the steps following that and said, I will get the policy for you. The facility policy regarding the process for narcotic prescription handling was requested. The facility provided a policy titled, Storage of Medications. The process for handling narcotic prescriptions was not addressed in this policy. On 9/13/22, during an end of day meeting the Facility Administrator and DON were made aware of the findings. No further information was provided. Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to provide routine and emergency drugs to meet the needs of residents and failed to provide safekeeping of hard scripts for controlled drugs, for 2 Residents (Resident #86 and 68) in a survey sample of 60 Residents. The findings included: 1. For Resident #86 the facility staff failed to obtain ordered narcotic pain medication, causing the Resident to wait 3 days for ordered pain medicine. On 9/12/22 a review of Resident #86's clinical record revealed she had pain medication ordered as follows: Oxycodone 5 mg [milligrams] / 5 ml [milliliters 5 ml via PEG-Tube every 8 hours for pain beginning on admission 8/13/22. The following are excerpts from Resident #86's nursing progress notes: 9/2/22 3:09 PM-eMar -Medication Administration Note Note Text: oxycodone HCl Oral Solution 5 MG/5ML Give 5 ml via PEG-Tube every 8 hours for pain Pharmacy stated resident needs script . 9/8/2022 4:24 PM eMar -Medication Administration Note Note Text: oxycodone HCl Oral Solution 5 MG/5ML Give 5 ml via PEG-Tube every 8 hours for pain. Awaiting for pharmacy . 9/8/2022 10:00 PM - 2 -eMar -Medication Administration Note Note Text: oxycodone HCl Oral Solution 5 MG/5ML Give 5 ml via PEG-Tube every 8 hours for pain Awaiting pharmacy delivery . 9/9/2022 10:04 PM eMar -Medication Administration Note Note Text: oxycodone HCl Oral Solution 5 MG/5ML Give 5 ml via PEG-Tube every 8 hours for pain awaiting pharmacy delivery. A review of the MAR (Medication Administration Record) revealed that Resident #88 did not receive her ordered narcotic pain medication until 09/12/22, however the Resident was receiving her PRN Tylenol and her muscle relaxers during that period of time. The following excerpts are from the physician progress notes: 9/1/2022 13:39 Nurse Practitioner/PA Progress Note (Narrative) Note Text: [Physician practice name redacted] Medical Progress Note CC: asked by nursing to see for back pain . 9/13/2022 2:40 PM Nurse Practitioner/PA Progress Note (Narrative) Note Text: Medical Progress Note CC: asked by nursing to see for back pain Chronic Back Pain, Lumbar degenerative disc disease was admitted to [Hospital name redacted] 8/10-8/12/22 due to back spasm pain along with wanting a different rehab other than [Rehab name redacted] in Arlington where pt. was just at. Pt has Recent ALS diagnosis . Back pain- improves with oxycodone use but needs sooner. On 9/12/22 at approximately 3:00 PM an interview was conducted with LPN G who was asked what the procedure was for reordering medication. She stated that the orders would be sent to the pharmacy and if it would arrive on the next shipment. When asked if you needed a medication sooner what could you do she stated we could get it from the stat box. When asked if narcotics are located there she said they were. On 9/12/22 at approximately 4:00 PM an interview was conducted with the DON and she was asked the process for obtaining medications if the Resident had a new order and needed them immediately. She stated the facility could use the stat box or the backup pharmacy. When asked what the expectation is if a Resident has a G Tube and the medication ordered is not available in the stat box in liquid form. She stated they are expected to call the physician and see if a substitute would be available or if they wanted to try a different medication or get an order to crush a pill and dissolve it in water to administer. At on 9/15/22 at during the end of day conference the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility record review, clinical record review, and in the course of a complaint investigation, the facility staff failed to ensure 1 Resident was free from unnecessary medications (Resident #101) in a survey sample of 33 Residents. The findings included: Resident #101 received Atenolol anti-hypertensive medication, Dexamethasone anti-inflammatory steroid medication, and Metronidazole antibiotic medication against physician ordered parameters. Resident #101 was admitted to the facility on [DATE]. Diagnoses included but were not limited to; hypertension. Resident #101's most recent Minimum Data Set assessment (a federal assessment protocol) was a discharge assessment dated [DATE]. Review of the physician's orders and Medication Administration Record (MAR), in the clinical record, revealed the following; 1. Ordered 7-10-22 - Atenolol for high blood pressure - 100 MG (milligrams) in the morning, hold for systolic blood pressure (SBP) less than 110. The Atenolol unnecessary medication was given on the following days; On 7-22-22 with an SBP of 105, On 8-10-22 SBP of 104, On 8-14-22 SBP of 100, On 8-28-22 SBP of 102, On 10-29-22 SBP of 101. 2. Ordered 7-11-22 - Dexamethasone for diverticulitis inflammation - 1 MG in the morning for 3 days. However, the Dexamethasone medication was given for 7 days. 3. Ordered 7-10-22 - Metronidazole antibiotic for diverticulosis - 500 MG once per day, and the next day on 7-11-22 the order changed to - Metronidazole antibiotic for diverticulitis - 500 MG every 8 hours (3 times per day) for 7 days. There were 2 extra does of Metronidazole given. On 1-10-23 an interview was conducted with LPN D who stated about the Atenolol medications being administered unnecessarily, she stated we don't want to give Antihypertensives outside of parameters because we don't want them to bottom out. (become Hypotension), and antibiotics and steroids should only be given for a short time and per orders. The facility policy for Medication Administration was reviewed, and documented that medications must be given according to the physician's orders. On 1-10-23 at 12:00 p.m., the Administrator and Director of Nursing (DON) were made aware of the findings. At the time of exit the DON stated there was no further information available to submit to surveyors. Complaint Deficiency

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation the facility staff failed ensure the nutritional needs and special diet orders 1 Resident (#86) in a survey sample of 60 Residents. The findings included: For Resident #86 the facility staff failed to obtain orders for the tube feeding formula (i.e. Jevity 1.2); the facility staff only received orders for the tube feeding flushes on admission. On 9/12/22 at approximately 4:00 PM the following observation was made: Tube feed Jevity 1.2 was hanging and infusing via enteral pump at 45 ml per hour. The 60 ml piston syringe was not dated and the tube feeding was not dated nor was the tubing. On 9/13/22 a review of the clinical record revealed that Resident # 86 was admitted on [DATE] with diagnoses that included dysphasia, failure to thrive, and a peg tube had been inserted at the hospital. Per signed admission orders the Resident had orders for flushing the G Tube both PRN (as needed) and routine flushing before and after feeding and medication administration, however they had neglected to secure orders for the tube feeding itself. On 9/13/22 at approximately 5:00 PM an interview was conducted with LPN B who stated that the Resident came into the facility with a g-tube and Jevity 1.2 infusing at 45/ml per hour on the enteral pump. She stated that they continued to hang Jevity at that rate until they got new orders from the Speech Therapist or Dietician. She stated she gets pleasure trays now like ice cream & ginger ale. On 9/14/22 at approximately 4:30 PM Employee O (dietary staff) was asked to print out the tray ticket for Resident #86. Employee O gave this surveyor a ticket that read: [Resident #86 name] Reg / Full Liquids . Chicken Asparagus, potato, bread and ice cream. When asked what that meant Reg/ Full liquids Employee O stated it means she gets regular tray with full liquids not thickened and no fluid restriction. On 9/15/22 at approximately 2:30 PM an interview was conducted with the Speech Therapist who stated that she has been working with Resident #86 since admission. When asked about the tray ticket she stated that this is something she has been dealing with for a long time. In the beginning Resident #86 was supposed to be NPO no tray at all until she had done her evaluations and trials with her. She said the Resident can now have soups and broths that are not chunky, she can have ice cream with supervision. She stated she will not eat much at all but they still should not be giving her regular trays. Resident #86's signed admission orders for dietary read: NPO (Nothing by Mouth), NPO Texture, NPO Consistency dated 8/13/22'. The physician put in enteral Feed orders that read: Enteral Feed Order As needed flush. Flush with at least 30 ml. of water before and after each med pass and feeding Enteral Feed Order Every 8 hours as needed for Tube Flush. Flush tube with at least 5 ml. water with each medication. On 8/25/22 admission Nutrition Assessment was completed by the Dietician and read as follows: Full liquid diet Jevity 1.5 @ 45mL/hr . RD recs: -initiate free water flush 100mL Q 6hrs for hydration -clarify tube feeding order to say Jevity @ 45mL/hr. x 20 hours. A review of the weights revealed that Resident # 86 lost 2 lbs. from 8/12/22 - 9/7/22. Her recorded weights were as follows: 9/7/2022 - 112.8 Lbs. 8/30/2022 - 113.0 Lbs. 8/12/2022 - 114.8 Lbs. On 9/20/22 during the end of day meeting the Administrator and the DON were made aware of the concerns and no further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to have an accurate system to track the immunization status, provide COVID-19 immunizations, and provide COVID-19 booster immunizations for two employees (Employee GG and CNA-X) in a survey sample of 6 employees reviewed. The findings included: On 9/12/2022, the facility staff provided the survey team with a copy of the staff vaccination matrix. On 9/13/2022 at 10:30 a.m., review of the matrix revealed five employees listed as not vaccinated. There were 19 employees listed as not Boosted. On 9/13/2022 at 2:45 p.m., an interview was conducted with the Infection Preventionist who stated all of the employees were fully vaccinated and that there were no employees with an exemption. When asked about the 5 employees listed as unvaccinated, the Infection Preventionist stated the Administrator must have scanned the wrong documents. She stated she updates the forms every day and that there were multiple copies. The Infection Preventionist stated she would send the correct copy of the vaccination matrix. She again stated none of the employees had an exemption. During the end of day debriefing on 9/13/2022, the Administrator, Director of Nursing and Regional Consultants were informed that the staff vaccination matrix/tracking system in use on the first day of survey was not complete and accurate. Review of the corrected copy of the vaccination matrix revealed there were no unvaccinated staff members listed on the matrix. There were 3 listed as not Boosted. CNA-X, had completed a primary COVID-19 vaccine series on 5/12/21 and 6/2/2021 but had not received a booster dose. Employee GG, had completed a primary COVID-19 vaccine series 9/7/2021 and second dose on 9/28/2021 but had not received a booster dose. On 9/21/2022, during the end of the day meeting, the facility Administrator, Regional Nurse Consultant, Regional Consultant for Infection Control and Director of Nursing again were informed that the staff vaccination matrix/tracking system in use on the first day of survey was not complete and accurate. On 9/22/2022, the Infection Preventionist provided copies of the immunization cards as requested. An interview was conducted with the Infection Preventionist who confirmed the findings and stated, I do follow-up on whether or not a staff member gets a booster shot. I send an email and I discuss it at our meetings too. The Infection Preventionist stated there were employees who did not have booster doses. She stated she did provide education on the importance of the full vaccination series along with a booster. The Infection Preventionist stated she did not document the education she provided to the employees about the importance of booster dose. The CDC (Centers for Disease Control and Prevention) document titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 3, subtitle, Vaccinations, read, Remaining up to date with all recommended COVID-19 vaccine doses is critical to protect both staff and residents against SARS-CoV-2 infection. No additional information was received.

Based on observation, Resident interview, staff interview and facility documentation review, the facility staff failed to provide a functional bedside table for one Resident (Resident #35) in a survey sample of 60 Residents. The findings included: On 9/14/22 at 9:30 AM, Surveyor B visited Resident #35 in his room. Surveyor B observed the bedside table, which had 3 drawers. The top drawer had no handle and the second drawer the handle was broken and attached on only one side. Resident #35 was asked how he accesses items in the top drawer and he said he couldn't. On 9/14/22 at approximately 9:45 AM, an interview was conducted with Employee F, the Maintenance Director. Employee F described the process by which he is made aware of items needing repair as an electronic system that any employee is able to enter maintenance requests into. Employee F provided Surveyor B with a listing of maintenance work orders that had not been completed and Resident #35's bedside table was not noted on the list. Employee F accompanied Surveyor B to the room of Resident #35. Employee F made an observation of the bedside table and confirmed the above finding. Employee F said, he was not aware of this and would get this replaced right now. The facility policy regarding the upkeep of facility provided equipment and maintenance work orders was requested. The facility policy titled, Maintenance Work Request System was reviewed. This policy read, Policy: 1. to establish an effective means of requesting, coordinating and completing maintenance of a corrective nature. Procedure: 1. Corrective maintenance can be defined as those actions required to restore equipment, buildings and grounds to normal condition and operation. The following procedures are established to initiate and carry out an effective program and is considered a normal means for obtaining maintenance action On 9/14/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above findings. No additional information was provided.

Based on Resident interview, staff interview, and facility documentation review, the facility staff failed to provide Residents with quarterly statements of their trust account/bank accounts effecting 4 Residents (Resident #2, 20, 91, and 70) in a survey sample of 60 Residents. The findings included: On 9/15/22, an interview was conducted with Resident #20. Resident #20 was asked if he gets statements quarterly as to how much money is in his trust account. Resident #20 said, No, I don't get statements and I would like to know how much is in there. On 9/15/22, Resident #2 was interviewed regarding trust statements. Resident #2 said he doesn't receive any statements from the facility. On 9/19/22, Resident #70 was interviewed and stated he doesn't receive trust statements and would like to know how much is in his account. On 9/19/22 at 3:15 PM, Surveyor B went to the business office and asked to see evidence of trust statements for the last 3 quarters. Employee J, the Regional Director of Revenue Cycle said she had discovered that there was no evidence that the statements from June 2022, had been delivered to Residents so she gave them to the Administrator on 9/16/22, to deliver to Residents. Employee J said the facility protocol is for the Residents to sign the statements to provide evidence that they received the statement. Employee J was asked if the Residents are then given a copy to keep for themselves and she was not sure. Employee J stated she had no evidence that the Residents were provided the statements on a quarterly basis. Trust statements for December 2021, March 2022, and June 2022, were received and reviewed. The statements for December 2021 and March 2022 had no indication that the Residents received a copy. The March 2022, statements had a form RFMS Quarterly Statement Certification for Proof of Mailing that was not filled out and was blank. The trust statements for June 2022, were signed by Residents #2, 91 and 20 on 9/16/22. The clinical record for Residents ##2, 20, 91, and 70, was reviewed. There was no evidence that the Residents had received trust account statements documented within the clinical record. A review of the facility policy titled, Resident Trust Fund was conducted. This policy read, .9. Quarterly Statement of Account. A quarterly accounting of the funds managed by the facility is provided to each resident or their legal representative per State guidelines. Quarterly statements are received from RFMS (Resident Fund Management System) by the Business Office and then reviewed and approved by the Executive Director and provided to the resident or mailed to the resident's legal representative not later than the 20th of the month following the end of each quarter. In addition, the Executive Director is to sign the Certification of Mailing as proof that the statements were mailed. Copies of the statements provided or mailed and the Certification of Mailing are to be filed in the resident trust fund monthly file of the last month in each quarter . On 9/17/22, the facility Administrator was made aware of the above findings. No additional information was received.

Based on observation, and staff interview, the facility staff failed to provide required postings, including a list of names, addresses, and telephone numbers for State Agencies, and advocacy groups, which are mandated by regulation to be accessible and understandable for the resident population. The findings included; During the surveyor's initial tour of the facility on 9-12-22 observations included all resident rooms and common areas of the two floors where residents resided in the building. No posting which listed the required names, addresses, and telephone numbers for State Agencies and advocacy groups which are accessible, and understandable to residents, could be found. The Social worker was asked where the posting could be found, and she stated it had been posted by the elevators, but was taken down during renovations, and it had not been replaced. When asked how long ago that happened, she stated she could not remember, and further stated it was awhile ago. On 9-13-22 the LPN unit Manager was asked about the posting, and she stated they were going to replace it. On 9-14-22 during Resident Council meeting, all of the Residents in attendance stated they had no idea how to contact advocacy organizations if they were fearful of abuse, or had a grievance or complaint about their care, and had no idea how to find the information. On 9-22-22 at the time of survey exit, the posting had still not been replaced. The Administration was made aware of the findings and had nothing further to add.

Based on observation, Resident interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to maintain a Resident's personal privacy and failed to protect personal health information for 3 Residents (Resident #35, 268, and 78) in a survey sample of 60 Residents. The findings included: 1. For Resident #35, the facility staff failed to provide a privacy curtain to ensure the Resident's personal privacy and dignity were protected during ADL (activities of daily living) care. On 9/14/22 at 9:30 AM, Resident #35 was visited in his room. The Resident requested of the surveyor, Can you see about getting me a privacy curtain. Surveyor B observed that there was no privacy curtain around Resident #35's bed. When asked where he changes clothes or takes a bath he said, Well, now I have to go into the bathroom to do it. On 9/14/22 at approximately 9:45 AM, an interview was conducted with CNA D. CNA D was asked what the purpose of a privacy curtain is, CNA D said, To protect their privacy. When asked if Resident #35's requires assistance with ADL's, CNA D said, Yes, because of his leg we have to help him. When he puts his pants on he sits on the bed and then we put the pants on him. Surveyor B told CNA D that Resident #35 reporting washing up/bathing in the bathroom, CNA D said, Sometimes we do it in the room and have him sit on the bed. CNA D confirmed Resident #35 had been without a curtain about two weeks because they said it was soiled. CNA D said, We just have to close the door and hope no one opens it while we are providing care. Review of Resident #35's clinical record confirmed that he requires assistance with ADL's, the care plan read, [Resident #35's name redacted], ADL Self Care Performance deficit, requires assistance with ADL r/t [related to] left femur fracture, surgery, impaired mobility, cognition. The facility policy regarding Resident privacy was requested and what was received was with regards to HIPAA and confidentiality of records/information, not personal privacy. The facility policy titled, Resident Rights was reviewed. This policy read, .d. To have their privacy respected when treatment, medication, or care is being administered including, i. door closed or privacy curtain drawn ii. Not have treatment, medication or care performed in common areas such as hallways, dining rooms or other including but not limited to 1. Personal care includes but not limited to a. Bathing, dressing, grooming, b. Nail care/ clipping (unless as an activity), c. Oral hygiene . On 9/15/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above concern. The Administrator stated, This started about 2 weeks ago, I told them to change them. No further information was provided prior to the end of survey. 3. For Resident #78, the facility staff failed to protect personal health information by utilizing Resident #78's roommate and staff members from ancillary departments to interpret conversations due to a language barrier. On 09/12/2022 at 12:45 P.M., Resident #78 was observed in bed awake. When I asked if they had any concerns about the care received at the facility, Resident #78 motioned to their neck and pointed to their roommate, Resident #38. Roommate (Resident #38) stated that [Resident #78] cannot speak but responds to yes/no questions. The Roommate (Resident #38) also stated that [Resident #78]'s primary language is not English. This surveyor observed there were no communication aids in the room and no information about a language line was observed. The roommate (Resident #38) was asked if staff used interpreter to communicate with Resident #78, and the roommate stated staff sometimes ask her to interpret because she can also speak Resident #78's primary language. When asked what she is asked to interpret, the roommate Resident #38 stated, I let them know what food she doesn't like or I let them know when she has an upset stomach. On 09/13/2022, Resident #78 clinical record was reviewed. According to the Face Sheet under the section Primary Language, it was documented, English. According to the admission Evaluation dated 09/13/2017 under the section entitled, Communication, the choices were English or Other. The option Other was selected and Spanish was written in the text box. On 09/14/2022 at 10:15 A.M., the Assistant Director of Nursing, RN E, was interviewed. When asked how staff communicate with Resident #78, the Assistant Director of Nursing (ADON) indicated she didn't know and stated Let me get that information for you. The ADON then stated that she would go to an interpretation site on the Internet. At approximately 10:18 A.M., CNA O was asked how staff communicate with Resident #78 and CNA O stated that there are two housekeepers that speak the same language as Resident #78. The staff were identified and placed in staff identifier as Employee Q, a laundry aide and Employee R, a housekeeper. On 09/15/2022 at 9:20 A.M., Employee Q was interviewed. When asked if the staff ask her to interpret for Residents, Employee Q stated that sometimes she would interpret but I only speak a little bit of English. When asked how often she serves as interpreter, Employee Q indicated she didn't understand the question and wanted to get her supervisor to interpret the question. On 09/15/2022 at 9:30 A.M., Employee R was interviewed. When asked if staff ask her to interpret, Employee R stated that the nurses ask her to interpret. Employee R also stated that she is not fluent in English but understands a little bit. When asked which Residents she serves as interpreter, Employee R stated Resident #78's name and Resident #6 in the sample. Employee R stated that sometimes Resident #6 will say she has pain in her leg or hip. Employee R stated Resident #6 speaks no English. When asked about Resident #78, Employee R stated that when she is interpreting for Resident #78, sometimes she will need medication. Employee R stated that Resident #78 Doesn't talk, only answers yes/no questions. I will ask her questions and she will answer. Employee R stated that she interprets when the doctor is seeing her and sometimes the nurses will ask me to go in there and check on her. On 09/15/2022 at approximately 6:45 P.M., the Administrator and Director of Nursing were notified of findings. On 09/20/2022 at approximately 10:35 A.M., Employee T, a physician, was interviewed. When asked how she communicates with Resident #78, the physician stated she asks the roommate to interpret sometimes or usually a maintenance person will do it. The physician also stated that she can speak a little bit of Resident #78's language but it was more difficult to understand her. The physician stated that Resident #78 points things out .points to things. When asked how long she had been caring for Resident #78, the physician indicated she has been seeing Resident #78 for 2 years. On 09/21/2022 at approximately 3:45 P.M., a copy of the facility's communication policy was requested and the Corporate Clinical Registered Nurse, Employee D, stated that they do not have a communication policy. A copy of their policy on protecting personal health information was requested and the facility staff provided a copy of their policy with the category entitled, Privacy and Security - Human Resources. The subject was entitled, Administrative Safeguards - Sanctions. The policy did not address safeguarding Residents' personal health information as it relates to communication management for Residents in need of interpretive services. The facility staff provided a copy of their policy entitled, Routine Resident Care in Section (1)(h), an excerpt documented, Licensed Staff will include the following services based upon their scope of practice, but not limited to: (h) maintains confidentiality of resident information at all times . 2. For Resident # 268 the facility staff failed to ensure the privacy of his medical records by posting a marketing flyer (in the elevator) using his photo, medical diagnosis, and rehab progress . On 9/12/22 at approximately 2:00 PM Surveyor D observed a marketing flyer in the elevator that read: [Company name and logo redacted] Celebrating Success . We are pleased to share another wonderful rehab success story from: [Address and phone number of facility redacted. [Resident #269 name redacted] came to [Facility name redacted] from [hospital name redacted]. [Resident #269 name redacted] experienced a fall at home due to a Urinary Tract Infection, luckily no injuries sustained from the fall. [Resident #269 name redacted] had difficulty with walking and performing steps so he could return home. [Resident #269 name redacted] required help with his bathing, dressing, and toileting. [ Resident # 269 name redacted] family was very supportive and very involved with his care. While at [facility name redacted], [Resident # 269's name redacted] made significant gains with his therapy plan of care, he was able to increase his walking abilities to over 350 ft. and was able to successfully navigate steps with no increased pain or assistance. [Resident #269 name redacted] was able to bathe, dress, and complete his toileting with little to no assistance. Name: [redacted] Admitting Diagnosis: UTI with a fall LOS: [length of stay] 34 days Discharge Location: Home [There was a graph on the page that showed his Functional Outcome Measures from admission to Discharge for Bathing, Bed mobility, Grooming, Toileting, Upper body Dressing, Lower Body Dressing, Gait, Stairs, Transfers.] On 9/12/22 during the end of day meeting Surveyor D requested that the Administrator show documentation that Resident #269 approved or gave consent to disclose his protected health information (diagnosis of UTI and fall) that was used in the marketing flyer posted in the elevator, Surveyor D requested again on 9/13/22 and was told that the Administrator was awaiting for regional manger to get back to him. On 9/15/22 at 1:02 PM an interview was conducted with the Administrator and Employee D (the Regional Nurse Consultant). On 9/16/22 when the admission package was reviewed it was found that the resident signed giving to use his photo however nothing was mentioned about using his protected health information along with his photo. The Administrator and Employee D (Regional Nurse Consultant) were both asked about permission to use his diagnosis and both stated that all they have is what is in the admission Contract. [Please note the photo used was the admission photo showing Resident #269 in a hospital gown. On 9/16/22 an excerpt of the facility's HIPAA policy read as follows: 1 - To respect the privacy and confidentiality of any information you may have access to through our computer system or network and that you will access or use only that information necessary to perform your job . 3 - To disclose confidential resident, business, financial or employee information ONLY to those authorized to receive it . 7 - Not to release or disclose the contents of an resident or facility record except to fulfill your work. On 9/16/22 a review of the facility's Routine Resident Care Policy read: h. Maintains confidentiality of resident information at all times including but not limited to: i. photographs . ii. social media . iii. unauthorized email, fax, texting or telephone communication . iv. unauthorized communication in inappropriate environments such as open hallways, within the immediate vicinity of other residents/family or outside of the facility. On 9/16/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to maintain a clean, comfortable and home like environment for one Resident (Resident #46) and on two of two nursing units. The findings included: 1. The facility staff failed to maintain Resident rooms and bathrooms in a clean, comfortable and homelike manner for multiple Residents residing on both of the nursing units. a. On 9/12/22, during initial tour Surveyor B observed that a Resident residing in a room on the first floor, Colonial hall that had splatters and lines of a tan colored substance running down the wall at the head of the bed that were dried. Throughout the entire survey, which concluded on 9/22/22, Surveyor B observed the splatters and lines without any improvements noted. b. On 9/14/22, Surveyor B observed the following in a Resident room on the first floor, [NAME] hall. A bathroom with a large section of wall paper missing that measures approximately 15 inches wide and four inches long. The wall paper in the bathroom was peeling extensively and rolled up several inches in several bathrooms observed. Toilet tissue was stored on the sink in one bathroom because there was no center rod on the toilet tissue holder. c. On 9/14/22, Surveyor B observed the following in Resident rooms/bathrooms on the second floor [NAME] hall. A room with the baseboard missing on the wall beside the bathroom door. A room with paint peeling off of the wall and chunks of sheet rock missing which leaves exposed the metal strip that runs down the corner of the wall. Additional observations were made throughout the survey, which concluded on 9/22/22. There were no noted repairs, cleaning or improvements to the above. On 9/14/22, an interview was conducted with Employee F, the maintenance director. Employee F stated that the facility uses an electronic system for work orders and preventative maintenance. He also said sometimes staff will call down to the maintenance shop to notify them of repairs that are needed. Maintenance work orders for the month of September that had been completed and what was outstanding were requested. Upon review of the maintenance work orders for September there were no work orders with regards to the above findings or any other Resident room conditions noted above. A review was conducted of the facility policy titled, Maintenance Work Request System. This policy read, 1. Corrective maintenance can be defined as those actions required to restore equipment, buildings and grounds to normal condition and operation .2. The maintenance work request system will be divided by the environmental services department into three major categories which are defined as follows: A. Urgent .B. Routine .C. Deferred . 3. Ultimate priority assigned to the Work Request will normally be determined by the Department Director upon review of the written request .5. The Department Director will assign Work Requests to personnel and daily review completed work orders for completeness and correctness of repairs and/or the need for purchases or outside assistance. On 9/21/22, during an end of day meeting, the facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. No further information was provided. Complaint related deficiency. 2. For Resident #46, the facility staff failed to maintain a comfortable homelike environment as evidenced by scuff marks and stains on the floor, baseboards, and walls. Also, the baseboard next to Resident #46's bed was separating from the wall and the baseboard to the right of the bathroom door was gone, revealing a small hole in the wall and ripped drywall. For Resident #46, the facility staff failed to maintain a comfortable homelike environment as evidenced by scuff marks and stains on the floor, baseboards, and walls. Also, there were strips of scotch tape on wall across from Resident #46's bed with ripped paper attached. Also, the baseboard next to Resident #46's bed was separating from the wall and the baseboard to the right of the bathroom door was gone, revealing a small hole in the wall and ripped drywall. On 09/13/2022 at 9:20 A.M., Resident #46 was observed lying in his bed. When asked about concerns with the facility, Resident #46 said everything was alright. When asked how he felt about the extensive amount of scuff marks, stains, and tape on the floor and walls, Resident #46 then pointed to the baseboard on the right side of his bed. This surveyor observed that the entire strip of baseboard was not tightly secured to the wall. Furthermore, the baseboard from the right side of the bathroom to the end of the wall was gone revealing a small hole in the wall and ripped drywall. On 09/13/2022 at approximately 5:30 P.M., the Administrator and Director of Nursing were notified of findings. On 09/20/2022 at approximately 2:45 P.M., Resident #46's room still had extensive scuff marks, stains, and tape on the floor and walls as well as loose/missing baseboards as observed on 09/13/2022. On 09/20/2022 at 3:20 P.M., the Maintenance Director, Employee F, and Employee U, maintenance staff, were interviewed. When asked about the process for work orders, the Maintenance Director stated that some requests are by word-of-mouth and some are put into the system. When asked about current work orders needing to be done, the Maintenance Director stated there were two work orders in the system. This surveyor and the Maintenance Director observed the work order screen and there was not a work order for Resident #46's room. When asked about any requests made for Resident #46's room, the Maintenance Director and Employee U both stated they were unaware of any work orders for Resident #46's room. At approximately 3:25 P.M., this surveyor, the Maintenance Director, and Employee U entered Resident #46's room for an observation of the loose/missing baseboard and hole in the wall. The Maintenance Director stated he was not aware of this and would fix it. The facility staff provided a copy of their policy entitled, Resident Rights. The policy did not address the Residents' rights to a clean, comfortable, homelike environment. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. The facility staff failed to obtain a criminal background check within 30 days of hire for 13 Employees (Staff #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16, #21, and #23). On 9/15/22, Surveyor G reviewed 25 employee records for criminal background checks which revealed the previously listed findings. On 9/20/22, the Human Resources (HR) Director was interviewed and confirmed the findings for the 13 referenced facility staff members. On 9/21/22, the Facility Administrator was informed of the findings. He stated, Criminal background checks are obtained before we hire anyone because we must be certain that our residents are not exposed to people with a criminal history such as abuse of any kind. Review of the facility's policy titled, Abuse, Neglect, and Exploitation Policy-Virginia, revised 10-27-2021, subtitle, Policy, page 9, read, in part, .Furthermore, it is the intent of this facility to employ only properly screened persons as a part of the resident care team by the applicable requirements and subtitle, Procedure, page 9, section I Screening, item 2 read, A criminal background check will be completed to meet state requirements. No further information was provided. 7. The facility staff failed to perform professional license verification to ensure licensed employees held current licensure or certification and to determine if they had been subject to disciplinary action against their professional license as a result of abuse, neglect or mistreatment for 13 Employees (Staff #3, #5, #7, #8, #10, #11, #13, #18, #19, #20, #21, and #23). On 9/15/22, Surveyor G reviewed 19 licensed employee records for professional license verification which revealed the previously listed findings. On 9/20/22, the Human Resources (HR) Director was interviewed and confirmed the findings for the 13 referenced clinical staff members. On 9/21/22, the Facility Administrator was informed of the findings. He stated, We obtain verifications for anyone who holds a professional license, to be sure they are qualified to provide proper care for our residents and that their license is free from any disciplinary actions by the State [licensing board]. Review of the facility's policy titled, Abuse, Neglect, and Exploitation Policy-Virginia, revised 10-27-2021, subtitle, Policy, page 9, read, in part, .Furthermore, it is the intent of this facility to employ only properly screened persons as a part of the resident care team by the applicable requirements. Also contained within the facility's abuse policy, subtitle, Procedure, page 9, section I Screening, item 4 read, Licensure/registry check will also be performed, as applicable, after the interview to verify: a. The Nurse Aide Registry, b. State Board of Nursing, c. Other professional registries and item 6 read, This facility will not employ individuals who have had a disciplinary action taken against their professional license by a state licensure body as a result of a finding of abuse, neglect, mistreatment of residents, or misappropriate of their property. No further information was provided. 8. The facility staff failed to provide staff abuse/neglect prevention/reporting training for 3 Employees (Director of Nursing, CNA B, and CNA C). On 9/14/22, Surveyor G reviewed 5 employee records for staff training which revealed the previously listed findings. On 9/14/22, the Staff Development Coordinator (SDC) was interviewed and confirmed the findings for the 3 referenced clinical staff members. The SDC stated, All training is done on the computer through Relias training modules, if it [the training] is not on the transcripts that were provided, then it wasn't done. On 9/15/22, the Facility Administrator was informed of the findings, He stated, HR [Human Resources] is responsible for staff compliance with training, it is supposed to be monitored every day but it doesn't appear that it has been happening, all of the staff in the HR department are new so they are not monitoring this [staff training compliance] yet. On 9/15/22, the Human Resources (HR) Director stated, [name redacted, Staff Development Coordinator] handles all staff training including records, I've not been told otherwise. Review of the facility's policy titled, Abuse, Neglect, and Exploitation Policy-Virginia, revised 10-27-2021, subtitle, Policy, page 9, read, in part, .Furthermore, it is the intent of this facility to employ only properly screened persons as a part of the resident care team by the applicable requirements. Also contained in the facility's abuse policy, subtitle, Procedure, page 9, section II Training, item 1 read, Provide education and training upon hire, annually, and as needed for re-training to include but not limited to: (a) Definition of abuse/neglect/misappropriate of personal property,(c) Methods of protecting residents from verbal, mental, sexual and physical abuse, misappropriation, (d) No employment of those convicted of abuse/neglect or mistreatment of individuals, (e) Observations that may identify abuse or neglect, (f) Reporting allegations of abuse/neglect/misappropriation without fear of reprisal, (g) Interventions to deal with aggressive behaviors, (h) Recognition of burn out, frustration/stress in self and others, and (i) Timely and appropriate reporting of reasonable suspicion of crime in the facility and item 2 read, Education and training in-services documentation of attendance will be maintained. No further information was provided. COMPLAINT DEFICIENCY Based on Resident interview, staff interview, clinical record review, facility documentation review, and during the course of a complaint investigation, the facility staff failed to implement their abuse policy for 10 Residents (Resident #35, 117, 31, 84, 367, 369, 19, 52, 217, and 21) in a survey sample of 60 Residents. Additionally, the facility staff failed to implement their abuse policy by (1) not obtaining criminal background checks for 13 employees (Staff #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16, #21, and #23) in a sample of 25 employee records reviewed, (2) not performing professional license verification for 13 licensed employees (Staff #3, #5, #7, #8, #10, #11, #13, #18, #19, #20, #21, and #23) in a sample of 19 licensed employee records reviewed and (3) not providing staff abuse/neglect training for 3 employees (Director of Nursing, CNA B, and CNA C) in a sample of 5 employee training records reviewed. The findings included: 1. For Resident #35, the facility staff failed to implement their abuse policy with regards to the timely reporting of an allegation of misappropriation of money and failure to conduct pre-hire screening of the employee who misappropriated money and exploited the resident. On 9/12/22 at 3:07 PM, an interview was conducted with Resident #35. Resident #35 said, I had trouble when I first came here, thieves got hold of the books and it was a minor thing to them. I woke up one morning and the checking account was down to zero. It was an inside job, no one cared about how the books were managed. On 9/15/22, an interview was conducted with Adult Protective Services (APS). They were able to provide information regarding their investigation which revealed a preponderance of evidence to substantiate that Residents #35 and 368 were victims of financial exploitation by a facility employee in excess of $50,000. On 9/15/22, during an interview with Adult Protective Services (APS), Surveyor B was notified that APS had called the facility and made an on-site visit on 4/29/22, and reported the allegation of misappropriation to the facility's Director of Nursing (DON). The facility human resources department indicated they did not have an employee file for the employee that had exploited Resident #35, therefore there was no evidence that they had conducted pre-hire screening of the employee to determine they were suitable for employment and would not pose a risk to Residents. The facility provided the survey team with a Facility Reported Incident (FRI) regarding this allegation of misappropriation. It was dated 5/2/22. The facility didn't report the allegation to the state survey agency or law enforcement until 4 days after they were made aware of the allegation. On 9/15/22 at 12:06 PM, an interview was conducted with the DON. During this interview the DON confirmed that APS had notified her of the allegation. The DON stated, I was here and the lady from APS wanted to see me, she said she had an allegation that one of our staff was involved with Resident's money going missing. She had a list of documents she wanted, I gave her those documents and she left. I called the Administrator and when she came back she took over the investigation. The DON was shown the Facility Reported Incident (FRI) that was dated 5/2/22. The DON said, I am aware of the FRI reporting requirements and we have to report abuse but the ED [executive director/administrator] handles that. When asked who is in charge in the absence of the Administrator, the DON said, If the ED is on vacation I can assume that role. If they are just out for the day, I called them and they do it. On 9/15/22 at 6 PM, during an end of day meeting, the facility Administrator was interviewed. The Administrator stated that a FRI (Facility Reported Incident) is completed for anything causing harm, potential harm, or when something happens to a patient, a patient to patient situation or staff to patient. We report the FRI and send to the OLC and APS via fax and the Ombudsman. The initial notification is within 2 hours, we make sure the Resident is safe and start an investigation. Within 5 days we report to the OLC our investigation and what we found out as well as the resolution. On 9/22/22 at 9:39 AM, an interview was conducted with Employee E, the social worker. Employee E stated, If you have an allegation of abuse you have to report it immediately because it has to be reported to the state, APS, and Ombudsman within 2 hours. Also, you need to make sure the Resident is safe during that time, if you don't report immediately you can put the Resident at risk. When asked about the timing of the investigation, Employee E said, Everything has to be done in 5 days. The facility policy titled, Abuse, Neglect and Exploitation Policy was received and reviewed. This policy read, .VII. Reporting and Response: VIRGINIA. i. Within 24 hours of learning of an incident the facility must report it to the OLC unless the incident is an allegation of abuse or involves serious bodily injury and then the facility must report to the OLC within 2 hours. Incidents shall be submitted to the OLC Complaint Department via fax at [fax number redacted]. ii. Any incident or event with a suspicion of a crime is to be reported to the local police department within 2 hours NOTE: Absence of the facility administrator, or designated alternate, from the facility cannot be used to delay implementation of the facility investigation protocols . On 9/15/22 at 6 PM, and again on 9/21/22, during end of day meetings the facility Administrator, Director of Nursing and Corporate staff were made aware the survey team had identified concerns regarding the implementation of their abuse policy. No further information was received. 2. For Resident #117, 31, 84, 367, 369, and 19, the facility staff failed to implement their abuse policy with regards to identifying concerns/reports as allegations of abuse, take measures to protect the Resident(s), conduct an investigation and report the allegation(s). A. On 9/15/22, the survey team discovered that on 5/27/22, Resident #117's family reported to facility staff that assigned CNA was rough while providing perineal care and washing her . The facility was asked to provide all Facility Reported Incidents (FRI's) and there was no FRI on file for the allegation reported 5/27/22, involving Resident #117. Review of the facility provided documents revealed the facility completed a grievance form on 5/27/22, and indicated on the form that that Administrator, Director of Nursing, and Social Services Director were notified. There is no evidence that the facility staff identified this as an allegation of abuse, took any measures to protect the Resident, conducted any investigation or reported the allegation as identified in their abuse policy. B. On 9/15/22, the survey team discovered that Resident #31 reported that a CNA [name redacted] was rough during ADL's [activities of daily living] and keep washing and washing her and it is rough on her skin [sic]. Following this report from the Resident, the facility completed a concern form dated 6/10/22. There is no evidence that the facility staff identified this as an allegation of abuse, took any measures to protect the Resident, conducted any investigation or reported the allegation as identified in their abuse policy. C. On 8/3/22, the facility staff identified that the narcotic count was off for Residents #84, 367, 369 and 19. The facility completed a Facility Reported Incident form, however on the form they indicated that physician notification was N/A [not applicable] and the APS (Adult Protective Services) area was blank with no indication of them being made aware. In the course of the facility investigation they identified a staff member as a suspect and included a report form to the Department of Health Professions (licensing board for nurses) but failed to sign the form and gave no indication/evidence that they were notified of the findings and investigation. D. During the Resident and Family interviews conducted by the facility staff on 9/16/22, Resident #62 was asked, Has a staff, a resident or anyone else here abused you? Resident #62 said, Yes, verbally. The facility staff failed to respond to this allegation of abuse. On 9/20/22 at 12:45 PM, the facility staff were made aware that an allegation of abuse had been reported that they had failed to respond to. On the afternoon of 9/20/22, the facility staff submitted documents to the survey team that indicted the interview conducted with Resident #62 had been changed to indicate that no abuse was reported. This was brought to the attention of the facility Administrator, Director of Nursing and Corporate staff, with no explanation being afforded. On 9/21/22 at 11:35 AM, the facility presented additional documentation, which included a Facility Reported Incident that was completed on 9/20/22 regarding Resident #62's allegation. The facility failed to identify and respond timely to a report of abuse, report the allegation and initiate an investigation as per their abuse policy. E. During a family interview conducted by facility staff on 9/17/22, the family of Resident #31 reported, A few weeks ago a man came in her room at night and he yelled at her. On 9/20/22 at 12:45 PM, the facility staff were made aware that an allegation of abuse had been received and they failed to respond to it. On 9/20/22 at 4:30 PM, the facility provided a Facility Reported Incident that was completed on 9/20/22 regarding Resident #31's allegation. The facility failed to identify and respond timely to a report of abuse, report the allegation and initiate an investigation as per their abuse policy. On 9/15/22 at 6 PM, during an end of day meeting, the facility Administrator was interviewed. The Administrator stated that a FRI (Facility Reported Incident) is completed for anything causing harm, potential harm, or when something happens to a patient, a patient to patient situation or staff to patient. We report the FRI and send to the OLC and APS via fax and the Ombudsman. The initial notification is within 2 hours, we make sure the Resident is safe and start an investigation. Within 5 days we report to the OLC our investigation and what we found out as well as the resolution. On 9/22/22 at 9:39 AM, an interview was conducted with Employee E, the social worker. Employee E defined abuse as, It can be physical, mental, sexual, confinement, misappropriation of Resident's finances or property. Neglect was defined as, Failure to provide services. Employee E stated, If you have an allegation of abuse you have to report it immediately because it has to be reported to the state, APS, and Ombudsman within 2 hours. Also, you need to make sure the Resident is safe during that time, if you don't report immediately you can put the Resident at risk. When asked about the timing of the investigation, Employee E said, Everything has to be done in 5 days. The facility policy titled, Abuse, Neglect and Exploitation Policy was received and reviewed. This policy read, .4. An employee who is alleged or accused of being a party to abuse, neglect, misappropriation of property will be immediately removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. 5. After completing the statement(s), the employee(s) will be asked to vacate the facility until further investigation of the incident is completed . The above referenced policy went on to read, .IV. Identification of incidents and allegations. 1. The accurate and timely identification of any event which would place our residents at risk is a primary concern of the facility. 2. The following procedure will assist the staff in the identification of incidents and direct them to appropriate steps of intervention. a. Each occurrence of resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect or misappropriation of funds will be identified and reported to the supervisor and investigated timely. b. The supervisor or designee will notify the Director of Nursing and Executive Director allegation immediately. Upon being notified of incident or allegation will direct required notification of agencies, physician, family and resident representative c. The Executive Director will direct the investigation . Section 5 of the policy read, .V. Investigation of Incidents: 1. In the event a situation is identified as abuse, neglect or misappropriation, an investigation by the executive leadership will immediately follow .d. In the event the alleged perpetrator is a staff member that staff member will be removed from areas of resident living and interviewed by nurse on duty. e. The staff member will be escorted off of the premises by another staff member f. The accused staff member will be suspended, by the Executive Director or designee, pending the outcome of the investigation of the incident The above referenced policy went on to say, .2. Alleged violations are reported immediately to the Executive Director of the facility. a. The ED/designee will report appropriate incidents to the Adult Protective Services and the Division of Licensing and Regulation as required by state law. 3. The results of the facility's investigation must be reported to the survey agency, the ED/Designee and other officials in accordance with state law, within five working days of the incident . Pages 18 and 19 of the Abuse policy read, . iii. Facilities must conduct an internal investigation and document their findings for all alleged incidents at the facility within 5 days of the incident. A thorough internal investigation should include, but not limited to: iv. A timely and thorough facility investigation, which is recorded in an investigation report, is critical to substantiate finding of misconduct . Note: Absence of the facility administrator, or designated alternate, from the facility cannot be used to delay implementation of the facility investigation protocols . On 9/16/22 and again on 9/21/22, the facility staff were made aware that they survey team had significant concerns that they failed to identify and respond to allegations of abuse in accordance with regulation requirements and their facility policy. No further information was provided. 3. For Resident #52, the facility staff failed to implement their abuse policy and protect Resident #52 form an alleged perpetrator on 09/13/2022. Also, the facility did not report and adequately investigate the allegation of abuse to the state agency timely. On 09/13/2022 at 11:00 A.M., a Resident Council meeting with 6 Residents was conducted. At 11:18 A.M., the Social Worker entered the Resident Council meeting. When this surveyor asked the social worker why she was entering the meeting, Resident #88 stated he invited the social worker to the meeting. When the other Residents were asked about this, the other Residents in attendance also indicated they would like the social worker to be present. The meeting resumed and when the Residents were asked if call bells were answered timely, Resident #52 stated that the aides appear angry, not giving good service. Resident #52 also stated staff was yelling at me. Resident #52 also indicated she didn't want to provide names. Resident #52 also stated she had experienced retaliation for reporting issues and did not want to elaborate further at the time of the meeting. Resident #88 also reported experiencing retaliation due to their loved one advocating for their care. When asked about what happened, Resident #88 stated that when he would ask for something, the staff wouldn't do it. Resident #88 also stated that the staff would say his loved one was mean and they would laugh at her. On 09/13/2022 at 12:10 P.M. following the Resident Council meeting, the administrator was notified of findings. On 09/13/2022 at 4:26 P.M., the Administrator entered the conference room to present a packet of documents to the survey team. The top page was a document entitled, F600 Abatement Plan 09/13/2022. The opening sentence documented, The facility failed to protect Residents from abusive behavior from staff i.e yelling at residents. Under the header Identification of Others it was documented, All residents have the potential to be affected by this deficient practice. Interview all residents to identify if similar resident abuse exists. Implement action to protect resident if similar allegation is identified by ED [Executive Director] and DON [Director of Nursing] 9/13/22. Interviews conducted house-wide on residents with BIMS [Brief Interview for Mental Status] 12 or greater related to abuse by ED and DON and SW [Social Worker] 9/13/22. Skin assessments conducted house-wide on those with BIMS [Brief Interview for Mental Status] less than 12 UM [unit manager] and DON 9/13/22. Under the header Education the following excerpts were documented: Educate all staff .to organization abuse prevention policies, behavior management, and one on one care guidelines by ED and DON or designee 9/13/22. Facility Leadership team to conduct daily ambassador rounds and interviews to assure residents with potential for abuse, behavioral concerns, and requiring one to one guidelines are identified, investigation initiated, and reported to the state agency timely per guidelines by Designee/ED and SW ongoing. Under the header System Change the following excerpts were documented: Education will be provided to all new employees upon hire and annually on the Abuse policy, behavior management guidelines by HR [Human Resources]. All supervisors will be educated on the process of dealing with difficult behaviors, and when/if a resident complains of any form of abuse, or any abuse is witnessed, staff will notify supervisor immediately and supervisor to inform ED, DON, and MD [Medical Doctor]. There were 14 pages of in-service sheets in the packet of documents with a date range of 06/20/2022 through 09/13/2022 on various topics to include abuse and neglect. There was no evidence in the packet that the allegation of abuse reported on 09/12/2022 by Resident #52 was reported to the state agency or an investigation initiated. On 09/14/2022, Resident #52's clinical record was reviewed. Resident #52's Minimum Data Set with an Assessment Reference Date of 07/27/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 10 out of possible 15 indicative of moderate cognitive impairment for that 7-day look-back period. On 09/15/2022 at 1:00 P.M., a copy of the Facility-Reported Incident (FRI) related to Resident #52's allegation of abuse on 09/13/2022 was requested from the administrator. The Administrator stated a grievance form was filed and an investigation was started. On 09/15/2022, the facility staff provided a document dated 09/13/22 entitled, Concern Form for Resident #52. Under the header Description of Concern it was documented, Resident verbalize [sic] staff yells at her. Under the header Actions to resolve the concern documented, Social Services interviewed all residents w/a [with a] BIMS [Brief Interview for Mental Status] score of 12 and above with no concerns voiced of verbal, physical, or sexual abuse. The document was signed by the Social Worker on 09/14/2022 and the Administrator on 09/15/2022. On 09/15/2022 at 6:25 P.M., the Administrator was interviewed. When asked about the process for allegations of verbal abuse, the Administrator stated that staff would put a note in the system and it would be investigated and reported initially to the state agency within 2 hours and a follow-up report would be sent to the state agency in 5 days. When asked about a FRI regarding Resident #52's allegation of verbal abuse, the administrator stated a FRI was not done. The facility staff provided a copy of their policy entitled, Abuse, Neglect, and Misappropriation. In Section (IV)(2)(a), it was documented, Each occurrence of resident incident, bruise, abrasion, or injury of unknown source; or report of alleged abuse, neglect, or misappropriation of funds will be identified and reported to the supervisor and investigated timely. In Section (V)(1), it was documented, In the event a situation is identified as abuse, neglect, or misappropriation, an investigation by the executive leadership will immediately follow. In Section (V)(2)(a), it was documented, The ED [executive director]/designee will report appropriate incidents to the Adult Protective Services and Division of the Licensing and Regulation as required by state law. 5. For Resident # 21 the facility staff failed to implement the abuse policy. On 5/1/22 the facility submitted a FRI (Facility Reported Incident) to the OLC (Office of Licensure and Certification) regarding an allegation of abuse of Resident #21 by LPN F. The FRI read: Describe incident, including location, and action taken: CNA [name redacted] reported seeing a male nurse, [name redacted] hit Resident from behind the privacy curtain in room [ROOM NUMBER]. Resident was assessed w/o [without] injury. Employee action initiated or taken - [Employee name redacted] placed on suspension 5/1/22 pending investigation. The investigation contained a statement from the CNA that witnessed the incident. The CNA stated in her witness statement, that she went downstairs upset and was told that they would notify the DON however the CNA stated she did not trust the DON due to hearing her say Stuff like that does not happen on my floor. The CNA went outside and called the police to report the abuse and that the police came and took her statement. A review of the payroll account revealed that the LPN F was not placed on suspension. He worked 5/1/22 through 5/5/22. LPN F continued at the facility as an active employee until 9/16/22 when he was terminated. A review of the employee file included the license verification completed on hiring the nurse. LPN F's license read: Additional Public Information - YES [Please note when YES comes up on a license verification it is indicative of the licensee being brought before the Board of Nursing, and the facility either neglected to click the Yes to find out what the further information was or they checked it and chose to hire the LPN anyway.] The facility had no evidence that they had checked to see what that further information was until after this incident took place. During the course of their investigation they found that LPN F had been terminated from 2 previous facilities for negligence and verbal abuse. A review of the Abuse Neglect and Exploitation Policy # NS 1019-01-VA read: Page 10 4. License / registry check will also be performed as applicable after the interview to verify: a. The Nurse Aide Registry b. The State Board of Nursing c. Other Professional Registries. 6. This facility will NOT employ individuals who have had a disciplinary action taken against their professional license by a state licensure body as a result of abuse, neglect, mistreatment of residents or misappropriation of resident's property. The nurse was terminated from employment on 9/16/22. On 9/16/22 the Administrator was made aware of the concerns and no further information was provided 4. For Resident # 217, the facility staff failed to implement the policies on abuse/neglect Resident # 217 was admitted to the facility on [DATE] for skilled services in nursing and therapy with the diagnoses of, but not limited to, Asthma, Congestive Heart Failure (CHF), Chronic Kidney Disease Stage 3, Hypertension, Atrial Fibrillation, Obstructive Sleep Apnea (OSA), Infection due to Multi-resistant organism and Morbid Obesity with BMI (Body Mass Index) 60-69. Review of the Resident # 217's closed clinical record revealed the most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 9/16/2021. The MDS coded Resident #217 as requiring extensive to total assistance of one to two staff persons with activities of daily living and frequently incontinent of bowel and bladder. Review of the closed clinical record was conducted on 9/12/2018 through 9/22/2022. Review of the Progress Notes revealed documentation of a nurses note dated 5/28/2020 at 8:19 a.m. which stated: Resident The CNA (Certified Nursing Assistant) and I transferred (gender redacted) to the wheelchair. At around 10:30 p.m., I asked the CNA to help put (gender redacted) back to bed because it would be difficult if nobody is around to put (gender redacted) to bed. Resident refused to go to bed. (gender redacted) later on asked to be put to bed and I said (Resident # 217's name redacted) not by myself. I will need someone to help me. There was nobody at the moment and (gender redacted) was in the wheelchair for a while until when (Name of CNA redacted) came to help with (name of another resident redacted), then we put (gender redacted) to bed. An interview was conducted with the Administrator on 9/21/2022 regarding reporting the allegation of neglect for Resident # 217. The Administrator stated that he had not been aware of documentation in the nurses progress note until the surveyor informed the Regio

2. For Resident #117, who reported an allegation of abuse, the facility staff failed to report the allegation to the OLC (Office of Licensure and Certification/state survey agency) and Adult Protective Services. On 9/15/22, the survey team discovered that Resident #117's family reported to facility staff that assigned CNA was rough while providing perineal care and washing her . The facility completed a grievance form on 5/27/22, and indicated on the form that that Administrator, Director of Nursing, and Social Services Director were notified. There is no evidence that the facility reported this allegation to the State survey agency or Adult Protective Services nor the results of an investigation. On 9/15/22 at 6 PM, during an end of day meeting, the facility Administrator was interviewed. The Administrator stated that a FRI (Facility Reported Incident) is completed for anything causing harm, potential harm, or when something happens to a patient, a patient to patient situation or staff to patient. We report the FRI and send to the OLC and APS via fax and the Ombudsman. The initial notification is within 2 hours, we make sure the Resident is safe and start an investigation. Within 5 days we report to the OLC our investigation and what we found out as well as the resolution. On 9/22/22 at 9:39 AM, an interview was conducted with Employee E, the social worker. Employee E stated, If you have an allegation of abuse you have to report it immediately because it has to be reported to the state, APS, and Ombudsman within 2 hours. Also, you need to make sure the Resident is safe during that time, if you don't report immediately you can put the Resident at risk. When asked about the timing of the investigation, Employee E said, Everything has to be done in 5 days. The facility policy titled, Abuse, Neglect and Exploitation Policy was received and reviewed. This policy read, .V. Reporting of Incidents and Facility Response: 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. a. If the events that cause the allegation do not result in serious bodily injury, reporting to the administrator and to other reporting regulatory bodies must occur within twenty-four hours. The above referenced policy went on to say, .2. Alleged violations are reported immediately to the Executive Director of the facility. a. The ED/designee will report appropriate incidents to the Adult Protective Services and the Division of Licensing and Regulation as required by state law. 3. The results of the facility's investigation must be reported to the survey agency, the ED/Designee and other officials in accordance with state law, within five working days of the incident . On 9/15/22 at 6 PM, and again on 9/21/22, during end of day meetings the facility Administrator, Director of Nursing and Corporate staff were made aware the survey team had identified concerns regarding the timing of FRI reporting, the lack of evidence that the appropriate agencies were notified and the lack of evidence of final/5 day reports being made. No further information was received. 3. For Resident #31, the facility staff failed to report to the OLC (Office of Licensure and Certification/state survey agency) and Adult Protective Services an allegation of abuse. On 9/15/22, the survey team discovered that Resident #31 reported that a CNA [name redacted] was rough during ADL's [activities of daily living] and keep washing and washing her and it is rough on her skin [sic]. Following this report from the Resident, the facility completed a concern form dated 6/10/22, and had no evidence of this allegation being reported to the OLC or Adult Protective Services. On 9/15/22 at 6 PM, during an end of day meeting, the facility Administrator was interviewed. The Administrator stated that a FRI (Facility Reported Incident) is completed for anything causing harm, potential harm, or when something happens to a patient, a patient to patient situation or staff to patient. We report the FRI and send to the OLC and APS via fax and the Ombudsman. The initial notification is within 2 hours, we make sure the Resident is safe and start an investigation. Within 5 days we report to the OLC our investigation and what we found out as well as the resolution. On 9/22/22 at 9:39 AM, an interview was conducted with Employee E, the social worker. Employee E stated, If you have an allegation of abuse you have to report it immediately because it has to be reported to the state, APS, and Ombudsman within 2 hours. Also, you need to make sure the Resident is safe during that time, if you don't report immediately you can put the Resident at risk. When asked about the timing of the investigation, Employee E said, Everything has to be done in 5 days. The facility policy titled, Abuse, Neglect and Exploitation Policy was received and reviewed. This policy read, .V. Reporting of Incidents and Facility Response: 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. a. If the events that cause the allegation do not result in serious bodily injury, reporting to the administrator and to other reporting regulatory bodies must occur within twenty-four hours. The above referenced policy went on to say, .2. Alleged violations are reported immediately to the Executive Director of the facility. a. The ED/designee will report appropriate incidents to the Adult Protective Services and the Division of Licensing and Regulation as required by state law. 3. The results of the facility's investigation must be reported to the survey agency, the ED/Designee and other officials in accordance with state law, within five working days of the incident . On 9/15/22 at 6 PM, and again on 9/21/22, during end of day meetings the facility Administrator, Director of Nursing and Corporate staff were made aware the survey team had identified concerns regarding the timing of FRI reporting, the lack of evidence that the appropriate agencies were notified and the lack of evidence of final/5 day reports being made. No further information was received. 4. The facility staff failed to report an allegation of misappropriation of narcotic medication involving Residents #84, 367, 369, and 19. On 8/3/22, the facility staff identified that the narcotic count was off for Residents #84, 367, 369 and 19. The facility completed a Facility Reported Incident form, however on the form they indicated that physician notification was N/A [not applicable] and the APS (Adult Protective Services) area was blank with no indication of them being made aware. In the course of the facility investigation they identified a staff member as a suspect and included a report form to the Department of Health Professions (licensing board for nurses) but failed to sign the form and gave no indication/evidence that they were notified of the findings and investigation. On 9/15/22 at 6 PM, during an end of day meeting, the facility Administrator was interviewed. The Administrator stated that a FRI (Facility Reported Incident) is completed for anything causing harm, potential harm, or when something happens to a patient, a patient to patient situation or staff to patient. We report the FRI and send to the OLC and APS via fax and the Ombudsman. The initial notification is within 2 hours, we make sure the Resident is safe and start an investigation. Within 5 days we report to the OLC our investigation and what we found out as well as the resolution. On 9/22/22 at 9:39 AM, an interview was conducted with Employee E, the social worker. Employee E stated, If you have an allegation of abuse you have to report it immediately because it has to be reported to the state, APS, and Ombudsman within 2 hours. Also, you need to make sure the Resident is safe during that time, if you don't report immediately you can put the Resident at risk. When asked about the timing of the investigation, Employee E said, Everything has to be done in 5 days. The facility policy titled, Abuse, Neglect and Exploitation Policy was received and reviewed. This policy read, .V. Reporting of Incidents and Facility Response: 1. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. a. If the events that cause the allegation do not result in serious bodily injury, reporting to the administrator and to other reporting regulatory bodies must occur within twenty-four hours. The above referenced policy went on to say, .2. Alleged violations are reported immediately to the Executive Director of the facility. a. The ED/designee will report appropriate incidents to the Adult Protective Services and the Division of Licensing and Regulation as required by state law. 3. The results of the facility's investigation must be reported to the survey agency, the ED/Designee and other officials in accordance with state law, within five working days of the incident . On 9/15/22 at 6 PM, and again on 9/21/22, during end of day meetings the facility Administrator, Director of Nursing and Corporate staff were made aware the survey team had identified concerns regarding the timing of FRI reporting, the lack of evidence that the appropriate agencies were notified and the lack of evidence of final/5 day reports being made. No further information was received. Complaint related deficiency. Based on Resident interviews, staff interviews, clinical record reviews, facility documentation review, and in the course of a complaint investigation, the facility staff failed to report allegations of abuse timely for 7 Residents (Resident #52, Resident #117, Resident #31, Resident #84, Resident #367, Resident #369, Resident #19) in a sample size of 60 Residents. The findings included: 1. For Resident #52, the facility staff failed to report the allegation of abuse to the state agency and adult protective services timely. On 09/13/2022 at 11:00 A.M., a Resident Council meeting with 6 Residents was conducted. At 11:18 A.M., the Social Worker entered the Resident Council meeting. When this surveyor asked the social worker why she was entering the meeting, Resident #88 stated he invited the social worker to the meeting. When the other Residents were asked about this, the other Residents in attendance also indicated they would like the social worker to be present. The meeting resumed and when the Residents were asked if call bells were answered timely, Resident #52 stated that the aides appear angry, not giving good service. Resident #52 also stated staff was yelling at me. Resident #52 also indicated she didn't want to provide names. Resident #52 also stated she had experienced retaliation for reporting issues and did not want to elaborate further at the time of the meeting. Resident #88 also reported experiencing retaliation due to their loved one advocating for their care. When asked about what happened, Resident #88 stated that when he would ask for something, the staff wouldn't do it. Resident #88 also stated that the staff would say his loved one was mean and they would laugh at her. On 09/13/2022 at 12:10 P.M. following the Resident Council meeting, the administrator was notified of findings. On 09/14/2022, Resident #52's clinical record was reviewed. Resident #52's Minimum Data Set with an Assessment Reference Date of 07/27/2022 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 10 out of possible 15 indicative of moderate cognitive impairment for that 7-day look-back period. On 09/15/2022 at 1:00 P.M., a copy of the Facility-Reported Incident (FRI) related to Resident #52's allegation of abuse on 09/13/2022 was requested from the administrator. On 09/15/2022 at 6:25 P.M., the Administrator was interviewed. When asked about the process for allegations of verbal abuse, the Administrator stated that staff would put a note in the system and it would be investigated and reported initially to the state agency within 2 hours and a follow-up report would be sent to the state agency in 5 days. When asked about a FRI regarding Resident #52's allegation of verbal abuse, the administrator stated a FRI was not done. On 09/19/2022, the facility staff provided a copy of the FRI dated 09/16/2022 and fax notification documents associated with Resident #52's allegation of verbal abuse on 09/13/2022. The fax notification to the state agency was sent on 09/16/2022 at 9:57 P.M. The notification to Adult Protective Services was sent on 09/16/2022 at 6:44 P.M. This was over three days after the Administrator learned of the allegation of verbal abuse. The facility staff provided a copy of their policy entitled, Abuse, Neglect, and Misappropriation. In Section (VII)(i), an excerpt documented, Within 24 hours of learning of an incident the facility must report it to the OLC [state agency] unless the incident is an allegation of abuse or involves serious bodily injury and then the facility must report to the OLC within 2 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to revise the care plan for 7 Resident (Resident #318, Resident #78, Resident #68, Resident #318, Resident #86, Resident #35, Resident #14) in a sample size of 60 Residents. The findings included: 1. For Resident #318, the facility staff failed to address communication on the care plan. On 09/12/2022 at 3:50 P.M., Resident #318 was observed awake in her bed. When asked if she had any concerns about the care received at the facility, Resident #318 spoke in a foreign language. There were no communication aids or language line number observed at the bedside. On 09/13/2022, Resident #318's clinical record was reviewed. Under the Assessment tab in the electronic health record, there was no evidence Resident #78's understanding of the English language was assessed. According to the Face Sheet under the section Primary Language, it was documented, Hindi. According to the admission Evaluation dated 08/31/2022 under Section 5 entitled, Is English primary language? the answer no was selected. In Section 5a entitled, Primary Language it was documented, Paru. Under the Miscellaneous tab in the electronic health record, there was a scan entitled, admission info. A document form another facility entitled, admission Record Report documented that Resident #318's primary language was Farsi. Resident #318's care plan did not have a focus, goals, or interventions addressing Resident #318's primary language and communication management to effectively communicate with Resident #318. On 09/19/2022, the facility staff provided a copy of their policy entitled, Plan of Care Overview. Under the header Policy, it was documented, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Safety is a primary concern for our residents, staff and visitors. The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of person-centered care planning and that this planning includes the provision of services to enable the resident to live with dignity and supports the resident's goals, choices, and preferences including, but not limited to, goals related to the their daily routines and goals to potentially return to a community setting. On 09/21/2022 at 9:55 A.M., Resident #318 was observed with a visitor at the bedside. The visitor indicated she was a family friend and visits often in the morning-time. When asked about Resident #318's primary language, the family friend stated Urdu. When asked about Resident #318's ability to understand/communicate in English, the family friend stated that Resident #318 understands some English, but not everything. The family friend also stated that Resident #318 can speak a few words in English. When asked how the staff communicated with Resident #318, the family friend stated she didn't know because they're not here when I'm here. On 09/21/2022 at approximately 10:00 A.M., Certified Nursing Assistant W (CNA W) was interviewed. CNA W verified she was assigned to care for Resident #318. When asked for Resident #318's primary language, CNA W indicated she didn't know. CNA W then stated that Resident #318 sometimes speak English but she is not fluent. On 09/21/2022 at approximately 10:05 A.M., Registered Nurse D (RN D) was interviewed. RN D verified she was assigned to care for Resident #318 this day. When asked for Resident #318's primary language, RN D stated that she didn't know and added that she doesn't speak much English. When asked how she communicates with Resident #318, RN D stated that she understands when we talk with her. RN D also stated that the family friend that visits in the morning will help as well. The facility staff provided a copy of their policy entitled, Plan of Care Overview. Under the header Policy, an excerpt documented, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. On 09/21/2022 at approximately 4:15 P.M., the Administrator and Director of Nursing were notified of findings. 2. For Resident # 78, the facility staff failed to address communication on the care plan. On 09/12/2022 at 12:45 P.M., Resident #78 was observed in bed awake. When I asked if she had any concerns about the care received at the facility, Resident #78 motioned to their neck and pointed to her roommate, Resident #38. Roommate (Resident #38) stated that [Resident #78] cannot speak but responds to yes/no questions. The Roommate (Resident #38) also stated that [Resident #78]'s primary language is not English. This surveyor observed there were no communication aids in the room and no information about a language line was observed. The roommate (Resident #38) was asked if staff used interpreter to communicate with Resident #78, and the roommate stated staff sometimes ask her to interpret because she can also speak Resident #78's primary language. When asked what she is asked to interpret, the roommate Resident #38 stated, I let them know what food she doesn't like or I let them know when she has an upset stomach. On 09/13/2022, Resident #78 clinical record was reviewed. Under the Assessment tab in the electronic health record, there was no evidence Resident #78's understanding of the English language was assessed. According to the Face Sheet under the section Primary Language, it was documented, English. According to the admission Evaluation dated 09/13/2017 under the section entitled, Communication, the choices were English or Other. The option Other was selected and Spanish was written in the text box. A focus on the care plan initiated on 09/20/2017 entitled, [Resident #78] has a communication problem r/t Expressive Aphasia, Language barrier, Anarthria and dysarthria documented the following interventions: Anticipate and meet needs. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Ensure/provide a safe environment: Call light in reach, adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Another focus on the care plan was entitled, [Resident #78] is a native (Chilies, Mexican, etc.) and English is the her [sic] second language. The language barrier may limit participation during programs. Interventions associated with this focus were the following: Assess previous and current leisure interests and lifelong routines. [Resident #78] enjoys attending religious services and will be added to church list .Invite, remind and encourage to activities of stated interests as requested and tolerated. Offer and support according to needs and preferences: (life review activities, quality time with chosen relatives, friends, staff, other residents, spiritual support, touch, massage, music of preference, reading aloud, reading of preference, etc.). Offer social, recreational and volunteer visits within her tolerance and preferences. Provide and review monthly calendar with resident, offer alternatives that can be done individually. Provide one-on-one visits (in the room, at bedside, etc.) to stimulate senses and provide contact, target supportive programs such as (listening to relaxing music, hand massage, relaxation techniques). Respect her right to refuse groups and set own leisure routine. Staff will invite, remind and escort to programs of interests. Another focus on the care plan dated 04/25/2022 entitled, [Resident #78] has a communication problem r/t [related to] other disease process / condition had the following interventions: Observe effectiveness of communication strategies and assistive devices. Observe for declines in communication. Observe/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. There were no interventions on the care plan addressing how to effectively communicate with Resident #78. On 09/14/2022 at 9:30 A.M., this surveyor observed Licensed Practical Nurse H (LPN H) administer medications to Resident #78. As this surveyor and LPN H entered the room, Resident #78 grimaced, held up 2 fingers, then pointed to her abdomen. As LPN H offered the Colace (a laxative), Resident #78 motioned with her hand and shook her head no. LPN H spoke to Resident #78 in English and asked Resident #78 if she was having loose stools and Resident #78 nodded her head yes and held up 2 fingers. LPN H asked Resident #78 if she had 2 loose stools and Resident #78 nodded her head yes. LPN H returned to the medication cart after the med pass and stated to this surveyor that Resident #78 had anti-diarrhea available to administer as needed. When asked how staff communicate with Resident #78, LPN H stated that staff don't use an interpreter because [Resident #78] cannot speak and she understands English. LPN H then approached Certified Nursing Assistant H (CNA H) and asked if Resident #78 had loose stools this day. CNA H stated that Resident #78 has not had a bowel movement this day. When asked how staff communicate with Resident #78, CNA H stated, We've been around her a long time; we just know what she is saying. LPN H then saw the nurse practitioner (Employee FF) in the hall and informed her of the loose stools. The nurse practitioner then started walking toward Resident #78's room. This surveyor asked to observe the nurse practitioner interact with Resident #78. The nurse practitioner stated, Do you have to be there? I'll be asking [Resident #78] a lot of questions. The nurse practitioner then turned to the nurse (LPN H) and stated she would need an interpreter. LPN H walked down to the nurse's station to ask the unit manager about an interpreter. LPN H returned and stated that the unit manager, Registered Nurse C (RN C), went to the basement to get an interpreter. On 09/14/2022 at 10:15 A.M., the Assistant Director of Nursing, RN E, was interviewed. When asked how staff communicate with Resident #78, the Assistant Director of Nursing (ADON) indicated she didn't know and stated Let me get that information for you. The ADON then stated that she would go to an interpretation site on the internet. At approximately 10:18 A.M., CNA O was asked how staff communicate with Resident #78 and CNA O stated that there are two housekeepers that speak the same language as Resident #78. The staff were identified and placed in staff identifier as Employee Q, a laundry aide and Employee R, a housekeeper. On 09/14/2022 at 10:21 A.M., LPN H provided a document entitled, Language Line with a phone number and PIN. On 09/14/2022 at 10:30 A.M., the ADON provided a copy of another document entitled, Language Line with a different phone number and PIN. The ADON stated that this was the correct one because she got it from the social worker. On 09/15/2022 at 9:20 A.M., Employee Q was interviewed. When asked if the staff ask her to interpret for Residents, Employee Q stated that sometimes she would interpret but I only speak a little bit of English. When asked how often she serves as interpreter, Employee Q indicated she didn't understand the question and wanted to get her supervisor to interpret the question. On 09/15/2022 at 9:30 A.M., Employee R was interviewed. When asked if staff ask her to interpret, Employee R stated that the nurses ask her to interpret. Employee R also stated that she is not fluent in English but understands a little bit. When asked which Residents she serves as interpreter, Employee R stated Resident #78's name and Resident #6 in the sample. Employee R stated that sometimes Resident #6 will say she has pain in her leg or hip. Employee R stated Resident #6 speaks no English. When asked about Resident #78, Employee R stated that when she is interpreting for Resident #78, sometimes she will need medication. Employee R stated that Resident #78 Doesn't talk, only answers yes/no questions. I will ask her questions and she will answer. Employee R stated that she interprets when the doctor is seeing her and sometimes the nurses will ask me to go in there and check on her. On 09/15/2022 at approximately 6:45 P.M., the Administrator and Director of Nursing were notified of findings. The facility staff provided a copy of their policy entitled, Plan of Care Overview. Under the header Policy, an excerpt documented, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. 3. For Resident #34 the facility failed to develop and implement a comprehensive person-centered care plan that includes methods of communication for a non-English speaking Resident who has also had a stroke. On 09/12/2022 at approximately 12:35 P.M., Resident #68 was interviewed. When asked about having any concerns about care at the facility, Resident #68 stated that he has not received physical therapy. On 09/13/2022, Resident #68's clinical record was reviewed. A physician's order dated 08/10/2021 documented, Physical therapy evaluate and treat for generalized weakness, bilateral lower extremity weakness. Resident #68's care plan was reviewed. A focus initiated on 12/23/2019 entitled, [Resident #68] has hemiplegia/hemiparesis to left side r/t [related to] stroke. The goal associated with this focus initiated on 12/23/2019 and revised on 12/06/2021 documented, [Resident #68] will maintain optimal status and quality of life within limitations imposed by hemiplegia/hemiparesis through review date. An intervention associated with this focus initiated on 12/23/2019 included but was not limited to PT, OT, ST evaluate and treat as ordered. There was no evidence the care plan was reviewed quarterly or revised when the physician ordered physical therapy services on 08/10/2021. On 9/15/22 at 9:50 AM, Employee E was asked about care planning. She said, The care plan is reviewed every 90 days. When asked when a change occurs, when that would be reflected in the care plan, Employee E said, The care plan should get updated that same day as to when the change occurred. The facility staff provided a copy of their policy entitled, Plan of Care Overview. Under the header Policy, an excerpt documented, It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. 5. For Resident #86 the facility staff failed to review and revise the care plan as the tube feeding and oral feeding orders changed. On 9/12/22 at approximately 4:00 PM the following observation was made: Tube feed Jevity 1.2 was hanging and infusing via enteral pump at 45 ml per hour. The 60 ml piston syringe was not dated and the tube feeding was not dated nor was the tubing. On 9/12/22 at end of day meeting the DON was asked for the tube feeding policy. On 9/13/22 at approximately 2PM the tube feeding policy was again requested. On 9/13/22 a review of the clinical record revealed that Resident # 86 was admitted on [DATE] with diagnoses that included dysphasia, failure to thrive, and a peg tube had been inserted. Resident #86's signed admission orders for diet read: NPO (Nothing by Mouth), NPO Texture, NPO Consistency dated 8/13/22 The physician put in enteral Feed orders that read: Enteral Feed Order As needed flush. Flush with at least 30 ml. [Resident name redacted] requires, tube feeding Date Initiated: 08/13/2022 Revision on: 08/13/2022 (Please note that no Tube Feeding was ordered only flushes were ordered) The baseline care plan read: FOCUS [Resident #86 name redacted] will maintain adequate nutrition and hydration status though review date. Date Initiated: 08/13/2022 Revision on: 08/13/2022 GOAL [Resident #86 name redacted] will remain free of complications through review date Date Initiated: 08/13/2022 Revision on: 08/13/2022 INTERVENTION: Administer flushes per medical provider's order. Date Initiated: 08/13/2022 Administer medications via tube, per orders. Date Initiated: 08/13/2022 Check for placement and residuals per policy. Date Initiated: 08/13/2022 Head of bed elevated 30 degrees or higher. Date Initiated: 08/13/2022 Nutritional consult on admission, quarterly, and PRN. Date Initiated: 08/13/2022 Obtain weights as ordered. Date Initiated: 08/13/2022 Provide supplemental meals per diet order. Provide assistance with meals as needed. Date Initiated: 08/13/20 **Please note it says Nutritional Consult on admission and PRN. No consult was done until 8/25/22 (2 weeks after admission) ** On 9/19/22 at approximately 4PM an interview was conducted with the DON who was asked how the care plan is developed. She stated the Interdisciplinary team meets and we each have a part of the care plan. Who is on the interdisciplinary team she stated a member from each department the doctor, nursing, food services, therapy and social work and activity as well as the Resident or family member. A review of the care plan policy revealed that When asked about Resident #86's interdisciplinary team with regards to her tube feeding, how much where were the orders and how was she eating. The DON stated she gets tube feeding and when asked about the tube feeding she could not answer why no tube feeding only flushes had been ordered from 8/13/22-8/25/22. She did not know why it took so long to get a Nutrition consult for the Resident. When asked w Another request for the tube feeding policy and procedure was made at that time. Surveyor: [NAME], [NAME] 6. For Resident #14, who developed a contracture of her left elbow, wrist and hand while a Resident of the facility, the facility staff failed to review and revise the care plan to identify the contracture and limited range of motion. On 09/12/22 at 02:49 PM, Resident #14 was visited in her room and a family member was at the bedside. A Resident and family interview were conducted. Resident #14's family member said he is very concerned about the Resident's left hand, she is no longer able to use it and when you touch it she has pain. The family member confirmed that Resident #14's hand was not like this when she came to the facility. During the above interview, Surveyor B observed Resident #14's left hand and noted that her fingers appeared to be contracted in a closed position, her wrist appeared to have some limited movement as well. When asked if she (Resident #14) could open her hand she was not able to do so independently. Review of the clinical record for Resident #14 revealed the following entries that noted the contracture(s): a. A physician order dated 7/13/22, that read, OT [occupational therapy] evaluation for splint for left hand contracture of fingers. A progress note written by the provider the same day read, .Assessment / Plan 1. Contracture of multiple joints- particularly left hand with apparent pain with movement and when try to examine it but seems comfortable when left alone . b. A physician progress note dated 8/23/22, that read, .Follow-up: Contracture of multiple joints .Musculoskeletal System: Hand: no erythema or warmth and limited both active and passive extension left finger(s); able to move arm to examine and hand but does draw away when attempt to open fingers, rings on fingers but distal neurovascular intact. Musculoskeletal System contracture of extremities . c. The MDS [minimum data set/an assessment tool] conducted 3/6/22, which was coded as an annual assessment was reviewed. This assessment was coded in section G0400. Functional Limitation in Range of Motion, question G0400 A: Upper extremity (shoulder, elbow, wrist, hand): no impairment d. The MDS [minimum data set/an assessment tool] conducted 6/24/22, which was coded as a quarterly assessment was reviewed. This assessment was coded in section G0400. Functional Limitation in Range of Motion, question G0400 A: Upper extremity (shoulder, elbow, wrist, hand): no impairment On 9/15/22 at 7:20 PM, the therapy director provided the survey team with a copy of the Occupational Therapy (OT) evaluation that was completed for Resident #14 on 9/15/22. It read, .Reason for Referral: Patient is a 88 y/o [year old] female referred to skilled OT evaluation for assessment and management of LUE [left upper extremity] flexor contractures at elbow, wrist and hand due to hx [history] of R [right] intracranial hemorrhage LUE [left upper extremity] ROM [range of motion]= Impaired (L wrist rests in 80 degrees flexion with ~30 degrees of passive extension from fixed position available. L D3 [left digit 3/finger] and 4 most severe with 90 degree contractures from MCP [Metacarpophalangeal joint/commonly known as knuckles] to DIP [Distal Interphalangeal Joint/bones at the tip of the fingers]. L thumb proximal phalange in fixed adducted position with hyperextension of IP joint, unable to form functional grasp. L D2 and D5 [left digit 2 and 5/ index and pinky fingers] are least affected with resting MCP flexion at 90 degrees and ability to extend 45 degrees from this position, distal segments flaccid and passively WFL [Within Functional Limits]. L elbow passively WFL, shoulder flexion PROM [passive range of motion] 0-120 degrees and AROM [active range of motion] 0-35 degrees; patient rests in elbow flexion (~70 degrees) and internal rotation . The evaluation by OT revealed Resident #14 had significant impairments/limitations of her left arm and hand due to the contractures. Resident #14's care plan was reviewed and did not identify or address the hand contracture and therefore no interventions were in place to prevent further decline. On 9/15/22 at 9:50 AM, an interview was conducted with Employee E, the social worker, who confirmed she is a member of the interdisciplinary care plan team. Employee E was asked about care planning during the above interview. She said, The care plan is reviewed every 90 days. When asked when a change occurs, when that would be reflected in the care plan, Employee E said, The care plan should get updated that same day as to when the change occurred. Review of the facility policy titled, Plan of Care Overview was conducted. The policy read, PoC [plan of care]: for the purpose of this policy the Plan of Care, also Care Plan is the written treatment provided for a resident that is resident-focused and provides for optimal personalized care .1. d. The facility will: iii. Review care plans quarterly and/or with significant changes in care . On 9/21/22, the facility Administrator and Director of Nursing were made aware of the above findings during an end of day meeting. No additional information was received. 7. For Resident #35, the facility staff failed to review and revise the care plan to reflect a change in discharge plan when it was determined the Resident would remain in the facility for long-term care versus returning home. On 9/12/22 at 3:07 PM, Resident #35 was interviewed. During the interview, Resident #35 said, I would rather go home and do the best we can versus stay here and go broke. A clinical record review for Resident #35 revealed a care plan that read, [Resident #35's name redacted] wished to be discharged to home when his skilled therapy service end. Also in the clinical record there was evidence that skilled care ended and his payer status/source changed on 7/13/22. A progress note dated 5/12/22, read, .planning to stay in LTC [long-term care] facility . On 9/15/22 at 9:50 AM, an interview was conducted with Employee E, the social worker. Employee E stated, The goal was to transition him [Resident #35] home, he needs supervision. He looked at an assisted living facility and the decision to leave changed. Employee E said she worked with Resident #35 and his spouse about a month and a half ago to transfer to an assisted living. Employee E was asked about care planning during the above interview. She said, The care plan is reviewed every 90 days. When asked when a change occurs, when that would be reflected in the care plan, Employee E said, The care plan should get updated that same day as to when the change occurred. Review of the facility policy titled, Plan of Care Overview was conducted. The policy read, PoC [plan of care]: for the purpose of this policy the Plan of Care, also Care Plan is the written treatment provided for a resident that is resident-focused and provides for optimal personalized care .1. d. The facility will: iii. Review care plans quarterly and/or with significant changes in care . On 9/21/22, during an end of day meeting, the facility Administrator and Director of Nursing were made aware of the above concern of Resident #35's care plan still indicating a goal to return home. No further information was provided. 4. For Resident #318, the facility staff failed to revise the comprehensive care plan to include interventions for newly aquired pressure sores. The findings included: Resident #318, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included hypertension, dementia, adult failure to thrive, deprssion, and an open left buttocks pressure wound. Resident #318's most recent Minimum Data Set assessment was not yet submitted.on 9-12-22. The Resident required total dependance on staff for all activities of daily living. On 9-5-22 physician's orders were received for treatments to newly aquired deep tissue injury to bilateral heels, and a stage 2 sacral wound. There was no progress note in the clinical record for a visit on this date. The first progress note of any kind found in the clinical record was a physician visit on 9-9-22. Resident #318 was seen by the physician on 9-9-22 who documented in a progress note recommendations for newly developed pressure wounds on the sacrum, and both heels in the note. Those recommendations included the following; 1. Air matress 2. Emollients to feet 3. Nutrician consult 4. Heel protection Resident #318's care plan was reviewed and revealed none of the ordered treatments from 9-5-22, nor new physician recommendations from 9-9-22 were placed on the care plan to guide treatment. At the end of day meeting on 9-15-22, the Administrator, and DON were notified of the concerns regarding the lack of implementing revisions to careplans to address the management of pressure sores. They were asked if it was the facility's policy to review and revise care plans with treatment plans for wounds, and both agreed it was their policy to do so. No further information was provided by the facility.

Based on staff interview and facility documentation review, the facility staff failed to ensure that required competencies were completed for 6 of 6 nursing staff members including, Registered Nurses (RN), Certified Nursing Aides (CNA), and Licensed Practical Nurses (LPN). The survey sample of 6 consisted of; (RN/DON), (CNA B), (CNA C), (CNA F), (LPN F), and (LPN G). The Facility failed to complete required initial, and annual, competency training, and evaluations. The Findings included: On 9-14-22 a review was requested for employee education/training and competency evaluations. The facility Administrator was asked for employee records for the 6 staff members. Each day from 9-14-22 through 9-18-22 the employee records were requested, and surveyors were told by the Administrator oh yes, I have them on my desk, I will send them to your email. On 9-19-22 education records and evaluation information was received. There were 4 of the 6 included and a call was placed to the Administrator to ask for the other 2 missing documents. The Administrator stated We can find nothing for those employees. The 4 that were received stated on the email from the Administrator the following; CNA (C) (name) does not have an annual eval on file, CNA (B) (name) has none, DON (name) has none, and LPN (F) (name) we only have termination. No mention was given for the other 2 staff LPN (G), and CNA (F) which were never received. The documents were reviewed and revealed that for all 6 staff members no annual evaluations nor competency evaluations had been completed in the past year. In review of the education records received, only 3 staff members had education records. For the 3 employees who did have education records (DON, CNA (B) and CNA (C) none of them had received education in mandatory training to include the following; Preventing and reporting abuse/neglect and exploitation. Dementia care and management. Infection Control. Resident rights. Person Centered Care. Communication. Skin and wound Care. (Only the DON had training for this requirement). Medication management. Pain management. Identification of change in condition. Cultural competency. Care of the cognitively impaired resident. Implementation of care plans. On 9-20-22 Director of Human Resources (Employee X) stated the employee training records were computer-based Relias training conducted in the facility. Employee X utilized her computer to facilitate the review, and provided copies to the Administrator to forward to the surveyors. The Director of Human Resources was asked who was responsible for clinical staff training, and she stated that it was the nursing departments' responsibility to ensure that the required training was completed. She stated annual training is based on date of hire. On 9-20-22 the Administrator, and the Director of Nursing (DON) were informed of the findings. When asked about the nursing departments' responsibility to ensure that nursing staff received the required training, the DON stated, I can't tell you about all of the required training. Staff are required to complete it online. I can follow-up with the Completion Report printed from Relias. During the course of the 2 week survey deficient practice was levied at Immediate Jeopardy (IJ), and harm, in the area of abuse/neglect and exploitation, and in not providing rehabilitative services. It was also found that accident hazards existed for a demented resident, an unsafe discharge was performed for a dependant resident, quality of life was deficient, quality of care was levied at harm in 3 areas to include pressure sores and range of motion, significant medication errors were found, and notices for advocacy agencies were not posted for resident use. Residents recounted allegations of fear and retaliation during the entire survey, and facility known resident allegations of abuse had gone unreported and uninvestigated by the facility, and logged in a grievance file. The lack of training for staff competency may have contributed to these outcomes. On 9-20-22 at the end of day debrief the Administrator and DON stated that all of the staff education records they had were given to the survey team. No further information was provided by the facility at the time of exit on 9-22-22 at 4:30 p.m.

Based on staff interview and facility documentation review, the facility staff failed to ensure that required annual performance reviews, with in-service training based on those reviews, were completed for 3 of 3 Certified Nursing Aides (CNA) in the survey sample, (CNA B), (CNA C), and (CNA F). The Findings included: On 9-14-22 a review was requested for CNA employee Performance reviews and training records. The facility Administrator was asked for employee records for the 3 staff members. Each day from 9-14-22 through 9-18-22 the employee records were requested, and surveyors were told by the Administrator oh yes, I have them on my desk, I will send them to your email. On 9-19-22 two of the requested 3 CNA records were received. A call was placed to the Administrator to ask for the other missing documents. The Administrator stated We can find nothing for that employee. The 2 that were received stated on the email from the Administrator the following; CNA (C) (name) does not have an annual eval on file, CNA (B) (name) has none, and no mention was given for the other CNA (F), which was never received. The documents were reviewed and revealed that for all CNA staff members no annual evaluations nor competency evaluations had been completed in the past year. In review of the education records received, only 2 of the 3 requested staff members had education records. For the 2 CNA's who did have education records (CNA (B) and CNA (C) neither of them had received an employee performance review and so training needs would not have been known. Their education in annual mandatory training was also not completed to include the following; Preventing and reporting abuse/neglect and exploitation. Dementia care and management. Infection Control. Resident rights. Person Centered Care. Communication. Skin and wound Care. Medication management. Pain management. Identification of change in condition. Cultural competency. Care of the cognitively impaired resident. Implementation of care plans. On 9-20-22 Director of Human Resources (Employee X) stated the employee training records were computer-based Relias training conducted in the facility. Employee X utilized her computer to facilitate the review, and provided copies to the Administrator to forward to the surveyors. The Director of Human Resources was asked who was responsible for clinical staff training, and she stated that it was the nursing departments' responsibility to ensure that the required annual performance reviews and subsequent training was completed. On 9-20-22 the Administrator, and the Director of Nursing (DON) were informed of the findings. When asked about the nursing departments' responsibility to ensure that nursing staff received the required performance reviews and training, the DON stated, I can't tell you about all of the required training. Staff are required to complete it online. I can follow-up with the Completion Report printed from Relias. On 9-20-22 at the end of day debrief the Administrator and DON stated that all of the staff performance reviews and education records they had were given to the survey team. No further information was provided by the facility at the time of exit on 9-22-22 at 4:30 p.m.

Based on staff interview and facility documentation review, the facility staff failed to ensure that required knowledge of, appropriate training for, and competencies were completed to care for residents with mental, psychological, and psycosocial disorders for 6 of 6 nursing staff members including, Registered Nurses (RN), Certified Nursing Aides (CNA), and Licensed Practical Nurses (LPN). The survey sample of 6 consisted of: (RN/DON), (CNA B), (CNA C), (CNA F), (LPN F), and (LPN G). The Findings included: The Facility failed to complete required initial, and annual, competency training, and evaluations. On 9-14-22 a review was requested for employee education/training and competency evaluations. The facility Administrator was asked for employee records for the 6 staff members. Each day from 9-14-22 through 9-18-22 the employee records were requested, and surveyors were told by the Administrator oh yes, I have them on my desk, I will send them to your email. On 9-19-22 education records and evaluation information was received. There were 4 of the 6 included and a call was placed to the Administrator to ask for the other 2 missing documents. The Administrator stated We can find nothing for those employees. The 4 that were received stated on the email from the Administrator the following; CNA (C) (name) does not have an annual eval on file, CNA (B) (name) has none, DON (name) has none, and LPN (F) (name) we only have termination. No mention was given for the other 2 staff LPN (G), and CNA (F) which were never received. The documents were reviewed and revealed that for all 6 staff members no annual evaluations nor competancy evaluations had been completed in the past year. In review of the education records received, only 3 staff members had education records. For the 3 employees who did have education records (DON), CNA (B) and CNA (C) none of them had received education in mandatory training to include the following; Dementia care and management. Respecting resident rights. Communication and interpersonal skills. Promoting residents independence. Caring for the residents enviroment. Mental health and social service needs. Care of the cognitively impaired resident. The DON had received training in behavioral health 1-31-22. On 9-20-22 Director of Human Resources (Employee X) stated the employee training records were computer-based Relias training conducted in the facility. Employee X utilized her computer to facilitate the review, and provided copies to the Administrator to forward to the surveyors. The Director of Human Resources was asked who was responsible for clinical staff training, and she stated that it was the nursing departments' responsibility to ensure that the required training was completed. On 9-20-22 the Administrator, and the Director of Nursing (DON) were informed of the findings. When asked about the nursing departments' responsibility to ensure that nursing staff received the required training, the DON stated, I can't tell you about all of the required training. Staff are required to complete it online. I can follow-up with the Completion Report printed from Relias. During the course of the 2 week survey deficient practice was levied at Immediate Jeopardy (IJ), and harm, in the area of abuse/neglect and exploitation, and in not providing rebabilitative services. It was also found that accident hazards existed for a demented resident, an unsafe discharge was performed for a dependant resident, quality of life was deficient, quality of care was levied at harm in 3 areas to include pressure sores and range of motion, significant medication errors were found, and notices for advocacy agencies were not posted for resident use. Residents recounted allegations of fear and retaliation during the entire survey, and facility known resident allegations of abuse had gone unreported and uninvestigated by the facility, and logged in a grievance file. The lack of training for staff competency may have contributed to these outcomes. On 9-20-22 at the end of day debrief the Administrator and DON stated that all of the staff education records they had were given to the survey team. No further information was provided by the facility at the time of exit on 9-22-22 at 4:30 p.m.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free of significant medication errors for 2 Residents (#'s 88, & 86) in a survey sample of 60 Residents. The findings included 1. For Resident #88 the facility staff failed to ensure the correct administration of the anticoagulant Lovenox (generic name Enoxaparin Sodium) was ordered and given as directed by the physician. On 9/13/22 at approximately 2:00 PM an interview was conducted with Resident # 88 who stated that he has been getting the wrong dose of medication for his blood clots and just found out this week it was the wrong dose. He stated his doctor that he sees for his blood clot had put him on shots in the stomach and the medication should have been 100 mg every 12 hrs. But that he was only getting 80 mg. A review of the clinical record revealed that Resident #88 had physician's orders that read: 8/11/22 8:15 PM Enoxaparin Sodium Injection Solution Prefilled Syringe 100 MG/ML (Enoxaparin Sodium) Inject 1 ml subcutaneously every morning and at bedtime for clotting A review of the MAR (Medication Administration Record) for the month of August 2022 revealed the record was signed off as being given as follows: Enoxaparin Sodium Injection Solution Prefilled Syringe 100 MG/ML (Enoxaparin Sodium) Inject 1 ml subcutaneously every morning and at bedtime for clotting -D/C Date 08/12/2022 2:13 PM . (**Please note the Resident received the correct dose for 8/11/22 and 8/12/22 the order was then discontinued and the following order was initiated.) On 8/12/22 9:00 PM the order was changed to: Medication: Enoxaparin Sodium Injection Solution Prefilled Syringe 80 MG/0.8 Generic: Enoxaparin Sodium Medication Class: ANTICOAGULANTS Enoxaparin Sodium Injection Solution Prefilled Syringe 80 MG/0.8 ML (Enoxaparin Sodium) Inject 100 mg/ml subcutaneously every 12 hours for PE/DVT until 08/16/2022 12:02 for 8 administrations On 9/14/22 at 9:30 AM an interview was conducted with LPN C who was asked how she administers medications and she stated that she looks at the order and the medication available in the drawer making sure the order and the medication are the same before administering the medication. When asked about the dangers of giving the wrong dose of an Anticoagulant she stated that if a Resident gets too much of it he or she can bleed out, if he or she gets too little they risk a blood clot. On 9/14/22 at approximately 3:00 PM an interview was conducted with the DON who was asked if the nurses should be checking the dosage with the medication and comparing to ensure proper dosage. She stated that this is the expectation for all nurses to perform the Rights of medication administration. When she was asked about the Lovenox order for Resident #88 she stated was aware that this happened but she insisted that the Resident was never given in the wrong dose. She stated that the medication was ordered and received by the pharmacy in the 100 mg / 1 ml prefilled syringes. When asked why the order was changed from the original (correct) ordered dosage to an incorrect dose she stated that the nurse who put the order in the system hit the wrong line on the drop down box and ordered 80 mg/0.8 ml instead of the 100 ml / ml prefilled syringes. When asked if anyone clarified the order to see what the correct order should be when comparing the dose ordered with the medication on hand she stated they did not. ON 9/15/22 during the end of day meeting the Administrator was made aware of the concern and no further information was provided. 2. For Resident # 86 the facility staff failed to administer Oxycodone (a narcotic pain medication) as prescribed by physician. On 9/20/22 at approximately 3:00 PM Surveyor D observed a Resident orders for Oxycodone. The orders read as follows: Oxycodone HCl Oral Solution 5 MG/5 ML (Oxycodone HCl) Give 5 milliliter via PEG-Tube every 6 hours for pain Start Date 9/13/22 6:00 PM - D/C Date 09/18/2022 11:27 AM . [Please note this is a ROUTINE not PRN] . Oxycodone HCl Oral Solution 5 MG/5 ML (Oxycodone HCl) Give 5 milliliter via PEG-Tube every 6 hours as needed for pain Start Date 9/13/22 -D/C Date 09/18/2022 11:27 AM Oxycodone HCl Oral Solution 5 MG/5 ML (Oxycodone HCl) Give 5 ml via G-Tube every 6 hours as needed for pain Date Started 9/13/22 - [Active Order] . Oxycodone HCl Oral Solution 5 MG/5 ML (Oxycodone HCl) Give 7.5 ml via G-Tube every 6 hours for pain, Start Date 9/18/22 12:00 PM [Active Order] [Please note this is a ROUTINE order not PRN]. As per the MAR and physicians orders the Resident had duplicate PRN Oxycodone orders. In the medication cart Resident #86 had 2 bottles of Oxycodone labeled as follows: 9/19/22 - Oxycodone 5 MG/5 ML Give 5 milliliter via Peg tube every 6 hours for pain and give 5 milliners via peg tube every 6 hours as needed for pain. 9/20/22 - Oxycodone 5 MG/5 ML Give 7.5 ML per peg tube every 6 hours for pain. A review of the narcotic sheets revealed that the Resident received the correct dosages of medications however the nursing staff dispensed the medications from incorrectly labeled bottles. [They did not follow label instructions thus they did not compare the label to order.] 9/19/22 - Oxycodone 5 MG/5 ML Give 5 milliliter via Peg tube every 6 hours for pain and give 5 milliners via peg tube every 6 hours as needed for pain 9/18/22 - 5 ml at 2100 PM 9/19/22 - 7.5 ml at 12:30 AM 9/19/22 - 7.5 ml at 6:00 AM 9/19/22 - 7.5 ml at 12:15 PM 9/19/22 - 7.5 ml at 6:00 PM 9/20/22 - 7.5 ml at 12:00 AM 9/20/22 - 7.5 ml at 6:00 AM 9/20/22 - 5 ml at 9:00 AM 9/21/22 - 5 ml at 9:00 AM 9/20/22 - Oxycodone 5 MG/5 ML Give 7.5 ML per peg tube every 6 hours for pain. 9/20/22 - 7.5 ml [no time administered is recorded] 9/20/22 - 7.5 ml at 6:00 PM 9/21/22 - 7.5 ml at 12:00 AM 9/21/22 - 7.5 ml at 6:00 AM 9/21/22 - 7.5 ml at 1:20 PM On 9/21/22 an interview was held with the DON who was made aware of the medication label being incorrect and the Medication being administered in doses that were not indicated on the label of each bottle. When asked what the expectation of the nurses are when giving medications she stated they are expected to read the order as well as the label on the prescription bottle. A review of the facility Policy #39 entitled Medication Labels read: Procedures . 6. if the physician's directions for use change or the label is inaccurate, the nurse may place a Change of Order-Check Chart label on the container indicating there is a change in directions for use, taking care not to cover important label information. a. When such a label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the physicians order for current information. b. The pharmacy is informed prior to the next refill of the prescription so the new container will contain an accurate label and quantity. No Change of Order - Check Chart label was found on either bottle. On 9/21/22 during the end of day meeting the Administrator was made aware and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation the facility staff failed to properly store Drugs and Biological's for 2 of the facility's 4 medication carts. The Findings Included: On 9/21/22 while completing the medication administration facility tasks Surveyor D made the following observations: At 2:50 PM on the Colonial Hall cart 1, observed artificial tears eye drops labeled with the Resident name and room number as well as the opened date on the box only, LPN L was asked was asked what the process was for labeling medications and she stated that the name, and date opened should be on the box on the bottle as well. When asked why she stated that if it's not labeled correctly the medication could get mixed up with someone else's. At 2:53 PM on the [NAME] Hall cart 1, observed artificial tears eye drops labeled with the Resident name and room number as well as the opened date on the box only, LPN M was asked was asked what the process was for labeling medications and she stated that the name and room number, and date opened should be on the box and the bottle. When asked why she stated that if it's not labeled correctly the medication could get mixed up with someone else's. Also on the [NAME] Hall cart 1, was a sticky bottle of lactulose with no date opened on the bottle. The prescription label shows the date it was sent to facility as 8/22/22. LPN M was asked how long the medication is good for once it is opened and she stated 30 days. Then said we have no way of knowing what date it was opened I will have to check in PCC (electronic health record.) When asked what is the correct way to label the medication she stated the date you open the med should be written on the bottle with the Residents name. At 3:30 PM on the Independence Hall cart 1 observer a Budesonide inhaler labeled the Resident name and room number only written on the box. The inhaler itself was tabled. RN D was asked what the process was for labeling medications and she stated that the name and room number should be on the inhaler and the box and the box should have the date it was opened also written on it. When asked why she stated that if it's not labeled correctly the inhaler could get mixed up with someone else's inhaler. A review of the facility policy for medications labeling and storage read as follows: Policy #39 entitled Medication Labels Procedures 1. Labels are permanently affixed to the outside of the prescription container. No medicine is accepted with the label inserted into a vial. If a label does not fit on the product. e.g . Eye drops, the label may be affixed to the outside container or carton, but the Resident's name must be maintained directly on the actual product . 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse place a date opened sticker on the medication and enter the date opened. b. If the vial or container is found without a date opened the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly. On 9/21/22 during the end of day meeting the Administrator was made aware and no further information was provided

Based on observation, interview, clinical record review and facility documentation the facility staff failed to establish and maintain an effective infection prevention control program to prevent the development and spread of diseases and infections for 1 Resident (#88), and the facility as a whole. In addition, 8 facility staff on 4 of 4 units failed to maintain an effective infection prevention and control program. The findings included: 1. For Resident #88 the facility staff failed to ensure proper care and cleaning of Resident #88's suprapubic catheter. A review of the clinical record revealed that Resident #88 was brought to the hospital by his fiancée on 8/5/22 and was admitted with a diagnosis of Poly-Microbial (more than one bacteria) UTI (Urinary Tract Infection). The identified bacteria were: Providencia Stuartii. Enterococcus Fecalis Providencia, P. rettgeri and P. stuartii are the most common cause of catheter-associated urinary tract infections, especially in the elderly with long-term indwelling urinary catheters. While, both of these bacteria are normal when found in the gastrointestinal system, they are infection causing when found in the urinary tract.) Resident #88 was discharged to the facility on 8/11/22 with orders to continue IV antibiotics started in the hospital. On 9/12/22 at 12:00 PM and again on the morning of 9/13/22 Resident # 88 was observed with this suprapubic catheter collection bag hanging from the back of his wheel chair near the handle above his waist height. On 9/13/22 at approximately 10 AM an interview was conducted with Resident #88 and he was asked if it was usual practice for the staff to hang his collection bag for his catheter on the wheel chair handle and he stated that it was. On 9/12/22 at approximately 12:15 PM CNA E was asked if his bag was hanging correctly and she stated yes it has got to be up here so it doesn't hit the floor. On 9/13/22 the following notes were taken by Surveyor D in the Resident Council meeting. A review of the Resident counsel minutes for July 2022 revealed that Resident Counsel had been complaining about call bells not being answered timely and incontinence care not being provided timely. Resident #88 stated that call bell answer times are still an issue. He further elaborated that what the staff are doing is come by and shut light off and say they'll get your aide or say someone is coming but no one comes. If they do show up it takes a long time for them to come take care of your needs. Per the Social Worker the facility conducted in-services about call bells, and incontinence care however she did not know the dates. A review of the facility documentation revealed that on 8/27/22 a, Training Sign-In Log was signed by 17 staff members both CNA's and Nurses, on the topics of timely answering of call bells, Perineal Care and ADL care. On 9/13/22 during the end of day meeting a request was made for the facility's policy and procedure on Catheter Care. On 9/15/22 at 1:00 PM an interview was conducted with the DON who was asked if placing the catheter collection bag above the waist height was acceptable. She stated that it was not when asked why she stated that the urine could back flow into the bladder and cause infection. The DON was asked a second time to provide a policy on Catheter care. On 9/14/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. Eight staff members on 4 units failed to appropriately wear PPE (personal protective equipment) in the facility during an outbreak of Covid-19. All staff were required to wear N-95 source control masks, and eye protection at all times in the facility. Staff were also required to use gowns and gloves when providing care to residents who had Covid-19, or who had been exposed during hospitalization, and were newly admitted into quarantine for 10 days. On 9-12-22 during entrance and initial tour of the facility, and continuing through 9-13-22 the following observations were made by Surveyors; 9-12-22 during initial tour Certified Nursing Assistant (CNA M) was observed wearing an N-95 with the bottom strap off and hanging loosely in front of the mask, and stated it was an accident. CNA (M), and Licensed Practical Nurse (LPN G) the unit manager, were working with Resident #320. They were asked if the Resident was on droplet/Covid-19 precautions and both stated no. LPN (G) then stated I will have to ask. Resident #320 was on droplet Covid-19 precautions. On 9-13-22 after day observations had been completed, surveyors returned to the facility to make evening observations at 9:15 p.m Upon entrance to the building, CNA (T) had no mask on, 2 staff members on the 100 hall had no mask or eye protection on, and hurried away upon seeing surveyors approach, CNA (G) was observed without a mask, and asked why, she responded so I can breathe, and the mask gives me a rash. CNA (G) called CNA (K) out of a resident room, and he exited the room of 2 residents without a mask or eye protection on. LPN (B) was standing in the hallway at the medication cart with the bottom strap of her mask off and no eye protection, then proceeded down the hall and into a resident room with no changes to her PPE. The Administrator was asked what the facility was currently requiring all staff to use for PPE in the facility and he stated that all staff are instructed to wear N-95 masks with face shields or goggles throughout the building. On 9-14-22 during the end of day debriefing the Administrator, and Director of Nursing were made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 4 Residents, Residents #6, #35, #111, and #88, in a sample of 5 Residents reviewed for resident COVID-19 testing. The findings included: For Residents #6 and #35, facility staff failed to conduct COVID-19 testing for admission/re-admission to the facility and for Resident #111, facility staff did not document the results of COVID-19 testing in the clinical record. 1. For Resident #6, the facility staff failed to conduct COVID-19 testing upon her re-admission to the facility on 8/19/22. On 9/14/22, a clinical record review was conducted and revealed that Resident #6 was re-admitted to the facility on [DATE] following her admission to the local hospital on 8/12/22. There was no evidence of any COVID-19 testing until 8/22/22. 2. For Resident #35, the facility staff failed to conduct COVID-19 testing upon his re-admission to the facility on 5/5/22. On 9/14/22, a clinical record review was conducted and revealed that Resident #35 was re-admitted to the facility on [DATE] following his admission to the local hospital on 5/3/22. There was no evidence of any COVID-19 testing until 5/27/22. 3. For Resident #111, the facility staff failed to document the results of COVID-19 testing performed on 4/14/22 and 4/21/22. On 9/14/22, a clinical record review was conducted and revealed facility staff performed COVID-19 tests for Resident #111 on 4/14/22 and 4/21/22, however failed to document the results of the tests in his medical record. On 9/15/22 at approximately 2:30 PM, an interview was conducted with the facility Infection Preventionist (IP) who confirmed the facility conducts COVID-19 testing for all residents in accordance with CDC (Centers for Disease Control and Prevention) recommendations. The IP was asked about the facility's protocol for testing newly admitted residents for COVID-19 and she stated, we test all new admits within a day of their arrival and again in 5 to 7 days .testing and results are documented in their [medical] record. A copy of the facility's COVID-19 testing policy was requested and received. Review of the facility policy titled, Facility [COVID] Testing Requirements, revised 2/4/2022, page 2, subheading, Policy, item #4b read, Document in the resident records that testing was offered, completed (as appropriate to the resident's testing status), and the results of each test and on page 8, item #4 read, New admission/readmission residents and residents who have left the facility for >24 hours, regardless of vaccination status, should have a series of two viral tests for Covid-19 infection; test immediately and, if negative, test again on day 7. The CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2, 2022, page 4, subheading, Testing, item 3, read, Newly-admitted residents and residents who have left the facility for (greater than) 24 hours, regardless of vaccination status, should have a series of two viral tests for SARS-CoV2 infection; immediately and, if negative, again 5-7 days after their admission. Review of the CMS (Centers for Medicare & Medicaid Services) Memo Ref: QSO-20-38-NH, revision date 3/10/2022, page 11, revealed, the results of tests must be done in accordance with standards for protected health information. For residents, the facility must document [COVID-19] testing results in the medical record. On 9/21/22, the Facility Administrator, Director of Nursing, and IP were made aware of the findings. No further information was provided. 4. For Resident #88 the facility staff failed to perform Covid-19 testing on a symptomatic Resident. On 9/13/22 a review of the clinical record revealed that on 8/1/22 Resident # 88 complained of a sore throat on 8/3/22 excerpts from the nurses notes are as follows: 8/3/2022 2:23 PM -Nurses Note: Late Entry: Note Text: Resident is complaining of throat pain. Resident rated a pain of 4/10, pain medication was given with effect. Resident assessed and there are no redness or swelling noted. Resident is able to swallow but in little quantity. Resident was able to eat and drink and resident tolerated both meals and all due meds well. Resident is not coughing and all his vitals are within his limit. Resident has been prescribed lozenges PRN Q 2HRS by the in house NP. RP notified. Excerpts from the Nurse Practitioner's note read: 8/3/2022 9:01 PM- PHP Progress Note In addition, he presented with sore throat. It is located diffusely. It is described as dull. The symptom is gradual in onset. History: J44.9-496 Chronic obstructive pulmonary disease unspecified, Active S 30.810A-911.8 Excoriation of buttocks, Venelex cream, Active J45.998-493.90 Other asthma, Active J02.9-462 Pharyngitis, Cepacol lozenges ordered 8/5/2022 5:39 PM - Nurses Note Late Entry: Note Text: Resident went out to Dr's appt. for neurology appt. Resident was later sent out to the ER by his fiancée [Responsible Party name Redacted]. The ER was called and this writer talked with nurse [name redacted] for an update on the resident The ER nurse asked his writer to hold on so she could ask the resident if she could give information to this writer. The ER nurse later got back to me and stated that the resident and [RP name redacted] does not want her to disclose any information to any work in this facility. Resident is currently still at the ER with status unknown 8/5/2022 10:10 PM - Nurses Note- Note Text: Follow up called made to Virginia Hospital Center, resident has been admitted for positive Covid-19 and UTI. [Hospital name redacted] charge nurse [name redacted], gave report to this writer. ** Please note Resident #88 was symptomatic on 8/3/22 with sore throat and no Covid Testing was done and subsequently tested positive 2 days after when his fiancée took him to the ER. On 9/14/22 at approximately 5:00 PM an interview was conducted with Resident #88 who called his RP / Fiancée on Face Time. The Resident explained that he had not been feeling well on August 3rd and had told the nurse who had the Nurse Practitioner come and see him on the evening of 8/3/22. He stated that she said it was nothing serious and gave him throat lozenges. He stated he kept feeling bad and taking the sore throat lozenges, but it didn't help. On the 5th when he and his fiancée went to the wound clinic, they suggested he be tested for COVID. His fiancee stated she felt the facility was not taking Resident #88's complaints seriously; therefore, she took him to the ER, where he was diagnosed with Covid-19 and a UTI. On 9/15/22 at approximately 1:50 PM, the IP nurse was interviewed and she was asked what the policy is for testing symptomatic residents for Covid-19. She stated the Policy was to test any symptomatic resident or staff member. When asked if a sore throat without fever or cough could be a symptom of Covid she stated that it could be. When asked if she would recommend testing a resident with a sore throat she stated that she would. When asked if the facility policy is in keeping with the CDC recommendations she stated that it was. CDC guidance :( website - https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Flong-term-care.html) 'Perform SARS-CoV-2 Viral Testing' Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. On 9/16/22, during the end of day meeting, the Administrator was made aware of concerns and no further information was provided. .

Based on staff interview, and facility documentation review, the facility staff failed to ensure that required training for Abuse/neglect, misappropriation, exploitation, dementia management, and abuse prevention were conducted for all 6 of the employees in the employee sample, (RN/DON), (CNA B), (CNA C), (CNA F), (LPN F), and (LPN G). The Findings included: The Facility failed to complete required abuse and dementia competency training, and evaluations. On 9-14-22 a review was requested for employee education/training and competency evaluations. The facility Administrator was asked for employee records for the 6 staff members. Each day from 9-14-22 through 9-18-22 the employee records were requested, and surveyors were told by the Administrator oh yes, I have them on my desk, I will send them to your email. On 9-19-22 education records and evaluation information was received. There were 4 of the 6 included and a call was placed to the Administrator to ask for the other 2 missing documents. The Administrator stated We can find nothing for those employees. The 4 that were received stated on the email from the Administrator the following; CNA (C) (name) does not have an annual eval on file, CNA (B) (name) has none, DON (name) has none, and LPN (F) (name) we only have termination. No mention was given for the other 2 staff LPN (G), and CNA (F) which were never received. The documents were reviewed and revealed that for all 6 staff members no annual evaluations nor competency evaluations had been completed in the past year. In review of the education records received, only 3 staff members had education records. For the 3 employees who did have education records (DON, CNA (B) and CNA (C) none of them had received education in mandatory training to include; Abuse/neglect, misappropriation, exploitation, dementia management, and abuse prevention. On 9-20-22 Director of Human Resources (Employee X) stated the employee training records were computer-based Relias training conducted in the facility. Employee X utilized her computer to facilitate the review, and provided copies to the Administrator to forward to the surveyors. The Director of Human Resources was asked who was responsible for clinical staff training, and she stated that it was the nursing departments' responsibility to ensure that the required training was completed. On 9-20-22 the Administrator, and the Director of Nursing (DON) were informed of the findings. When asked about the nursing departments' responsibility to ensure that nursing staff received the required training, the DON stated, I can't tell you about all of the required training. Staff are required to complete it online. I can follow-up with the Completion Report printed from Relias. During the course of the 2 week survey deficient practice was levied at Immediate Jeopardy (IJ), and harm, in the area of abuse/neglect and exploitation, and in not providing rehabilitative services. It was also found that accident hazards existed for a demented resident, an unsafe discharge was performed for a dependant resident, quality of life was deficient, quality of care was levied at harm in 3 areas to include pressure sores and range of motion, significant medication errors were found, and notices for advocacy agencies were not posted for resident use. Residents recounted allegations of fear and retaliation during the entire survey, and facility known resident allegations of abuse had gone unreported and uninvestigated by the facility, and logged in a grievance file. The lack of training for staff competency may have contributed to these outcomes. On 9-20-22 at the end of day debrief the Administrator and DON stated that all of the staff education records they had were given to the survey team. No further information was provided by the facility at the time of exit on 9-22-22 at 4:30 p.m.

Based on staff interview and facility documentation review, the facility staff failed to ensure that the required 12 hours per year of in-service training was completed for Certified Nursing Aides (CNA's). The survey sample of of 3 CNA's consisted of; (CNA B), (CNA C), and (CNA F). The Findings included: The Facility failed to ensure 12 hours of training annually for CNA's. On 9-14-22 a review was requested for employee education/training and competency evaluations. The facility Administrator was asked for employee records for the 6 staff members. Each day from 9-14-22 through 9-18-22 the employee records were requested, and surveyors were told by the Administrator oh yes, I have them on my desk, I will send them to your email. On 9-19-22 education records and evaluation information was received. There were 2 of the 3 included and a call was placed to the Administrator to ask for the other missing document. The 2 that were received stated on the email from the Administrator the following; CNA (C) (name) does not have an annual eval on file, CNA (B) (name) has none. No mention was made regarding CNA (F) which was never received. The documents were reviewed and revealed that for the 2 CNA staff members education records that were received, neither of them had received 12 hours of education in mandatory training. On 9-20-22 Director of Human Resources (Employee X) stated the employee training records were computer-based Relias training conducted in the facility. Employee X utilized her computer to facilitate the review, and provided copies to the Administrator to forward to the surveyors. The Director of Human Resources was asked who was responsible for clinical staff training, and she stated that it was the nursing departments' responsibility to ensure that the required training was completed, and the 12 hours of training was based on date of hire, not calendar year. On 9-20-22 the Administrator, and the Director of Nursing (DON) were informed of the findings. When asked about the nursing departments' responsibility to ensure that nursing staff received the required training, the DON stated, I can't tell you about all of the required training. Staff are required to complete it online. I can follow-up with the Completion Report printed from Relias. On 9-20-22 at the end of day debrief the Administrator and DON stated that all of the staff education records they had were given to the survey team. No further information was provided by the facility at the time of exit on 9-22-22 at 4:30 p.m.

Based on observation, Resident interview, and staff interview, the facility failed to post survey results in a place readily accessible to Residents and families, which had the potential to affect all 119 Residents residing in the facility. The findings included: On 09/13/22 at 11:00 AM, a resident Council meeting was conducted. When the group of Residents were asked if they knew where the survey results were located, all of the residents in the meeting indicated they did not know where the survey results were located. On 09/13/2022, Surveyor B toured the entire facility looking for the previous survey results, they were unable to be located. On 9/13/22 at 8:43 AM, the receptionist/Employee G, was asked where the survey results from prior surveys are located. Employee G said, They are normally kept right out in the open, they used to be on a table as you entered station 1, since they renovated I am not sure, let me ask. Employee G found a binder at the receptionist desk, located in the lobby, but noted that the binder was empty. Employee C then entered the lobby and when Employee G asked her about it, she said the Administrator had it. The facility Administrator was asked where the survey results are located. The facility Administrator went to his office and pulled a binder that included the plan of correction for the most recent survey. Surveyor B explained she was looking for the prior survey results/reports that are accessible to Residents and families. The Administrator and Surveyor B then to the nursing station on the first floor and they were unable to be located. On 9/13/22 at 9:10 AM, the facility Administrator approached Surveyor B and had a binder with survey results and said, It was at the reception desk. On 9/13/22 at 10:20 AM, a follow-up interview was conducted with Employee G/the receptionist. Employee G stated she had overlooked the book with survey results previously when she looked. Employee G confirmed the receptionist desk is staffed from 7 AM until 8 PM, Monday through Friday. On the weekends it is staffed from 8 AM until 8 PM. On 9/15/22, upon the survey teams entry to the facility it was observed that a sign had been posted on the lobby side of the door between the lobby and Resident care unit, that read, [facility name redacted] Annual State Survey Results are Available at the Front Desk in the reception Area. On 9/15/22, an interview was conducted with the receptionist. When asked if Residents have access to the lobby since there is a door that requires a code to enter the lobby from the Resident care areas, Employee G confirmed that staff have to assist Residents and they do not have unrestricted access. The facility policy regarding the posting of/accessibility of survey results was requested and not received. The facility Administrator, Director of Nursing and Corporate staff were made aware of the above findings. No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to post the required correct daily nursing staffing information which was visible to Residents, staff, and visitors, on four of four nursing units. The findings included: On 9-12-22 at approximately 11:30 AM, during initial tour of the building the daily staffing posting information was not correct, nor visibly posted. The posting continued to be incorrect on the second day of survey, 9-13-22. The posting simply had the name of staff members, and their arrival time. The posting was in a small back alcove with a desk behind the nursing station used for nurse and physician documentation and storage of documents. The posting was in the back of the alcove, not visible to anyone other than staff. On 9-13-22, the Director of Nursing (DON) was interviewed. The DON stated she would correct it immediately. On 9-13-22, during an end of day debrief with the facility Administrator and DON, they were made aware of the above findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to maintain respect and dignity for one resident (Resident #261) in a sample size of 43 residents. The findings included: 1. For Resident # 261, the facility staff failed to ensure a dignified experience during an admission skin assessment. Resident # 261 was woken up between 1:00 am and 1:30 am for a skin assessment. Resident # 261 was a [AGE] year old female admitted to the facility on [DATE] with the diagnoses of, but not limited to, Anxiety Disorder, Insomnia, Gastroesophageal Reflux Disease, Wedge Compression Fracture of first Lumbar Vertebra, Low Back Pain, muscle weakness and lack of coordination. Resident #261 did not have a Minimum Data Set (MDS) because she had only recently been admitted . Resident # 261 stayed in the facility for 3 days and was discharged on 6/25/2018. Review of the clinical record was conducted on 11/6/2019 at 2:30 PM. Review of a Facility Reported Incident (FRI) dated 6/25/2018 revealed: The report stated that on 6-25-18, the Administrator received a voicemail from Resident # 261's son on 6/25/2018 reporting that his mother (Resident # 261) alleged that she had been violated by a staff member on 6-22-2018, day of admission. Per the son, ____(Resident # 261) called him the morning of 6/23/18 to report that nurse _____ (LPN E) had performed a cavity search on her without her consent and was indelicate during the procedure. The son reports that his mother denied any penetration occurred during the alleged cavity check but was alarmed by the forced examination and expressed pain and discomfort in her back as result of being turned and repositioned. The son requested a change in caregiver and it was facilitated; however, he elected not to disclose the rationale for this request with the staff on duty. The son admitted that he waited to share the details of the incident with facility management. Local law enforcement was called and reported to the facility on 6-25-18. The son requested to have his mother moved to another SNF (Skilled Nursing Facility). Facility complied with this request and discharged the patient on 6/25/18 to the facility chosen by the patient and her son. Patient discharged at approximately 7:30 p.m. Review of the FRI update form dated 6/29/2018 revealed the following documentation: We are unable to substantiate the patient's claim that she was subjected to a forced cavity check by Nurse (LPN E) or any other staff member. The facility has initiated education for all staff on reporting and escalating allegations of abuse to the appropriate personnel in real time. We have also begun educating all nurses on the proper method to admit a patient, including performing all assessments with another caregiver present, explaining all procedures to the patient in a manner that is easily understood, and ensuring the patient is fully awake and coherent before commencing with any tests, procedures, or medication administration. On 11/7/2019 at 10:10 a.m., an interview was conducted with the Administrator who stated he remembered the incident and FRI that was submitted to the State Agency. The Administrator was asked to present the investigation file of the FRI for Resident # 261 for the surveyor to review. The Administrator returned with the investigation file at approximately 10:25 a.m. Review of the investigation file included the Facility Reported Incident forms, several witness statements and documentation of portions of the clinical record. Review of typed witness statements revealed documentation included but not limited to statements from Resident # 261, the nurse accused of performing a cavity search LPN (Licensed Practical Nurse) E, the nurse who actually performed the skin assessment (LPN F), the RN (Registered Nurse) Supervisor, the Acting Director of Nursing (Employee G) and the Administrator. Review of a typed statement from Resident # 261 revealed this statement: I came to the center from _____(name of hospital) on Friday, 6/22/2018 after 6 pm. I was walking trying to do some exercise on the hallway and to the second floor dining room on and off till approximately 11:30 pm and went to sleep. I asked ____ (LPN E) to give me my flexeril and she told me she was in the process of getting it form (sic) the pharmacy which later on gave it to me before I went to bed. I also met most of the staff and patients on the hallway and in the nursing station. At 1:30 am, the nurse,_____ (LPN E) woke me up from my deep sleep and she was ripping off all my clothes rough without asking for permission and she rolled me on my side which caused me to have pain and muscle spasm on my back surgical site. I was yelling at ___ (LPN E) what she was doing and to leave me alone and I tried to push her away and she was strong. Again, I asked her why are you doing this to me again and again and she told me she was checking my skin. I told her that she was lying and she was not checking my skin and she was trying to put something in my rectum, she stopped. Then I called my son at around 1:50 am and gave him all the details of what happened. I did not go to sleep till 7 am in the morning, I was frightened. On Saturday 6/23/2018, my son called _____ (RN-Registered Nurse G), the nurse who was taking care of me on the day shift and told him that LPN E the nurse should not come back to my room and if that happened he will call a police. On the night shift of 6/24/2018, the nurse ____(LPN H) took care of me and he was good. The name of Resident # 261 was typed at top and the bottom of the statement. It was not signed and was not dated. Review of the typed witness statements from the nurse who actually performed the skin assessment (LPN F), revealed documentation: On 6/23/2018, approximately 12 am, I took report from the outgoing nurse _____ (LPN E) about ______ (Resident # 261). ______( Resident # 261) was admitted to the facility on [DATE] around 6:30 pm to room ______(room number) per the outgoing nurse report. Approximately between 1:00 am and 1:30 am, _____(Resident # 261) was sleeping and I woke her up and I told her that my name was _______. (LPN F) her nurse and I explained to her that I was performing admission head to toe assessment and she gave the ok and I started taking her pant off first and her top and all her clothing. ______(Resident # 261) assisted me with the process by raising her bottom and rolling over to the side. First, I assessed the upper part of her body and I asked her to roller over on her side so that can see her back surgical scar and her bottom. While she was on her side, I assessed her buttocks, coccyx, and the sacrum. I opened her buttock and assessed her inner buttock to make sure she did not have any pressure injury. _____ Resident # 261 was asking me why I was checking her buttocks and if I was looking for drugs. I explained to _____(Resident # 261) that I was completing the skin assessment and it was a part of my duty to complete skin assessment. ______(Resident # 261) was repeatedly telling me that I was searching drugs and I again told her that I was not looking for drugs. After the completion of my skin assessment, I gave her gown and helped her to put it on. Again ______(Resident # 261) was telling me I was doing drug search and again I told her sorry that I was doing skin assessment. The whole time I was completing the skin assessment, ____ (Resident # 261) did not scream or raise her [NAME].(sic) After 10 minutes, I went back to her room with the vital sign machine and obtained her vitals. While I was checking her vitals, _____ (Resident # 261) was telling me that _____(LPN E) the nurse woke her up and ripped her cloth (sic) off her and she was upset about it. I explained to _______(Resident #261) that ____(LPN E ) left the floor before midnight and I was the one I who woke her up and did the skin assessment however ______(Resident #261) stated that (LPN E ) was the one who ripped her cloth (sic) off of her. I again told her that I was the one and she stated that I was not the one. I told her that I am (LPN F ). ________(Resident # 261) seems ok the whole time except that she was repeating about the drug search and her cloth (sic) was stripped off of her by (LPN E ). The form had the typed name of LPN F at the top and the bottom of the form. It was not signed. There was no date on the form indicating when the statement was typed. On 11/7/2019 at 3:35 p.m., an interview was conducted with the Administrator who stated the facility had the expectation for admission skin assessments to be completed within a certain number of hours after admission. The Administrator stated he would check the facility policy to determine the exact time frame for admission skin assessments to be completed. The Administrator returned to the conference room and stated that the admission skin assessments should be completed within the first 24 hours and presented a copy of the facility policy on admission assessments. The Administrator stated the nurse had time to wait until a more appropriate hour to complete the skin assessment. The Administrator stated after he became aware of the situation on 6/25/2018 and completed the investigation, he made changes to the admission process. The Administrator stated the nurse (LPN F) should have had another staff member with her during the assessment and could have waited until later to complete the assessment since the resident was asleep. The Administrator stated the nursing staff had been educated on completing assessments with another staff member present, making sure the resident is fully awake, alert and understands the assessment and gives consent. Review of the facility policy entitled admission Evaluation Effective: 1/24/2007, Revised: 10/30/2013, 9/21/2016. Reviewed: 5/29/2019 revealed the definition: admission: the first 24 hours the resident is in the facility or returning to the facility. Under Policy was written: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. A systematic evaluation is completed by a licensed nurse upon admission/readmission to assist in determining the most effective and appropriate care needs of each resident admitted to the center. Procedure: 1. Complete the admit/Readmit/Quarterly Screener assessment and appropriately triggered assessments electronically as soon as feasible but within 24 hours. On 11/7/2019 at 4:05 p.m., an interview was conducted with the Assistant Director of Nursing (Employee F). Employee F stated the resident (Resident # 261) nurses should perform nursing assessments with another staff member present after they obtain consent for the assessment. Employee F stated Resident # 261 was assessed by her physician at the facility and transferred to another skilled nursing facility. Employee F stated the resident and her son were upset. Review of the Nurses Notes revealed no documentation of the skin assessment performed by LPN F and/ or the response by Resident # 261. Review of the admission Assessments (admission Observation Tool and Skin Grid Pressure Assessment revealed both were dated 6/23/2018 were signed by LPN F. There was no documentation either of those documents of Resident # 261's response during the assessments. LPN F was no longer employed at the facility at the time of survey. Two attempts to reach her via telephone were unsuccessful-voicemail message stated voicemail is full. On 11/8/2019 at 12:30 PM, attempt to reach Resident # 261's son via telephone was unsuccessful. The phone rang several times but no voicemail was available. Another attempt to reach Resident # 261's son via telephone, the son answered but stated it was not a convenient time. The resident's son stated he would return the call to the surveyor. During the end of day debriefings on 11/7/2019 and 11/8/2019, the facility Administrator and Director of Nursing were informed that the facility staff performed an admission skin assessment between 1:00 am and 1:30 am, and continued with the assessment when the resident was upset indicated by the fact that she verbalized more than once that she thought it was a drug search. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to assess a Resident to determine if they were safe to administer medications, before leaving medications at the bedside for one Resident (Resident #86) in a survey of 43 Residents. The findings included: For Resident #86 the facility staff left medications at the bedside for the Resident when the Resident had not been assessed or determined to be clinically appropriate to self administer medications. Resident #86 was admitted to the facility on [DATE]. Resident #86's diagnoses included but were not limited to: Spinal Stenosis, Urinary tract infection, obstructive and reflux uropathy, degenerative disease of the nervous system, cirrhosis of liver, acute kidney failure, hemochromatosis, hydronephrosis, and muscle weakness. Resident #86's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/15/19 was coded as an admission assessment. Resident #86 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated intact cognitive skills. Resident #86 was coded as required extensive assistance in transfers, bed mobility, dressing, personal hygiene, and toileting. Resident #86 was coded as having been frequently incontinent of bowel and occasionally incontinent of bladder. On 11/6/19 at 9:19 AM during facility rounds, Resident #86 was observed to not be in his room. Observation of the room revealed, on the over-bed table at the bedside, was a medicine cup with a small, 1/2 of a white, round pill and a cup of water beside it. No staff were present. On 11/6/19 at approximately 9:40 AM, RN D was asked to accompany Surveyor C to Resident #86's room. When RN D was asked what the cup was, RN D stated I didn't give him his meds [medications] but I think it is Metoprolol. When Surveyor C asked RN D if it is routine to leave medications at the bedside, RN D stated, usually we stand there to make sure they taken them. RN D was asked if Resident #86 self-administers medications, RN D stated No. On 11/6/19 at approximately 9:50 AM, RN D and Surveyor C returned to the nursing station. RN D approached LPN D and told LPN D, he left this at his bedside, we have to call the doctor and let him know. LPN D confirmed the 1/2 of a pill was metoprolol. On 11/6/19 a review of Resident #86's current physician orders revealed an order Metoprolol Tartrate Tablet, give 12.5 mg by mouth two times a day for HTN [hypertension]. The order date was 10/10/19 and continued as an active order for Resident #86. On 11/6/19 a complete review of Resident #86's entire clinical record was conducted, to include the careplan and revealed no assessment of, or determination that Resident #86 had been assessed for self-administration of medication. On 11/6/19 at 11:37 AM, a request was made for any assessments or determination that Resident #86 had been assessed to self administer medications. The facility Director of Nursing stated they had no such documents. On 11/07/19 at 04:31 PM the facility Administrator was asked his expectations regarding medication administration, the Administrator stated, I expect them to follow the 7 rights of medication administration. When asked if medications can be left at the bedside, the Administrator stated, of course not, she has to observe the resident take the meds. On 11/8/19 at 9:00 AM a review of Resident #86's electronic clinical record revealed a nursing note dated 11/6/19 at 10:52 AM, written by RN D that read, Patient was given his morning medications today, however, it was noted that he did not take his blood pressure medication metoprolol 12.5mg. Medication was noted on his bedside table, and patient went down for therapy. MD was called and informed of the above. New order given to re-check patient's blood pressure upon return on the floor since patient blood pressure this morning was within normal limit (124/79), and to give the blood pressure medication after. Another nursing note entry was made by LPN D at 12:34 PM that read, patient returned to the floor, was informed that he had not taken his blood pressure medication, patient its oh I didn't, it must have been stick [sic] to the bottom of the cup. Review of the facility policy titled Resident Self-Administration of Medications with a review date of 5/29/19 read on page 2, a. Resident may not self-administer medication until the assessment is completed by the IDT team and determined to be safe to do so. Review of the facility policy titled Medication Administration with a review date of 5/29/19 read on page 4, remain with resident until the medication is swallowed, do not leave medication at bedside. The facility administrator and Director of Nursing (DON) were advised during an end of day meeting on 11/7/19 at 4:31 PM and again at end of day meeting on 11/8/19, of medications being left at the bedside of Resident #86. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to provide accommodations to call for assistance for 1 resident (Resident #41) in a survey sample of 43 residents. The findings include: For Resident #41, the callbell was located beyond his reach, making it unavailable for him to call for assistance. Resident #41, an [AGE] year old male who was admitted to the facility on [DATE] with diagnoses to include but not limited to muscle weakness, anemia, and contracture of the right knee. Resident #41's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/18/2019 was coded as an annual assessment. Resident #41 was coded with a Brief Interview of Mental Status (BIMS) score of 9 out of possible 15, indicating moderately impaired cognition. He was coded requiring extensive assistance for all of his ADL's (activities of daily living). On 11/5/19 at approximately 10:15 am during initial tour, Resident #41 was observed lying awake in his bed with his callbell located on the wall to the right of the head of his bed, wrapped around a soap dispenser. He stated that he did not know where his callbell was located and when it was pointed out that it was dangling from the soap dispenser on the wall, he stated, I have no idea how it ended up there, I didn't put it there, I cannot get out of bed or even reach over there. Employee A was observed in the hallway and asked to come into Resident #41's room. An interview was conducted with Employee A with regard to the location of Resident #41's callbell and he stated, I do not know why the callbell is hanging off the wall, he is not on my assignment today. When asked if he thought Resident #41 could reach his callbell to call for assistance, he stated No, it should be kept within his reach at all times so he can use it. Employee A removed the callbell from the wall and secured it to Resident #41's bedspread. On 11/6/19, a facility policy regarding callbells was requested and received. The facility policy entitled, Resident Rights, policy #NS 1021-00, dated 8/11/2017, page 2, item c(i) read, Call light or bell access will be within reach of the resident as one method to communicate needs to staff.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to: 1) provide notification of non-coverage in a timely fashion for one of three sampled residents (Resident #315 ) and 2) complete an Advanced Beneficiary Notice (ABN) for one of three sampled residents (Resident #12 ) The findings included: A review of Resident #315's Notice to Medicare Provider Non-Coverage (NOMNC) while on survey revealed that the effective date coverage would end was 07/17/2019 and Resident #315 signed and dated the NOMNC 07/16/2019. A review of the ABN for Resident #12 revealed that although it was signed and dated by the responsible party, an option pertaining to the care and cost was not selected. On 11/08/19 at 09:33 AM, an interview with Employee P, the social worker, was conducted. When asked about the process for issuing NOMNCs and ABNs, Employee P stated that the NOMNC and ABN should be signed 48 to 72 hours, mostly 72 hours in advance. When asked why it was important to have more than a one day notice, Employee P stated To have enough notice for the appeal process. When Employee P was informed Resident #315 signed the NOMNC the day before services would end and the option selection on the ABN for Resident #12 was not completed, Employee P stated I can get back with you on that. Policies for obtaining NOMNCs and ABNs were requested. On 11/08/2019 at approximately 1:00 PM, the administrator and DON were notified of findings. The administrator verified that the facility does not have a policy pertaining to obtaining NOMNCs and ABNs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #66 the careplan did not address the current infections of osteomyelitis, C-Diff, receiving IV antibiotics, being on contact precautions, the need for assistance with ADL's, the presence of wounds, the need for wound care, the use of an anticoagulant or history of falls as identified in the comprehensive assessment Resident #66 was admitted to the facility on [DATE], with a readmission date of [DATE]. Resident #66's diagnoses included but were not limited to: chronic osteomyelitis with draining sinus of right femur, pyogenic arthritis, infection following a procedure, broken internal right knee prosthesis, local infection of the skin and subcutaneous tissue, pressure ulcer of the sacral region stage 4, and enterocolitis due to clostridium difficile (C-Diff). Resident #66's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of [DATE] was coded as an admission assessment. Resident #66 was coded as having had a BIMS (brief interview for mental status) score of 14, which indicated intact cognitive skills. Resident #66 was coded as having required extensive assistance for dressing, personal hygiene, bed mobility and toileting. Ambulation and transfers were coded as having not occurred. Resident #66 was coded as having been always incontinent of bowel and bladder. This same MDS was also coded to indicate Resident #66 had diagnoses of deep vein thrombosis and received anticoagulants (blood thinner), received scheduled pain management regimen, and had a fall in the month prior to admission. On [DATE] during rounds it was observed that contact isolation supplies were outside of Resident #66's room. The nurse was asked about this and indicated that Resident #66 was on contact precautions due to C-Diff. On [DATE] review of the electronic clinical record for Resident #66 revealed that the careplan did not address the current infections of osteomyelitis, C-Diff, receiving IV antibiotics, being on contact precautions, the need for assistance with ADL's, the presence of wounds, the need for wound care, the use of an anticoagulant or history of falls as identified in the comprehensive assessment. On [DATE] at 5:10 PM an interview was conducted with RN F, who was the MDS Coordinator who writes the electronic careplan's. When asked about the process for developing and initiating careplan's, RN F stated, we do a 48 hour baseline careplan and after 21 days we put it in the computer. When asked what should be careplanned, RN F stated diagnosis, health conditions, medications like psychotropic, if have falls or behaviors the nurse taking care of the patient takes care of that. When asked where the paper careplans can be found, RN F stated, the unit manager has a binder with it. When shown the careplan for Resident #66 that included only the 3 focus areas of: discharge, CPR and weight changes, RN F stated, his careplan should be on paper, his assessment was done [DATE]. On [DATE] at approximately 5:15 PM, an interview was conducted with RN C, Charge Nurse. RN C was asked what the importance of a careplan is, RN C stated, the careplan is to give information to the staff to be able to take care of a resident, it is like a guideline. On [DATE] at approximately 5:20 PM, surveyor C asked the Unit Manager, RN E for the paper careplan for Resident #66. RN E provided a document titled 48 hour baseline careplan V3- V 3, which had an effective date of [DATE]. There were multiple handwritten entries on page 7 which read, Focus problems safety/fall precautions infection control skin/wound care management, prevent surgical wound complications emotional support, prevent emotional breakdown monitor PICC site to prevent complications pain management with appropriate interventions as indicated assist with d/c planning needs monitor ABT [antibiotic] therapy with interventions as indicated On the back of page 7 the following was written: monitor ext [external] fixator and do pin site as indicated contact precautions/isolation It was observed that none of these entries were dated as to when written and failed to have measurable objectives and timeframes to meet the Resident's medical and nursing needs. On [DATE] at 5:28 PM an interview was conducted with the facility DON (Director of Nursing) and RN E. The DON and RN E were asked when the handwritten entries were made on the 48 hour baseline careplan and the DON stated, we write on it during the clinical meeting that was held when it was signed which had a date of [DATE]. However, the contact precautions were not ordered until [DATE] so this wasn't the case. On [DATE] a review of the facility policy titled Plan of Care Overview with a review date of [DATE] read, for the purpose of this policy the plan of care, also care plan is the written treatment provided for a resident that is resident-focused and provides for optimal personalized care. The purpose of the policy is to provide guidance to the facility to support the inclusion of the resident or resident representative in all aspects of persona-centered care planning and that this planing includes the provision of services to enable the resident to live with dignity and supports the resident's goals, choices, and preferences including, but not limited to, goals related to the their [sic] daily routines and goals to potentially return to a community setting. On [DATE] during an end of day meeting the facility Administrator and Director of Nursing were made aware of the facility staff's failure to develop a comprehensive person-centered careplan. No further information was provided. Based on observation, Resident and staff interview facility documentation and clinical record review the facility staff failed to develop and implement a comprehensive care plan for 3 Residents (#73, 75, #66) in a survey sample of 43 Residents. The findings included: 1. For Resident #73 the facility staff failed to care plan scheduled nebulizer treatments and changing of tubing for nebulizer. Resident #73, a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Chronic Respiratory Failure, COPD (chronic obstructive pulmonary disease), Trach, G-Tube, dysphagia, dementia, major depressive disorder, psychosis, anxiety disorder, and seizures. Resident # 73's most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] codes the Resident as being extensive assist with 2 person physical assistance for bed mobility, transfers and dressing and total assistance with physical assistance of 1 for bathing, feeding, and mobility. Resident #73 uses a wheel chair for transport and is unable to propel herself, she has a g-tube for feeding and a trach. On [DATE] at 3:00 PM during tour noted that Resident # 73 had undated tubing to her nebulizer. On [DATE] at approximately 3:05 PM an interview was conducted with LPN A and she stated the tubing should be changed weekly by night shift. On [DATE] at 9:55 AM during clinical record review it was noted that the Residents care plan addressed the trach care and oxygen usage along with the scheduled tube changing weekly however they omitted the nebulizer treatment on the care plan. 2. For Resident # 75 the facility staff failed to develop and implement plan to include nebulizer treatments and scheduled tubing change. Resident #75 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to CHF (Congestive Heart Failure), acute respiratory failure, major depressive disorder, COPD, Acute Kidney Failure and heart disease of coronary artery. Resident #75's most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] codes resident #75 as having a (Brief Interview of Mental Status ) BIMS of 15 indicating no cognitive impairment. The Resident was also coded as needing extensive assistance of 2 person physical assistance for bed mobility and transfers and unable to walk. She required extensive assistance of 1 person physical assist for bathing dressing and hygiene and toileting. On [DATE] at 3:00 PM during tour noted that Resident # 75 had a nebulizer. The clinical record review and it was noted that the Residents care plan addressed the PRN use of oxygen along with the scheduled tube changing weekly however it omitted the nebulizer treatment on the care plan. On [DATE] at 1:00 PM an interview was conducted with RN A who stated all treatments should be care planned. She also stated that Nebulizer tubing like oxygen tubing should be dated and changed weekly by night shift staff. The facility policy for Continuous Aerosol Therapy [nebulizer] read: Page # 2 Paragraph II. Equipment and Maintenance a. Aerosol/Trach masks are to be changed once a week and PRN b. Disposable aerosol tubing and drain bags are to be changed once a week and PRN. c. Non - refilled nebulizers are to be changed 3 times a week and filled as needed by respiratory or nursing staff d. Refilled nebulizers are to be changed when empty or once a week. On [DATE] at 2:30 PM the DON stated that it was her expectation that the Nebulizer tubing be changed weekly and care planned as such. On [DATE] during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed, for one resident (Resident # 79) in the survey sample of 43 residents, to review and revise the plan of care. The Findings included: 1. For Resident #79, the facility staff failed to review and revise the care plan after the development of unstageable pressure ulcers on his left ankle and left heel. Resident #79 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #79's diagnoses included Cerebral Infarction, Generalized Muscle Weakness, Dementia, Major Depressive Disorder Hypertension, and Congestive Heart Failure. The Minimum Data Set, which was a Significant Change Assessment with an Assessment Reference Date of 10/11/19 was reviewed. Resident #79 had a Brief Interview of Mental Status Score of 12, indicating mildly impaired cognition. He was coded as requiring the extensive physical assistance of at least two people for bed mobility, and transfers. Resident #79's range of motion was impaired in both of his upper and lower extremities. He was coded as having unstageable pressure ulcers. His previous MDS, which was a Quarterly Assessment, with an Assessment Reference Date of 8/26/19 was reviewed. He was not coded for any pressure ulcers. On 11/5/19 a review was conducted of Resident #79's clinical record. According to a wound care note, on 9/11/19, an unstageable pressure ulcer was initially identified by a wound care physician. Resident #79's care plan was reviewed. It did not document anything regarding his pressure ulcers, including their existence or treatment. The Plan of Care Overview policy dated 5/30/19 was reviewed. An excerpt read, Care Plan is the written treatment provided for a resident that is resident-focused and provides for optimal personalized care. Review care plans quarterly and/or with significant changes in care. Nurses are expected to participate in the resident plan of care for reviewing and revising the care plan of residents they provide care for as the resident's condition warrants. On 11/6/19 an interview was conducted with the facility Administrator (Employee A) in the conference room. When asked about his expectation about when a care plan must be revised, he stated that it should be revised within 24 hours of the change in condition, with focused goals and interventions to mitigate further pressure injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation review and clinical record review the facility staff failed to ensure residents are free of significant medication errors for one Resident (Resident #107) in a survey sample of 43 Residents. The findings include: 1a. For Resident #107 the facility staff failed to administer insulin as ordered by the physician on 6 of 16 scheduled doses. Resident #107, was admitted to the facility on [DATE]. Resident #107's diagnoses included but were not limited to: sepsis, osteomyelitis of vertebra sacral and sacrococcygeal region, pressure ulcer sacral region stage 4, pressure ulcer of right upper back stage 4, unspecified dementia without behavioral disturbance, type 2 diabetes mellitus without complications, and hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side. Resident #107's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/26/19 was coded as an admission assessment. Resident #107 was coded as having not been interviewable for a BIMS (brief interview for mental status) score. The staff assessment indicated the Resident is severely cognitively impaired. Resident #107 was coded as required total assistance of staff for transfers, bed mobility, dressing, personal hygiene, toileting, and bathing. Resident #107 was coded as having been always incontinent of bowel. On the afternoon of 11/7/19 a review of Resident #107's clinical record revealed a physician order dated 10/21/19 that read, Toujeo Solostar Solution Pen-Injector 300 unit/ML (insulin Glargine) Inject 14 unit subcutaneously at bedtime for DM [diabetes mellitus]. Review of the Medication Administration Record (MAR) for October and November 2019 revealed that Resident #107 was not administered 6 of the scheduled 16 doses, (10/21/19, 10/24/19, 10/28/19, 10/31/19, 11/2/19, and 11/3/19) which were due from admission on [DATE] through 11/5/19. Review of Resident #107's careplan revealed a focus initiated on 10/30/19 that read [Resident name redacted] has diabetes mellitus, the interventions stated diabetes medication as ordered by doctor. On 11/8/19 at approximately 9:10 AM, RN B, the unit manager was asked what NC on the MAR for Toujeo indicated. RN B looked at the legend attached to the MAR and indicated it meant no insulin coverage required. RN B added, if the blood sugar falls below certain range they don't give. Surveyor C asked what that range was, RN B stated, I will have to look. RN B went on to state, the nurse does the accu check and long acting insulin doesn't have a range so they use their judgement, if they hold it they call the doctor. RN B was asked if it would be expected that a nursing note entry would be entered into the clinical record regarding this and RN B stated, I believe so, ,yes. A review of the nursing notes for Resident #107 revealed no notes on the dates of 10/21/19, 10/24/19, 10/28/19, 10/31/19, 11/2/19, and 11/3/19 to indicate why the Toujeo was not administered as per the physician order. On 11/8/19 at 10:58 AM, RN B returned to Surveyor C after reviewing the clinical record for Resident #107. RN B stated, those days are the same nurse [referencing the dates of the missed medication], the sliding scale insulin has parameters but the long acting does not. That nurse is a new nurse and just finished orientation, he is the only nurse recording NC and I didn't see any communication with the doctor. RN B was asked if she would have administered the Toujeo on the days in question, RN B stated, yes I would have given, I wouldn't have just held without communicating with the doctor. RN B was asked why it is important to give insulin as ordered, RN B stated, this is important for them to see if they need to make adjustments to insulin doses. Before we hold a medication we need to consult the doctor. RN B also stated that she had attempted to reach the nurse that had failed to administer the insulin but didn't reach them via telephone but would be doing some education upon their return to work for their next shift. 1b. For Resident #107 the facility staff failed to administer IV antibiotics for sepsis, osteomyelitis and wound infection, for 28 doses (four times daily/every 6 hours on 10/24/19-10/30/19), as ordered by the physician. On the afternoon of 11/7/19 a review of Resident #107's clinical record revealed the following physician orders: *On 10/22/19 an order read, Unasyn Solution Reconstituted 3 (2-1) GM (Ampicillin-Sulbactam Sodium) Use 3 gram intravenously every 5 hours for sepsis, osteomyelitis. This order was discontinued on 10/22/19. The MAR for October revealed that this order was administered to Resident #107. * On 10/22/19 another order read, Unasyn Solution Reconstituted 3 (2-1) GM (Ampicillin-Sulbactam Sodium) Use 3 gram intravenously every 5 hours for sepsis, osteomyelitis until 10/31/19. This order was carried out and administered on 10/23/19 at 12:48 AM, 5:02 AM, 1:28 PM. The order was then discontinued on 10/23/19 at 12:22 PM. * On 10/23/19 an order read, Unasyn Solution Reconstituted 3 (2-1) GM (Ampicillin-Sulbactam Sodium) Use 3 gram intravenously every 6 hours for sepsis, osteomyelitis until 10/23/19, which was in error. This order was carried out and administered on 10/23/19 at 6:00 PM. * On 10/30/19 an order read, Unasyn Solution Reconstituted 3 (2-1) GM (Ampicillin-Sulbactam Sodium) Use 3 gram intravenously every 6 hours for wound infection for 6 weeks. This order was then carried out and administered as ordered for the duration of the month of Oct. and through the time of this review. A nursing note entry dated 10/22/19 at 18:53 read, unasyn Solution Reconstituted 3 (2-1) GM use 3 gram intravenously every 5 hours for sepsis, osteomyelitis until 10/31/19, confirming the order was to continue this medication. It further stated that the facility was awaiting pharmacy to deliver. On 11/8/19 at approximately 9:10 AM, RN B, the unit manager was asked about Resident #107's multiple IV antibiotic orders. RN B stated, someone entered it wrong, so as an interdisciplinary team we go back and change it. RN B was asked to clarify what she meant that it was entered wrong, RN B stated, it didn't have a stop date, we like all of our antibiotics to have an end date. RN B was then questioned about the multiple days that Resident #107 didn't receive the IV antibiotics, RN B stated, I don't know unless there was a delay from the pharmacy and agreed to look into this further. On 11/8/19 at 10:58 AM, RN B returned to Surveyor C after reviewing the clinical record for Resident #107. RN B stated, when this medication was first ordered it said every 5 hours, that was communicated with the doctor and it had not stop date. The doctor was called and an order was given to change to every 6 hours until 10/29/19 and then consult infectious disease. The nurse that entered the order had a start date of 10/23/19 and had a stop date of 10/23/19, so it didn't populate to the MAR and it was caught on review on 10/30/19 and infectious disease gave the order to continue it for 6 weeks. Review of the facility policy titled Physician Orders with a review date of 5/30/19 read on page 2, taking the order: a. do not try to memorize the order b. write down the order as stated, c. provide a read-back to validate, d. spell out/clarify sound alike drugs, e. discontinue any previous contradicting order, f. place orders in the electronic medical record, g. print copy for physician to sign and place in paper chart, h. contact pharmacy for changes. The Administrator and Director of Nursing were informed on 11/8/19 during a end of day meeting held in the Administrator's office with Surveyor C of the facility staff's failure to provide essential medications to Resident #107 as ordered by the physician. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to maintain an accurate clinical record for one Resident (Resident #86) in a survey sample of 43 Residents. The findings included: For Resident #86 the facility staff documented administration of medication which had been left at the bedside and was not taken. Resident #86 was admitted to the facility on [DATE]. Resident #86's diagnoses included but were not limited to: Spinal Stenosis, Urinary tract infection, obstructive and reflux uropathy, degenerative disease of the nervous system, cirrhosis of liver, acute kidney failure, hemochromatosis, hydronephrosis, and muscle weakness. Resident #86's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/15/19 was coded as an admission assessment. Resident #86 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated intact cognitive skills. Resident #86 was coded as required extensive assistance in transfers, bed mobility, dressing, personal hygiene, and toileting. Resident #86 was coded as having been frequently incontinent of bowel and occasionally incontinent of bladder. On 11/6/19 at 9:19 AM during facility rounds, Resident #86 was observed to not be in his room. Observation of the room revealed on the over-bed table at the bedside, was a medicine cup with a small, 1/2 of a white, round pill and a cup of water beside it. No staff were present. On 11/6/19 at approximately 9:40 AM, RN D was asked to accompany Surveyor C to Resident #86's room. When RN D was asked what the cup was, RN D stated I didn't give him his meds [medications] but I think it is Metoprolol. When Surveyor C asked RN D if it is routine to leave medications at the bedside, RN D stated, usually we stand there to make sure they taken them. RN D was asked if Resident #86 self-administers medications, RN D stated No. On 11/6/19 at approximately 9:50 AM, RN D and Surveyor C returned to the nursing station. RN D approached LPN D and told LPN D, he left this at his bedside, we have to call the doctor and let him know. LPN D confirmed the 1/2 of a pill was metoprolol. On 11/6/19 a review of Resident #86's current physician orders revealed an order Metoprolol Tartrate Tablet, give 12.5 mg by mouth two times a day for HTN [hypertension]. The order date was 10/10/19 and continued as an active order for Resident #86. On 11/6/19 a complete review of Resident #86's entire clinical record was conducted, to include the medication administration record (MAR). The MAR had been recorded as Resident #86 being administered his Metoprolol on 11/6/19 at the 9 AM dose. Review of the facility policy titled Medication Administration with a review date of 5/29/19 read on page 4, remain with resident until the medication is swallowed, do not leave medication at bedside, medications will be charted when given, medications that are refused or withheld or not given will be documented. The facility administrator and Director of Nursing (DON) were advised during an end of day meeting on 11/7/19 and again at end of day meeting on 11/8/19 of medications being left at the bedside of Resident #86 and documented as being administered by nursing staff. No further information was provided.

Based on observation, resident interview, and staff interview, the facility staff failed to maintain shower equipment and the shower room in a sanitary manner to prevent the spread of infection in 1 of 4 shower rooms. The findings included: On 11/6/19 at approximately 2:18 PM during the group Resident Council meeting, it was shared that the shower room on the 2nd floor was dirty. The Resident council reported specifically that the floor drain was clogged and the shower bench was dirty and discolored. On 11/6/19 at 2:47 PM the bathing suite on the 2nd floor was observed and the following was noted: * the shower drain was obstructed with a gray matter covering 1/2 of the drain holes in the floor drain of the shower stall. * the shower bench back was observed and revealed heavy discoloration of pink and black substances throughout the entire back. On 11/6/19 at approximately 3:15 PM, Employee N, the housekeeping supervisor accompanied the surveyor to the 2nd floor bathing suite. When asked about the process for cleaning, the housekeeping supervisor stated, we do the toilet and floors, the nurses are supposed to wipe down the shower chairs when they are done. I just took that project on, on Monday [referencing shower equipment, such as shower chairs/bench]. When asked about the shower drain, Employee N stated, I will get them right on that. When asked about the shower bench and Employee N was asked to observe the back of the shower bench, the housekeeping supervisor stated, my housekeeper brought that to my attention yesterday and we have ordered a new one. On 11/6/19 during the end of day meeting the facility Administrator was made aware of the shower room's lack of sanitary conditions as expressed by Resident Council. The Centers for Disease Control and Prevention (CDC) recognizes in their Emerging Infectious Disease article Volume 25, Number 11-November 2019 Serratia marcescens, which can cause nosocomial outbreaks,and urinary tract and wound infections, is abundant in damp environments. It can be easily found in bathrooms, including shower corners and basins, where it appears as a pink-orange-red discoloration, due to the pigment known as prodigiosin. article accessed online at : https://wwwnc.cdc.gov/eid/article/25/11/et-2511_article No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #2, the facility staff failed to administer cardiac medication (Diltiazem) as scheduled. Resident #2, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnoses included but are not limited to heart rhythm abnormality, congestive heart failure, high blood pressure, stroke, dementia, and inability to speak. Resident #2's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/2019 was coded as a quarterly review. Resident #2 was coded with severely impaired cognition. On 11/7/19 at approximately 3:15 PM, a family interview was conducted with Resident #2's son who was also her Responsible Party. He expressed concern that Resident #2's medications were occasionally given later than scheduled on the night shift. On 11/7/19, clinical record review was conducted for Resident #2. The physician orders dated 1/28/2019 read, Diltiazem HCl tablet 30mg, give 30 mg via G-Tube every 6 hours for high blood pressure/chest pain. Her dose was scheduled to be given at 6:00 AM, 12:00 PM, 6:00 PM, and 00:00 AM every day. A Medication Administration Audit Report for the month of November 2019 was requested and provided by facility staff. Resident #2 received Diltiazem HCl as follows: 11/01/19, time scheduled 00:00 AM, time administered 05:14 AM 11/01/19, time scheduled 6:00 AM, time administered 05:15 AM 11/04/19, time scheduled 00:00 AM, time administered 02:23 AM 11/04/19, time scheduled 6:00 AM, time administered 05:39 AM On 11/16/19 at approximately 9:45 AM, the Director of Nursing (DON, Employee B) was interviewed and stated, my expectations for med pass include [medication to be given] one hour before and one hour after [the] scheduled time. When asked about the possible outcomes if Diltiazem HCl is not given as ordered at the scheduled time intervals for Resident #2, she stated, if the resident does not receive the Diltiazem as scheduled at the correct times, it could cause problems with her blood pressure. If it is administered too close together, it could cause her blood pressure to drop too much, that would not be good and I expect the medication nurses to document the actual time that medication is administered. Review of the facility's policy entitled, Medication Administration (revision date 12/14/17), under subheading Procedure, item ff, Medications will be administered within the time frame of one hour before up to one hour after time ordered. Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to follow professional standards for three Residents (Resident #86, #107, #2) in a survey sample of 43 Residents. The findings included: 1. For Resident #86 the facility staff failed to following nursing standard of practice by failure to observe a Resident (Resident #86) take medication, and left medication at the bedside. Resident #86 was admitted to the facility on [DATE]. Resident #86's diagnoses included but were not limited to: Spinal Stenosis, Urinary tract infection, obstructive and reflux uropathy, degenerative disease of the nervous system, cirrhosis of liver, acute kidney failure, hemochromatosis, hydronephrosis, and muscle weakness. Resident #86's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/15/19 was coded as an admission assessment. Resident #86 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated intact cognitive skills. Resident #86 was coded as required extensive assistance in transfers, bed mobility, dressing, personal hygiene, and toileting. Resident #86 was coded as having been frequently incontinent of bowel and occasionally incontinent of bladder. On 11/6/19 at 9:19 AM during facility rounds, Resident #86 was observed to not be in his room. Observation of the room revealed on the over-bed table at the bedside, was a medicine cup with a small, 1/2 of a white, round pill and a cup of water beside it. No staff were present. On 11/6/19 at approximately 9:40 AM, RN D was asked to accompany Surveyor C to Resident #86's room. When asked if it is routine to leave medications at the bedside, RN D stated, usually we stand there to make sure they taken them. On 11/6/19 a review of Resident #86's current physician orders revealed an order Metoprolol Tartrate Tablet, give 12.5 mg by mouth two times a day for HTN [hypertension]. The order date was 10/10/19 and continued as an active order for Resident #86. On 11/07/19 at 04:31 PM the facility Administrator was asked his expectations regarding medication administration, the Administrator stated, I expect them to follow the 7 rights of medication administration. When asked if medications can be left at the bedside, the Administrator stated, of course not, she has to observe the resident take the meds. Review of the facility policy titled Medication Administration with a review date of 5/29/19 read on page 4, remain with resident until the medication is swallowed, do not leave medication at bedside, medications will be charted when given, medications that are refused or withheld or not given will be documented. The DON stated the facility uses [NAME] as their nursing standard of practice. Guidance from [NAME]'s Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration 1. Right patient Check the name on the order and the patient. Use 2 identifiers. Ask patient to identify himself/herself. When available, use technology (for example, bar-code system). 2. Right medication Check the medication label. Check the order. 3. Right dose Check the order. Confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well. 4. Right route Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route. 5. Right time Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. 7. Right reason Confirm the rationale for the ordered medication. What is the patient's history? Why is he/she taking this medication? Revisit the reasons for long-term medication use. 8. Right response Make sure that the drug led to the desired effect. If an anti-hypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant? Be sure to document your monitoring of the patient and any other nursing interventions that are applicable. Reference: Nursing2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 3/8/18. The facility administrator and Director of Nursing (DON) were advised during an end of day meeting on 11/7/19 at 4:31 PM and again at end of day meeting on 11/8/19, of medications being left at the bedside of Resident #86. No further information was provided. 2a. For Resident #107 the facility staff failed to administer insulin as ordered by the physician on 6 of 16 scheduled doses. Resident #107, was admitted to the facility on [DATE]. Resident #107's diagnoses included but were not limited to: sepsis, osteomyelitis of vertebra sacral and sacrococcygeal region, pressure ulcer sacral region stage 4, pressure ulcer of right upper back stage 4, unspecified dementia without behavioral disturbance, type 2 diabetes mellitus without complications, and hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side. Resident #107's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/26/19 was coded as an admission assessment. Resident #107 was coded as having not been interviewable for a BIMS (brief interview for mental status) score. The staff assessment indicated the Resident is severely cognitively impaired. Resident #107 was coded as required total assistance of staff for transfers, bed mobility, dressing, personal hygiene, toileting, and bathing. Resident #107 was coded as having been always incontinent of bowel. On the afternoon of 11/7/19 a review of Resident #107's clinical record revealed a physician order dated 10/21/19 that read, Toujeo Solostar Solution Pen-Injector 300 unit/ML (insulin Glargine) Inject 14 unit subcutaneously at bedtime for DM [diabetes mellitus]. Review of the Medication Administration Record (MAR) for October and November 2019 revealed that Resident #107 was not administered 6 of the scheduled 16 doses, (10/21/19, 10/24/19, 10/28/19, 10/31/19, 11/2/19, and 11/3/19) which were due from admission on [DATE] through 11/5/19. On 11/8/19 at 8:45 AM, an interview was conducted with LPN C. LPN C was asked about the physician order for Resident #107's Toujeo, LPN C stated, she gets 14 units at bedtime. When asked if this is every night, LPN C stated, yes, she gets it every night. LPN C was asked if there was any indications as to when he would not give the scheduled medication, LPN C stated, it depends on the blood sugar, if the blood sugar is very low, I would hold it and confirm with the doctor. LPN C was asked if that would be documented in the clinical record, LPN C stated, yes. On 11/8/19 at approximately 9:10 AM, RN B, the unit manager was asked what NC on the MAR for Toujeo indicated. RN B looked at the legend attached to the MAR and indicated it meant no insulin coverage required. RN B added, if the blood sugar falls below certain range they don't give. Surveyor C asked what that range was, RN B stated, I will have to look. RN B went on to state, the nurse does the accu check and long acting insulin doesn't have a range so they use their judgement, if they hold it they call the doctor. RN B was asked if it would be expected that a nursing note entry would be entered into the clinical record regarding this and RN B stated, I believe so, yes. A review of the nursing notes for Resident #107 revealed no notes on the dates of 10/21/19, 10/24/19, 10/28/19, 10/31/19, 11/2/19, and 11/3/19 to indicate why the Toujeo was not administered as per the physician order. On 11/8/19 at 10:58 AM, RN B returned to Surveyor C after reviewing the clinical record for Resident #107. RN B stated, those days are the same nurse [referencing the dates of the missed medication], the sliding scale insulin has parameters but the long acting does not. That nurse is a new nurse and just finished orientation, he is the only nurse recording NC and I didn't see any communication with the doctor. RN B was asked if she would have administered the Toujeo on the days in question, RN B stated, yes I would have given, I wouldn't have just held without communicating with the doctor. RN B was asked why it is important to give insulin as ordered, RN B stated, this is important for them to see if they need to make adjustments to insulin doses. Before we hold a medication we need to consult the doctor. RN B also stated that she had attempted to reach the nurse that had failed to administer the insulin but didn't reach them via telephone but would be doing some education upon their return to work for their next shift. 2b. For Resident #107 the facility staff failed to administer IV antibiotics for sepsis, osteomyelitis and wound infection, for 28 doses (four times daily/every 6 hours on 10/24/19-10/30/19), as ordered by the physician. On the afternoon of 11/7/19 a review of Resident #107's clinical record revealed the following physician orders: *On 10/22/19 an order read, Unasyn Solution Reconstituted 3 (2-1) GM (Ampicillin-Sulbactam Sodium) Use 3 gram intravenously every 5 hours for sepsis, osteomyelitis. This order was discontinued on 10/22/19. The MAR for October revealed that this order was administered to Resident #107. * On 10/22/19 another order read, Unasyn Solution Reconstituted 3 (2-1) GM (Ampicillin-Sulbactam Sodium) Use 3 gram intravenously every 5 hours for sepsis, osteomyelitis until 10/31/19. This order was carried out and administered on 10/23/19 at 12:48 AM, 5:02 AM, 1:28 PM. The order was then discontinued on 10/23/19 at 12:22 PM. * On 10/23/19 an order read, Unasyn Solution Reconstituted 3 (2-1) GM (Ampicillin-Sulbactam Sodium) Use 3 gram intravenously every 6 hours for sepsis, osteomyelitis until 10/23/19, which was in error. This order was carried out and administered on 10/23/19 at 6:00 PM. * On 10/30/19 an order read, Unasyn Solution Reconstituted 3 (2-1) GM (Ampicillin-Sulbactam Sodium) Use 3 gram intravenously every 6 hours for wound infection for 6 weeks. This order was then carried out and administered as ordered for the duration of the month of Oct. and through the time of this review. A nursing note entry dated 10/22/19 at 18:53 read, unasyn Solution Reconstituted 3 (2-1) GM use 3 gram intravenously every 5 hours for sepsis, osteomyelitis until 10/31/19, confirming the order was to continue this medication. It further stated that the facility was awaiting pharmacy to deliver. On 11/8/19 at approximately 9:10 AM, RN B, the unit manager was asked about Resident #107's multiple IV antibiotic orders. RN B stated, someone entered it wrong, so as an interdisciplinary team we go back and change it. RN B was asked to clarify what she meant that it was entered wrong, RN B stated, it didn't have a stop date, we like all of our antibiotics to have an end date. RN B was then questioned about the multiple days that Resident #107 didn't receive the IV antibiotics, RN B stated, I don't know unless there was a delay from the pharmacy and agreed to look into this further. On 11/8/19 at 10:58 AM, RN B returned to Surveyor C after reviewing the clinical record for Resident #107. RN B stated, when this medication was first ordered it said every 5 hours, that was communicated with the doctor and it had not stop date. The doctor was called and an order was given to change to every 6 hours until 10/29/19 and then consult infectious disease. The nurse that entered the order had a start date of 10/23/19 and had a stop date of 10/23/19, so it didn't populate to the MAR and it was caught on review on 10/30/19 and infectious disease gave the order to continue it for 6 weeks. Review of the facility policy titled Physician Orders with a review date of 5/30/19 read on page 2, taking the order: a. do not try to memorize the order b. write down the order as stated, c. provide a read-back to validate, d. spell out/clarify sound alike drugs, e. discontinue any previous contradicting order, f. place orders in the electronic medical record, g. print copy for physician to sign and place in paper chart, h. contact pharmacy for changes. The facility Director of Nursing indicated that the facility staff uses [NAME] as their nursing standard of practice. Lippincott Manual of Nursing Practice eighth edition, states on page 18, box 2-3 Common Legal Claims for Departure from Standards of Care as failure to implement a physician order properly or in a timely fashion. Fundamentals of Nursing, by [NAME], stated The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Guidance is given from [NAME] Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR or EMAR (Electronic Medication Administration Record). If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. The Administrator and Director of Nursing were informed on 11/8/19 during a end of day meeting held in the Administrator's office with Surveyor C of the facility staff's failure to following nursing standards of practice. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Clinical Record Review and Staff Interview, facility staff failed to refer a resident with a diagnosed mental illness for a level II PASARR screening for 1 resident, Resident #75, in a sample of 35 residents. For Resident #75, the facility failed to refer him for a level II PASARR. The Findings included: Resident #75 was admitted on [DATE]. His most recent Minimum Data Set (MDS) Assessment was a Medicare-15 Day Assessment with an Assessment Reference Date (ARD) of 5/16/18. Resident #75's diagnoses included Unspecified Psychoses, Schizoaffective Disorder Bipolar Type, Hypertension, and Cellulitis of the Left Lower Extremity. Resident #75 was totally dependent on 1 staff member for bathing, required extensive assistance of 1 staff member for transfers, dressing, hygiene, bed mobility, and toileting, and setup assistance for eating. On 5/22/18, a review of Resident #75's record was conducted. Resident #75 was noted to have diagnoses including schizoaffective disorder, bipolar type. No PASARR was found in the Electronic Health Record (EHR). Facility staff were asked to locate Resident #75's PASARR. On 5/23/18, facility staff provided this surveyor with a document entitled VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES MI/MR SUPPLEMENT LEVEL I. For the question titled 2. DOES THE INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS? the box no is marked with a check. For the question titled 5. RECOMMENDATION, option b. No referral for Level II is needed because individual: is checked. None of the sub-options to this item are selected. On 5/24/18 at 10:12a.m., an interview was conducted with Employee G, the Director of Social Services. Employee G was asked to review the PASARR document for Resident #75 provided to surveyors, and to describe what it meant. Employee G stated that the form indicated that Resident #75 did not have a significant mental illness and was not in need of a level II PASARR. Resident #75's diagnoses of Unspecified Psychosis and Schizoaffective Disorder Bipolar Type were read to Employee G. She was asked whether these diagnoses constituted significant mental illness. Employee G replied yes. Employee G was asked whether the PASARR form for Resident #75 appeared accurate and complete. She replied no. Employee G was asked why Resident #75 was not referred for a Level II Screening despite his diagnoses. She replied that Resident #75 saw his own Psychiatrist outside the facility, and it was thought that a Level II referral was unnecessary. Employee G was asked whether Resident #75's outside Psychiatrist was qualified to perform a Level II PASARR screening. She replied that she did not know. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 5/24/18. The Administrator stated, we have to own it and indicated they would be auditing residents' PASARRs. No further documents were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Clinical Record Review and Staff Interview, facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 2 residents (#75 and #8) in a sample of 35 residents. 1. For Resident #75, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was accurate. 2. For Resident #8, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. The Findings included: 1. Resident #75 was admitted on [DATE]. His most recent Minimum Data Set (MDS) Assessment was a Medicare-15 Day Assessment with an Assessment Reference Date (ARD) of 5/16/18. Resident #75's diagnoses included Unspecified Psychoses, Schizoaffective Disorder Bipolar Type, Hypertension, and Cellulitis of the Left Lower Extremity. Resident #75 was totally dependent on 1 staff member for bathing, required extensive assistance of 1 staff member for transfers, dressing, hygiene, bed mobility, and toileting, and setup assistance for eating. On 5/22/18, a review of Resident #75's record was conducted. Resident #75 was noted to have diagnoses including schizoaffective disorder, bipolar type. No PASARR was found in the Electronic Health Record (EHR). Facility staff were asked to locate Resident #75's PASARR. On 5/23/18, facility staff provided this surveyor with a document entitled VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES MI/MR SUPPLEMENT LEVEL I. For the question titled 2. DOES THE INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS? the box no is marked with a check. For the question titled 5. RECOMMENDATION, option b. No referral for Level II is needed because individual: is checked. None of the sub-options to this item are selected. On 5/24/18 at 10:12a.m., an interview was conducted with Employee G, the Director of Social Services. Employee G was asked to review the PASARR document for Resident #75 provided to surveyors, and to describe what it meant. Employee G stated that the form indicated that Resident #75 did not have a significant mental illness and was not in need of a level II PASARR. Resident #75's diagnoses of Unspecified Psychosis and Schizoaffective Disorder Bipolar Type were read to Employee G. She was asked whether these diagnoses constituted significant mental illness. Employee G replied yes. Employee G was asked whether the PASARR form for Resident #75 appeared accurate and complete. She replied no. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 5/24/18. The Administrator stated, we have to own it and indicated they would be auditing residents' PASARRs. No further documents were provided. 2. For Resident #8, the Preadmission Screening and Resident Review (PASARR) was not completed prior to admission to the facility. Resident #8, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included seizures, anxiety, depression, and psychotic disorder other than schizophrenia. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 2/14/18. Resident #8 was coded with a Brief Interview of Mental Status score of 15 indicating no cognitive impairment and required extensive assistance with activities of daily living. Upon review of Resident #8's clinical record, the PASARR could not be located. The Administrator and Director of Nursing (DON) were asked to provide the PASARR on 5/23/18 at 5:15 p.m. The following morning, the form titled Psychotropic Medication Evaluation was provided. The form included all the psychotropic medications ordered for Resident #8. A meeting was held with the Administrator and DON on 5/24/18 around 11:00 a.m. They were notified that survey team was provided the Psychotropic Medication Evaluation form instead of the PASARR. The PASARR was again requested. A PASARR Level I dated 5/24/18 was provided. The Administrator stated that they had to get the PASARR from the hospital because it was not in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility record review, and clinical record review, the facility staff failed to devise, and implement a comprehensive care plan for three Residents (Resident #76, 62, and 54) in a survey sample of 35 Residents. 1. Resident #76's care plan did not address his dementia or behaviors. 2. Resident #62's care plan did not address anxious behaviors. 3. For Resident #54, the facility failed to include targeted behaviors and non-pharmacological interventions for the use of Ativan. The findings included: 1. Resident #76's care plan did not address his dementia or behaviors. Resident # 76 was admitted to the facility on [DATE]. Diagnoses for Resident #76 included but not limited to dementia, carotid endarterectomy with stent placement and legal blindness. Resident #76's Minimum Data Set (an assessment protocol) was a quarterly assessment with an Assessment Reference Date of 5/9/18 coded Resident #76 with a BIMS (brief interview of mental status) score of 14 out of a possible 15, or no cognitive impairment. Resident #76 required extensive assistance for his ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. The resident was legally blind. On 5/22/18 at 9:30 AM, Resident #76 was observed in his room, being fed by staff. Review of the clinical record revealed the resident was currently taking Zyprexa (antipsychotic used for hallucinations, psychosis) 2.5 mg (milligrams) twice daily for psychosis. Review of the care plan dated 5/14/18 revealed the following problem: The resident uses antipsychotic medication related to unspecified psychosis. There were no targeted behaviors addressed on the plan of care for behaviors, nor were there any non pharmacological interventions included. On 05/24/18 at 08:40 AM: An interview with RN (registered nurse) A concerning Resident #76. She stated, He doesn't show any behaviors with me. He is blind and will yell out, but once he knows where he is, he will calm down. On 05/24/18 at 10:20 AM: An interview with MDS coordinators regarding care plan for Resident #76's behaviors. MDS Coordinator (Employee B) stated, He is legally blind. He will be in bed, calling out. He will hear people out in the hall outside the room, it is not hallucinations. She went on to state that should be included in the care plan. MDS coordinator (other A) stated regarding dementia care planning for Resident #76, The resident should be checked for pain or hunger if there are behaviors with dementia. 2. Resident #62's care plan did not address anxious behaviors. Resident # 62 was admitted to the facility on [DATE]. Diagnoses for Resident #62 included but not limited to dementia, atrial fibrillation, high blood pressure and anxiety. Resident #62's Minimum Data Set (an assessment protocol) was an admission assessment with an Assessment Reference Date of 3/28/18 coded Resident #62 with a BIMS (brief interview of mental status) score of 7 out of a possible 15, or moderate cognitive impairment. Resident #62 required extensive assistance for her ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. On 5/22/18 at 9:00 AM, Resident #62 was observed in her bed on oxygen at 2 liters per minute. She had a sling on her right arm. Review of the clinical record revealed Resident #62 was on Ativan (an antianxiety medication) one mg tablet every 24 hours for anxiety. Review of the care plan dated 4/2/18 revealed the following: The resident uses antianxiety medication for anxiety disorder. There were no non pharmacological interventions to attempt prior to administration of the medication on the care plan. On 05/24/18 at 10:20 AM: An interview with MDS coordinator (other A) stated for Resident #62's anxiety, When she was readmitted , she wanted to go back home, but there are no issues now and that should have been addressed in the care plan. On 5/24/18 at approximately 11:30 AM, the DON (director of nursing) was notified of above findings. 3. For Resident #54, the facility failed to include targeted behaviors and non-pharmacological interventions for the use of Ativan. Resident #54, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included reflux, hypertension, dementia, anxiety, and osteoarthritis. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/25/18. Resident #54 was coded with a Brief Interview of Mental Status score of 3 indicating moderate cognitive impairment and required extensive assistance with activities of daily living. On 5/23/18 at 9:00 a.m., Resident #54 was observed in her room, dressed and seated in her wheel chair. The breakfast meal tray was on the table in front of her. Resident #54 consumed most of the meal. She was pleasant but confused during the conversation. Resident #54's physician orders were reviewed. Included was an order dated 3/19/18 for Ativan tablet 0.5 milligram by mouth every 8 hours as needed for anxiety. According to the 2018 Medication Administration Records (MAR), the Ativan was administered on the following occasions: 3/26/18, 3/27/18, 4/13/18, 4/20/18, 4/22/18, 4/25/18, 5/1/18, 5/7/18, and 5/9/18. The care plan was reviewed. Included was the focus dated 4/19/18 The resident uses, anti-anxiety medication (ativan) r/t (related to) Anxiety disorder. The interventions included psych consult as needed, give anti-anxiety medications ordered by physician, monitor side effects/ effectiveness, monitor mood as needed. The care plan did not indicate the targeted behaviors to indicate use. The care plan did not indicate non-pharmacological interventions to be used before administering the medication. On 5/23/18 at 5:00 p.m., the Director of Nursing, Administrator and Corporate staff were asked to provide the target behaviors and non-pharmacological interventions to support the use of the PRN ativan. They were asked again to provide the information at the end of day meeting on 5/24/18. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and clinical record review, the facility staff failed to revise the care plan for 1 Resident (Resident #193) in a survey sample of 35 Residents. For Resident #193, the facility staff failed to include the diagnosis of Methicillin-Resistant Staphylococcus Aureus (MRSA) on the care plan and failed to identify the correct location of the infected wound. The findings included: Resident #193, a [AGE] year old, was re-admitted to the facility on [DATE]. Diagnoses included hypertension, diabetes, reflux, dislocation of right hip prosthesis, and MRSA infection of right hip wound. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/4/18. Resident #193 was coded with a Brief Interview of Mental Status score of 14 indicating no cognitive impairment and required extensive assistance with activities of daily living. Resident #193 was re-admitted to the facility on [DATE]. The History and Physical was signed by the Nurse Practitioner (NP) on 5/20/18. Section 1. Present Illness read 73 yo f back for skilled nursing post recent hosp. was sent for rt (right) hip dislocation and new drainage Seen by orthopedics reduction done with I and D (incision and drainage) of area Seen by ID (infectious disease) started on vancomycin PICC line placed on 5/17 and discharge back here with further ABX (antibiotics) Section C, Physical Examination was reviewed. The section 1. Assessment read Right Prosthetic Hip Dislocation; new onset drainage s/p 5/3: wash out, extraction of sinus, closure on IV (intravenous) vanco (antibiotic) for MRSA infection right hip, in association with hardware. dose adjusted due to high troughs and CKD (chronic kidney disease). Vancomycin 500 mg (milligram) IV q 48 hours. follow trough continue 6 week course (thru 6/14/18) Will need suppressive ABX indefinitely for chronic PO suppressive therapy weekly labs, fax to (doctor name) Resident #193's care plan was reviewed. Included was a Focus initiated on 8/1/17 and revised on 5/23/18 The resident is on, IV Medications vancomycin r/t (related to) left hip wound infection. The care plan did not indicate that MRSA was present in the wound. In addition, the incorrect hip was documented in the care plan. The right hip had the infected wound rather than the left. Resident #193's right hip wound was observed on 5/24/18. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review the facility staff failed for 2 residents (Resident #54 and 193) of 35 residents in the survey sample to ensure the highest practicable level of well being. 1. For Resident #54 the facility staff failed to ensure a bowel protocol was in place to manage constipation. 2. For Resident #193, the facility staff failed to start an antibiotic to treat a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection of the right hip wound until 6 days after return to the facility. The findings included: 1. For Resident #54 the facility staff failed to ensure a bowel protocol was in place to manage constipation. Resident #54, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included reflux, hypertension, dementia, anxiety, and osteoarthritis. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/25/18. Resident #54 was coded with a Brief Interview of Mental Status score of 3 indicating significant cognitive impairment and required extensive assistance with activities of daily living. The following nursing note dated 2/14/18 was reviewed During therapy, resident present with lethargy and was unable to participate as per therapist. Resident was brought back to her room and was assessed by this writer. Vital signs were measured and the following were noted: blood pressure 172/95 mmHg (millimeters of mercury), Heart rate 84 beats per minutes, temperature of 96.3 degrees Fahrenheit, respiration rate of 19 breaths per minute, and oxygen saturation of 95% on room air. MD (doctor) was notified of resident's clinical situation. MD (doctor) was also notified of absent bowel movement for the resident for 3 days. New orders were given to administer Dulcolax suppository 10 mg (milligram) x 1 now and as needed every 24 hours for constipation; Clonidine 0.1 mg (milligram) every eight hours as needed for systolic blood pressure equal or greater than 170; and UA C&S (urine culture) in AM (morning). Clonidine 0.1 mg and Dulcolax suppository 10 mg were administered as ordered. Incoming shift will reassess resident. Resident's guardian was notified or resident's clinical condition. The care plan was reviewed. Included was the focus dated 1/23/18 Resident is at risk for constipation as related to immobility, inadequate fluid intake, medication side effect. Interventions included bowel medication regime as ordered by doctor, dietary interventions, encourage fluids. Resident #54's medication were reviewed. Prior to 2/14/18, there were no bowel medications ordered to manage constipation. There were no dietary interventions such as the use of prune juice ordered. At the end of day meeting on 5/23/18, the Administrator, Director of Nursing (DON) and corporate staff were asked to provide the bowel movement record for the month of February 2018. The following morning on 5/24/18, the DON stated that she had looked at the bowel record but forgot to bring it with her to speak to the survey team. The bowel record was requested again at the end of day meeting on 5/24/18. At this time, the facility administration explained that they did not have access to the bowel record because they recently purchased the facility on 3/1/18 and they could not access the requested document dated 2/14/18 from the previous owner. On 5/24/18 at 12:15 p.m. the DON was asked if a resident had the problem of constipation would the resident be on a scheduled medication for the issue. She stated that there should be some kind of intervention in place, either a medication or a dietary intervention such as prune juice. When asked what types of conditions would cause constipation, the DON stated decreased mobility or narcotic use. No further information was provided. 2. For Resident #193, the facility staff failed to start an antibiotic to treat a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection of the right hip wound until 6 days after return to the facility. Resident #193, a [AGE] year old, was re-admitted to the facility on [DATE]. Diagnoses included hypertension, diabetes, reflux, dislocation of right hip prosthesis, and MRSA infection of right hip wound. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/4/18. Resident #193 was coded with a Brief Interview of Mental Status score of 14 indicating no cognitive impairment and required extensive assistance with activities of daily living. On 5/1/18, Resident #193 was discharged to the hospital. The Medical Discharge Summary completed by the physician on 5/5/18 read Patient readmitted to long term care after hospitalization for anemia and guaiac positive stools. She had been non ambulatory following multiple surgeries right hip after fracture repair and prosthesis with revisions. She had been table (sic) but noted to have drainage from old right hip incision. Xray showed probable chronic dislocation and she was transferred to hospital for recurrent hip prosthesis infection. The hospital Discharge Note read Principal Problem: Infection. The Discharge Note also included a Patient Active Problem List which included the following diagnoses related to infection: Cellulitis of drainage site, post-operative, initial encounter Deep incisional surgical site infection, initial encounter Post op infection Wound infection Acute osteomyelitis of left foot Osteomyelitis Infection The section Hospital Course read Seen by ID (Infectious Disease) started on vancomycin with daily vancomycin level check and redosing based on vancomycin level and PICC (peripherally inserted central catheter) line placed and discharge to SNF (skilled nursing facility) with antibiotics per ID (Infectious Disease). Discharge Instructions read Follow-up with PCP (primary care doctor), orthopedics and ID (infectious disease) An order for antibiotics was not included in the hospital discharge orders. Resident #193 was re-admitted to the facility on [DATE]. The History and Physical was signed by the Nurse Practitioner (NP) on 5/20/18. Section 1. Present Illness read 73 yo f back for skilled nursing post recent hosp. was sent for rt (right) hip dislocation and new drainage Seen by orthopedics reduction done with I and D (incision and drainage) of area Seen by ID (infectious disease) started on vancomycin PICC line placed on 5/17 and discharge back here with further ABX (antibiotics) Section C, Physical Examination was reviewed. The section 1. Assessment read Right Prosthetic Hip Dislocation; new onset drainage s/p 5/3: wash out, extraction of sinus, closure on IV (intravenous) vanco (antibiotic) for MRSA infection right hip, in association with hardware. dose adjusted due to high troughs and CKD (chronic kidney disease). Vancomycin 500 mg (milligram) IV q 48 hours. follow trough continue 6 week course (thru 6/14/18) Will need suppressive ABX indefinitely for chronic PO suppressive therapy weekly labs, fax to (doctor name) The following nursing note was written on 5/21/18, 6:54 p.m. Spoke with daughter (name) regarding resident doctor's appointment with infection disease doctor because of resident has a PICC line on left upper arm but not using for med pass, per daughter (name), when resident discharged from hospital they told her, she should continues with ABT (antibiotic) A Skilled nursing note dated 5/22/18, 11:13 a.m. read New order received from Infection Disease. (name) Start Vancomycin 500 mg (milligram) IV q48hrs for MRSA (R) hip until 6/14/18. Yes, patient is on ABT therapy. patient will start vancomycin 500 mg IV for MRSA infection on the (R) hip on 5/23/18. The May 2018 Medication Administration Record (MAR) was reviewed. According to the MAR, no antibiotic was administered to Resident #193 until 5/23/18 when the Vancomycin was started. On 5/24/18 at 9:35 a.m., it was reviewed with the DON that Resident #193 was discharged from the hospital to the facility for PICC line care and antibiotic administration. It was reviewed that the antibiotic was not started until 6 days after Resident #193 was discharged from the hospital. The DON stated that she understood. The DON stated that (nurse practitioner) should have picked up that there was no antibiotic order when the skilled nursing facility admitting orders were written. The DON stated that the physician approached her on 5/22/18 to address the fact that Resident #193 was not started on an antibiotic. The DON was informed that the survey team wanted to observe the wound care for the right hip. When asked if Resident #193 had MRSA, the DON stated that she needed to check. Resident #193's care plan was reviewed. Included was a Focus initiated on 8/1/17 and revised on 5/23/18 The resident is on, IV Medications vancomycin r/t (related to) left hip wound infection. The care plan did not indicate that MRSA was present in the wound. In addition, the incorrect hip was documented in the care plan. The right hip had the infected wound. Complaint Deficiency

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review the facility staff failed for 1 residents (Resident #193) of 35 residents in the survey sample to ensure the physician reviewed medications and treatments at each visit. For Resident #193, the facility staff failed to start an antibiotic to treat a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection of the right hip wound until 6 days after return to the facility. The findings included: Resident #193, a [AGE] year old, was re-admitted to the facility on [DATE]. Diagnoses included hypertension, diabetes, reflux, dislocation of right hip prosthesis, and MRSA infection of right hip wound. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/4/18. Resident #193 was coded with a Brief Interview of Mental Status score of 14 indicating no cognitive impairment and required extensive assistance with activities of daily living. On 5/1/18, Resident #193 was discharged to the hospital. The Medical Discharge Summary completed by the physician on 5/5/18 read Patient readmitted to long term care after hospitalization for anemia and guiac positive stools. She had been non ambulatory following multiple surgeries right hip after fracture repair and prosthesis with revisions. She had been table (sic) but noted to have drainage from old right hip incision. Xray showed probable chronic dislocation and she was transferred to hospital for recurrent hip prosthesis infection. The hospital Discharge Note read Principal Problem: Infection. The Discharge Note also included a Patient Active Problem List which included the following diagnoses related to infection: Cellulitis of drainage site, post-operative, initial encounter Deep incisional surgical site infection, initial encounter Post op infection Wound infection Acute osteomyelitis of left foot Osteomyelitis Infection The section Hospital Course read Seen by ID (Infectious Disease) started on vancomycin with daily vancomycin level check and redosing based on vancomycin level and PICC (peripherally inserted central catheter) line placed and discharge to SNF (skilled nursing facility) with antibiotics per ID (Infectious Disease). Discharge Instructions read Follow-up with PCP (primary care doctor), orthopedics and ID (infectious disease) An order for antibiotics was not included in the hospital discharge orders. Resident #193 was re-admitted to the facility on [DATE]. The History and Physical Effective Date was 5/18/18 and it was signed by the Nurse Practitioner (NP) on 5/20/18. Section 1. Present Illness read 73 yo f back for skilled nursing post recent hosp. was sent for rt (right) hip dislocation and new drainage Seen by orthopedics reduction done with I and D (incision and drainage) of area Seen by ID (infectious disease) started on vancomycin PICC line placed on 5/17 and discharge back here with further ABX (antibiotics) Section C, Physical Examination was reviewed. The section 1. Assessment read Right Prosthetic Hip Dislocation; new onset drainage s/p 5/3: wash out, extraction of sinus, closure on IV (intravenous) vanco (antibiotic) for MRSA infection right hip, in association with hardware. dose adjusted due to high troughs and CKD (chronic kidney disease). Vancomycin 500 mg (milligram) IV q 48 hours. follow trough continue 6 week course (thru 6/14/18) Will need suppressive ABX indefinitely for chronic PO suppressive therapy weekly labs, fax to (doctor name) The following nursing note was written on 5/21/18, 6:54 p.m. Spoke with daughter (name) regarding resident doctor's appointment with infection disease doctor because of resident has a PICC line on left upper arm but not using for med pass, per daughter (name), when resident discharged from hospital they told her, she should continues with ABT (antibiotic) A Skilled nursing note dated 5/22/18, 11:13 a.m. read New order received from Infection Disease. (name) Start Vancomycin 500 mg (milligram) IV q48hrs for MRSA (R) hip until 6/14/18. Yes, patient is on ABT therapy. patient will start vancomycin 500 mg IV for MRSA infection on the (R) hip on 5/23/18. The May 2018 Medication Administration Record (MAR) was reviewed. According to the MAR, no antibiotic was administered to Resident #193 until 5/23/18 when the Vancomycin was started. On 5/24/18 at 9:35 a.m., it was reviewed with the DON that Resident #193 was discharged from the hospital to the facility for PICC line care and antibiotic administration. It was reviewed that the antibiotic was not started until 6 days after Resident #193 was discharged from the hospital. The DON stated that she understood. The DON stated that (nurse practitioner) should have picked up that there was no antibiotic order when the skilled nursing facility admitting orders were written. The DON stated that the physician approached her on 5/22/18 to address the fact that Resident #193 was not started on an antibiotic. The DON was informed that the survey team wanted to observe the wound care for the right hip. When asked if Resident #193 had MRSA, the DON stated that she needed to check. Resident #193's care plan was reviewed. Included was a Focus initiated on 8/1/17 and revised on 5/23/18 The resident is on, IV Medications vancomycin r/t (related to) left hip wound infection. The care plan did not indicate that MRSA was present in the wound. In addition, the incorrect hip was documented in the care plan. The right hip had the infected wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review the facility staff failed for 1 resident (Resident #54) of 35 residents in the survey sample to ensure resident was free from psychotropic medications. Resident #54 had a current order for PRN ativan that was originally ordered on 3/19/18, an excess of 14 days. In addition, there were not targeted behaviors documented or non-pharmacological interventions indicated. The findings included: Resident #54, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included reflux, hypertension, dementia, anxiety, and osteoarthritis. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/25/18. Resident #54 was coded with a Brief Interview of Mental Status score of 3 indicating significant cognitive impairment and required extensive assistance with activities of daily living. On 5/23/18 at 9:00 a.m., Resident #54 was observed in her room, dressed and seated in her wheel chair. The breakfast meal tray was on the table in front of her. Resident #54 consumed most of the meal. She was pleasant but confused during the conversation. Resident #54's physician orders were reviewed. Included was an order dated 3/19/18 for Ativan tablet 0.5 milligram by mouth every 8 hours as needed for anxiety. According to the 2018 Medication Administration Records (MAR), the Ativan was administered on the following occasions: 3/26/18, 3/27/18, 4/13/18, 4/20/18, 4/22/18, 4/25/18, 5/1/18, 5/7/18, and 5/9/18. The care plan was reviewed. Included was the focus dated 4/19/18 The resident uses, anti-anxiety medication (ativan) r/t (related to) Anxiety disorder. The interventions included psych consult as needed, give anti-anxiety medications ordered by physician, monitor side effects/ effectiveness, monitor mood as needed. The care plan did not indicate the targeted behaviors to indicate use. The care plan did not indicate non-pharmacological interventions to be used before administering the medication. On 5/23/18 at 5:00 p.m., the Director of Nursing, Administrator and Corporate staff were asked to provide the target behaviors and non-pharmacological interventions to support the use of the PRN ativan. They were asked again to provide the information at the end of day meeting on 5/24/18. No further information was provided.

Based on Observation and Staff Interview, facility staff failed to hold prepared hot foods at a safe temperature. Pureed toast was observed at 114 degrees Fahrenheit and Oatmeal was observed at 124 degrees Fahrenheit. On 5/22/18 at 7:29 a.m., a tour of the kitchen was conducted with Employee F. Employee F was observed taking the temperature of foods on the steam table prior to preparation of resident meal trays. Upon testing the temperature of the pureed toast, Employee F verbalized the temperature as 114 degrees Fahrenheit. When asked what temperature hot foods should be held at, Employee F stated we aim for 160 or above. When the temperature of oatmeal was tested, Employee F verbalized the temperature reading as 124 degrees Fahrenheit. Employee F stated its gotta be like 160-165. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 5/23/18. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review the facility staff failed for 1 residents (Resident #54) of 35 residents in the survey sample to ensure a complete medical record was available. For Resident #54 the facility staff failed to ensure the February 2018 bowel movement record was available. The findings included: Resident #54, an [AGE] year old, was admitted to the facility on [DATE]. Diagnoses included reflux, hypertension, dementia, anxiety, and osteoarthritis. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/25/18. Resident #54 was coded with a Brief Interview of Mental Status score of 3 indicating significant cognitive impairment and required extensive assistance with activities of daily living. The following nursing note dated 2/14/18 was reviewed During therapy, resident present with lethargy and was unable to participate as per therapist. Resident was brought back to her room and was assessed by this writer. Vital signs were measured and the following were noted: blood pressure 172/95 mmHg (millimeters of mercury), Heart rate 84 beats per minutes, temperature of 96.3 degrees Fahrenheit, respiration rate of 19 breaths per minute, and oxygen saturation of 95% on room air. MD (doctor) was notified of resident's clinical situation. MD (doctor) was also notified of absent bowel movement for the resident for 3 days. New orders were given to administer Dulcolax suppository 10 mg (milligram) x 1 now and as needed every 24 hours for constipation; Clonidine 0.1 mg (milligram) every eight hours as needed for systolic blood pressure equal or greater than 170; and UA C&S (urine culture) in AM (morning). Clonidine 0.1 mg and Dulcolax suppository 10 mg were administered as ordered. Incoming shift will reassess resident. Resident's guardian was notified or resident's clinical condition. At the end of day meeting on 5/23/18, the Administrator, Director of Nursing (DON) and corporate staff were asked to provide the bowel movement record for the month of February 2018. The following morning on 5/24/18, the DON stated that she had looked at the bowel record but forgot to bring it with her to speak to the survey team. The bowel record was requested again at the end of day meeting on 5/24/18. At this time, the facility administration explained that they did not have access to the bowel record because they recently purchased the facility on 3/1/18 and they could not access the requested document dated 2/14/18 from the previous owner. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The drain coming from the ice machine was in direct contact with the floor drain. On 5/22/18 at 7:29 a.m., a tour of the kitchen was conducted with Employee F. After touring the kitchen, Employee F showed this surveyor two ice machines. Employee F described one ice machine as the therapy ice machine, located in an alcove off the ground level dining room. It was found to have no air gap between the machine drain and the floor drain. The machine drain was observed to be in contact with the floor surface, and the opening of the machine drain was in contact with the grate over the opening of the floor drain. On 5/24/18, an interview was conducted with Employee D, the Head of Maintenance. Employee D was asked to describe the purpose of an Air Gap on an ice machine. He stated that the purpose is to prevent waste water from flowing back up into the ice machine from the floor drain. When asked how big an Air Gap should be, Employee D stated 4 inches. The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 5/24/18. No further information was provided. Based on observation, staff interview, and clinical record review the facility staff failed to implement an effective infection control program for 2 residents (Resident #193 and 54) of 35 residents in the survey sample and failed to ensure that the ice machine plumbing had an air gap to prevent the backflow of contaminated water. 1. For Resident #193, the facility staff failed to start an antibiotic to treat a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection of right hip wound. 2. Resident #193 had MRSA in the hip wound. Wound care was observed with the treatment nurse's arms and shirt coming in contact with the bed surface. 3. Resident #54's unused wound care items were placed (in a Ziploc bag) on the resident's bed and then unused items were placed back into the treatment cart. 4. The drain coming from the ice machine was in direct contact with the floor drain. The findings included: 1. For Resident #193, the facility staff failed to start an antibiotic to treat a Methicillin-Resistant Staphylococcus Aureus (MRSA) infection of right hip wound. Resident #193, a [AGE] year old, was re-admitted to the facility on [DATE]. Diagnoses included hypertension, diabetes, reflux, dislocation of right hip prosthesis, and MRSA infection of right hip wound. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 4/4/18. Resident #193 was coded with a Brief Interview of Mental Status score of 14 indicating no cognitive impairment and required extensive assistance with activities of daily living. On 5/1/18, Resident #193 was discharged to the hospital. The Medical Discharge Summary completed by the physician on 5/5/18 read Patient readmitted to long term care after hospitalization for anemia and guaiac positive stools. She had been non ambulatory following multiple surgeries right hip after fracture repair and prosthesis with revisions. She had been table (sic) but noted to have drainage from old right hip incision. Xray showed probable chronic dislocation and she was transferred to hospital for recurrent hip prosthesis infection. The hospital Discharge Note read Principal Problem: Infection. The Discharge Note also included a Patient Active Problem List which included the following diagnoses related to infection: Cellulitis of drainage site, post-operative, initial encounter Deep incisional surgical site infection, initial encounter Post op infection Wound infection Acute osteomyelitis of left foot Osteomyelitis Infection The section Hospital Course read Seen by ID (Infectious Disease) started on vancomycin with daily vancomycin level check and redosing based on vancomycin level and PICC (peripherally inserted central catheter) line placed and discharge to SNF (skilled nursing facility) with antibiotics per ID (Infectious Disease). Discharge Instructions read Follow-up with PCP (primary care doctor), orthopedics and ID (infectious disease) An order for antibiotics was not included in the hospital discharge orders. Resident #193 was re-admitted to the facility on [DATE]. The History and Physical was signed by the Nurse Practitioner (NP) on 5/20/18. Section 1. Present Illness read 73 yo f back for skilled nursing post recent hosp. was sent for rt (right) hip dislocation and new drainage Seen by orthopedics reduction done with I and D (incision and drainage) of area Seen by ID (infectious disease) started on vancomycin PICC line placed on 5/17 and discharge back here with further ABX (antibiotics) Section C, Physical Examination was reviewed. The section 1. Assessment read Right Prosthetic Hip Dislocation; new onset drainage s/p 5/3: wash out, extraction of sinus, closure on IV (intravenous) vanco (antibiotic) for MRSA infection right hip, in association with hardware. dose adjusted due to high troughs and CKD (chronic kidney disease). Vancomycin 500 mg (milligram) IV q 48 hours. follow trough continue 6 week course (thru 6/14/18) Will need suppressive ABX indefinitely for chronic PO suppressive therapy weekly labs, fax to (doctor name) The following nursing note was written on 5/21/18, 6:54 p.m. Spoke with daughter (name) regarding resident doctor's appointment with infection disease doctor because of resident has a PICC line on left upper arm but not using for med pass, per daughter (name), when resident discharged from hospital they told her, she should continues with ABT (antibiotic) A Skilled nursing note dated 5/22/18, 11:13 a.m. read New order received from Infection Disease. (name) Start Vancomycin 500 mg (milligram) IV q48hrs for MRSA (R) hip until 6/14/18. Yes, patient is on ABT therapy. patient will start vancomycin 500 mg IV for MRSA infection on the (R) hip on 5/23/18. The May 2018 Medication Administration Record (MAR) was reviewed. According to the MAR, no antibiotic was administered to Resident #193 until 5/23/18 when the Vancomycin was started. On 5/24/18 at 9:35 a.m., it was reviewed with the DON that Resident #193 was discharged from the hospital to the facility for PICC line care and antibiotic administration. It was reviewed that the antibiotic was not started until 6 days after Resident #193 was discharged from the hospital. The DON stated that she understood. The DON stated that (nurse practitioner) should have picked up that there was no antibiotic order when the skilled nursing facility admitting orders were written. The DON stated that the physician approached her on 5/22/18 to address the fact that Resident #193 was not started on an antibiotic. The DON was informed that the survey team wanted to observe the wound care for the right hip. When asked if Resident #193 had MRSA, the DON stated that she needed to check. Resident #193's care plan was reviewed. Included was a Focus initiated on 8/1/17 and revised on 5/23/18 The resident is on, IV Medications vancomycin r/t (related to) left hip wound infection. The care plan did not indicate that MRSA was present in the wound. In addition, the incorrect hip was documented in the care plan. The right hip had the infected wound. 2. Resident #193 had MRSA in the hip wound. Wound care was observed with the treatment nurse's arms and shirt coming in contact with the bed surface. 05/24/18 10:55 AM Resident # 193: An observation of the resident's hip wound and heels with the ADON (assistant director of nursing) was conducted. Resident #193 denied pain, stating, Not now. The right hip incision was clean with sutures approximating, no redness or drainage evident. The ADON was asked if the resident had MRSA (methicillin resistant staph aureus) in the hip wound. The ADON stated, They did not say if she has MRSA. During the treatment of cleaning and dressing of the wound, the ADON's arms and front of the shirt were observed to be touching the bed surface as the resident was not wearing a gown. On 5/24/18 at approximately 9:30 AM, the DON (director of nursing) was notified of above findings. 3. Resident #54's unused wound care items were placed (in a Ziploc bag) on the resident's bed and then unused items were placed back into the treatment cart. Resident # 54 was admitted to the facility on [DATE]. Diagnoses for Resident #54 included but not limited to dementia, anemia, high blood pressure and muscle weakness. Resident #54's Minimum Data Set (an assessment protocol) was a quarterly assessment with an Assessment Reference Date of 4/25/18 coded Resident #54 with a BIMS (brief interview of mental status) score of 3 out of a possible 15, or severe cognitive impairment. Resident #54 required extensive assistance for her ADL's (activities of daily living such as bed mobility and toileting) of one to two staff members. 05/23/18 8:55 AM Resident # 54: Observed wound care to left and right feet, arterial insufficiency per the wound care physician. Packet (Ziploc) bag containing 4 x 4's, normal saline and Qtips placed on the resident's bed. Areas are black with dry eschar. The areas were cleansed with normal saline, Skin prep spray was applied to blackened areas, Betadine applied to toe on left foot. Resident was uncomfortable during the treatment; had been medicated at 6:00 AM with Tylenol 500 mg 2 tablets. After the treatment, the nurse (ADON- assistant director of nursing) placed the Ziploc bag containing unused items back into the treatment cart. On 05/24/18 at 09:11 AM The Infection Control program was reviewed with the Quality and Compliance Educator. The Educator was questioned regarding the observation of the wound care done for Resident #54. The Educator stated, I would have only taken in items that were needed and trash items not used in the treatment. Review of the facility's infection control/wound care policy did not address discarding un-used items after the treatment was completed. On 5/24/18 at approximately 9:30 AM, the DON (director of nursing) was notified of above findings.