**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F600 AFTER F689 Based on clinical record review, staff, and resident interviews, the facility staff failed to ensure adequate assistance was implemented for bed mobility, which the facility had control over to prevent accidents for one (1) of five (5) residents in the survey sample, Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of Multiple Sclerosis, hemiplegia, and hemiparesis following a stroke affecting the right dominant side, muscle wasting and atrophy at multiple sites, lymphedema, spinal stenosis in the lumbar region without neurogenic claudication, and pulmonary embolism. Resident #1's Other Payment Assessment Minimum Data Set (MDS) with an assessment reference date of 3/25/25 coded for bed mobility (how the resident moves to and from lying position, turns side to side, and positions their body while in bed) as needing extensive assistance and support from 2 or more persons (s), physical assistance. Resident #1 Brief Interview for Mental Status (BIMS) scored 15 out of 15, indicating no cognitive impairment. Resident had a revised care plan dated 3/3/25 as having an ADL (Activity of Daily Living) self-care performance deficit related to weakness, Stroke, deconditioned status post hospitalization, Hemiparesis/Hemiplegia, muscle wasting and atrophy, and sequelae of the stroke. The care plan failed to address bed mobility needs, including two staff members for assistance. Review of Resident #1's progress notes dated 3/26/25 at 2:41 PM indicated that at approximately 10:40 AM, CNA #1 reported that Resident #1 had fallen out of bed and was lying on the floor. Facility staff documented that Resident #1 was immediately assessed and observed positioned on the right side of the bed on the floor. Resident #1 was alert, responded WNL (Within Normal Limits), and had no pain. ROM (Range of Motion) was WNL. Resident #1 was administered PRN (as needed) Tylenol as a pain preventative. The facility's staff immediately installed bed rails to the upper portion of the resident's bed to assist with bed mobility during turning and repositioning. An interview was conducted on 4/1/25 at 12:10 PM with Resident #1 regarding the incident. Resident #1 was just readmitted to the facility after being hospitalized from [DATE] to 3/31/25, for a condition determined to be unrelated to the fall. Resident #1 was eating in the facility's TV room. Resident #1 observed CNA #1 walking with the surveyor into the facility's TV room, at which time she stated, That's the nurse who dropped me! Resident #1 expressed that CNA #1 was bathing her and attempted to turn her to the right side. The resident said there were usually two or more nurses helping when repositioning her in bed. Resident #1 said she believed the facility is short of staff. Resident #1 stated, I remember being turned to the right side of the bed and continuously rolling straight towards the floor. I could hear the CNA repeatedly saying I'm Sorry! I'm sorry! She rushed out of the room to get help, leaving me on the floor alone. Resident #1 said the facility Administrator and Director of Nursing entered the room after the fall. Resident #1 stated she experienced pain in her back, and both legs were swollen. The resident remembered being transferred back into bed after the incident. Resident #1 stated she was having difficulty staying awake and told the facility staff, Just sit me in a chair. Resident #1 said that since the fall, she felt apprehensive about the staff assisting with bathing or showering. On 4/1/25 at 12:53 PM with CNA #1, an interview was conducted regarding the residents' fall. CNA said, I normally don't provide care for this resident, but I did it. I was bathing Resident #1, and I turned the resident onto her side using a drawsheet (a flat sheet, often smaller than a regular bed sheet, used in a healthcare setting to assist in repositioning or transferring patients in bed). I pulled too hard on the drawsheet, and Resident #1 rolled towards the right side of the bed. I observed the resident attempting to reach outward with her only functional left arm as she fell onto the floor on the opposite side of the bed, away from me. I heard (Resident #1's name) moaning on the floor. I immediately left the resident's room to get assistance. CNA said that LPN #2 entered the room, assessed the resident, and stayed with the resident on the floor. CNA #1 stated that the Director of Nursing (DON) and nurse practitioner (NP) came into Resident #1's room and assisted with getting the resident back into bed by utilizing the full mechanical lift. CNA #1 said she told everyone present how the incident occurred and that she dropped Resident #1 by accident. A meeting was conducted on 4/1/25 at 2:28 PM with the Facility's Nurse Practitioner (NP #6), who arrived in Resident #1's room after the fall. NP #6 stated he was called to assist with getting the resident back in bed after the fall. NP #6 said the resident was on the floor when he arrived in the room. NP #6 stated Resident #1 had no broken bones, but he was concerned about her legs swelling. He said the resident had no complaints of pain. NP #6 stated the facility usually waits a couple of hours before calling emergency medical services for residents who fall, if there is no obvious evidence of broken bones or immediate neurological changes. A review of the facility's residents' fall investigations for January 2025 through March 2025. The facility Director of Nursing (DON) presented the fall investigations binder, but the binder did not include information regarding Resident #1's fall investigation. The investigation binder was returned to the DON, and the fall investigation binder was asked if it was complete. The DON later returned the investigation binder, and Resident #1's information regarding the resident's fall was included. The DON did not explain why Resident #1's fall investigation was not initially included in the binder. A meeting with the DON was conducted on 4/1/25 at 2:45 PM regarding Resident #1. The DON stated CNA #1 came to her office for help when Resident #1 fell. The DON said NP 6 and the facility Administrator were in the room. Resident #1 was lying on the floor, lying on her back, and said she was not in pain. The DON stated Resident #1 was assessed, and the resident wanted to get up. She said Neuro checks were within normal limits, and Resident #1 denied hitting her head, which was corroborated by the CNA. DON stated CNA #1 provided morning care to Resident #1, while CNA #1 turned the resident on her side, the resident continued to roll off the mattress to the floor. The final exit meeting was conducted on 4/22/25 at 12:30 PM with the facility Administrator and Director of Nursing. No additional information was presented regarding this incident.

Based on observations, staff interview, resident interview and clinical record review, the facility staff failed to ensure reasonable accommodation of needs for one Resident (Resident #35) in a survey sample of 26 residents. The findings include: For Resident #35, the facility staff failed to ensure the large clock on the bedroom wall was working. Resident #35's most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 5/19/2023. Resident # 35's BIMS (Brief Interview for Mental Status) Score was a 8 out of 15 indicating severe cognitive impairment. Review of the clinical record was conducted on 6/6/2023-6/7/2023. During the initial tour on 6/6/2023 11:45 a.m., the clock in Resident # 35's room had the time of 3:24. Resident 35 was in the room, sitting in the bed and watching television. On 6/6/2023 at 2:40 p.m., the clock had the time of 3:24. The second hand was not moving. Resident # 26 was observed sitting in his wheelchair and propelling himself in the hallway. He stated he was going back to his room after participating in an activity. On 6/6/2023 at 3:00 p.m., the clock had the time of 3:24. Resident # 35 was sitting on his bed watching TV. On 6/7/2023 at 9:30 a.m., the clock had the time of 3:24. Resident # 35 was sitting in the wheelchair in the room. When asked if he could tell time, he replied yes. When asked what time it was, Resident # 35 looked and the clock and stated the clock was wrong. He stated the Activities personnel lets him know when it is time to go to Activities. On 6/7/2023 at 12:10 p.m., the clock had the time of 3:24. On 6/7/2023 at 4:40 p.m., the clock had the time of 3:24. During the end of day debriefing on 6/7/2023 at 5:45 p.m., the Regional [NAME] President, Director of Nursing and Corporate Nurse Consultants were informed of the issue. They all stated the clocks should be accurate. During an interview with the Director of Nursing, she stated it was important for clocks to be accurate because they would help with orientation of the residents. The Corporate consultants stated they would check all of the clocks for accuracy. They stated the Maintenance Director would be informed of the need to replace batteries where needed. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to develop and implement a baseline care plan that included instructions to provide person-centered care for one resident (Resident #255) in a sample of 26 residents. The findings included: For Resident #255, the facility staff failed to develop a baseline care plan to address the care needs of the Resident which would include the use of a 1) CPAP (continuous positive airway pressure) machine when sleeping, 2) wounds on his right foot, and 3) a PICC (peripherally inserted central catheter), that were present on admission and required facility staff management. Resident #255 was admitted to the facility on [DATE]. Physician orders on admission included order for the treatment of wounds and care of a PICC line. On 6/6/23, Resident #255 was visited in his room. Upon initial interaction it was noted that Resident #255 had a bandage on his right foot/ankle. Resident #255 was unable to give any details as to what was wrong. Surveyor E also noticed that Resident #255 had a PICC line to the right side and a CPAP machine was noted at the bedside. On the afternoon of 6/6/26, Employee L, the unit manager, told Surveyor E that Resident #255 had been in the facility previously and they had healed his foot wounds. She went on to say Resident #255 discharged home but has now been back about 2 weeks and has wounds again that require treatment. On 6/7/23, during the morning, Resident #255 was visited in his room and observed to be asleep with his CPAP in use. On the afternoon of 06/8/23, the facility management staff provided Surveyor E with Resident #255's care plan and indicated that items initiated on admission were part of the baseline care plan. This review revealed that the baseline care plan for Resident #255 did not address the use of a CPAP machine, PICC line or wounds to the Resident's right foot. On 06/8/23, during an end of day meeting, the administrator, director of nursing (DON), and corporate staff 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, interview, clinical record review and facility documentation the facility staff failed to provide care that meets professional standards of care for 1 Residents (#5) in a survey sample of 26 Residents. The findings included: 1. For Resident #5, the facility staff administered 2 doses of Rosuvastatin 80 mg when the order stated Rosuvastatin 40 mg. On 6/7/23 during the medication administration pass for Resident #5, the nurse pulled up the Resident #5's record and began pulling medications. When she came to Resident #5's Rosuvastatin, she read the dosage out loud (Rosuvastatin 40 mg) and then read the card containing 28 pills and it said Rosuvastatin 80 mg. She stopped and said the amounts are not the same. When asked what her next step is, she stated that she would finish pulling the rest of the meds, give them, and notify the Nurse Practitioner (NP) of the pharmacy error. She stated she would also notify her Unit Manager and document the medication that was found and let the NP know that the wrong dose had been pulled and given on the 2 previous days. On 6/8/23 at approximately 245 PM, an interview was conducted with LPN E who was asked if she had administered medications the previous 2 days and she stated that she had. When asked, did she sign off for the medication Rosuvastatin, she indicated that she did. When asked if she was aware of the dose, she stated that she had been told when she came to work it was an error from pharmacy. The acting DON forwarded an email to this surveyor where she had been in communication with the pharmacy since the error was discovered. The pharmacy was to send the correct medication dose on the next run. According to the [NAME] website: https://www.nursingcenter.com/ncblog/may-2011/8-rights-of-medication-administration 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 antihypertensive 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. On 6/8/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure 1 resident (Resident # 1) in a survey sample of 26 residents received oxygen care in a manner to prevent the spread of infection. Findings included: 1. For Resident # 1, the facility staff failed to label and date the oxygen tubing. Resident # 1's clinical record was reviewed on 6/6/2023 and 6/7/2023. During the initial tour on 6/6/2023 at 11:40 AM, Surveyor C observed Resident # 1 lying in bed with oxygen, via nasal cannula, delivered by an oxygen concentrator located on the right side of the bed. The oxygen tubing was not labeled and dated. On 6/6/2023 at 12:45 p.m., Resident #3's oxygen tubing was observed again and noted to be without label or date. An interview was conducted with LPN (Licensed Practical Nurse) C who stated oxygen tubing should be labeled and dated. LPN C observed the tubing and stated there was no label on the tubing. LPN C stated she knew the tubing had been changed on the night shift on Sunday 6/4/2023 because she was the nurse who worked that night. LPN C stated she forgot to put the label and date on the tubing. LPN C stated it was important to change, label and date the tubing weekly to decrease the risk of infection. During the end of day debriefing on 6/6/2023, an interview was conducted with the Interim Director of Nursing (DON) who stated, Oxygen tubing should be labeled and dated and also changed weekly in order to prevent infections. LPN B stated the facility staff should change the oxygen tubing weekly and staff should check the date on the tubing prior to using it to make sure it is not longer than a week due to potential for infection control problems. Review of the Physicians Orders revealed the following orders for oxygen therapy: for Oxygen at 2 Liters per minute via nasal cannula every shift. There was an order revised on 5/10/2023 for Oxygen Tubing, cannula / mask every _Sunday_______ and as needed when soiled. (every Sunday night shift) Review of the facility policy entitled Oxygen Therapy revealed no documentation of the policy on the frequency of changing oxygen tubing and humidifier or of labeling and dating the tubing. The policy did not state how often the tubing should be changed. During the end of day debriefing on 6/6/2023, the Regional Administrative Consultant, Corporate Nurse Consultant and interim Director of Nursing were informed of the failure of the staff to change, label and date the oxygen tubing weekly. The Corporate Nurse Consultant stated the oxygen tubing should be changed weekly, labeled and dated. No further information was provided.

Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 3 medication errors in 35 opportunities, resulting in an 8.57% error rate. The findings included: On 6/7/23 at 8:18 AM, Licensed Practical Nurse C (LPN C) and LPN D were observed during the medication administration of Resident #28. LPN C pulled Resident #28's medications which were a total of 10 pills (tablets and capsules). LPN C mentioned that they did not have the MiraLax to administer. LPN C said, it [MiraLax] has been out for several days- we have had hard time getting it from the pharmacy, it is out of stock. Since it is OTC [over the counter], supply has to order it. Following the medication administration, LPN C continued with her medication pass and did not make any attempts to clarify that a supply had/had not come in, notify the physician, or take any other actions. On 06/07/23 at 08:21 AM, LPN C and LPN D were observed during medication administration. LPN C entered the room and administered Resident #16's medications, which included 10 pills and 1 inhaler. LPN D had obtained the Diclofenac gel, and waited until LPN C administered the medications and then she applied the Diclofenac gel to both of Resident #16's knees. Following the observation of medication administration, Surveyor E conducted a clinical record review of Resident #28 and #16's medication orders and medication administration record. This review revealed the following: a. Resident #28 had an order for GlycoLax Powder 17 GM/Scoop (Polyethylene Glycol 3350) [MiraLax] Give 1 scoop by mouth one time a day for constipation, which was scheduled for a 9 am administration. b. Resident #16's order for the Diclofenac gel read, Apply to left knee, right shoulder topically two times a day related to unilateral primary osteoarthritis left knee, apply 2 gm (grams). This administration was not signed off as having been administered. c. Resident #16 had an order for the following: Refresh Tears Solution (Carboxymethylcellulose Sodium). Instill 2 drop in both eyes four times a day for dry eyes two drops in each eye four times per day. The eye drops had been signed off for the 9 am, but were not given. Surveyor E then returned to the floor and interviewed LPN C. LPN C was asked about the administration of the Diclofenac gel being applied to both knees when the order was for the left knee and right shoulder. Surveyor E also notified LPN C the administration was not signed off. LPN C did not respond. Surveyor E then questioned the Refresh Tears eye drops that had been signed off and were not administered. LPN C confirmed the eye drops were not in-house and not available for administration. During the above interview, LPN C further confirmed that medications are to be signed off at the time of administration and only if they are administered. Review of the facility policy titled; Administering Medications was conducted. This policy read, .4. Medications are administered in accordance with prescriber orders, including any required time frame .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . The facility policy titled, Unavailable Medication was received and reviewed. This policy read, . 2. In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed [administered], nursing staff shall: a. Contact the pharmacy regarding the unavailable medication. b. Attempt to obtain the medication from the facility's automated medication dispensing system or emergency kit. c. Notify the physician of the unavailable medication . No further information was provided/received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility documentation the facility staff failed to properly store medications for 1 of 2 medication carts inspected. The findings included: On [DATE] at 8:33 AM, while completing the medication storage tasks Surveyor E made the following observations of the medication cart for the 200 hall in the presence of LPN C and LPN D: 1. Resident #32 had a Lispro insulin pen that had an open date of [DATE], that was on the cart and available for use. Resident #32 also had a multi-use vial of Lantus, which had no date opened. 2. Resident #206, had an aspart insulin pen and a Degludec insulin pen that had no labeling for the date opened. 3. Resident #32 had a Basaglar Kwik pen in the cart, which did not have an open date. A Novolog insulin pen which had an open date of [DATE], remained in the cart and available for use. LPN C confirmed all of the above findings and confirmed the date opened on the ones that had a date and commented, They are only good for 28 days. LPN C also confirmed that she could not find a date opened on the other ones noted above. LPN C further added that, He [Resident #32] isn't here anymore, he is deceased . A review of the facility policy titled; Administering Medications was reviewed. It read, .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container . The facility policy regarding the storage of medications did not address the labeling of insulin or multi-use vials. An excerpt from the policy did read, . Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . On the afternoon of [DATE], the director of nursing was asked about the storage of and labeling of insulin. The DON stated insulin is to be labeled when opened because it is only good for 28 days after being opened/accessed. The DON also confirmed that medications that are not in use or if the resident is no longer at the facility should be removed from the cart. On [DATE] during the end of day meeting the Administrator was made aware and no further information was provided.

Based on observations, interview, clinical record review and facility documentation the facility staff failed to ensure the medical record was accurate for 1 Resident (#32) in a survey sample of 26 Residents. The findings included: For Resident #32 the facility staff failed to ensure that his clinical record contained only his information. On 6/8/23 when the electronic medical record was accessed for Resident #32 to view the Pre-admission Screening And Resident Review (PASARR) screening, a tab that said PASARR was clicked and what opened up was a document containing 33 PASARR's. Resident #32's PASARR was among the 33 PASARRs. On 6/8/23 at approximately 2PM, an interview was conducted with Employee N who was asked how assessments and records get put in the EHR (electronic health record), she stated that they are scanned and uploaded into the system. When asked if they do one chart at a time, she indicated that they did. When asked if a document is scanned into the wrong person's chart what happens, she stated that when they are aware of it, they immediately correct it. When asked why this is important, she stated because it's a Health Information Portability and Accountability Act violation. On 6/8/23 at approximately 4:15 PM, an interview was conducted with the DON, Corporate VP and Administrator who were made aware of the finding of 33 PASARR's in Resident #32's chart. The Corporate VP stated that it must have been when medical records scanned it in incorrectly and attached the entire file instead of only Resident #32's. On 6/8/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to determine the Resident's immunization status and offer influenza and pneumonia vaccines for 2 Residents (Resident #255 & #48) in a survey sample of 5 residents reviewed for immunizations. The findings include: 1. The facility staff failed to determine Resident #255's current immunization information and offer any immunizations the Resident was eligible. A clinical record review was performed on 6/7/23. Resident #255's clinical record revealed, under the immunization tab, that the flu vaccine and pneumococcal immunizations were, historical. The record had no information to support where the facility obtained this data. On 6/8/23, an interview was conducted with the facility's Director of Nursing (DON) who accessed the clinical record for Resident #255 and verified the findings. The DON further confirmed there was no Virginia Immunization Information System (VIIS) uploaded into the record as evidence that the facility had attempted to obtain the Resident's current immunization status. 2. The facility staff failed to identify/assess Resident #48's current immunization status so that they could offer any immunizations the Resident was eligible for. A clinical record review was performed on 6/7/23. Resident #48's clinical record revealed, under the immunization tab, that there was no information with regards to flu vaccine and pneumococcal immunizations. Nor was there any evidence that facility staff had offered education or the vaccines to Resident #48. On 6/9/23, an interview was conducted with the facility's Director of Nursing (DON) who accessed the clinical record for Resident #48 and confirmed the above findings. The DON further confirmed there was no Virginia Immunization Information System (VIIS) uploaded into the record as evidence that the facility had attempted to obtain the Resident's current immunization status. The DON stated that the facility's process is for admissions to check the VIIS and upload it into the clinical record and then nursing will educate and offer any immunizations the Resident is eligible to receive. She said the importance of immunization is, we are trying to help the community be healthier and safer. Following the above interview, the DON advised Surveyor E that no one in the facility has access to the VIIS system. Review of the facility policy entitled, Pneumococcal Vaccinations, was conducted. This policy read, 1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine within (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . The facility policy titled, Influenza, Prevention and Control of Seasonal was reviewed. An excerpt from this policy read, .Vaccination: 1. The infection preventionist organizes and oversees an annual influenza campaign. 2. All residents and staff are offered the vaccine at or before the onset of the influenza season. 3. All residents and staff are encouraged to receive the vaccine unless there is a medical contraindication . On 6/8/23 during the end of day meeting, the Facility Administrator, DON, and corporate staff were made aware of the findings. No further information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to offer COVID-19 immunizations for 2 Residents (Resident #255 and 48) in a survey sample of 5 Residents reviewed for COVID-19 immunizations. The findings include: 1. The facility staff failed to determine Resident #255's current immunization status and offer any COVID-19 immunizations the Resident was eligible for. A clinical record review was performed on 6/7/23. Resident #255's clinical record revealed, under the immunization tab, that the Resident had only received a primary vaccination series for COVID-19 and had not received any booster doses. Therefore, the Resident was eligible to receive the bivalent COVID-19 booster. On 6/8/23, an interview was conducted with the facility's Director of Nursing (DON) who accessed the clinical record for Resident #255 and verified the above findings. The DON further confirmed there was no evidence that Resident #255 had received education or been offered the COVID-19 bivalent booster. 2. The facility staff failed to identify/assess Resident #48's current COVID-19 immunization status so that they could offer any COVID-19 immunizations for which the Resident was eligible. A clinical record review was performed on 6/7/23. Resident #48's clinical record revealed, under the immunization tab, that there was no information with regards to COVID-19 immunizations. Nor was there any evidence that facility staff had offered education or been offered any COVID-19 vaccines to Resident #48. On 6/9/23, an interview was conducted with the facility's Director of Nursing (DON) who accessed the clinical record for Resident #48 and confirmed the above findings. The DON further confirmed there was no evidence that Resident #48 had been educated on or been offered any COVID-19 immunizations. The DON stated that the facility's process is for admissions to check the Virginia Immunization Information System (VIIS) and upload it into the clinical record and then nursing will educate and offer any immunizations the Resident is eligible to receive. She said the importance of immunization is, we are trying to help the community be healthier and safer. Following the above interview, the DON advised Surveyor E that no one in the facility has access to the VIIS system. Review of the facility policy entitled; COVID-19 Vaccination was conducted. This policy read, Eligible staff members and residents who meet eligibility criteria will be offered the COVID-19 vaccine . 2. Prior to offering the vaccine, individuals will be screened for prior immunization, medical precautions, and contraindications to determine if they are appropriate candidates for vaccination .Documentation: 1. The facility will document the following in the resident's medical record: a. That the resident (or representative) was provided education regarding the benefits and potential side effects of the COVID-19 vaccine, including the date the education, and offering took place . On 6/8/23 during the end of day meeting, the Facility Administrator, DON, and corporate staff were made aware of the findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to maintain water temperatures in a range to mitigate burns, scalding and other injuries. On the afternoon of 6/6/23, an interview was conducted with the maintenance director/Employee C. The maintenance director was asked if he checks water temperatures and the maintenance director stated, he checks temperatures weekly. Review of his water temperature logs revealed that temperatures are checked resident rooms routinely. The maintenance director was asked to obtain his thermometer used to check water temperatures. When asked how often he calibrates the thermometer he uses to check temperatures, the maintenance director stated, I haven't ever calibrated it. The maintenance director then went and borrowed a digital thermometer from the kitchen as well. The maintenance director accompanied Surveyor E to the room of Resident #4. The maintenance director used his thermometer to measure the water temperature and it was 118 degrees. The maintenance director then used the thermometer from the kitchen and the water measured 120.7 degrees. Both Surveyor E and the maintenance director did the same in 2 additional resident rooms and both measured 120.7-120.8 degrees on the digital thermometer. The maintenance director confirmed that this was too hot, and someone could get burned. On the morning of 6/7/23, the maintenance director and vice president of plant operations (VPPO) confirmed that they had purchased a new thermometer and made adjustments to the water mixing valve to decrease the water temperature to safe range in Resident rooms. The maintenance director and VPPO accompanied Surveyor E to several rooms on each resident care hallway and verified water temperatures to be between 103-111 degrees. Both again confirmed that the temperature reading of 120 degrees the day prior, was too hot and could be a potential hazard to Residents. On 6/7/23, the facility's corporate staff confirmed they were unable to pull a report of incident tracking via the electronic system used for incidents and would have to make a list manually. They further confirmed that no Residents had any incidents of burns within the past 3 months. Review of the facility policy titled water temperatures, safety of was conducted. This policy read, Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit or the maximum allowable temperature per state regulation .4. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor . Access to water at 120 degrees in 5 minutes can cause 3rd degree burns, according to [NAME], A.R., [NAME] F.C. Jr. (1947). Studies of Thermal Injury: 11. The Relative Importance of Time and Surface temperatures in the Causation of Cutaneous Burns. Am J Pathology, 23, 695-720. On 6/7/23 and again on 6/8/23, 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. Based on observation, interview, clinical record review and facility documentation the facility staff failed to 1) mitigate hazards for Residents that use slings, for 1 Resident (#33) in a survey sample of 26 Residents and 2) the facility staff failed to maintain water temperatures in a range to mitigate burns, scalding and other injuries. The findings included: 1) For Resident #33, the facility staff used a mechanical lift without the safety clips being on the hook to prevent the sling from backing out. On 6/7/23 at approximately 11:45 AM CNA's C and D were observed as they prepared to transfer Resident #33 from the bed to the shower stretcher. One CNA was on either side of the bed as they carefully rolled the Resident side to side to get the lift sling positioned under her correctly. The CNAs began explaining everything to the Resident who was responding and following directions. At that time, the Resident requested to be weighed and the CNA's stated that would be no problem as the lift has a weight scale on it. As the CNA's were getting the pad clipped onto the lift, it was noted that 2 of the hooks did not have clips on them. When asked what the clips were for CNA D stated that they were to prevent the lift sling from backing out and slipping off of the hook. CNA D stated that they had notified the former DON and she was supposed to have maintenance fix it. She stated she was told the facility had only lift with a scale, so they had to continue to use it. CNA C started we have another lift, but it does not have a scale on it. We also have 2 different lifts, but we were told we could not use them as they belong to a sister facility. CNA C told the surveyor where the lifts were located. There were 4 lifts on the back hall 1 without a scale and 2 that appeared to be new. On 6/7/23, an interview was conducted with the acting DON at approximately 1PM, who stated that she was unaware of the condition of the lift, and it has been taken out of service until the maintenance director could repair it. The sister facility's lifts were being used in the meantime. A review of the manufacturer's instructions read: After the first year of use, the hooks of the hanger bar and the mounting brackets of the boom should be inspected every three months to determine the extent of wear. If these parts become worn, replacement must be made. Casters and axle bolts require inspections every six months to check for tightness and wear. After the first twelve months of operation, inspect the hanger bar and the eye of the boom (to which it attaches) for wear. If the metal is worn, the parts MUST be replaced. Make this inspection every six months thereafter. Regular maintenance of patient lifts and accessories is necessary to assure proper operation. On 6/7/23 during the end of day meeting the Administrator was made aware of the finding and no further information was provided

Based on interview, and facility documentation the facility staff failed to maintain Registered Nurse coverage 7 days a week. This has the potential to affect Residents who need the services of a Registered Nurse (RN). The findings included: The facility staff failed to maintain RN coverage for at least 8 consecutive hours a day on 10/15/22. On 6/7/23 during entrance conference, the facility was asked if they had any kind of waivers and they stated that they did not. On 6/7/23, a review of Payroll Based Journal reports revealed that the facility lacked RN coverage on 10/8/22, 10/15/22, 10/22/22 and 10/23/22. On 6/7/23, the Human Resource director ran a report of the nursing staff scheduled for the months of September and October of 2022. A staffing schedule showed that on 10/8/22, 10/22/22, and 10/23/22, there appeared to be a Registered Nurse scheduled. However, on 10/15/22 the schedule appeared to be missing RN coverage. A request was made for timecard punches for 10/8/22, 10/15/22, 10/22/22, and 10/23/22 as credible evidence that the facility was staffed properly for those days. There was no time punch for an RN on 10/15/22. An interview with Employee H who stated that staffing the facility had been a challenging job at that time. She stated that they had been doing their best to ensure Registered Nurse coverage as well as floor staffing needs. She stated that they have finally gotten their staffing to where they are no longer using agency staff and going forward RN coverage should not be an issue. On 6/8/23 during the end of day meeting, the Administrator was made aware of the concerns and no further information was provided.

2. During the medication administration observation, the facility staff did not have available medications ordered by the physician for Resident #28 and Resident #16. On 6/7/23 at 8:18 AM, Licensed Practical Nurse C (LPN C) and LPN D were observed during the medication administration of Resident #28. LPN C mentioned that they did not have the MiraLax (Polyethylene Glycol 3350) to administer. LPN C said, it [Polyethylene Glycol 3350] has been out for several days- we have had hard time getting it from the pharmacy, it is out of stock. Since it is OTC [over the counter], supply has to order it. The clinical record review revealed Resident #28 had an order for GlycoLax Powder 17 GM/Scoop (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for constipation, which was scheduled for a 9 am administration. On 06/07/23 at 08:21 AM, LPN C and LPN D were observed during medication administration for Resident #16. Following the observation, Surveyor E reviewed the physician orders. This review revealed that Resident #16 had an order for Refresh Tears Solution (Carboxymethylcellulose Sodium). Instill 2 drops in both eyes four times a day for dry eyes two drops in each eye four times per day. The eye drops had been signed off for the 9 am, administration, however they were not observed to be given. The facility policy titled, Unavailable Medication was received and reviewed. This policy read, . 2. In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed [administered], nursing staff shall: a. Contact the pharmacy regarding the unavailable medication. b. Attempt to obtain the medication from the facility's automated medication dispensing system or emergency kit. c. Notify the physician of the unavailable medication . On 6/7/23, during an end of day meeting, the facility administrator, Director of Nursing (DON) and corporate staff were made aware of the above observations and medications not available for administration to Residents. The Regional [NAME] President stated that the concerns of the pharmacy had been brought to his attention and they had a meeting scheduled with their pharmacy. No further information was provided/received. Based on observation, interview, clinical record review, and facility documentation the facility staff failed to 1) ensure controlled substances were disposed of correctly and 2) failed to provide routine medications for 2 Residents (#28 and 16). The findings included: 1. The facility staff failed to ensure proper disposal of 24 controlled substances for Residents who no longer reside in the facility or who no longer use the controlled medication. On 6/7/23 at approximately 8 AM, during the medication pass it was discovered that there were 24 controlled substances, in various bottles and cards, to include liquid morphine, liquid Ativan, oxycodone, hydrocodone, gabapentin, Vimpat, morphine ER, and Ambien for Residents who no longer reside in the facility or who no longer use the medication. A review of the facility's Policy entitled Discarding and Destroying Medications, read: Medications will be disposed of in accordance with federal, state and local regulations governing the management of nonhazardous pharmaceuticals, hazardous waste and controlled substances. 1. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. On 6/8/23 at approximately 11 AM, an interview was conducted with the Assistant Director of Nursing (ADON) who stated that the policy was to destroy controlled substances with 2 RN's and since the Director of Nursing (DON) quit, she was the only Registered Nurse (RN). On 6/8/23 at approximately 1 PM, an interview was conducted with the Acting DON who stated she had only been in the facility since 6/5/23 and was unaware of the number of controlled substances being stored in the carts and in the refrigerator. When asked what the process was for disposal of controlled substances, she stated that 2 nurses had to waste controlled substances, but she was pretty sure the DON was responsible for disposal of controlled substances when the Residents were discharged or otherwise not using the medication. She further stated that going forward the disposal will happen weekly to rid the carts and refrigerators of any discontinued controlled substances. On 6/8/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to maintain an ongoing antibiotic stewardship program to monitor the use of antibiotics which had the ability to impact numerous Residents throughout the facility on all nursing units/resident care units. The findings included: On 6/8/23 at 11:42 AM, an interview was conducted with the facility's Infection Preventionist (IP)/Employee J, and the Director of Nursing. Review of the infection surveillance revealed that the facility uses an electronic form to review antibiotic usage to determine if McGreer criteria was met. Several Residents were noted to be prescribed and receiving antibiotics and the assessment indicated antibiotic use was not warranted. The assessment read, Does not meet criteria and Does not meet requirements. The Director of Nursing stated when this happens the facility staff are to talk with the physician and document the conversation about antibiotic use not being warranted and note any new orders received. In each of the instances reviewed where the Resident was noted to not meet criteria for antibiotic usage, the facility had no evidence of a conversation being held with the prescriber/physician to see if they wanted to discontinue the antibiotic. Each of the Resident's completed a full course of antibiotics. During the above interview, the Director of Nursing discussed that the risk of antibiotic use when it was not warranted leads to antibiotic resistance. Review of the facility policy titled, Antibiotic Stewardship, was conducted. This policy read, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. 2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community . On 6/8/23, the facility Administrator, Director of Nursing and Corporate staff were made aware that the facility had failed to provide evidence of an ongoing antibiotic stewardship program. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to maintain an infection control and prevention program to help prevent the development and transmission of infections, which has the ability to affect all Residents residing at the facility. The findings included: 1. The facility staff failed to develop and implement a water management plan for Legionella with regards to a risk assessment to identify where Legionella and other waterborne bacteria could grow. On 6/7/23, during review of the facility water management program the facility Maintenance Director of [NAME] President of Plant Operations were present. When asked for their facility risk assessment with regards to water management, which used to identify where Legionella and other waterborne bacteria could grow and spread in the facility water system, the facility had nothing to provide. On the morning of 6/8/23, the Corporate VP of Plant Operations (VPPO) stated they had been unable to locate any type of risk assessment with regards to water management and had nothing to submit. The facility Administrator was made aware of the lack of a water management program on 6/8/23, during the end of day meeting. No further information was provided. 2. The facility staff failed to maintain an infection control program that included a system of infection surveillance. On the afternoon of 6/8/23, Surveyor E met with the Director of Nursing (DON) and Infection Preventionist (IP) to review documents. The IP had a line listing of facility staff who displayed signs of infections from March and April 2023. The IP had no evidence of any infection surveillance/tracking, etc. for facility staff prior to March 2023 to submit. Review of the surveillance of Resident infections was reviewed and revealed that the tracking and trending was inaccurate and incomplete. The evidence included: a. For the month of June 2022, the facility noted 15 Resident infections. Of the 15 infections, 6 were UTI's (urinary tract infections). On the facility floor plan where they monitor for trends of infections, no UTI's were noted. b. For the month of January 2023, the facility noted 2 UTI infections, 5 COVID infections and 2 with pneumonia. Of these, only the pneumonia infections were noted on the facility floor plan, which is used to monitor for trending and potential spread of infection. c. For the month of February 2023, the facility noted 2 infections with pneumonia, either of which were noted on the floor plan for trending. None of the infection control documents submitted had any evidence of the evaluation of the data or any trends noted and the facility's response. On 6/8/23, the DON and IP were present for the above review and noted the same findings. When a discussion was held, both said they understood and agreed that the current infection control program was inadequate and missing a lot of information. The DON said, the reason infection surveillance is important is, To monitor for any best practices and to monitor for patterns or issues, where we are causing the infection through breaches in infection control and tracking it room to room. It allows us to take the best care of our residents. especially with flu and cold seasons. Review of the facility's infection control policy was conducted. The policy titled, Surveillance for Infections read, 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent further infections. Another excerpt read, .3. Infections that will be included in routine surveillance include those with: a. evidence of transmissibility in a healthcare environment; . c. clinically significant morbidity or mortality associated with infection (e.g., pneumonia, UTIs, C. Difficile) During the end of day meeting held on 6/8/23, with the facility administrator, director of nursing and corporate staff, they were made aware of the above findings. No further information was provided.

Based on observation, interview, facility documentation and clinical record review the facility staff failed to ensure Residents rights to a dignified existence for 1 Resident (#46) in a survey sample of 28 Residents. The findings included For Resident #46 the facility staff failed to answer a call bell in timely manner when Resident rang for pain and incontinence care. On 2/16/22 at approximately 1:05 PM Surveyor C entered the room of Resident #46 and found her in bed the sheets pulled away from the corners of the bed, she was dressed in a hospital gown and she stated I'm soaked honey and I'm hurting from my knees to my toes. When asked if she had called the nurse she stated I don't have a call bell. When asked if they had given her anything for pain she said Yes I didn't sleep well and they gave me Tylenol earlier but it doesn't help. The call bell was draped over the headboard out of the Resident's reach. The Resident was handed the call bell and she rang it. Surveyor C stepped into the hall and observed the following: At 1:14 PM - Resident began yelling out Please someone help me my legs hurt so badly. At 1:18 PM - Employee J came in and asked if she needed help she stated that she was in pain and the Employee J stated she would let her nurse know. She turned the call bell off at that time. At 1:20 PM - Resident yelling out Please help me I'm in pain. Where are they at I'm hurting. At 1:24 PM - Resident talking to self and alternating Please God let someone come in here. At 1:30 PM - Resident said Please don't treat me like this just because you can. At 1:35 PM - CNA came down the hall with the Lunch Trays. At 1:40 PM - The Regional Director of Clinical Services was assisting with passing trays and she spoke to the Resident and realized she needed incontinence care and she located 2 CNA's to assist with the incontinence care. At approximately 1:45 PM an interview was conducted with Employee J who stated I notified the DON when I came out of her room that she was in pain. At approximately 1:50 PM an interview was conducted with LPN E who stated Yes the DON let me know but I already gave her pain meds at noon actually she got Tylenol at 11:58 AM so she can't have anything else. A review of the clinical record revealed that LPN C did give Tylenol at 11:58 AM however she did not recheck or evaluate the resident's pain relief until 2:30 PM and it was rated a 3 /10 at that time. On the morning of 2/17/22 the DON was asked her expectation of evaluating pain medicine for effectiveness and she stated within an hour the nurse should recheck the resident and evaluate for pain relief. At this time the DON stated I went in and checked her at 1:00 PM and she was fine. When asked if she documented the interaction with the Resident she stated that she had not. When asked if she had addressed the incontinence she stated that she had not. On 2/17/22 at 2:29 PM the DON entered the following note Late entry for 2/15/22 Resident had complained of pain in her legs at 11:58 AM and this writer ask [sic] her at 1:00 PM if her pain was relieved she said yes. Per the facility call light policy: General Guidelines: 6. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. Documentation: 1. Document any significant requests or complaints made by the resident and how the request or complaint was addressed. On 2/17/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations, Resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide reasonable accommodation to Residents who had paralysis for two (2) Residents (Resident #33 and #44) in a survey sample of 28 Residents. The facility staff failed to take into consideration the Residents' paralysis and inability to use one side, when placing the call bell so that they could call for assistance if needed. The findings included: 1. On 2/15/22 at 02:56 PM, Resident #33 was visited in his room. Resident #33 was lying in bed, left side paralysis was noted, which Resident #33 confirmed. The call bell was observed wrapped around the arm of a chair located on the left side of the bed past where the head of the bed was elevated and was out of reach. On 2/17/22 at 8:47 AM, Resident #33 was observed sitting in his wheelchair between his bed and the bed of the roommate, in the middle of the room. His hand bell that had been provided to summons staff in the event he needed assistance, was observed on the far side of the room, on the bed side table and was not within reach/accessible. Resident #33 was not able to move his wheelchair efficiently to get to the call bell due to his paralysis. A review of the clinical record for Resident #33 revealed the following diagnosis: hemiplegia and hemiparesis following cerebral infarction affecting left dominant side. Resident #33's care plan had the following intervention, Be sure my call light is within reach and encourage me to use it for assistance as needed, which was initiated 11/9/2021. 2. On 02/16/22 at 08:28 AM, Resident #44 was observed lying in bed, the head of the bed was elevated. Resident #44 was observed to have left side paralysis. His call bell was draped over the head of the bed and resting at the top of the mattress on the left side. Resident #44 demonstrated that he was not able to access/reach the call bell. On 2/16/22 at 4:50 PM, Resident #44 was visited in his room. Resident #44's call bell was positioned on his left side at the head of the bed. Resident #44 was not able to access the call bell without surveyor intervention to give verbal cues to its location and direct the Resident where to reach for it. Resident #44 was observed to have extreme difficulty, and it took Resident #44 approximately 6 minutes to be able to get to the call bell. On 2/17/22 at 9:06 AM, Resident #44 was visited in his room. Resident #44 was lying in bed and his call bell was observed to be under his left shoulder. Resident #44 had no use of his left side. Resident #44 was asked to demonstrate how he would call staff if he needed assistance and was not able to do so. A clinical record review for Resident #44 was conducted. Resident #44 was noted to have the following diagnosis: hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side. The care plan for Resident #44 included a focus area that was initiated 8/5/2020, and read, I am at risk for falls related to impaired cognition, Left hemiplegia, and has previous history of falls. Interventions included, but were not limited to: Resident to have all belongings with resident and staff to make sure call bell within reach. On 02/16/22 at 08:58 AM, an interview was conducted with RN A. RN A stated call bells are used so that If the resident needs assistance or a staff member needs assistance, it alerts us. RN A confirmed that call bells should be positioned so that Residents can get to them at all times. On 2/17/22 at 9:17 AM, CNA G was interviewed. CNA G stated, Call bells are used to notify staff of emergency situations or needs. CNA G accompanied Surveyor D to Resident #44's room and confirmed that with it placed under his back on his left side he would not be able to access it to call for assistance due to his left side paralysis. A review of the facility policy titled, Answering the Call Light, was conducted. This policy read, .5. When the resident is in bed or confined to the chair be sure the call light is within easy reach of the resident. On 2/17/22 at 1:00 PM, the facility Administrator and Director of Nursing were made aware of the findings. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility documentation the facility and in the course of a complaint investigation, staff failed to revise a care plan for 2 Residents ( #46 and #208) in a survey sample of 28 Residents. The findings included: 1. For Resident # 46 the facility failed to revise a care plan to include the need for psych services ordered in 11/8/21. Resident # 46 was admitted to the facility on [DATE], per her initial MDS (Minimum Data Set) she had a BIMS (Brief Interview of Mental Status) score of 9/15 indicating moderate cognitive impairment. Her most recent MDS dated [DATE] recorded the Resident as having a BIMS score of 7/15 indicating severe cognitive impairment. The MDS dated [DATE] Section E 0100 Psychosis - (Box B was checked) Delusions (misconceptions or beliefs that are firmly held contrary to reality). E 0200 Behavioral Symptoms - (Box B was checked) - Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) - 3 -Behavior of this type occurred daily. A review of the care plan revealed the Resident was care planned for behavior of playing with feces and becoming verbally aggressive with others. A review of the physician's orders revealed that the Resident is taking Buspar for anxiety and Citalopram for depression. The Resident had an active order for psych services dated 11/8/21. On 2/17/22 at approximately 1:50 PM an interview was conducted with LPN C who was asked who updates care plans, she stated that the nurses can update the care plans. When asked who is responsible for obtaining psych consults she stated that usually it is the DON or the Social Worker. On 2/17/22 at approximately 2:00 PM, the DON was interviewed and was asked about the order for psych services dated 11/8/21 a few days after her admission. The DON stated that Resident had not seen psych services as far as she knew. She further stated that the Resident was her own RP. When asked if she had any concerns about a Resident being their own RP when they have delusions, and a BIMS of 8, she stated Well we cannot get hold of the daughter she as much as admitted she dumped her here because of her behaviors. She does not answer calls or letters. When asked about the BIMS score she stated That is the social worker she handles that. On 2/17/22 at approximately 4:00 PM an interview was conducted with the Social Worker who stated that she did another BIMS score that morning and her BIMS is a 4 / 15 indicating Severe Cognitive Impairment. She was asked if there was a concern about a Resident having a BIMS score of 4 being her own RP. She stated that there was and that she had arranged a psych consult. When asked if she was aware that Resident #46 had an order for Psych services since 11/8/21 she stated that she was not aware. She stated they were trying to decide which competency form to use between the facility and the provider of psych services. She stated that psych services would be in the building on Friday and that Resident #46 will be seen at that time. Per the facility care plan policy: 14. The interdisciplinary team must review and update the care plan: a. When there has been a significant change in the residents condition b. When the desired outcome is not met c. when the resident has been readmitted to the facility from a hospital stay and d at least quarterly, in conjunction with the required quarterly MDS assessment. On 2/17/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided. 2. For Resident # 208 the facility failed to review and revise the care plan to include an actual fall and UTI (urinary tract infection). On 2/17/22 the closed clinical record was conducted and the following was noted. Concerning UTI's, Resident #208's care plan read: I am at risk for UTI due to her incontinence, need for assistance with meals and fluid intake secondary to cognitive decline Date Initiated: 09/03/2020 Canceled Date: 06/30/2021 Progress notes read as follows: 5/27/21 at 5:15 AM -Note Text: Continues ABT/UTI Temp 97.8 no side effects from therapy noted, resident HAD no s/s of pain or discomfort when voiding and no c/o lower FLANK PAIN encouraged FLUIDS THIS SHIFT ,RESIDENT REFUSED ALL FLUIDS OFFERED. 6/22/21 at 11 PM - Upon assisting cna with repositioning of resident at approximately 9p, both writer and can noticed that resident felt warm to the touch. Vitals taken and temperature read 100.1. All other vitals stable .Resident also had clear drainage coming from her nose. No cough, congestion, or SOB present. No distress observed. Respirations even/unlabored. No facial grimacing or s/s of discomfort noted. Telehealth consulted and new orders received for CBC [Complete Blood Count], CMP [Comprehensive Metabolic Panel], UA [Urinalysis], C&S [Culture & Sensitivity] and a CXR [Chest X Ray]. 6/23/21 at 8:57 PM - Note Text: New order for macrobid, [Antibiotic used for UTI] RP [name redacted] is aware. However, the UTI care plan was not updated with new interventions when Resident #208 was diagnosed with a UTI on 6/23/2021 Concerning falls, Resident #208's care plan read: I am at risk for falls r/t History of falls. Hypotension, Psychoactive drug use , Unaware of safety needs, Fx hip Date Initiated: 05/02/2021 Canceled Date: 06/30/2021 5/5/2021 10:58 Health Status Note Resident found on floor apparently fell out of bed landing on Right hip. ROM is WNL. No facial grimacing with movement no apparent injury. Resident placed back in bed by staff. Total assist. RP and MD notified. However, the fall care plan was not updated with new interventions when Resident #208 fell on 5/5/2021. Per the facility care plan policy: 14. The interdisciplinary team must review and update the care plan: a. When there has been a significant change in the residents condition b. When the desired outcome is not met c. when the resident has been readmitted to the facility from a hospital stay and d at least quarterly, in conjunction with the required quarterly MDS assessment. On 2/17/22 during the end of day meeting the Administrator was made aware of the concerns not further information was provided.

2. For Resident #41, the facility staff failed to provide ADL (activity of daily living) assistance with showers/bath(s) once weekly as per Resident preference. On 2/15/22 during mid-morning, Resident #41 was visited in her room. Resident #41 verbalized that she only showers once weekly per her preference, and she receives showers on Tuesdays on second shift. On 2/15/22, Surveyor D asked RN A, How are showers are documented? RN A said there was a book at the desk that the CNA's use to document showers and they are also put in the electronic health record. Surveyor D reviewed the shower book at the desk and noted that there was no recorded showers for Resident #41. The Director of nursing walked up to the desk while Surveyor D was reviewing the shower book and said, It may not be in there, they wait until the end of the week to fill out those forms many times. Included in the shower book was a shower schedule which was requested and received. Review of the schedule revealed Resident #41 was scheduled to receive showers on Tuesday and Fridays on the second shift (3-11 PM). On 2/16/22, Resident #41 was visited in her room and asked if she received her shower yesterday. Resident #41 said, No, because they only had 2 CNA's [certified nursing assistants]. On 2/16/22 a review of the clinical record for Resident #41 revealed that in the past 30 days, 1/18/22-2/15/22, Resident #41 only received one (1) shower. There was documentation that she was offered a shower on 2/1/22, 2/4/22, and 2/6/22, on the third shift and had refused. There was no evidence of Resident #41 being offered a shower on the following Tuesdays: 1/18/22, 1/25/22, 2/8/22, or 2/15/22. Resident #41 was coded on the bathing ADL sheet as being totally dependent upon staff for bathing. Review of the care plan for Resident #41 revealed the following entry for ADL's, Resident needs one to two person assist with bed mobility, transfer, locomotion, personal hygiene, dressing and bathing. On 2/17/22 at 1 PM, CNA C reviewed the shower book and indicated she didn't see any indication that Resident #41 had received a shower that week. When CNA C was advised that Resident #41 said she didn't get a shower due to only having 2 CNA's, CNA C said, That's possible. They have been working short on 2nd shift. When asked why showers are important, CNA C said, Obviously for their hygiene and if they have wounds it is important. On 2/17/22 at 1:06 PM, the Director of Nursing (DON) was made aware of the above findings and of Resident #41's report of not getting a shower on 2/15, due to staffing. The DON said, probably so, occasionally that happens so we will get one today. A review of the facility policy titled, Bath, Shower/Tub was conducted. This policy read, .Documentation: 1. the date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. 3. All assessment data (e.g., any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. 4. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken .Reporting: 1. Notify the supervisor if the resident refuses the shower/tub bath . A review of the facility policy titled, Activities of Daily Living (ADLs), Supporting was conducted. This policy read, 2. Appropriate care and services will be provided for Residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) . On 2/17/22 at 1:00 PM, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided. Complaint related deficiency. Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to provide proper ADL care for dependant Residents, for 2 Residents (#46 and #41) in a survey sample of 28 Residents. The findings included: 1. For Resident #46 the facility staff failed to provide timely incontinence care for Resident #46. On 2/16/22 at approximately 1:05 PM Surveyor C entered the room of Resident #46 and found her in bed the sheets pulled away from the corners of the bed, she was dressed in a hospital gown and she stated I'm soaked honey and I'm hurting from my knees to my toes. When asked if she had called the nurse she stated I don't have a call bell. The call bell was draped over the headboard out of the Resident's reach. The Resident was handed the call bell and she rang it. Surveyor C stepped into the hall and observed the following: At 1:14 PM - Resident began yelling out Please someone help me my legs hurt so badly. At !:18 PM - Employee J came in and asked if she needed help she stated that she was in pain and the Employee J stated she would let her nurse know. She turned the call bell off at that time. At 1:20 PM - Resident yelling out Please help me I'm in pain. Where are they at I'm hurting. At 1:24 PM - Resident talking to self and alternating Please God let someone come in here. At 1:30 PM - Resident said Please don't treat me like this just because you can. At 1:35 PM - CNA came down the hall with the Lunch Trays. At 1:40 PM - The Regional Director of Clinical Services was assisting with passing trays and she spoke to the Resident and realized she needed incontinence care and she located 2 CNA's to assist with the incontinence care. On the morning of 2/17/22 the DON stated I went in and checked her at 1:00 PM and she was fine. When asked if she documented the interaction with the Resident she stated that she had not. When asked if she had addressed the incontinence she stated that she had not. On 2/17/22 at 1:36 PM an interview was conducted with CNA B who was asked about incontinence care for Residents she stated that they try to get there as soon as possible and get them cleaned up. She stated We usually check the Residents every 2 hours but there was a power outage this morning and we are short staffed today so everything is kind of behind. We usually have lunch at 12 and as you can see its 1:30 and I'm just passing the trays now. Per the call light policy: Documentation: 1. Document any significant requests or complaints made by the resident and how the request or complaint was addressed. On 2/17/22 the Administrator was made aware of the concerns and no further information was provided.

Based on observations, staff interview, facility documentation, and clinical record review, the facility staff failed to apply a hand splint to prevent the progression of contractures for one (1) Resident (Resident #27) in a survey sample of 28 Residents. The findings included: On 2/15/22 at 3:29 PM, Resident #27 sitting up in a Geri-chair (type of recliner chair) with a hand splint observed on her over bed table, not in use. Resident #27 was non-interviewable. On 2/16/22 at 8:18 AM, Resident #27 was observed lying in bed. The hand splint was noted to be on the over bed table, not in use. On 2/16/22 at 4:48 PM, Resident #27 was observed in bed, without a splint on. On 2/17/22 at 12:12 PM, Resident #27 was observed in bed, and did not have her splint on. A review of the clinical record for Resident #27 was performed. This review revealed a physician order dated 10/20/20, that read, Pt. [patient] to wear palm guard in left hand as tolerated. Review of the care plan for Resident #27 noted the following: A focus area initiated 8/5/2020, that read, I am at risk for pain due to impaired mobility and contractures. Interventions included, but were not limited to: Utilize resting hand orthosis for L hand to prevent further contractures, which was initiated: 12/31/2021. On 2/17/22 at 12:13 PM, an interview was conducted with CNA D. CNA D confirmed she was assigned to care for Resident #27. CNA D and Surveyor D went to the room of Resident #27 and made observations of the Resident. Observations were made of the skin integrity of Resident #27's left hand, with no noted areas of concern. CNA D was asked about a splint for the left hand since she has contractures, and stated she was not aware Resident #27 had a splint. CNA D found the splint in the bed side table drawer and proceeded to apply the splint. CNA D said the splint is important to Keep her nails from digging into her palm and keep the contracture from worsening. Review of the facility policy titled, Assistive Devices and Equipment was received and reviewed. This policy read, 1. Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. 2. The facility provides the resident with assistance in locating available resources to obtain assistive devices that are not provided by the facility. 3. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan. 4. Staff and volunteers are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents . On 2/17/22 at approximately 1:00 PM, the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on staff interview and facility documentation review, the facility staff failed to ensure that competencies were completed for 1 of 5 sampled staff (LPN C). The Findings included: On 2-16-22, a review was conducted of employee records. The facility Director of Human Resources (Employee F) was interviewed. The employee training records were computer-based Relias training, and some paper copies of training which was conducted in the facility. Employee F utilized her computer to facilitate the review, and provided copies to surveyors. According to the Relias Computer System Course Completion History, and all paper copies of training in the facility, the facility failed to implement required training for LPN (C). LPN (C) was hired on 12-27-19. Review of training from 1-1-2021 through 12-31-21 showed no training for Infection Control. On 02/15/2022 LPN (C) was observed passing medications without any eye protection 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 2-15-22 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 2-17-22 at 12:00 p.m., 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 2-17-22 at 6:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility documentation the facility staff failed to provide behavioral heath services for 1 Resident (#46) in a survey sample of 28 Residents. The findings included: For Resident #46 the facility staff failed to obtain a consult for psych services when ordered on 11/8/21. Resident # 46 was admitted to the facility on [DATE], per her initial MDS (Minimum Data Set) she had a BIMS (Brief Interview of Mental Status) score of 9/15 indicating moderate cognitive impairment. Her most recent MDS dated [DATE] recorded the Resident as having a BIMS score of 7/15 indicating severe cognitive impairment. The MDS dated [DATE] Section E 0100 Psychosis - (Box B was checked) Delusions (misconceptions or beliefs that are firmly held contrary to reality). E0200 Behavioral Symptoms - (Box B was checked) - Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) - 3 -Behavior of this type occurred daily. A review of the physician's orders revealed that the Resident is taking Buspar for anxiety and Citalopram for depression. The Resident had an active order for psych services dated 11/8/21. On 2/17/22 at approximately 2:00 PM the DON was interviewed and was asked about the order for psych services dated 11/8/21. The DON stated that Resident had not seen psych services as far as she knew. On 2/17/22 at approximately 4:00 PM an interview was conducted with the Social Worker. When asked if she was aware that Resident #46 had an order for Psych services since 11/8/21 she stated that she was not aware. She stated they were trying to decide which competency form to use between the facility and the provider of psych services. She stated that psych services would be in the building on Friday and that Resident #46 will be seen at that time. On 2/17/22 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, interview and facility staff failed to store drugs appropriately in locked compartments for one of the two med carts at the facility. The findings included: 1. LPN C left several medications on the top of the cart while she went to the Resident's room to administer the medications. On 2/16/22 at approximately 8:30 AM while observing a Med Pass with LPN C, Surveyor C observed LPN C pull medications, place them in a medication cup, leave the medication cards on the top of the cart, and walking off to give the medications to a Resident. LPN D was at the nurses station and she was interviewed at that time and she was asked if it was usual practice to leave the medications on the top of the cart, she stated Oh no those meds should not be left on the cart ever. At approximately 8:35 AM Employee J the corporate RN was asked to look at the cart and she stated No meds should never be left unattended. She might have been nervous about being watched by a surveyor but still she shouldn't leave the meds on the cart. Per the facility Page 2 Medication Administration Policy : 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room , with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications and all outward sides must be in accessible to resident's or others passing by. On 2/16/22 at approximately 10:00 AM the [NAME] was interviewed and she stated that she was aware of the incident with the LPN leaving the meds on the top of the cart and she stated the expectation is that the cart stays in view of the nurse at all times if it is not locked and if it is not in view then it is to be locked and meds are never left on top. On 2/17/22 during the end of day meeting the Administrator was made aware of the concern and no further information was provided.

Based on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to accommodate meal preferences for two Residents (Resident #33 and #10) in a survey sample of 28 Residents. The findings included: On 2/15/22 at approximately 10:30 AM, a tour of the kitchen was conducted. This tour included an interview with the cook, Employee F. Employee F confirmed that he was preparing baked ziti as per the menu. On 2/15/22, the menu was reviewed which indicated the following items were to be served: Baked Ziti with meat sauce, broccoli florets, garlic breadstick, and cinnamon brown sugar blondie. The alternate meal was listed as: smothered turkey patty, Caesar salad, and mashed potatoes. On 2/15/22, the distribution of meal trays to Residents was observed. 1. Resident #33's meal ticket was noted to read, Baked Ziti with meat sauce, broccoli florets, garlic breadstick, cinnamon brown sugar blondie square, creamy peanut butter & jelly sandwich and fortified mashed potatoes. Resident #33 was observed to not have the garlic breadstick, a regular chocolate brownie was served instead of the cinnamon brown sugar blondie square, and he had not received a creamy peanut butter & jelly sandwich. An interview was conducted and Resident #33 said he usually gets the sandwich at lunch time. Administration Employee D, the registered dietician accompanied Surveyor D to the room of Resident #33, and confirmed Resident #33 had not received the items as noted above. On 2/15/22 during the afternoon, Employee F, the cook was asked why Resident #33 gets a peanut butter and jelly sandwich. Employee F said, I don't know, I just know he gets it every day. Employee F confirmed that he had not prepared Resident #33's peanut butter and jelly sandwich for the noon meal. 2. On 2/15/22, during the lunch meal, Resident #10's tray was observed. Her meal ticket indicated that she was supposed to receive a Caesar salad, which she did not receive. On 2/16/22, an interview was conducted with Resident #10 and she indicated she disliked broccoli. Review of the Resident Council meeting minutes from the meeting held January 31, 2022, revealed Residents reported they were not getting items they were supposed to. On 2/17/22, the Registered Dietician provided Surveyor D with the meal preference form for Resident #10, which indicated a dislike for broccoli. Administrative employee D, the registered dietician confirmed that Resident #10 did not receive the Caesar salad. On 2/17/22 at approximately 1:00 PM, the facility Administrator and Director of Nursing were made aware of the above findings. No additional information was provided prior to the conclusion of the survey.

Based on observation, Resident interview, facility staff interview, and facility documentation review, the facility staff failed to ensure there was a functional system for Residents to call staff for assistance, for one Resident (Resident #33) in a survey sample of 28 Residents. The findings included: On 02/15/22 at 2:56 PM, during an interview with Resident #33, the Resident reported his call bell didn't work and had not for quite some time. Surveyor D engaged the call bell and noted that it did not light the indicator outside of the room. On 2/15/222, during the late afternoon, Surveyor D met with the Maintenance Director and requested a list of all pending maintenance work orders. On 02/16/22 at 8:57 AM, Surveyor D visited Resident #33 in his room. The call bell was pressed/engaged by the surveyor, and was noted to not be working. On 02/16/22 at 8:58 AM, an interview was conducted with RN A. RN A confirmed the call bell is engaged in the room, gives an auditory alarm, lights up out in the hall and has a notification at the desk. RN A further confirmed that call bells are used If the resident needs assistance or a staff member needs assistance in the room as a means to alert staff. On 02/16/22 at 9:04 AM, RN A accompanied Surveyor D to the room of Resident #33. RN A engaged the call bell and confirmed it did not provide any auditory alarm, didn't light up outside of the room and didn't alarm at the nursing station. She said This is one of our renovated rooms, I will put a work order in. RN A confirmed Resident #33 had no other means to call staff for assistance. On 02/16/22 at 9:09 AM, RN A notified the Director of Nursing (DON) of the call bell for Resident #33 not working. The DON said, she was aware of it over the weekend, a work order was in place and maintenance was waiting on parts to make the repairs. On 2/16/22 at approximately 9:12 AM, RN A provided Resident #33 with a hand bell to summons staff if assistance was needed. On 2/16/22 at 11:09 AM, the facility staff provided the survey team with the requested listing of all maintenance work orders for the month of February. Review of this document revealed the only maintenance work order for Resident #33's call bell was entered on 2/16/22. On 2/17/22 at 8:47 AM, Resident #33 was observed sitting in his wheelchair between his bed and the roommate's bed. The hand bell to be used to call for assistance was observed across the room, on the opposite side of his bed on the bed side table out of reach. Resident #33 had no means to summons facility staff if assistance was needed. On 2/17/22 at 9:02 AM, an interview was conducted with the Maintenance Director with regards to Resident #33's call bell. The Maintenance Director stated, The plate on the wall was damaged during the renovation and we are getting a new call bell system mid-March. The maintenance director further indicated that no repairs would be made to Resident #33's call bell until the call bell system is replaced in mid-March and that he was not waiting on parts to make repairs. Review of the facility policy titled, Answering the Call Light was conducted. This policy read, General Guidelines .4. Be sure that the call light is plugged in and functioning at all times .7. Report all defective call lights promptly. Review of the facility policy titled, Maintenance Service was conducted. This policy read, 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . On 2/17/22, at approximately 1:00 PM, the facility Administrator and Director of Nursing were made aware of the above noted findings. No further information was provided prior to the conclusion of the survey.

Based on staff interview, employee record review and facility documentation review, the facility staff failed to operationalize policies and procedures on screening for 12 of 25 new employees in the Employee Records Check Sample. The findings include: 1. For Employees # 8, # 11, # 14, # 19 and # 24, the facility staff failed to ensure a criminal background check was obtained within 30 days of hire. On 2/17/2022 at 8:40 a.m., review of the employee files selected for Employee Records Check was conducted with the Human Resources Manager (Employee F) in her office. Review revealed the following: Employee # 8-Registered Nurse, Director of Nursing- hired 1/15/2020- Criminal Background Check on 7/8/2020 Employee # 11-Certified Nursing Assistant-hired 3/18/2020-Criminal Background Check on 7/8/2020 Employee # 14- Licensed Practical Nurse-hired 1/22/2020-Criminal Background Check on 7/8/2020 Employee # 19- Certified Nursing Assistant-hired 7/3/2019- No Criminal Background Check in employee file Employee # 24- Certified Nursing Assistant-hired 2/15/2020-No Criminal Background Check in employee file On 2/17/2022, an interview was conducted with the Human Resources Manager who stated the corporate office usually obtained all of the required information during the hiring process. The Human Resources Manager stated the Corporate office conducted Criminal Background Checks upon hire but she later learned that those did not meet the requirements. The Human Resources Manager stated she would be sure all future new hires would have Criminal Background Checks within 30 days of hire. On 2/17/2022 at 11:32 a.m., an interview was conducted with the Administrator who stated the Human Resources Manager was hired in 2019. The Administrator stated that audits were done on employee files after they were informed about Sworn Statements being signed before or on the day of hire. The Administrator stated she explained to the Human Resources Manager that criminal background checks must be obtained within 30 days of hire. Review of the Abuse Policy entitled Abuse Prevention Program, Revised May 2017, revealed the following: Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 2. Conduct employee background checks and will not knowingly employ or otherwise engage any who has: a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law On 2/27/2022 at 3:59 p.m. during the end of day debriefing, the facility Administrator was again informed of the findings. The Administrator stated Criminal Background Checks should be conducted on all new hires. The Administrator stated she had no questions about the findings. No further information was provided. 2. The facility staff failed to verify licensure on 2 (Employees # 7 and # 8) of 3 Registered Nurses upon hire and failed to verify licensure for 3 (Employees # 6, # 14, and # 17 ) of 3 Licensed Practical Nurses and failed to verify certification for 3 (Employees # 11, 19, and # 20) of 12 Certified Nursing Assistants. On 2/17/2022 at 8:40 a.m., review of the employee files selected for Employee Records Check was conducted with the Human Resources Manager (Employee F) in her office. Review revealed the following: Employee # 7-Registered Nurse, Assistant Director of Nursing- hired 7/1/2021- No License Verification- no license look up date. There was a copy of a Maryland License which would expire on 8/28/2022. The Maryland License was a Compact State license that had been renewed on 6/23/2020. There was no date indicating the date of look up. Employee # 8-Registered Nurse, Director of Nursing- hired 1/15/2020- License Verification on 12/3/2021 Employee # 11-Certified Nursing Assistant-hired 3/18/2020-License Verification on on 7/8/2020 Employee # 14- Licensed Practical Nurse-hired 1/22/2020-License Verification on 10/6/2021. Employee # 17-Licensed Practical Nurse- hired-12/27/2019- License Verification on 1/7/2020, 2/6/2020 and 6/8/2020. Employee # 19- Certified Nursing Assistant-hired 7/3/2019- License Verification on 2/3/2020. Employee # 20-Certified Nursing Assistant-hired 8/25/2020-License Verification on 7/22/2021. Employee # 8-Registered Nurse, Director of Nursing- hired 1/15/2020- License verification on 12/3/2021. On 2/17/2022 at 10:44 a.m., an interview was conducted with the Human Resources Manager. The Human Resources Manager stated she audited the personnel files and found there were missing License Verification for some employees. The Human Resources Manager stated she had thrown the original license verifications away when the updated or renewed licenses were submitted. The Human Resources Manager stated she did not realize that was not the correct procedure until this surveyor requested the files along with a list of required documents on 2/16/2022. On 2/17/2022 at 11:32 a.m., the Business Office Manager stated Now I understand that the original Licenses cannot be thrown away when the new one is updated. I didn't know that at first. On 2/17/2022 at 11:32 a.m., an interview was conducted with the Administrator who stated the Human Resources Manager was hired in 2019. The Administrator stated she explained to the Human Resources Manager that original licenses must be verified prior to hire or care and maintained in the personnel files. She also stated that copies of verification of renewed licenses must be maintained in the files also. Review of the Abuse Policy entitled Abuse Prevention Program, Revised May 2017, revealed the following: Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 2. Conduct employee background checks and will not knowingly employ or otherwise engage any who has: . c. Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of abuse, neglect, exploitation, misappropriation of property. On 2/17/2022 at 3:59 p.m. during the end of day debriefing, the facility Administrator was again informed of the findings. The Administrator stated she had no questions about the findings. No further information was provided.

Based on observation, Resident interview, staff interview, and facility documentation review, the facility staff failed to prepare the meal in accordance with the menu, which affected 52 of the 57 Residents, residing at the facility during survey. The findings included: On 2/15/22 at approximately 10:30 AM, a tour of the kitchen was conducted. This tour included an interview with the cook, Employee F. Employee F confirmed that he was preparing baked ziti as per the menu. On 2/15/22, the menu was reviewed which indicated the following items were to be served: Baked Ziti with meat sauce, broccoli florets, garlic breadstick, and cinnamon brown sugar blondie. The alternate meal was listed as: smothered turkey patty, Caesar salad, and mashed potatoes. On 2/15/22 at approximately 1:00 PM, the lunch meal tray line was observed by Surveyor D. Employee F, the cook, identified the items prepared as: baked ziti, broccoli florets, brownie and the alternate as a chicken patty and mashed potatoes. The preparation of trays was observed and no Residents were served a garlic break stick nor cinnamon brown sugar blondie. The chicken patty was served without being smothered. Employee F, the cook confirmed that these items had not been prepared as per the menu. On 2/15/22 at approximately 1:30 PM, Surveyor D and the Registered Dietician received and evaluated a test tray the kitchen had prepared. Review of the test tray revealed the garlic breadstick and cinnamon brown sugar blondie were not provided as per the menu. The Registered Dietician confirmed she was not made aware of, nor did she approve, any menu substitutions. Review of the Resident Council meeting minutes from the meeting held January 31, 2022, revealed Residents reported they were not getting items they were supposed to. Included in documents provided to the survey team was a document titled, Action Plan that was signed off on 12/30/21. This document read, Review all orders with the district manager before submitting any order. In the event that any items that have been ordered are currently out of stock, the Manager In Training will need to call the supplier to find a substitution. If at any time there is an item missing from the menu for the daily meal, it needs to be reflected on the tray ticket and on the menu boards through the facility. You will also be required to inform your ED (executive director) during the morning meeting and have a copy of the changes present for them to review. All changes need to be recorded on the Meal Substitution Log A review of the facility policy titled, Menus was conducted. This policy read, .6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or special meal. On 2/16/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above findings. No further information was provided.

Based on observation, Resident interview, staff interview, and in the course of a complaint investigation, the facility staff failed to provide Residents with food at an appetizing temperature for 3 Residents (Resident #21, #33, and #41) in a survey sample of 28 Residents. The findings included: On 2/15/22, during Resident interviews, Residents #41, #33 and #21 reported their hot foods are served cold frequently. On 2/15/22, Surveyor D requested a test tray be prepared during the lunch meal service. On 2/15/22 at 1:58 PM, the last Resident meal tray was delivered to a Resident. Administrative Employee D, the Registered Dietician, then retrieved the test tray from the meal cart and accompanied Surveyor D to a nutrition room on the unit to review the test tray. Both Administrative Employee D and Surveyor D tasted each food item on the tray and both confirmed that the baked ziti was room temperature and was not at an appetizing temperature. On 2/15/22, following the test tray observation, Administrative Employee D stated that she expect foods to be delivered in a manner so that cold foods are cold and hot foods are hot. Review of the Resident Council meeting minutes from the meeting held January 31, 2022, revealed that Resident's reported to facility staff that their food was cold at times. Included in the documents provided to the survey team was a document titled, Action Plan that was signed off on 12/30/21. This document read, .Food Quality (Temperatures). Test trays need to be performed twice a day during. [sic] Check all temperatures for food and beverages before each meal service. Review of the facility policy titled, Meal Distribution: Infection Control Considerations was conducted. This policy read, .3. All food items will be transported promptly for appropriate temperature maintenance. On 2/15/22, during an end of day meeting the facility Administrator was made aware of the findings. No further information was received. Complaint related deficiency.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare and distribute food in accordance with professional standards for food service safety in 4 of 4 food storage and food preparation areas. The findings included: 1. The facility staff failed to store food in a manner consistent with professional standards for food service safety with regard to, labeling and protection from contaminates. On 2/15/22 at 10:30 AM, observations were made in the facility kitchen. The facilities dietary manager was not present during the survey, therefore Surveyor D was accompanied by Administrative Employee D, the registered dietician. In the dry storage room the following items were observed to be opened and not secured in a manner to protect from environmental contaminates: a bag of dry pasta ziti noodles and a bag of elbow macaroni dry pasta. Both bags were open to air, not secured and had no labeling to indicate when they were opened or to be used by. There was also a container of dry cereal that had been transferred out of its original packaging into a clear container with a lid but there was no label to indicate the product's date opened or use by date. There was a rack/tray that contained 7 bowls that had no label. Administrative Employee D opened one of the bowls and indicated it was cereal. There was two bags of hamburger buns that had no labeling to indicate the date received or a date to be used by. Administrative Employee D confirmed the above noted observations. In the walk-in cooler the following items were observed: a container was noted that contained a dark colored substance that was not able to be identified by the surveyor and there was no label to indicate the contents of the container. The registered dietician indicated that it was jelly. Also observed was a container with slices of cheese that the lid was not secured, the cheese was open to air and had no date as to when it was opened or to be used by. During initial tour of the kitchen, the walk-in freezer was not able to be observed due to stock being in the floor of the walk-in cooler. Administrative Employee D, the Registered Dietician stated they had just received their truck and were in the process of putting stock away. In the stand-alone cooler there was a container that was labeled as cranberry concentrate that was open to air. The Registered dietician acknowledged all of the above noted observations and stated that it was of concern to her as well. The Dietician stated, I will tell the staff about it, everybody is trying to do a little to help out and I come in and check when I am here. There is a regional person coming in to help with ordering. It is very important that we label items so we know when they came in, so we aren't giving Residents soiled products. On 02/15/22 at 1:05 PM, upon Surveyor D's return to the kitchen for further inspection, Other Employee C was introduced. Other Employee C was the former dietary manager and is currently a Regional Dietary manager in training. Additional observations were made within the facility which included the dry storage area. The ziti noodles bag was observed to be tied but contained no label. The elbow macaroni was noted to be open to air without a label. A box was noted on the shelf which contained a bag of thickener, which was open to air, the box was dated 2/1/22 as a date received but no date as to when the product was opened was noted. On 02/15/22 at 1:09 PM, while accompanied by Other Employee C, Surveyor D observed the sliced cheese in walk-in cooler, the lid was not secured, leaving the cheese open to air and there was no dating present. A container of unidentified substance, previously identified as jelly was noted with no label, the top to the container was observed to be cracked, which permitted the contents to be subjected to environmental containments. On 2/15/22 at 1:11 PM, the walk-in freezer was observed a case of hamburger patties was noted to be open, the bag containing the hamburger patties was open, not secured, leaving the product open to air. On 02/16/22 at 08:45 AM, a follow-up visit to the kitchen was made by Surveyor D. Other Employee D, the Regional Dietary Manager was present and accompanied Surveyor D. In the stand alone cooler 27 bowls of coleslaw was noted without any labeling as to when the product was made, put in the cooler or to be used by. Other Employee D confirmed the observations and stated We label items so we know when it was made and when it needs to be discarded. On 02/16/22 at 08:46 AM, observations of the walk-in cooler revealed 8 individual bowls of mandarin oranges that contained no label as to when they were prepared/put in bowls or when they were to be used by. The sliced cheese was still noted to not have any label. Other Employee D confirmed the observations. Review of the facility policy titled, Receiving was conducted. This policy read, .5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation . The policy titled, Food Storage: Dry Goods was received and reviewed. This policy read, .5. All packaged and canned food items will be kept clean, dry, and properly sealed . The facility policy titled, Food Storage: Cold Foods was reviewed and it read, .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. According to ServSafe Fourth Edition manual page 7-3 read, When food is stored improperly and not used in a timely manner, quality and safety suffer. Poor storage practices can cause food to spoil quickly with potentially serious results. General Storage Guidelines: Label food. All potentially hazardous, ready-to-eat food prepared onsite that has been held for longer than twenty-four hours must be properly labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Page 7-4 stated, Discard food that has passed the manufacturer's expiration date. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-302.12, pages 73-74 stated: Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food service establishment, shall be identified with the common name of the food. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-302.15, page 64 stated: Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-305.11 Food Storage .D. A date marking system that meets the criteria .(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded . Section 3-501.17 Ready-to-eat, Time/temperature control for safety food, date marking read, (A) .refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises . On 2/15/22 and on 2/17/21, during end of day meetings the facility Administrator was made aware of the findings. No further information was provided. 2. The facility staff failed to maintain handwashing facilities in the kitchen for food service staff to wash their hands prior to the handling of food. On 2/15/22 at approximately 10:15 AM, Surveyor D presented to the kitchen. Surveyor D was accompanied by Administrative Employee D, the registered dietician. Surveyor D approached the hand washing sink and identified there was no running water at the sink. Administrative Employee D then directed Surveyor D to another hand washing sink located on the opposite side of the kitchen. Surveyor D then performed hand hygiene and determined there were no paper towels to dry her hands. Administrative Employee D had to retrieve paper towels for Surveyor D to be able to dry her hands prior to conducting the kitchen inspection. The Registered Dietician (RD) stated that she was not aware of why there was not running water at the first sink and why the second sink was not stocked with supplies. The RD stated that all food service employees are to wash their hands prior to and between food service activities. No further information was provided. 3. The facility staff failed to maintain a sanitizer solution to sanitize food service equipment and work surfaces. On 2/15/22 at approximately 12:50 PM, Surveyor D asked Other Employee C, the former dietary manager and regional dietary manager in training to test the sanitation buckets distributed throughout the kitchen. Other Employee C used chemical test strips and tested 6 sanitation buckets distributed throughout the kitchen. Each of the buckets tested at 0 ppm (parts per million) of sanitizer being present. Other Employee C went to the 3 compartment sink and used the sanitizer distribution system to fill one of the sanitizer buckets and again it tested at 0 ppm. The same test strips were used to test the dish machine water and it did test appropriately. Other Employee C stated, the buckets are changed out every 2-3 hours and they use Quat Sanitizer. Other Employee C said, Something is wrong with the sanitizer at the sink, I will make sure to put this in as a work order. On 2/15/22 at 1:09 PM, an interview was conducted with Other Employee E, the cook. The cook confirmed that the sanitizer buckets are used to wipe down all of the kitchen/food preparation surfaces and it was critical that they be sanitized properly. Included in the documents submitted to the survey team was a document titled, Action Plan. This document read, .Labeling and Dating: Manager in Training must perform a thorough walk thru of the kitchen using the pocket process and also needs to submit pictures of the following daily before 8:30 am. Walk-in cooler and refrigerator, reach-in refrigerator, dry storage and nourishment room. All labels need to be facing forward and easy to read for the District Manger to review. The facility policy titled Environment was received and reviewed. This policy read, 1. The dining services Director will ensure that the kitchen is maintained in a clean and sanitary manner .2. The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces . According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-304.14, page 77 stated: cloths in-use for wiping counters and other equipment surfaces shall be: held between uses in a chemical sanitizer solution at a concentration specified under 4-501.114 On 2/15/22 and on 2/17/22, the facility Administrator was made aware of the findings. No further information was provided.

Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to maintain an infection control program in accordance with the Centers for Disease Control and Prevention (CDC) to prevent the spread of COVID-19 within the facility on 3 of 3 Resident halls within the facility. The findings included: 1. The facility staff failed to wear appropriate personal protective equipment (PPE) while providing care to a Resident (Resident #21) who was on quarantine for a COVID-19 exposure. On 2/15/22 at approximately 10:05 AM, Surveyor D observed CNA B enter the room of Resident #21. Prior to entering CNA B donned [put on] an isolation gown, face shield and gloves. CNA B was already wearing a procedure mask. There was a sign on the door that read, Special droplet contact precautions and indicated staff were to put on an N-95 mask, eye protection, isolation gown and gloves prior to entering the room. Upon exit, CNA B was interviewed and stated, I apologize, and I didn't put my N-95 on. On 2/15/22 at approximately 5 PM, Resident #21 was interviewed in her room. Resident #21 indicated she had previously had COVID-19 and recovered but had recently had an exposure and indicated that was the reason staff and her spouse wear On 2/15/22, a clinical record review was conducted and revealed that Resident #21 was on droplet precautions/isolation for a COVID-19 exposure. A review was conducted of the facility policy titled, Transmission Precautions for Patients and Donning and Doffing Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 which had a revision date of September 2021. This policy read, .PPE must be donned correctly before entering the patient care area (e.g., isolation room, cohort) .Special Droplet/Contact Precautions .3. Wear NIOSH-approved N95 or equivalent or higher-level respirator . On 2/15/22, during an end of day meeting, the facility Administrator was made aware of the findings. No further information was provided. 2. The facility staff failed to wear eye protection when providing direct Resident care, while the facility was located in an area of high COVID-19 transmission and in an active COVID-19 outbreak as per the guidance from CDC [Centers for Disease Control and Prevention]. Prior to the survey team's entry to the facility the CDC COVID Data Tracker was reviewed and it noted the facility was located in an area with a high level of community transmission for COVID-19. Accessed online at: https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=Virginia&data-type=Risk&list_select_county=51193 On 2/15/22 at 10:00 AM, upon the survey team's arrival to the facility, a sign was observed on the front door, which noted that the facility was in a current COVID-19 outbreak status. On 2/15/22 at approximately 10:05 AM, the facility Administrator confirmed that the facility was in a COVID-19 outbreak and currently had Residents on quarantine for COVID-19. Review of the Virginia Department of Health's COVID-19 data revealed the facility is located within an area with a high level of community transmission. On 2/15/22 from 10:05 AM, a tour of the facility was conducted of the kitchen and all Resident care/nursing halls by Surveyors C and D through 11 AM. Observations showed LPN C, LPN E, and LPN F going into Resident rooms and passing medications without any eye protection on. On 02/15/22 at 1:33 PM, Other Employee B was observed on the nursing unit distributing eye goggles to staff. When asked why she was doing this she replied, [Director of Nursing name redacted] told me to give one to everybody. Review of the facility policy titled, CDC Guidance- Personal Protective Equipment with a revision date of September 2021 read, .Eye protection should be worn during all patient care encounters when the facility's county transmission rate is substantial or high. The CDC guidance document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, with a revision date of Feb. 2, 2022, was reviewed. This document read, Implement Universal Use of Personal Protective Equipment for HCP [health care personnel] .Additionally, HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html On 2/17/22 at approximately 1:00 PM, the facility Administrator and Director of Nursing were made aware of the findings. No further information was provided. 3. The facility staff failed to wear appropriate PPE while providing care to a Resident (Resident #33) who was not fully vaccinated against COVID-19. On 2/15/22, the facility submitted a document indicating the vaccination status of each Resident. Resident #33 was noted on this document as having received only 1 dose of the COVID-19 Pfizer multi-dose vaccine. On 2/16/22 at approximately 9:00 AM, Resident #33 was observed in the dining room eating breakfast. Other Residents were also present and all of them were socially distanced. On 2/16/22, a clinical record review was conducted for Resident #33. This review revealed that Resident #33 had only received one dose of a multi-dose vaccination series for COVID-19. There was a nursing note dated 2/1/22, that was entered into the clinical record by the DON (Director of Nursing) that read, Resident has given permission for COVID 2nd vaccine but is unable to receive for 30 days after having COVID per Pharmacist [name and pharmacy name redacted]. Resident is aware and in agreement. On 2/17/22 at 8:45 AM, CNA F and CNA B were observed entering Resident #33's room wearing only a procedure mask and eye protection. On 2/17/22 at 8:50 AM, an interview was conducted with the DON, who is also the facility's infection preventionist. The DON confirmed that Resident #33 is not fully vaccinated for COVID-19. When asked what precautions are put in place for a Resident who is not fully vaccinated she indicated that if they come out of their room to common areas then everyone has to wear a mask, such as group activities. The DON was asked if any additional PPE had to be utilized when caring for Residents who are not fully vaccinated and she stated no. On 2/17/22 at approximately 8:55 AM, the DON confirmed that the facility follows all guidance from CDC with regards to COVID-19 response and mitigation. She was shown the CDC guidance document titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes which indicated that Residents who are not fully vaccinated should be cared for using full PPE. The DON stated, We don't wear an N95 if they are not on quarantine, I didn't know. On 2/17/22 at 10 AM, an interview was conducted with CNA D, who confirmed she was assigned to Resident #33. CNA D confirmed she had provided direct Resident care to Resident #33 which included personal hygiene and transfer to the wheelchair and had only worn a procedure mask. CNA D stated she was not aware of any additional PPE being needed/required since there was no signage on the door and not PPE located outside of the room. On 2/17/22 at 10:08 AM, the DON approached Surveyor D and stated, everyone has been educated [referring to the need to wear PPE when Residents are not fully vaccinated] and I have talked with him [referring to Resident #33] and let him know why. On 2/17/22 at 10:15 AM, CNA F was observed to enter the room of Resident #33 wearing a KN95 and eye protection. She did not don [put on] an isolation gown or gloves prior to entry. Review of the facility policy titled, CDC- Guidance- New Infection in Healthcare Personnel or Resident with a revision date of February 2022, was conducted. This policy read, .Residents and HCP who are not up to date with all recommended COVID-19 vaccine doses: These residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher level respirator, eye protection (goggles or a face shield that covers the front and side of the face), gloves and gown. They should not participate in group activities . Review of the CDC guidance document titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated Feb. 2, 2022, was conducted. This document read, New Infection in Healthcare Personnel or Residents Residents and HCP who are not up to date with all recommended COVID-19 vaccine doses: · These residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. They should not participate in group activities Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631030997450 On 2/17/22 at 1:00 PM, the facility Administrator and Director of Nursing were made aware of the findings. No additional 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 notify the physician of an unavailable diabetic management medication. For Resident #52, the facility staff failed to notify the physician of an unavailable diabetic management medication (Bydureon BCise auto-injector/insulin), resulting in the resident receiving the medication in 14 days, instead of 7 days, as per the signed physician order. The Findings included: Resident #52 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #52's diagnoses included: Diabetes Mellitus Type Two, Hyperlipidemia, Dementia, Seizure Disorder, Traumatic Brain Injury, Anxiety Disorder, and Post Traumatic Stress Disorder. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 1/15/19, was reviewed. It coded Resident #52 as having a Brief Interview of Mental Status Score of 2, indicating severe cognitive impairment. On 2/6/19 at 9:00 A.M., an observation was conducted of Resident #52 asleep in his bed. He was clean and dressed appropriately. On 2/6/19 a review was conducted of Resident #52's clinical record, revealing the following signed physician order, Bydureon Injection 2 MG. subcutaneously one time a day every week on Monday. The Medication Administration Record for January, 2019 was reviewed. On Monday, 1/28/19 11:53 A.M. it read, Not Administered Drug item unavailable. In addition, Resident #52's nursing progress notes were reviewed. There was no documentation of the physician being notified that the medication was unavailable, or that the facility staff decided to allow Resident #52 to go without his medication for an extra week, for a total of 14 days between doses. On 02/06/19 at 4:53 P.M., an interview was conducted with Resident #52's Registered Nurse (Employee C). She stated, It was delivered on the night of the 1/24/19. He didn't get the dose that morning we decided to wait until the following Monday to give it to him. She further stated that she could not find any documentation that the doctor had been notified. On 2/6/19 at 5:00 P.M. the facility Administrator (Employee A) was notified of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation and clinical record review the facility failed to provide a Medicaid/ Medicare Coverage Liability Notice for 1 Resident (Resident # 40) in a survey sample of 27 Residents. For Resident #4 the facility failed to provide Resident with a Medicaid/ Medicare Coverage Liability Notice prior to discharge. The findings include: Resident #40 a [AGE] year old woman was admitted to the facility with diagnoses of but not limited to Diabetes, Dementia, Atrial Fibrillation, Fracture of Femur, and (Urinary Tract Infection) UTI. Resident #40 had a (Brief Interview of Mental Status) BIMS score of 2 indicating severe cognitive impairment. She required physical assistance of 1 person with all aspects of (Activities of Daily Living) ADL care. On 02/07/2019 during the completion of facility tasks, the Administrator submitted the Medicaid/ Medicare Coverage Liability Notices and it was noted that one of the documents was not completed. On 02/07/2019, an interview was conducted with the Administrator who stated the prior Social Worker did not provide a notice to Resident #40. When asked what is the significance of the document she stated, This document lets the Resident and family know what their responsibility is pertaining to payment of the bill and what Medicare or Medicaid will cover. If we do not provide the letter to the family they will not know what their responsibility is. On 02/07/2019 during the end of day conference, the Administrator was notified and no new information was provided. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #39 the facility failed to ensure freedom from verbal abuse by a staff member and being undressed and held down and made to shower after having refused on several occasions. Resident #39 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Fracture of Femur, Dementia without behavioral disturbance, Arthritis and long term use of anticoagulants. Resident #39's last (Minimum Data Set) MDS coded as having a (Brief Interview of Mental Status) BIMS score of 99 indicating severe cognitive impairment. On [DATE] the facility provided their investigation of a complaint involving Resident #39. The complaint alleged the resident was physically abused by staff, forced to undress against her will and forced to shower against her will. The documents included witness statements made at the time of the incident. The facility submitted a file of documents from their investigation into the incident on [DATE]; included was a statement from CNA A stating [Resident #39 name] Shower day she didn't want. [CNA Names] took her in. [ADON name] said try later. [LPN A Name] was holding her down [Resident name] started kicking and hitting [LPN A name] said she stinks. When CNA A was asked what the usual practice is for Residents who refuse care she stated we usually try again later and we had approached her a couple of times and she refused. She went on to say we usually notify the nurse and document in the care notes if we cannot get them to shower. On [DATE] at 2:50 PM, CNA B was interviewed about incident. CNA B Stated It was a while ago but I remember we took her to the shower room it was her shower day and when she got combative CNA B said get the nurse. She became combative with the nurse also and she helped get her clothes off. She further stated the Resident got calmer after they got her showered, but then she was not like herself she went in her room and was sitting on the side of the bed limp, flaccid On [DATE] at 3:10 PM, an interview was conducted with LPN A who stated CNA B came to her and asked her to come to the shower and assist with Resident #39. She stated she went into the shower room and that Resident #39 was combative with the CNAs and that she tried to get her calmed down but she was still being combative. She stated that she ripped the incontinent briefs to get them off. She stated she got her clothes off while the resident was still being combative. She said that she Held her arms apart so she couldn't hit. After she was undressed she left the shower room. LPN A also stated Resident #39 has Dementia really bad and gets physical a lot when it's involving care or bathing. She also stated that the 2 CNAs reported her for abuse for helping get her undressed and blocking her arms from hitting them. She stated that she was suspended until they did the investigation and then she came back to work and is currently still supervising the two CNAs. She stated she was given no additional training or education upon return. CNA A was on leave of absence so a telephone interview was conducted on [DATE] at 5:15 PM. CNA A stated that Resident #39 didn't want to get a shower she was refusing and they reproached her a few times and CNA B asked LPN A to come to shower room. LPN A starting taking off her clothing even though she refused. She stated she needs a shower she stinks. CNA B stated this is her usual behavior when she gets a shower. She doesn't like to get undressed or get a shower. She stated after the shower she went to her room and was not acting like herself she was looking sad. Among the investigation documents provided by the facility was a Typed Statement without a name outlining the events and noting that the Residents family was made aware and they stated she has a history of not liking to bathe. In addition, the document stated APS came to the facility on [DATE] and they reviewed the records and attempted to interview the Resident however due to the cognitive status interview was unsuccessful. The document states that on [DATE] the resident had a fall in the evening. Then on [DATE] the resident was experiencing pain all over and did not get out of bed or eat any of her meals. It states it was Unclear if this is a change related to the fall or the incident in this shower. The same document has handwritten notes as follows: 1. Resident was reluctant to go to shower room. 2. Resident was tearful / crying once in the shower room. 3. Resident was told by primary nurse that she Stinks and needed a shower 4. Residents clothes were removed without consent by nurse, resident was combative while clothing was removed. 5. Resident was withdrawn after the shower. Also in included were progress notes dated [DATE] at 2:26 PM stating Bruise found on top of the right hand. Red blue in color. Self-inflicted due to fighting and hitting upon going to the bathroom or changing clothes RP notified and aware of situation MD notified. This note signed by LPN A Another progress note attached dated [DATE] stated Resident very combative during care, resident threw her shoe at staff and books. Staff left the room and went back a few minutes later and attempted to do care again resident was resistant but staff got it done. A review of Resident #39's care plan shows that behaviors during ADL Care and showering were not addressed until [DATE] even though according to staff interview and progress notes the Resident has had behaviors related to ADL care since admission. The Facility was asked if they had an Abuse Policy which they submitted to the team for review. The document entitled Abuse - Training Employees about Abuse Dated [DATE] was reviewed and found that according to the facility Policy: 'Mental Abuse' means but is not limited to, humiliation, harassment, threat of punishment Page 6 states: Facility Staff Will NOT: 1. Use verbal mental sexual or physical abuse corporal punishment or involuntary seclusion in caring for and in any interaction with residents. 2. Impose PHYSICAL or CHEMICAL Restraints for purposes of discipline or convenience. If and when the use of restraints is indicated to treat a residents' medical symptoms. Facility staff shall use the least restrictive alternative for the least amount of time and shall document ongoing re-evaluation of need for the restraint. Review of clinical record and Physicians Order sheets revealed no evidence of a physician's order to physically restrain or hold resident down to give shower. On [DATE] the Administrator was interviewed about the investigation and she stated It was before my time I have only been here a few months. The Acting DON (Employee B) also stated she was not present at the time of the incident. No further information was provided. Based on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation the facility staff failed to protect two Residents from abuse (Residents #13, and #39) in a survey sample of 27 residents. 1a and 1b. Resident #3 (male) willfully assaulted Resident #13 (female) on at least 2 occasions. The victim was not protected from her attacker. 2. For Resident #39 the facility failed to ensure freedom from verbal abuse by staff member and being undressed and held down and made to shower after having refused on several occasions. The findings included: 1a. Resident #13 was a female initially admitted to the facility on [DATE], with diagnoses including but not limited to; Dementia, cognitive communication deficit, hip pain, edema, dysphagia, folate deficiency anemia. The Resident was a Full Code status, meaning that CPR was requested to be performed as needed. The Resident was ambulatory and a known wanderer, with orders for a wanderguard bracelet to monitor the potential for elopement. The most recent Minimum Data Set Assessment (MDS) with an ARD (assessment reference date) of 11-17-18 coded Resident #13 as having a BIMS (brief interview of mental status) of severely cognitively impaired. Resident #13 was coded as needing limited to extensive assistance with ADL's (activities of daily living) such as bathing and dressing from 1 staff member, and for eating required only supervision and set up help. The Resident was ambulatory, and exhibited no negative behaviors. Review of the nursing progress notes revealed the Resident to be documented as docile, pleasant, and easily redirected, with wandering as her only behavior. The Resident liked to push residents wheel chairs to the dining room, and this habit was known by staff. The Nursing progress notes were reviewed from 7-1-18 through the time of survey, for a 7 month period, and no notes indicate any behaviors for this Resident. Bruises were documented in the nursing notes to be observed on the Resident by nursing staff on; 1-23-19, 9-26-18, 9-5-18, and 7-12-18. There is no report to the state agency for these injuries, nor is there any indication that any investigations were conducted to ascertain the cause of the bruises. The Administrator was asked for all investigations in the past year for this Resident, and the 7-31-18, and 9-4-18 incidents of abuse by Resident #3 were submitted, as the Administrator stated this is all we have for her. Two incidents of assault were documented as having occurred to this Resident, perpetrated by Resident #3. These occurred on 7-31-18, and again on 9-4-18. The first assault was reported to the state agency on 8-1-18, with a follow up report on 8-7-18, and both were timely. The second assault was reported to the state agency on 9-10-18, with a follow up on 9-12-18, and both were late reports. A synopsis of those events follow from the Nursing progress notes of the assailant Resident #3, as no description of the assaults were in the nursing notes of the victim Resident #13, and from the facility reported document, and a complaint that was received by the state agency regarding Resident #3: 7-31-18 Incident 4:54 p.m. The MD (doctor) observed Resident (#3) pull the leg of another Resident (#13) resulting in a fall . The Facility report to the state agency documented that Resident (#13) attempted to push Resident #3's wheel chair toward the dining room, Resident #3 was cursing at Resident #13 prior to grabbing her leg and making her fall. The report goes on to say that Resident #3 has a diagnosis of aggression toward others, and has verbal outbursts cursing staff and residents, and has episodic periods of aggression, in which he has kicked staff and shoved one resident's wheel chair into another resident. The conclusion of the facility in the report was; Resident #3 (name) acted in an aggressive manner. The report stated that the social services director has begun to attempt to identify alternate living arrangements for Resident #3 in the event his behaviors place others at danger, and Nursing staff will attempt to keep Resident #3 (name) and Resident #13 (name) separated. On 9-4-19, an incident at 8:00 p.m. was documented in the facility report as Resident #13 (name) was walking down the hall, and Resident #3 (name) grabbed her left arm twisting it in an aggressive manner while cursing at her. her wrist was red at the time.The next day a bruise was noted on Resident #13's wrist, and she was sent to the emergency room for evaluation, and returned with only the bruising diagnosis. Resident #3 was quoted as saying She was in his way, and he was trying to move her. The document goes on to say again as the 8-1-18 report stated that the admissions director has been exploring alternative living arrangement for Resident #3 should aggressive behaviors continue. Also, the report states as the previous report of 8-1-18 did, that nursing staff would attempt to keep Resident #13, and Resident #3 separated by redirecting residents away from each other while they are in common areas, and intervene as necessary. The notes indicate continued willful acts on the part of Resident #3, and the fact that Resident #13 is freely wandering with no supervision after 2 assaults by the same Resident, is a deficient practice on the part of the facility who continue to fail to protect Resident #13 from her attacker. Review of Resident #13's plan of care was conducted and revealed the interventions below for Behaviors: Interventions included; Out of room diversional activities - none were specified, instituted 9-1-16, give task, folding towels or organizing papers, instituted 8-30-17, redirect as needed, need not described, instituted 8-30-17, monitor where abouts frequently, not measurable, instituted 9-7-18, relocate when in common areas, no relocation alternative given, instituted 9-7-18, offer doll, instituted 11-26-18, give cart to push as substitute for wheel chair for her safety and others, instituted 1-23-19. Resident #13 was observed multiple times during the day, and on all 3 days of survey, and at no time were any of these interventions observed to be used. The only time supervision was observed, was when staff found Resident #13, where ever she was in the facility, took her hand, and lead her to the dining room at meal time. Only one Psychiatric consult was found and provided for 2018, dated 1-30-18. The note stated the Resident was stable with no concerns from staff, and received no psychotropic medications. At the time of survey the Resident only received 2 medications daily, Lasix, and senna, with tylenol given as needed for pain. The facility policy and procedure for abuse was reviewed and revealed that Residents would be protected from abuse, allegations of abuse would be investigated and reported timely according to federal and state law, and that they would identify, correct and intervene in situations in which abuse is likely to occur. During group resident council meeting, held with surveyors on 2-6-18 at 2:00 p.m., 9 out of the 13 residents who attended the meeting stated that residents who wander in the facility are a problem. They went on to share incidents of finding this Resident as well as others rummaging through their personal belongings at times, and waking up to find this resident and other residents entering their rooms at night while they are in bed, which was startling to them. No supervision was quantifiable nor measurable in the care plan for this Resident. Who will supervise, when to supervise, and how to supervise this Resident, were not included and were not person centered. This oversight indicated staff was unaware of this Resident's specific needs and how to meet them. In conclusion, the facility failed to maintain adequate supervision of Resident #13, and #3, resulting in at least one known repeated assault by Resident #3. The facility further failed to protect her from abuse, failed to investigate and report timely an allegation of abuse, and failed to operationalize their abuse policies for these three areas. On 2-6-19, and 2-7-19, at the end of day debrief, the facility failure was reviewed with the Administrator, and the Corporate Registered Nurse/ interim Director Of Nursing. No further information was provided by them. 1b. Resident #3 was admitted to the facility on [DATE]. Diagnoses included; mood affective disorder, diabetes, depression single episode, dementia with behavioral disturbance, hypertension and vascular disease. Resident #3's most recent Minimum Data Set Assessment was a quarterly assessment with an assessment reference date of 11-1-18. He was coded with a Brief Interview of Mental Status score of 7, or moderate cognitive impairment. He required only supervision and set up help from staff for all activities of daily living (ADLs), and ambulated independently with a wheel chair. The Resident was coded as Verbal behaviors directed at others 4-6 days out of 7 days. Resident #3 was observed multiple times during the three days of survey independently wheeling himself in unattended hallways, and common areas where Residents were present. Likewise Resident #13 was observed in common areas unsupervised. Resident #3 did not engage with surveyors, but watched cautiously each time they approached him, and gave only short answers when spoken to, then turned and left the area each time. The Resident was found to be appropriate in his answers and oriented. The Resident did not smile as he was greeted with a smile. Review of Resident #3's psychiatric evaluation for the last year revealed 2 visits. They were on 10-2-18, and 10-16-18. The 10-2-18 visit described the assault which occurred to Resident #13 on 9-4-18, and described the grabbing and twisting of Resident #13's arm, while cursing at Resident #13. The document further describes him standing up, from his wheel chair, when confronted by staff and posturing to fight the female nurses while yelling at them. The follow up visit on 10-16-18 shows nothing further. Neither of the notes indicate the psychiatric nurse practitioner was aware of the previous incident with Resident #13 on 7-31-18. Review of social work notes revealed that on 8-7-18 there was an altercation in the activity room with another resident. On 9-5-18, the social work professional documented Resident is a safety risk for this environment due to the random outbursts of aggression and the safety risk for staff and other residents. Review of Nursing progress notes revealed the following incidents of Resident #3's aggressive and abusive behavior in reverse chronological order; 1-28-19 the Resident continues to have behavior issues to include kicking out room mate, and verbal. 1-22-19 This trailer is mine, and my girlfriend comes here, you don't live here! (yelling at room mate) 12-22-18 Resident going into dining room, another resident in front of him moving too slow, Resident #3 pushed the resident hard into a table and Resident #3 had to be pushed in his wheel chair away from the resident due to verbal anger. 10-28-18 Resident #3 became impatient for other residents to enter the dining room in wheel chairs which caused him to have to wait, he yelled move the old B ch out of the way, and a second resident tried to calm him and Resident #3 threatened to hit her, and swung his arm out without making contact. 10-28-18 Resident #3 and a second resident (Resident #3's girlfriend) blocked the door to the TV room and would not allow a third resident to leave the room, Resident #3 yelled out that. he was not going to move, he was waiting for dinner, and the third resident would have to wait to leave the room. 9-4-18 assault on Resident #13, and nursing documented that Resident #3's behaviors seemed to be escalating. 8-14-18 refusing care and cursing at staff. 8-8-18 Altercation spoken of by social worker. 7-31-18 assault on Resident #13. 7-27-18 Resident #3 Shoved another Resident into a third resident upsetting several residents causing an argument between Resident #3 and a fourth resident who witnessed the incident. 7-18-18 Resident observed in dining room cursing and yelling at residents. 6-15-18 yelling at room mate & verbally aggressive. This entails 8 months of continued verbal and physical abuse aimed at multiple residents in the facility. A review of Resident #3's comprehensive care plan included interventions for behaviors. Those include as follows: Monitor for adverse signs of psyche med use - instituted 10-8-18, psyche nurse practitioner to evaluate and treat as necessary instituted 10-8-18, allow to vent feelings instituted 9-7-18, establish trusting relationship and allow time to speak and make choice, maintain calm environment, use soft voice, be welcoming instituted 9-7-18, assist to dining room, redirect if encounter conflict, help problem solve, distract instituted 12-24-18, monitor resident when out of room watching for aggressive physical or verbal behaviors towards other residents should resident exhibit aggressive behaviors remove other resident involved and 1:1 redirection may be provided instituted 9-5-18, monitor resident routinely while in common areas redirect resident to his room should he exhibit aggressive behavior instituted 8-1-18, remove self from harmful behavior exhibited by resident and attempt to perform activity at another time instituted 5-28-18, redirect with therapy or activity of choice if he becomes verbally aggressive instituted 2-27-18, assess record effectiveness of psyche drug treatment instituted 1-11-18. This Resident has been known by the facility as verbally and physically abusive to other residents for a period greater than one year as per the clinical record, On 2-6-19 at 3:30 p.m., a CNA in the hallway by Resident #3's room was asked if the Resident was difficult to care for, she stated, He is pretty mean, and scary at times, and if you don't give him what he wants immediately he gets mad and goes off. On 2-6-19, and 2-7-19, at the end of day debrief, the facility failure to protect the residents from the continued abuse of Resident #3 was reviewed with the Administrator, and the Corporate Registered Nurse/ interim Director Of Nursing. No further information was provided by them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, and in the course of a complaint investigation, the facility staff failed to operationalize the abuse policy to include documentation of training after investigation of injuries of unknown origin for 1 residents (Resident # 55) in a survey sample of 27 residents. 1. For Resident # 55, the facility staff failed to report train the staff regarding proper transfers after investigation of an injury of unknown origin revealed a staff member used improper transfer resulting in fracture of her right ankle. The findings included: Resident # 55 was a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses of but not limited to: Dementia, Hypertension, Deep Vein Thrombosis, and age-related Osteoporosis. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of [DATE]. The MDS coded Resident # 55 with severe cognitive impairment; Resident # 55 was coded as requiring extensive assistance of 1 staff person with Activities of Daily Living including transfer and bed mobility except required total assistance of one staff person for bathing; always incontinent of bowel and bladder. Resident # 55 was coded as not steady, only able to stabilize with staff assistance for moving from seated to standing position and surface to surface transfer. On [DATE] and [DATE], review of the clinical record was conducted. Review of the Nurses Progress Notes revealed: [DATE] at 5:40 AM Writer received fax results at 4:50 am with Impression Results reading: 1) There is a fracture through the lateral, medial as well as anterior malleolus. 2) Moderate soft tissue swelling and plantar calcaneal spur. 3) Diffuse Ostopenia (sic) Dr___paged @ 04:55 am- spoke with __. Notified DON (Director of Nursing) of results at 04:56- MD returned call to facility @ 5:00 with new order to send resident to ____ (Hospital) ER Emergency Room- notified RP. [DATE] at 6:22 AM_____(Transport) arrived to facility now with 2 attendants-report given and all paperwork and copy of DNR (Do Not Resuscitate) given to attendants -resident exiting facility via stretcher in stable condition. [DATE] 3:33 PM- Resident arrived via ambulance via stretcher with diagnosis of fracture rt (right) leg/ankle, has soft cast on rt leg. Review of the Mobile X-Ray of the Right Ankle 3- View results dated [DATE] revealed impression: Fracture through the lateral, medial and anterior malleolus. Review of the Final Report of the FRI (Facility Reported Incident) revealed documentation of a Summary of Interviews reporting one CNA (Certified Nursing Assistant)-G stated on [DATE] at approximately 1445 (2:45 PM) she assisted Resident # 55 to her bed from her wheelchair by sitting her forward in her wheelchair, placing her arms under resident's arm pits and pulling resident up; she then took a step back while resident was standing, turned and sat resident on the bed; she than (sic) lifted Resident's legs and placed them into the bed, enduring that Resident was positioned securely. (CNA-G) does not recall the exact positioning of resident's feet during the transfer and stated that nothing out the ordinary occurred. The Conclusion of the FRI stated Resident # 55 has a suspected right ankle fracture. It may have occurred while being transferred at some point in the later part of the day on [DATE]. The last transfer to occur prior to the bruising being observed to the ankle was at about 1500 (3:00 PM) when she was helped from her wheelchair to her bed. Resident ____does have a history of osteoarthritis and osteopenia, placing her at significant risk for musculoskeletal injury to include bone fractures. It is also known that resident has had multiple fractures in the past, including a previous fracture to the ankle in question. No evidence was found to indicate that ____(Resident # 55's) suspected ankle fracture was due to abuse or mistreatment. Disposition: Refresher training will be provided to all nursing staff regarding proper body mechanics and transferring residents. This will be completed on [DATE]. ______ (CNA_G) will receive corrective action for failure to adhere to the transfer directions for ___(Resident # 55) set forth in her care plan. Resident # 55 will be evaluated by physical therapy department during transfers and recommendations based on their observation will be put into place. Investigation completed [DATE] by (former Administrator) and (former Director of Nursing) Review of Resident # 55's Care Plan revealed documentation of Problem start date: [DATE]- resident requires assistance with Activities of Daily Living due to impaired mobility, cognitive impairments related to dementia. Edited: [DATE] Goal: Resident will have all of her daily needs met with staff assistance thru (through) next review Approach Start Date: [DATE] transfer with 2 person staff assist and gait belt Evaluation notes: [DATE] care plan evaluated and remains appropriate On [DATE], during the end of day debrief, the Administrator and DON were informed of the staff's failure to provide training to all nursing staff regarding proper body mechanics and transferring residents by [DATE] as stated in the Final FRI investigation. Review of training records revealed no documentation of any training to all nursing staff regarding proper body mechanics and transferring residents since the incident in [DATE]. No further information was provided. Based on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation the facility staff failed to implement and operationalize their abuse policies to protect by not investigating timely, and reporting to the state agency timely, an allegation of abuse for Resident #13 in a survey sample of 27 residents. Resident #3 (male) willfully assaulted Resident #13 (female) on 9-4-18 and the abuse investigation and reporting were not completed timely according to the facilities policies and procedures. The findings included: Resident #13 was a female initially admitted to the facility on [DATE], with diagnoses including but not limited to; Dementia, cognitive communication deficit, hip pain, edema, dysphagia, folate deficiency anemia. The Resident was a Full Code status, meaning that CPR was requested to be performed as needed. The Resident was ambulatory and a known wanderer, with orders for a wanderguard bracelet to monitor the potential for elopement. The most recent Minimum Data Set Assessment (MDS) with an ARD (assessment reference date) of 11-17-18 coded Resident #13 as having a BIMS (brief interview of mental status) of severely cognitively impaired. Resident #13 was coded as needing limited to extensive assistance with ADL's (activities of daily living) such as bathing and dressing from 1 staff member, and for eating required only supervision and set up help. The Resident was ambulatory, and exhibited no negative behaviors. Review of the nursing progress notes revealed the Resident to be documented as docile, pleasant, and easily redirected, with wandering as her only behavior. The Resident liked to push residents wheel chairs to the dining room, and this habit was known by staff. The Nursing progress notes were reviewed from 7-1-18 through the time of survey, for a 7 month period, and no notes indicate any behaviors for this Resident. Bruises were documented in the nursing notes to be observed on the Resident by nursing staff on; 1-23-19, 9-26-18, 9-5-18, and 7-12-18. There is no report to the state agency for these injuries, nor is there any indication that any investigations were conducted to ascertain the cause of the bruises. The Administrator was asked for all investigations in the past year for this Resident, and only the 7-31-18, and 9-4-18 incidents of abuse by Resident #3 were submitted, as the Administrator stated this is all we have for her. Two incidents of assault were documented as having occurred to this Resident, perpetrated by Resident #3. These occurred on 7-31-18, and again on 9-4-18. The first assault was reported to the state agency on 8-1-18, with a follow up report on 8-7-18, and both were timely. The second assault was reported to the state agency on 9-10-18, with a follow up on 9-12-18, and both were late reports. The facility policy and procedure for abuse was reviewed and revealed that Residents would be protected from abuse, allegations of abuse would be investigated and reported timely according to federal and state law, and that they would identify, correct and intervene in situations in which abuse is likely to occur. The facility failed to protect Resident #13 from abuse, failed to investigate and report timely an allegation of abuse, and failed to operationalize their abuse policies for these three areas. On 2-6-19, and 2-7-19, at the end of day debrief, the facility failure was reviewed with the Administrator, and the Corporate Registered Nurse/ interim Director Of Nursing. No further information was provided by them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation the facility staff failed to report an allegation of abuse timely for Resident #13 in a survey sample of 27 residents. Resident #3 (male) willfully assaulted Resident #13 (female) on 9-4-18 and no report was sent to the state agency until 6 days later. All abuse reporting must be completed within 24 hours of the incident, or sooner. The findings included: Resident #13 was a female initially admitted to the facility on [DATE], with diagnoses including but not limited to; Dementia, cognitive communication deficit, hip pain, edema, dysphagia, folate deficiency anemia. The Resident was a Full Code status, meaning that CPR was requested to be performed as needed. The Resident was ambulatory and a known wanderer, with orders for a wanderguard bracelet to monitor the potential for elopement. The most recent Minimum Data Set Assessment (MDS) with an ARD (assessment reference date) of 11-17-18 coded Resident #13 as having a BIMS (brief interview of mental status) of severely cognitively impaired. Resident #13 was coded as needing limited to extensive assistance with ADL's (activities of daily living) such as bathing and dressing from 1 staff member, and for eating required only supervision and set up help. The Resident was ambulatory, and exhibited no negative behaviors. Review of the nursing progress notes revealed the Resident to be documented as docile, pleasant, and easily redirected, with wandering as her only behavior. The Resident liked to push residents wheel chairs to the dining room, and this habit was known by staff. The Nursing progress notes were reviewed from 7-1-18 through the time of survey, for a 7 month period, and no notes indicate any behaviors for this Resident. Bruises were documented in the nursing notes to be observed on the Resident by nursing staff on; 1-23-19, 9-26-18, 9-5-18, and 7-12-18. There is no report to the state agency for these injuries, nor is there any indication that any investigations were conducted to ascertain the cause of the bruises. The Administrator was asked for all investigations in the past year for this Resident, and only the 7-31-18, and 9-4-18 incidents of abuse by Resident #3 were submitted, as the Administrator stated this is all we have for her. Two incidents of assault were documented as having occurred to this Resident, perpetrated by Resident #3. These occurred on 7-31-18, and again on 9-4-18. The first assault was reported to the state agency on 8-1-18, with a follow up report on 8-7-18, and both were timely. The second assault was reported to the state agency on 9-10-18, with a follow up on 9-12-18, and both were late reports. The facility policy and procedure for abuse was reviewed and revealed that Residents would be protected from abuse, allegations of abuse would be investigated and reported timely according to federal and state law, and that they would identify, correct and intervene in situations in which abuse is likely to occur. On 2-6-19, and 2-7-19, at the end of day debrief, the facility failure was reviewed with the Administrator, and the Corporate Registered Nurse/ interim Director Of Nursing. No further information was provided by them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #39 the facility failed to submit an accurate complete investigation to the OLC and failed to provide additional training to all involved staff. Resident #39 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Fracture of Femur, Dementia without behavioral disturbance, Arthritis and long term use of anticoagulants. Resident #39's last (Minimum Data Set) MDS coded as having a (Brief Interview of Mental Status) BIMS score of 99 indicating severe cognitive impairment. On [DATE] the facility provided their investigation of the complaint involving Resident #39. The complaint alleged the resident was physically abused by staff, forced to undress against her will and forced to shower against her will. Their documents included witness statements written at the time of the incident. The facility submitted a file of documents from their investigation into the incident on [DATE] included was a statement from CNA A stating [Resident #39 name] Shower day she didn't want. [CNA Names] took her in. [ADON name] said try later. [LPN A Name] was holding her down [Resident name] started kicking and hitting [LPN A name] said she stinks. On [DATE] at 2:50 PM CNA B was interviewed about incident. CNA B stated It was a while ago but I remember we took her to the shower room it was her shower day and when she got combative. CNA B said get the nurse. She became combative with the nurse also as she helped get her clothes off. CNA B was asked if she was provided any additional education or training after this incident she replied no. On [DATE] at 3:10 PM, an interview was conducted with LPN A who stated CNA B came to her and asked her to come to the shower and assist with Resident #39. She stated she went into the shower room and that Resident #39 was combative with the CNA's and that she tried to get her calmed down but she was still being combative. She stated that she ripped the incontinent briefs to get them off. She stated she got her clothes off while the resident was still being combative. She said that she Held her arms apart so she couldn't hit. After she was undressed she left the shower room. LPN A also stated Resident #39 has Dementia really bad and gets physical a lot when it's involving care or bathing. She also stated that the 2 CNA's reported her for abuse for helping get her undressed and blocking her arms from hitting them. She stated that she was suspended until they did the investigation and then she came back to work and is currently still working with Resident #39. She stated she was given no additional training or education upon return. CNA A was on leave of absence so a telephone interview was conducted on [DATE] at 5:15 PM. Resident #39 didn't want to get a shower she was refusing and they reproached her a few times and CNA B asked LPN A to come to shower room. LPN A starting taking off her clothing even though she refused. She stated she needs a shower she stinks. CNA A stated this is her usual behavior when she gets a shower. She doesn't like to get undressed or get a shower. She stated after the shower she went to her room and was not acting like herself she was looking sad. When asked if she was provided any additional education or training after this incident she replied no. In the investigation packet submitted by the facility was document states that on [DATE] the resident had a fall in the evening. Then on [DATE] the resident was experiencing pain all over and did not get out of bed or eat any of her meals. It states it was Unclear if this is a change related to the fall or the incident in this shower. The same document has handwritten notes as follows: 1. Resident was reluctant to go to shower room. 2. Resident was tearful / crying once in the shower room. 3. Resident was told by primary nurse that she Stinks and needed a shower 4. Residents clothes were removed without consent by nurse, resident was combative while clothing was removed 5. Resident was withdrawn after the shower. Also in included were progress notes dated [DATE] at 2:26 PM stating Bruise found on top of the right hand. Red blue in color. Self-inflicted due to fighting and hitting upon going to the bathroom or changing clothes RP notified and aware of situation MD notified. This note signed by LPN A Another progress note attached dated [DATE] stated Resident very combative during care, resident threw her shoe at staff and books. Staff left the room and went back a few minutes later and attempted to do care again resident was resistant but staff got it done. In the investigation that the facility submitted to the OLC, the facility stated that the allegations by [CNA A & CNA B] of abusive behavior by [LPN A] towards [Resident # 39] are unsubstantiated, however upon looking at the documents included in the investigation it is clear that the witness statements made at the time of the incident show that the Resident was held down and given a shower against her will, and told she needed a shower because she stinks. The investigation results sent to the OLC state that the Social Services director performed a psychosocial assessment of the Resident on [DATE] and it indicated no emotional or mental anguish. The Facility was asked if they had an Abuse Policy which they submitted to the team for review. The document entitled Abuse - Training Employees about Abuse Dated [DATE] was reviewed and found that according to the facility Policy: Mental Abuse means but is not limited to, humiliation, harassment, threat of punishment Page 6 states Facility Staff Will NOT: 1. Use verbal mental sexual or physical abuse corporal punishment or involuntary seclusion in caring for And in any interaction with the Residents. 2. Impose PHYSICAL or CHEMICAL Restraints for purposes of discipline or convenience. If and when the use of restraints is indicated to treat a residents' medical symptoms Facility staff shall use the least restrictive alternative for the least amount of time and shall document ongoing re-evaluation of need for the restraint. Review of clinical record and Physicians Order sheets revealed no evidence of a physician's order to physically restrain or hold resident down to give shower. On [DATE] the Administrator was interviewed about the investigation and she stated It was before my time I have only been here a few months. The Acting DON (Employee B) also stated she was not present at the time of the incident. No further information was provided. 3. For Resident # 55, the facility staff failed to properly document corrective action against CNA-G and provide follow up education of staff. Resident # 55 was a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses of but not limited to: Dementia, Hypertension, Deep Vein Thrombosis, and age-related Osteoporosis. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of [DATE]. The MDS coded Resident # 55 with severe cognitive impairment. Resident # 55 was coded as requiring extensive assistance of 1 staff person with Activities of Daily Living including transfer and bed mobility except required total assistance of one staff person for bathing; always incontinent of bowel and bladder. Resident # 55 was coded as not steady, only able to stabilize with staff assistance for moving from seated to standing position and surface to surface transfer. On [DATE] and [DATE], review of the clinical record was conducted. Review of the Nurses Progress Notes revealed: [DATE] at 5:40 AM Writer received fax results at 4:50 am with Impression Results reading: 1) There is a fracture through the lateral, medial as well as anterior malleolus. 2) Moderate soft tissue swelling and plantar calcaneal spur. 3) Diffuse Osteopenia (sic) Dr___paged @ 04:55 am- spoke with __. Notified DON (Director of Nursing) of results at 04:56- MD returned call to facility @ 5:00 with new order to send resident to ____ (Hospital) ER Emergency Room- notified RP. [DATE] at 6:22 AM_____(Transport) arrived to facility now with 2 attendants-report given and all paperwork and copy of DNR (Do Not Resuscitate) given to attendants -resident exiting facility via stretcher in stable condition. [DATE] 3:33 PM- Resident arrived via ambulance via stretcher with diagnosis of fracture rt (right) leg/ankle, has soft cast on rt leg. Review of the Mobile X-Ray of the Right Ankle 3- View results dated [DATE] revealed impression: Fracture through the lateral, medial and anterior malleolus. Review of the Final Report of the FRI (Facility Reported Incident) revealed documentation of a Summary of Interviews reporting one CNA (Certified Nursing Assistant)-G stated on [DATE] at approximately 1445 (2:45 PM) she assisted Resident # 55 to her bed from her wheelchair by sitting her forward in her wheelchair, placing her arms under resident's arm pits and pulling resident up; she then took a step back while resident was standing, turned and sat resident on the bed; she than (sic) lifted Resident's legs and placed them into the bed, enduring that Resident was positioned securely. (CNA-G) does not recall the exact positioning of resident's feet during the transfer and stated that nothing out the ordinary occurred. The Conclusion of the FRI stated Resident # 55 has a suspected right ankle fracture. It may have occurred while being transferred at some point in the later part of the day on [DATE]. The last transfer to occur prior to the bruising being observed to the ankle was at about 1500 (3:00 PM) when she was helped from her wheelchair to her bed. Resident ____does have a history of osteoarthritis and osteopenia, placing her at significant risk for musculoskeletal injury to include bone fractures. It is also known that resident has had multiple fractures in the past, including a previous fracture to the ankle in question. No evidence was found to indicate that ____(Resident # 55's) suspected ankle fracture was due to abuse or mistreatment. Disposition: Refresher training will be provided to all nursing staff regarding proper body mechanics and transferring residents. This will be completed on [DATE]. ______ (CNA_G) will receive corrective action for failure to adhere to the transfer directions for ___(Resident # 55) set forth in her care plan. Resident # 55 will be evaluated by physical therapy department during transfers and recommendations based on their observation will be put into place. Investigation completed [DATE] by (former Administrator) and (former Director of Nursing) Review of Resident # 55's Care Plan revealed documentation of Problem start date: [DATE]- resident requires assistance with Activities of Daily Living due to impaired mobility, cognitive impairments related to dementia. Edited: [DATE] Goal: Resident will have all of her daily needs met with staff assistance thru (through) next review Approach Start Date: [DATE] transfer with 2 person staff assist and gait belt Evaluation notes: [DATE] care plan evaluated and remains appropriate Review of the Employee Records for (CNA (Certified Nursing Assistant) -G and training records revealed no documentation of any training to all nursing staff regarding proper body mechanics and transferring residents. On [DATE] , an interview was conducted with the Administrator who stated she could not find any documentation of training to nursing staff regarding proper body mechanics and transferring residents. The Administrator also stated she did not find documentation of training for CNA- G. The Administrator stated the Corrective Action form for CNA-G should have been signed by the Department Head (the previous Director of Nursing and or the Previous Administrator). During the end of day debriefing on [DATE] , the facility Administrator was informed of the findings. There was a corrective action form found that was not signed by a department head, Director of Nursing or Administrator. The form was not an official part of CNA-G's employee file. No further information was provided. Based on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation the facility staff failed to investigate timely, and correct the issue, for 3 Residents (Residents #13, #39, and #55) and to prevent further abuse of Resident #13.in a survey sample of 27 residents. 1. Resident #13 (female) was willfully assaulted by Resident #3 (male) on at least 2 occasions. The victim was not protected from her attacker, the issues of supervision were not corrected, and the abuse reoccurred. The facility did not report the abuse until 6 days after the incident and a final investigation followed 8 days after the incident. Both the investigation and report were late. 2. For Resident #39 the facility failed to submit an accurate complete investigation to the OLC and failed to provide additional training to all involved staff. 3. For Resident # 55, the facility staff failed to properly document corrective action against CNA-G and provide follow up education of staff. The findings included: 1. Resident #13 (female) was willfully assaulted by Resident #3 (male) on at least 2 occasions. The victim was not protected from her attacker, the issues of supervision were not corrected, and the abuse reoccurred. The facility did not report the abuse until 6 days after the incident and a final investigation followed 8 days after the incident. Both the investigation and report were late. Resident #13 was a female initially admitted to the facility on [DATE], with diagnoses including but not limited to; Dementia, cognitive communication deficit, hip pain, edema, dysphagia, folate deficiency anemia. The Resident was a Full Code status, meaning that CPR was requested to be performed as needed. The Resident was ambulatory and a known wanderer, with orders for a wanderguard bracelet to monitor the potential for elopement. The most recent Minimum Data Set Assessment (MDS) with an ARD (assessment reference date) of 11-17-18 coded Resident #13 as having a BIMS (brief interview of mental status) of severely cognitively impaired. Resident #13 was coded as needing limited to extensive assistance with ADL's (activities of daily living) such as bathing and dressing from 1 staff member, and for eating required only supervision and set up help. The Resident was ambulatory, and exhibited no negative behaviors. Review of the nursing progress notes revealed the Resident to be documented as docile, pleasant, and easily redirected, with wandering as her only behavior. The Resident liked to push residents wheel chairs to the dining room, and this habit was known by staff. The Nursing progress notes were reviewed from 7-1-18 through the time of survey, for a 7 month period, and no notes indicate any behaviors for this Resident. Bruises were documented in the nursing notes to be observed on the Resident by nursing staff on; 1-23-19, 9-26-18, 9-5-18, and 7-12-18. There is no report to the state agency for these injuries, nor is there any indication that any investigations were conducted to ascertain the cause of the bruises. The Administrator was asked for all investigations in the past year for this Resident, and only the 7-31-18, and 9-4-18 incidents of abuse by Resident #3 were submitted, as the Administrator stated this is all we have for her. Two incidents of assault were documented as having occurred to this Resident, perpetrated by Resident #3. These occurred on 7-31-18, and again on 9-4-18. The first assault was reported to the state agency on 8-1-18, with a follow up report on 8-7-18, and both were timely. The second assault was reported to the state agency on 9-10-18, with a follow up on 9-12-18, and both were late reports. A synopsis of those events follow from the Nursing progress notes of the assailant Resident #3, as no description of the assaults were in the nursing notes of the victim Resident #13, and from the facility reported document, and a complaint that was received by the state agency regarding Resident #3: 7-31-18 Incident 4:54 p.m. The MD (doctor) observed Resident (#3) pull the leg of another Resident (#13) resulting in a fall . The Facility report to the state agency documented that Resident (#13) attempted to push Resident #3's wheel chair toward the dining room, Resident #3 was cursing at Resident #13 prior to grabbing her leg and making her fall. The report goes on to say that Resident #3 has a diagnosis of aggression toward others, and has verbal outbursts cursing staff and residents, and has episodic periods of aggression, in which he has kicked staff and shoved one resident's wheel chair into another resident. The conclusion of the facility in the report was; Resident #3 (name) acted in an aggressive manner. The report stated that the social services director has begun to attempt to identify alternate living arrangements for Resident #3 in the event his behaviors place others at danger, and Nursing staff will attempt to keep Resident #3 (name) and Resident #13 (name) separated. 9-4-19 incident at 8:00 p.m. was documented in the facility report as Resident #13 (name) was walking down the hall, and Resident #3 (name) grabbed her left arm twisting it in an aggressive manner while cursing at her. her wrist was red at the time.The next day a bruise was noted on Resident #13's wrist, and she was sent to the emergency room for evaluation, and returned with only the bruising diagnosis. Resident #3 was quoted as saying She was in his way, and he was trying to move her. The document goes on to say again as the 8-1-18 report stated that the admissions director has been exploring alternative living arrangement for Resident #3 should aggressive behaviors continue. Also, the report states as the previous report of 8-1-18 did, that nursing staff would attempt to keep Resident #13, and Resident #3 separated by redirecting residents away from each other while they are in common areas, and intervene as necessary. The notes indicate continued willful acts on the part of Resident #3, and the fact that Resident #13 is freely wandering with no supervision after 2 assaults by the same Resident, is a deficient practice on the part of the facility who continue to fail to protect Resident #13 from her attacker. The facility policy and procedure for abuse was reviewed and revealed that Residents would be protected from abuse, allegations of abuse would be investigated and reported timely according to federal and state law, and that they would identify, correct and intervene in situations in which abuse is likely to occur. The facility further failed to protect Resident #13 from abuse, failed to investigate and report timely an allegation of abuse, and failed to operationalize their abuse policies for these three areas. On 2-6-19, and 2-7-19, at the end of day debrief, the facility failure was reviewed with the Administrator, and the Corporate Registered Nurse/ interim Director Of Nursing. No further information was provided by them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, closed record review, and facility documentation, the facility staff failed to notify the ombudsman of transfer to hospital for one Resident (Resident #56) in a sample size of 27 residents. Because the resident was no longer at the facility, a closed record review was conducted. The findings included: Resident #56, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia, depression, anxiety, dysphagia, muscle weakness, and history of femur fracture. Resident # 56's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/2018 was coded as a significant change in status assessment. The Brief Interview of Mental Status (BIMS) for Resident #56 was not coded but cognitive ability for daily decision-making was coded as severely impaired. Functional status for eating, dressing, toileting, and personal hygiene was coded as requiring extensive assistance from staff. Transfers between surfaces were coded as requiring 2+ persons for physical assistance. Continence for bowel and bladder was coded as always incontinent. On 02/09/2018 at 10:24 AM, a nurse's note documented, Resident unresponsive, temp 99.9, can only hear systolic of 106. U/A came back 4+ bacteria, WBC 18.33, K+ (potassium) 5.3. All meds held this morning due to situation. MD called and I was instructed to send to hospital for UTI/sepsis. RP notified at this time. On 02/09/2018 at 7:33 PM, a nurse's note documented, Called [hospital], resident admitted for polynephritis (sic) & sepsis. On 02/07/2019 at 5:00 PM, the Corporate DON was asked about the usual process for ombudsman notification of hospital transfers. She stated the social worker faxes or emails the notification to the ombudsman. She also stated she had no evidence the ombudsman was notified when Resident #56 was transferred to the hospital. The facility policy for 'Transfers and Discharges' was reviewed. In Section 4 entitled Before transfer or discharge of a resident the facility will: it is documented under (a) (ii), The facility will notify a representative of the Office of the State Long Term Care Ombudsman at the same time by sending a copy of the notice. On 02/07/2019 at approximately 5:50 PM, the Administrator and DON were notified of findings and they offered no further information or documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, closed record review, and facility documentation, the facility staff failed to give notice of a bed hold when transferred to hospital for one Resident (Resident #56) in a sample size of 27 residents. Because the resident was no longer at the facility, a closed record review was conducted. The findings included: Resident #56, a [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses included but not limited to dementia, depression, anxiety, dysphagia, muscle weakness, and history of femur fracture. Resident # 56's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/2018 was coded as a significant change in status assessment. The Brief Interview of Mental Status (BIMS) for Resident #56 was not coded but cognitive ability for daily decision-making was coded as severely impaired. Functional status for eating, dressing, toileting, and personal hygiene was coded as requiring extensive assistance from staff. Transfers between surfaces were coded as requiring 2+ persons for physical assistance. Continence for bowel and bladder was coded as always incontinent. On 02/09/2018 at 10:24 AM, a nurse's note documented, Resident unresponsive, temp 99.9, can only hear systolic of 106. U/A came back 4+ bacteria, WBC 18.33, K+ (potassium) 5.3. All meds held this morning due to situation. MD called and I was instructed to send to hospital for UTI/sepsis. RP notified at this time. On 02/09/2018 at 7:33 PM, a nurse's note documented, Called [hospital], resident admitted for polynephritis (sic) & sepsis. On 02/07/2019, the Corporate DON was asked for a copy of the bed hold notification when Resident #56 was transferred to the hospital. She stated she does not have bed hold documentation. The facility policy for 'Transfers and Discharges' was reviewed. In Section 13 entitled The facility provides the following written information to residents and or resident representatives at the time of transfer to a hospital or when the resident goes on a therapeutic leave: it is documented under (i), (ii), and (iii), The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; The reserve bed payment policy in the state plan; The nursing facility policies regarding bed-hold policies. On 02/07/2019 at approximately 5:50 PM, the Administrator and DON were notified of findings and they offered no further information or documentation.

**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 provide supervision to mitigate accident hazards for two resident in a survey sample of 27 residents. 1. For Resident # 55, the facility staff failed to transfer properly using two person assistance and gait belt as written in the care plan. 2. The facility staff failed to provide supervision, to include cueing and oversight for Resident #10 while she drank scalding hot chocolate. The findings included: 1. For Resident # 55, the facility staff failed to transfer properly using two person assistance and gait belt as written in the care plan. Resident # 55 was a [AGE] year old female who was admitted to the facility on [DATE] with diagnoses of but not limited to: Dementia, Hypertension, Deep Vein Thrombosis, and age-related Osteoporosis. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 5/21/18. The MDS coded Resident # 55 with severe cognitive impairment; Resident # 55 was coded as requiring extensive assistance of 1 staff person with Activities of Daily Living including transfer and bed mobility except required total assistance of one staff person for bathing; always incontinent of bowel and bladder. Resident # 55 was coded as not steady, only able to stabilize with staff assistance for moving from seated to standing position and surface to surface transfer. On 2/6/2019 and 2/7/2019, review of the clinical record was conducted. Review of the Final Report of the FRI (Facility Reported Incident) revealed documentation of a Summary of Interviews reporting one CNA (Certified Nursing Assistant)-G stated on 8/1/2018 at approximately 1445 (2:45 PM) she assisted Resident # 55 to her bed from her wheelchair by sitting her forward in her wheelchair, placing her arms under resident's arm pits and pulling resident up; she then took a step back while resident was standing, turned and sat resident on the bed; she than (sic) lifted Resident's legs and placed them into the bed, enduring that Resident was positioned securely. (CNA-G) does not recall the exact positioning of resident's feet during the transfer and stated that nothing out the ordinary occurred. The Conclusion of the FRI stated Resident # 55 has a suspected right ankle fracture. It may have occurred while being transferred at some point in the later part of the day on 8/1/2018. The last transfer to occur prior to the bruising being observed to the ankle was at about 1500 (3:00 PM) when she was helped from her wheelchair to her bed. Resident ____does have a history of osteoarthritis and osteopenia, placing her at significant risk for musculoskeletal injury to include bone fractures. It is also known that resident has had multiple fractures in the past, including a previous fracture to the ankle in question. No evidence was found to indicate that ____(Resident # 55's) suspected ankle fracture was due to abuse or mistreatment. Disposition: Refresher training will be provided to all nursing staff regarding proper body mechanics and transferring residents. This will be completed on 9/15/2018. ______ (CNA_G) will receive corrective action for failure to adhere to the transfer directions for ___(Resident # 55) set forth in her care plan. Resident # 55 will be evaluated by physical therapy department during transfers and recommendations based on their observation will be put into place. Investigation completed 8/7/2018 by (former Administrator) and (former Director of Nursing) Review of Resident # 55's Care Plan revealed documentation of Problem start date: 11/29/2016- resident requires assistance with Activities of Daily Living due to impaired mobility, cognitive impairments related to dementia. Edited: 6/13/2018 Goal: Resident will have all of her daily needs met with staff assistance thru (through) next review Approach Start Date: 8/17/2017 transfer with 2 person staff assist and gait belt Evaluation notes: 6/13/2018 care plan evaluated and remains appropriate Review of the Hospital History and Physical form dated 8/2/2018 under Chief Complaint stated: Patient has swelling and pain in right ankle and non displaced fracture. According to EMS (Emergency Medical Service) report, bruising and swelling was noticed to the Rt (Right) ankle and anterior region of Rt foot around midnight today. Pt was then given xrays that confirmed there is a nondisplaced fx (fracture) through medial and lateral malleolus. Nursing home suspects fx could have been sustained during transfer because they deny known fall or injury. X-Ray Ankle 3+ Views Right Final Results-The ankle mortise appears intact. No fracture. No subluxation. There are two suspected acute fractures of the distal tibia to include the anterior lip and medial malleolus. Additionally, there is a suspected old more distal medial malleolar fracture. Impression: Anterior lip and medial malleolar acute fracture suspected superimposed on old distal medial malleolar fracture. There is prominent soft tissue swelling seen laterally but no definite fibular fracture. Review of the Employee file for CNA G revealed three corrective action forms. None of the three were related to the above complaint. The Administrator was asked if any more Corrective Action Forms existed for that particular employee. The Administrator stated there were some forms in a file drawer where Facility Reported Incidents and Investigations were in her office that were left by the previous administrator. The Administrator looked through the forms and presented a copy of a Corrective Action Notice for CNA . Review of the Corrective Action Notice Form documented a First Written Warning The Description of the Infraction or Allegation stated the CNA failed to follow resident ___ (Resident # 55's) Care Plan during transfers from wheelchair into bed, resulting in possible injury to Resident Instructions to Correct Future Performance CNA to check resident profile before performing care . I acknowledge that this Corrective Action Notice was discussed with me and I am aware that it will become a part of my personnel record. I understand that further infractions may lead to further corrective action up to and including termination of employment. The form was signed by the employee. There was no date on the form on the signature line and there was no Witness Signature. There was another typed form which stated _______( CNA-G) Failed to follow Resident ___(Resident # 55's) care plan with regards to transfers from her wheelchair into her bed. It was noted by several staff members, as well as ___(CNA-G's) own statements that she did not follow the care plan with transfers, which could have potentially resulted in injury to resident. (Resident # 55). Moving forward, ___(CNA-G) is to check the Resident Profile, for which she has received education on how to access, prior to completing any resident care. In addition to this she is to use a gait belt with all transfers. Since this incident, it has been noted that ___(CNA-G ) has come to work each day with her gait belt on her person, and has vocalized that she has been checking resident profiles prior to delivering care. The form had no signature nor date for the Department Head and a signature for the employee (CNA-G) but no date. During the end of day debriefing on 2/7/19, the facility Administrator, Director of Nursing and Corporate Consultant were informed of the findings. No further information was provided. COMPLAINT Deficiency 2. The facility staff failed to provide supervision, to include cueing and oversight for Resident #10 while she drank scalding hot chocolate. Resident #10 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #10's diagnoses included Gastro-esophageal Reflux Disease, Generalized Muscle Weakness, Other Chronic Pain, Inflammatory polyneuropathy, Functional dyspepsia, Sarcoidosis, Hypertension, Major Depressive Disorder, Hypokalemia, Heart Disease, and Diabetes Mellitus Type Two. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 8/11/18, coded Resident #10 as requiring the extensive assistance of two persons for bed mobility, transfers, and dressing. For eating, Resident #10 was coded as requiring supervision to include cueing and oversight. In addition, she was also coded as being on 2 opioid medications (narcotic pain medication that cause drowsiness), and having Shortness of Breath. Resident #10 was on the following physician-ordered medications: (Oxycodone, Tramadol, Elavil, Baclofen, and Neurontin). On 2/5/19 at 12:00 Noon, a review was conducted of the facility kitchen with the Dietary Manager (Employee E). The temperature logs were reviewed. The food temperatures had not been taken for the breakfast or lunch meals. In addition, coffee and hot water logs had not been done since January 2019. At that time the coffee and hot water temperatures were recorded as being between 175- 180 degrees Fahrenheit. When asked if the hot liquid temperatures were ever taken, the Dietary Manager stated, Oh, it's always extremely hot. On 2/5/19 at 12:30 P.M., an observation was conducted of Resident #10 in the dining room during lunchtime, for approximately 30 minutes. There were approximately 20 residents eating in the dining room. The two Certified Nursing Assistants were at other tables feeding other residents. Resident #10 sat at a table with two other residents. There were no facility staff present who provided supervision, including cueing and oversight for any of the three residents at the table. At 12:35 P.M., a staff person who was serving hot liquids, including coffee and hot chocolate to several of the residents, served Resident a cup of hot chocolate that had steam coming out of it at a brisk pace. She did not take the temperature prior to serving it. The cup did not have a lid on it. The facility cook (Employee D) was asked to take the temperature of Resident #10's hot chocolate. It took her approximately 5 minutes to obtain an thermometer and arrive at Resident #10's table. The surveyor obtained Resident #10's permission to allow the cook to take the temperature of her hot chocolate. The cook stated that the temperature was 158.35 degrees. At 12:50 P.M. the cook (Employee D) tested the water in the thermos that was used to make Resident #10's hot chocolate. It was 164 degrees Fahrenheit. In addition, at 1:00 P.M. the Dietary Manager (Employee E) stated that the hot water thermos that was in the kitchen had a temperature of 178.2. The Burn Care Foundation accessed on 2/12/19 at 11:56 A.M. at the website http://www.burncarefoundation.org/safety/hot-water-exposure.html provided the following information on burns: Exposure to 131° F water for 17 seconds would cause a second degree burn and exposure of 30 seconds would cause a third degree burn Exposure to 140° F water for 3 seconds would cause a second degree burn and exposure of 5 seconds would cause a third degree burn The following definition of scald was accessed on 2/11/19 at 12:00 P.M. at the Merriam Webster website found at https://www.merriam-webster.com/dictionary/scald: SCALD: To burn with or as if with hot liquid or steam. On 2/5/19, the facility was asked to provide a list of all residents who had received a Hot Liquid Assessment. Resident #10's name was not on the list. In addition, a review was conducted of Resident #10's clinical record. Both her paper chart, and computer chart were reviewed, including all documentation since the previous survey. Resident #10 had not received a Hot Liquid Assessment. Resident #10's care plan did not address feeding assistance, including supervision, cueing and oversight. It did address dehydration. It read: Resident is at risk for dehydration related to use of diuretic for hypertension. Assist with fluids for dehydration. On 2/7/19 at approximately 4:00 P.M., an interview was conducted with the MDS consultant (Employee K). When asked if she had ever worked with Resident #10, she stated that she hadn't worked with her. The MDS consultant was asked how often and under what circumstances Resident #10 required feeding assistance. She stated, When in doubt, provide the help. You can't supervise the resident if you're not there with her. On 2/7/19, after the last meeting with the facility prior to exit, the Director of Nursing (Employee B) stated that Resident #10 had a Hot Liquid Assessment done on 5/2/18, which stated that Resident #10 did not require supervision for eating/drinking. When asked where the assessment had been located since it was not in the clinical record, the DON stated, I don't know. When asked why the assessment conflicted with the MDS assessment, the DON stated, I don't know. When asked to explain what the dehydration care plan meant by the phrase, Assist with fluids for dehydration, the DON repeated the phrase twice. On 2/7/19 a review was conducted of facility documentation, revealing a Hot Liquid Assessment Policy dated 4/6/18. It read, Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. Assessments will be completed with residents on admission/readmission, quarterly and with significant changes by a licensed nurse. On 2/7/19 at 4:30 P.M. the facility Administrator (Employee A) was notified of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to ensure medication was available for use for 2 of 27 residents. 1. For Resident # 53, the facility staff failed to ensure medication was available for use. 2. For Resident #52, the facility staff failed to ensure that diabetic management medication was available for administration. The Findings Include: 1. For Resident # 53, the facility staff failed to ensure medication was available for use. Resident # 53 was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to Gastrointestinal hemorrhage, Muscle Weakness, Multiple fractures of ribs, left side, Malignant neoplasm of bronchus or lung, Malignant neoplasm of Kidney, long term use of anticoagulants, chest pain, fracture of sternum and Dementia without behavioral disturbance. Resident # 53's most recent Minimum Data Set (MDS) was a 30 day assessment with an Assessment Reference Date (ARD) of 1/15/2019. The MDS coded Resident # 53 with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating no cognitive impairment. Resident # 53 required supervision with no set up or physical help to set up help only assistance for activities of daily living except required supervision with assistance of one staff person for bed mobility and always continent of bowel and bladder. Review of the clinical record was conducted on 2/5/2019 at 2:30 PM. Review of the MAR (Medication Administration Record) revealed documentation: Percocet 5-325 milligrams Schedule II one tablet by mouth twice a day for pain. 1/29/2019 5:00 PM to 9:00 PM-Not Administered: Drug/Item Unavailable. Comment: Patient reports no pain. Eliquis 5 milligrams one tablet by mouth twice a day. 12/8/2018 5:0 PM - 9:00 PM-Not Administered: Drug/Item Unavailable 12/9/2018 7:30-11:30 AM-Not Administered: Drug/Item Unavailable Flomax 0.4 milligrams by mouth once a day; 12/1/2018 7:30 AM-11:30 AM Not Administered: Drug/Item Unavailable Isosorbide Dinitrate 30 milligrams by mouth twice a day- 12/21/2018 7:30 AM-11:30 AM-Not Administered: Drug/Item Unavailable Megestrol Suspension 40 milligrams per milliliter give one milliliter three times per day: 4 times Not administered due to Drug unavailable. 12/21/2018 at 9:00 AM, 12/21/2018 at 1:00 PM, 12/21/2018 at 5:00 PM Vitamin B-12 100 microgram tablet one tablet by mouth once a day: Not administered due to Drug unavailable. 12/21/2018 at 7:30 AM-11:30 AM Valid physician's orders were evident for the medications in question. On 2/7/2019 at 1:50 PM, an interview was conducted with the Director of Nursing and Administrator. When asked if there had been a change in Pharmacies over the past few months, the Director of Nursing replied no. The Director of Nursing stated the Pharmacy was available 24/7 (24 hours a day/7 days a week) to the facility staff. During the end of day debriefing, the Administrator, Director of Nursing and Corporate Nurse were informed of the findings. No further information was provided. 2. For Resident #52, the facility staff failed to ensure that diabetic management medication was available for administration. Resident #52 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #52's diagnoses included: Diabetes Mellitus Type Two, Hyperlipidemia, Dementia, Seizure Disorder, Traumatic Brain Injury, Anxiety Disorder, and Post Traumatic Stress Disorder. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 1/15/19, was reviewed, It coded Resident #52 as having a Brief Interview of Mental Status Score of 2, indicating severe cognitive impairment. On 2/6/19 at 9:00 A.M. an observation was conducted of Resident #52 asleep in his bed. He was clean and dressed appropriately. On 2/6/19 a review was conducted of Resident #52's clinical record, revealing the following signed physician order, Bydureon Injection 2 MG subcutaneously one time a day every week on Monday. The Medication Administration Record for January, 2019 was reviewed. On Monday, 1/28/19 11:53 A.M. it read, Not Administered Drug item unavailable In addition, Resident #52's nursing progress notes were reviewed. There was no documentation of the physician being notified that the medication was unavailable, or that the facility staff decided to allow Resident #52 to go without his medication for an extra week, for a total of 14 days between doses. On 02/06/19 at 4:53 P.M., an interview was conducted with Resident #52's Registered Nurse (Employee C). She stated, It was delivered on the night of the 1/24/19. He didn't get the dose that morning we decided to wait until the following Monday to give it to him. She further stated that she could not find any documentation that the doctor had been notified. On 2/6/19 at 5:00 P.M. the facility Administrator (Employee A) was notified of the findings. No further information was received.

**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 perform Medication Regimen Reviews for two Residents (# 53 and # 27) in a survey sample of 27 residents. 1. For Resident # 53, the facility staff failed to conduct a Monthly Medication Regimen Review in December 2018. 2. For Resident # 27, the facility staff failed to conduct a Monthly Medication Regimen Review in December 2018. Findings included: 1. For Resident # 53, the facility staff failed to conduct a Monthly Medication Regimen Review in December 2018. Resident # 53 was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to Gastrointestinal hemorrhage, Muscle Weakness, Multiple fractures of ribs, left side, Malignant neoplasm of bronchus or lung, Malignant neoplasm of Kidney, long term use of anticoagulants, chest pain, fracture of sternum and Dementia without behavioral disturbance. Resident # 53's most recent Minimum Data Set (MDS) was a 30 day assessment with an Assessment Reference Date (ARD) of 1/15/2019. The MDS coded Resident # 53 with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating no cognitive impairment. Resident # 53 required supervision with no set up or physical help to set up help only assistance for activities of daily living except required supervision with assistance of one staff person for bed mobility and always continent of bowel and bladder. Review of the clinical record was conducted on 2/5/2019 at 2:30 PM. Review of the Medication Regimen Reviews (MRR) revealed documentation of an MRR on 1/15/2018. There was no MRR in the clinical record for December 2018. On 2/7/2019 at 12:10 PM, an interview was conducted with the MDS (Minimum Data Set) Assessment Nurse (Employee H) who stated she did not see a MRR in December 2018 in the record. Employee H stated she would contact the Pharmacist to find out about MRR for December 2018. Employee H stated the Pharmacist told her a Medication Regimen was not done in December 2018 because Resident # 53 was not in the facility in December on the two dates when he conducted MRRs. Employee H stated the Pharmacist also stated MRRs are done when residents have 30 consecutive days in the facility. Review of the Resident Census Report revealed Resident # 53: admitted to the facility on [DATE]- discharged [DATE] readmitted [DATE] discharged [DATE] readmitted on [DATE]. During the end of day debriefing on 2/7/2019, the Administrator and Director of Nursing were informed of the findings. No further information was provided. 2. For Resident # 27, the facility failed to complete a Monthly Medication Regimen Review in December 2018. Resident # 27, a female, was admitted to the facility 3/24/2007. Her diagnoses included but were not limited to: Hemiplegia and hemiparesis following Cerebrovascular disease affecting left non-dominant side (stroke), Anxiety Disorder, Disorder, Gastroesophageal reflux Disease, Diabetes, Hypertension and muscle weakness. Resident # 27's most recent MDS with an ARD of 12/15/2018 was coded as a quarterly assessment. Resident # 27's BIMS (Brief Interview for Mental Status) Score was 12 out of a possible 15, indicating moderate cognitive impairment. Resident # 27 was coded as needing extensive assistance of one staff member to perform her activities of daily living except supervision for eating and total assistance of one staff person for bathing . Resident # 27 was coded as being able to hear, speak, understand, and be understood. Resident # 27 was always incontinent of bowel and occasionally incontinent of bladder. Review of the clinical record was conducted on 2/6/2019 at 12:25 PM. Review of the Medication Regimen Reviews (MRR) revealed documentation of an MRR on 1/15/2018. There was no MRR in the clinical record for December 2018. On 2/7/2019 at 12:10 PM, an interview was conducted with the MDS (Minimum Data Set) Assessment Nurse (Employee H) who stated she did not see a MRR in December 2018 in the record. Employee H stated she would contact the Pharmacist to find out about MRR for December 2018. On 2/7/2019 at 12:25 PM, Employee H presented a list of the Medication Regimen Reviews for Resident # 27. The list showed the dates 9/28/2018, 10/31/2018, 11/29/2018 and 1/15/2019. There was no MRR for December. Employee H stated the Pharmacist told her a Medication Regimen was done on December 20, 2018 but he forgot to put it in the clinical record. During the end of day debriefing on 2/7/2019, the Administrator and Director of Nursing 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 documentation the facility failed to ensure that Residents were free from unnecessary psychotropic medication for 1 Residents (Resident #6) in a survey sample of 27 Residents. 1. For Resident #6 the facility failed to ensure the Resident had the appropriate diagnosis for receiving Anti-psychotic medications. The findings include: Resident # 6 is a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Dementia with behavioral disturbance, fracture of femur, Contracture of left hand, major depressive disorder single episode unspecified, Unspecified mood disorder. Resident #6's last two (minimum Data Set) MDS (screening tool) coded as Quarterly on 8/8/18 and Annual on 11/8/18, both coded the resident in section E-0100- Psychosis as Z. None of the above indicating that the Resident has had no Hallucinations or Delusions. Under section I Active Diagnosis - Psychiatric/Mood Disorders both MDS' coded her as NOT having psychosis. On 2/6/2019 during clinical record review the it was found that the Resident had an order Seroquel 25 (Milligrams) twice a day. In a document entitled Note to Attending Physician/Prescriber dated 09/28/18 the Pharmacy states: This Resident was recently ordered the antipsychotic agent Seroquel 25 MG BID [twice per day] but lacks an allowable diagnosis to support its use. The following are appropriate diagnoses/conditions. Schizophrenia Schizoaffective disorder Delusional Disorder Mania, bipolar depression with psychotic features, treatment refractory major depression Psychosis NOS Atypical Psychosis Brief Psychotic Disorder Medical Illnesses/delirium with manic/psychotic symptoms/treatment related psychosis Resident #6 had PASARR dated 8/13/2018 that stated: 5B. No referral for active treatment needs assessment required because individual: Does not meet the applicable criteria for serious MI or IDD or related condition Has a PRIMARY diagnosis of Dementia (including Alzheimer's disease) and does not have a diagnosis of IDD. According to the manufacturer of Seroquel the Black Box Warning states: Seroquel isn't indicated for use in elderly patients with dementia-related psychosis because of increased risk of death from cardiovascular disease or infection. On 2/6/2019 in an interview with employee C she stated she was aware of the black box warning with Seroquel and she was aware of the Resident's diagnosis. When asked about her MDS she stated she was not aware that the Resident was NOT coded as having a psychosis. She also stated if she has that diagnosis it should be on her MDS. On 2/7/2019 the Administrator was notified of these issues and no further information was provided.

Based on staff interview and facility documentation, the facility staff failed to date a multi-dose vial that had been accessed. The findings included: On 02/07/2019 at 11:45 AM, LPN A, the Corporate DON, and this surveyor entered the medication room by the central nurse's station. The medication refrigerator was unlocked by LPN A and the contents were inspected. A multi-dose vial of Influenza Vaccine was in an open box. The vial was removed from the box to note the vial's plastic top was removed, the rubber stopper appeared to be needle-punctured, and there was approximately 2 ml of clear medication in the vial. There was no writing on the vial to indicate when it was first opened. When asked about the policy for dating multi-dose vials, the corporate DON stated, It should be dated when opened. When asked how long a multi-dose vial is good for before it is discarded, the corporate DON stated, 30 days. When asked what will be done with this undated vial, the corporate DON stated, I will pull it and discard it. The facility policy General Guidelines for Medication Storage was reviewed. The policy stated, Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. Storage of multi-dose vials after being accessed is not addressed in the policy. On 02/07/2019 at approximately 5:50 PM, the Administrator and DON were notified of findings and they offered no further information or documentation.

**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 to serve hot chocolate at a safe temperature. The facility staff failed to ensure that Resident #10 was not served scalding hot chocolate. The Findings included: Resident #10 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #10's diagnoses included Gastro-esophageal Reflux Disease, Generalized Muscle Weakness, Other Chronic Pain, Inflammatory polyneuropathy, Functional dyspepsia, Sarcoidosis, Hypertension, Major Depressive Disorder, Hypokalemia, Heart Disease, and Diabetes Mellitus Type Two. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 8/11/18, coded Resident #10 as requiring the extensive assistance of two persons for bed mobility, transfers, and dressing. For eating, Resident #10 was coded as requiring supervision to include cueing and oversight. In addition, she was also coded as being on 2 opioid medications (narcotic pain medication that cause drowsiness), and having Shortness of Breath. Resident #10 was on the following physician-ordered medications: (Oxycodone, Tramadol, Elavil, Baclofen, and Neurontin). On 2/5/19 at 12:00 Noon, a review was conducted of the facility kitchen with the Dietary Manager (Employee E). The temperature logs were reviewed. The food temperatures had not been taken for the breakfast or lunch meals. In addition, coffee and hot water logs had not been done since January 2019. At that time the coffee and hot water temperatures were recorded as being between 175- 180 degrees Fahrenheit. When asked if the hot liquid temperatures were ever taken, the Dietary Manager stated, Oh, it's always extremely hot. On 2/5/19 at 12:30 P.M., an observation was conducted of Resident #10 in the dining room during lunchtime, for approximately 30 minutes. There were approximately 20 residents eating in the dining room. The two Certified Nursing Assistants were at other tables feeding other residents. Resident #10 sat at a table with two other residents. There were no facility staff present who provided supervision, including cueing and oversight for any of the three residents at the table. At 12:35 P.M., a staff person who was serving hot liquids, including coffee and hot chocolate to several of the residents, served Resident a cup of hot chocolate that had steam coming out of it at a brisk pace. She did not take the temperature prior to serving it. The cup did not have a lid on it. The facility cook (Employee D) was asked to take the temperature of Resident #10's hot chocolate. It took her approximately 5 minutes to obtain an thermometer and arrive at Resident #10's table. The surveyor obtained Resident #10's permission to allow the cook to take the temperature of her hot chocolate. The cook stated that the temperature was 158.35 degrees. At 12:50 P.M. the cook (Employee D) tested the water in the thermos that was used to make Resident #10's hot chocolate. It was 164 degrees Fahrenheit. In addition, at 1:00 P.M. the Dietary Manager (Employee E) stated that the hot water thermos that was in the kitchen had a temperature of 178.2. The Burn Care Foundation accessed on 2/12/19 at 11:56 A.M. at the website http://www.burncarefoundation.org/safety/hot-water-exposure.html provided the following information on burns: Exposure to 131° F water for 17 seconds would cause a second degree burn and exposure of 30 seconds would cause a third degree burn Exposure to 140° F water for 3 seconds would cause a second degree burn and exposure of 5 seconds would cause a third degree burn The following definition of scald was accessed on 2/11/19 at 12:00 P.M. at the Merriam Webster website found at https://www.merriam-webster.com/dictionary/scald: SCALD: To burn with or as if with hot liquid or steam. On 2/5/19, the facility was asked to provide a list of all residents who had received a Hot Liquid Assessment. Resident #10's name was not on the list. In addition, a review was conducted of Resident #10's clinical record. Both her paper chart, and computer chart were reviewed, including all documentation since the previous survey. Resident #10 had not received a Hot Liquid Assessment. Resident #10's care plan did not address feeding assistance, including supervision, cueing and oversight. It did address dehydration. It read: Resident is at risk for dehydration related to use of diuretic for hypertension. Assist with fluids for dehydration. On 2/7/19, after the last meeting with the facility prior to exit, the Director of Nursing (Employee B) stated that Resident #10 had a Hot Liquid Assessment done on 5/2/18, which stated that Resident #10 did not require supervision for eating/drinking. When asked where the assessment had been located since it was not in the clinical record, the DON stated, I don't know. When asked why the assessment conflicted with the MDS assessment, the DON stated, I don't know. When asked to explain what the dehydration care plan meant by the phrase, Assist with fluids for dehydration, the DON repeated the phrase twice. On 2/7/19 a review was conducted of facility documentation, revealing a Hot Liquid Assessment Policy dated 4/6/18. It read, Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. Assessments will be completed with residents on admission/readmission, quarterly and with significant changes by a licensed nurse. On 2/7/19 at 4:30 P.M. the facility Administrator (Employee A) was notified of the findings.

Based on observation, staff interview, and facility documentation review, the facility staff failed to obtain holding temperatures of breakfast and lunch food items on 2/5/19. In addition, facility staff failed to obtain hot water and coffee temperatures since January 2019. The Findings included: On 2/5/19 at 12:00 Noon, a review was conducted of the facility kitchen with the Dietary Manager (Employee E). The temperature logs were reviewed. The food temperatures had not been taken for the breakfast or lunch meals. In addition, coffee and hot water logs had not been done since January 2019. On 2/5/19, an interview was conducted with the Dietary Manager (Employee E). When asked if the hot liquid temperatures were ever taken, the Dietary Manager stated, Oh, it's always extremely hot. The Dietary Manager also stated that the cook (Employee D) had recorded the breakfast and lunch temperatures. The cook (Employee D) was next door in the dinning room. She was observed preparing and passing plates of food to the aides, who served the residents. When asked if she had taken the breakfast and lunch food /liquid temperatures, the cook stated, I didn't take them. I assumed the other cook who left earlier took the breakfast temperatures, and that the Dietary Manager (Employee E) took the lunch temperatures. When asked about the importance of taking the food temperatures, the cook stated, To avoid bacteria. On 2/5/19 at 2:45 the facility Administrator was notified of the findings. No further information was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility record review, the facility staff failed to provide personal privacy, and a dignified living experience for 9 of 13 Residents in the Resident council meeting. Residents complained of no privacy due to staff refusal to close personal bedroom doors, no private areas to meet with family and friends, staff refuse residents requests to make their own telephone calls, wandering residents enter rooms freely without supervision, and staff will talk about Residents medical needs out in the open around visitors and other residents. The findings included: On 2-6-19 at 2:00 p.m., A private posted Resident Council meeting was held with surveyors. There were 13 Residents in attendance. 9 of the 13 Residents were found to be alert, and oriented to person, place, time and situation, and were able to give accurate historical information, as supported and expounded upon by their peers. The council expressed the following concerns: 1. The Residents unanimously agreed that they were not supplied with private meeting areas when requested, and were told by staff to go to their rooms if they wanted privacy, however, their rooms were occupied by roommates. 2. The council stated that their bedroom doors were never closed to keep down noise or deter wanderers, except for bathing times, and the excuse that staff gave was that their roommates were confused, and they had to be able to see them from the hallway during rounds. 3. One Resident who was in the sample asked Administration for a room change because her room mate was so disruptive and confused, and she stated that the current Interim Director of Nursing told her she would have to wait until the social worker came back from extended leave to handle that. 4. Wanderers (men and women) are allowed to walk into others rooms during the day and night without any supervision, and they rummage through residents belongings and take things. Those things that were taken never find their way back to the person whom they were them from. They stated staff just say oh they don't mean any harm, they are just confused, and the items that were taken get lost. 5. Residents stated they were not allowed to make private telephone calls, and stated the nurse insisted on dialing the number, and would sit right there at the nursing station and listen to every call. 6. When asked if these problems had been reported to the Administrator, they respond that Administration has historically never done anything about it when they report it to them, but they are hopeful that this new administration will change that. It is notable to add that during the private closed session of the annual Resident's Council meeting with surveyors at 2:30 p.m., a member of the therapy staff entered the meeting without knocking, interrupting the meeting. A sign was prominently posted on the door which read, Surveyors will meet with Residents in this room at 2:00 p.m. on this day for a group discussion. Residents are encouraged to talk openly in this confidential meeting without fear of retaliation from staff. This enables an open dialog with surveyors about their concerns without staff present. When the staff interrupt, the Residents became quiet and open discussion is lost. The therapy representative was told by the surveyor that this was a closed session, and staff were not permitted entry at any time during the meeting. He ignored the direction, and continued to speak loudly across the room to one of the Residents in attendance, telling the Resident about a therapy session planned for the Resident directly after the meeting with all of the Resident's peers in the room listening to the information. The Resident grimaced and appeared embarrassed. Staff were observed multiple times on the 3 halls, during the 3 days of survey, entering resident rooms without knocking, and did not make their presence known before entering. During initial tour of the facility only 4 room doors were found to be closed, and these were private rooms. All other room doors were open whether Residents were in them or not. The Director of Nursing gave [NAME] as their nursing practice standard. Fundamentals of Nursing, 7th Edition, [NAME]-[NAME], p. 475, provides guidance, A sense of dignity includes a person's positive self-regard, an ability to invest in and gain strength from one's own meaning in life, feeling valued by others, and how one is treated by caregivers. Nurses promote a client's self esteem and dignity by respecting him or her as a whole person with feelings, accomplishments, and passions independent of the illness experience .When caring for a client's bodily functions, show patience and respect, especially after the client becomes dependent. The administrator, Director of nursing/corporate consultant were informed of the failure of the staff to ensure a dignified and private living experience at the end of day debrief on 2-7-19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #39 the facility failed to develop and implement a person centered care plan to address behaviors related to refusing (Activities of Daily Living) ADL care. Resident #39 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Fracture of Femur, Dementia without behavioral disturbance, Arthritis and long term use of anticoagulants. Resident #39's last (Minimum Data Set) MDS coded as having a (Brief Interview of Mental Status) BIMS score of 99 indicating severe cognitive impairment. On 2/5/2019 in the course of a complaint investigation, a clinical record review was conducted and it was found that Resident # 39 had a history of refusing ADL care. Nurse's notes dated 3/26/18 at 2:26 PM stating Bruise found on top of the right hand. Red blue in color. Self-inflicted due to fighting and hitting upon going to the bathroom or changing clothes RP notified and aware of situation MD notified. This note signed by LPN A Another progress note dated 5/17/2018 stated Resident very combative during care, resident threw her shoe at staff and books. Staff left the room and went back a few minutes later and attempted to do care again resident was resistant but staff got it done. On 2/7/2019 an interview with the Administrator was conducted and she was asked if she was aware of the complaint from 7/5/2018 involving #39's being showered against her will and being told she stinks. The Administrator stated It happened before I got here but yes I am aware of it. When shown the care plan and asked if in her opinion it was accurate for this Resident, indicating the section relating to behaviors and ADL care, the Administrator replied Let me go see if I can find out if there is an earlier version or if this is the full care plan. She later returned to state that is the full care plan for Resident #39. When asked if the care plan properly addressed the behaviors related to ADL care, she replied No it should have been addressed a lot earlier. When she first was displaying those behaviors. On 2/5/19 during a clinical record review it was noted that the care plan for Resident # 39 was not updated to address behaviors during ADL care until 11/26/18. During the end of day conference on 2/7/2019 the Administrator was made aware of the issue and no further information was provided. Based on observation, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation the facility staff failed to develop and implement a comprehensive person centered care plan for 4 Residents, (Residents #13, 3, 10, and #39) in a survey sample of 27 residents. 1. Resident #13 was not supervised as indicated by her care plan and the care plan was not measurable relating to supervision. 2. Resident #3 was not supervised as indicated by his care plan and the care plan was not measurable relating to supervision. 3. For Resident #10, the facility staff failed to develop a comprehensive care plan to include feeding assistance, supervision, cueing and oversight. 4. For Resident #39 the facility failed to develop and implement a person centered care plan to address behaviors related to refusing (Activities of Daily Living) ADL care. The findings included: 1. Resident #13 was not supervised as indicated by her care plan and the care plan was not measurable relating to supervision. Resident #13 was a female initially admitted to the facility on [DATE], with diagnoses including but not limited to; Dementia, cognitive communication deficit, hip pain, edema, dysphagia, folate deficiency anemia. The Resident was a Full Code status, meaning that CPR was requested to be performed as needed. The Resident was ambulatory and a known wanderer, with orders for a wanderguard bracelet to monitor the potential for elopement. The most recent Minimum Data Set Assessment (MDS) with an ARD (assessment reference date) of 11-17-18 coded Resident #13 as having a BIMS (brief interview of mental status) of severely cognitively impaired. Resident #13 was coded as needing limited to extensive assistance with ADL's (activities of daily living) such as bathing and dressing from 1 staff member, and for eating required only supervision and set up help. The Resident was ambulatory, and exhibited no negative behaviors. Review of the nursing progress notes revealed the Resident to be documented as docile, pleasant, and easily redirected, with wandering as her only behavior. The Resident liked to push residents wheel chairs to the dining room, and this habit was known by staff. The Nursing progress notes were reviewed from 7-1-18 through the time of survey, for a 7 month period, and no notes indicate any behaviors for this Resident. Bruises were documented in the nursing notes to be observed on the Resident by nursing staff on; 1-23-19, 9-26-18, 9-5-18, and 7-12-18. There is no report to the state agency for these injuries, nor is there any indication that any investigations were conducted to ascertain the cause of the bruises. The Administrator was asked for all investigations in the past year for this Resident, and only the 7-31-18, and 9-4-18 incidents of abuse by Resident #3 were submitted, as the Administrator stated this is all we have for her. Two incidents of assault were documented as having occurred to this Resident, perpetrated by Resident #3. These occurred on 7-31-18, and again on 9-4-18. The first assault was reported to the state agency on 8-1-18, with a follow up report on 8-7-18, and both were timely. The second assault was reported to the state agency on 9-10-18, with a follow up on 9-12-18, and both were late reports. A synopsis of those events follow from the Nursing progress notes of the assailant Resident #3, as no description of the assaults were in the nursing notes of the victim Resident #13, and from the facility reported document, and a complaint that was received by the state agency regarding Resident #3: 7-31-18 Incident 4:54 p.m. The MD (doctor) observed Resident (#3) pull the leg of another Resident (#13) resulting in a fall . The Facility report to the state agency documented that Resident (#13) attempted to push Resident #3's wheel chair toward the dining room, Resident #3 was cursing at Resident #13 prior to grabbing her leg and making her fall. The report goes on to say that Resident #3 has a diagnosis of aggression toward others, and has verbal outbursts cursing staff and residents, and has episodic periods of aggression, in which he has kicked staff and shoved one resident's wheel chair into another resident. The conclusion of the facility in the report was; Resident #3 (name) acted in an aggressive manner. The report stated that the social services director has begun to attempt to identify alternate living arrangements for Resident #3 in the event his behaviors place others at danger, and Nursing staff will attempt to keep Resident #3 (name) and Resident #13 (name) separated. 9-4-19 incident at 8:00 p.m. was documented in the facility report as Resident #13 (name) was walking down the hall, and Resident #3 (name) grabbed her left arm twisting it in an aggressive manner while cursing at her. her wrist was red at the time.The next day a bruise was noted on Resident #13's wrist, and she was sent to the emergency room for evaluation, and returned with only the bruising diagnosis. Resident #3 was quoted as saying She was in his way, and he was trying to move her. The document goes on to say again as the 8-1-18 report stated that the admissions director has been exploring alternative living arrangement for Resident #3 should aggressive behaviors continue. Also, the report states as the previous report of 8-1-18 did, that nursing staff would attempt to keep Resident #13, and Resident #3 separated by redirecting residents away from each other while they are in common areas, and intervene as necessary. The notes indicate continued willful acts on the part of Resident #3, and the fact that Resident #13 is freely wandering with no supervision after 2 assaults by the same Resident, is a deficient practice on the part of the facility who continue to fail to protect Resident #13 from her attacker. Review of Resident #13's plan of care was conducted and revealed the interventions below for Behaviors: Interventions included; Out of room diversional activities - none were specified, instituted 9-1-16, give task, folding towels or organizing papers, instituted 8-30-17, redirect as needed, need not described, instituted 8-30-17, monitor where abouts frequently, not measurable, instituted 9-7-18, relocate when in common areas, no relocation alternative given, instituted 9-7-18, offer doll, instituted 11-26-18, give cart to push as substitute for wheel chair for her safety and others, instituted 1-23-19. Resident #13 was observed multiple times during the day, and on all 3 days of survey, and at no time were any of these interventions observed to be used. The only time supervision was observed, was when staff found Resident #13, where ever she was in the facility, took her hand, and lead her to the dining room at meal time. During group resident council meeting, held with surveyors on 2-6-18 at 2:00 p.m., 9 out of the 13 residents who attended the meeting stated that residents who wander in the facility are a problem. They went on to share incidents of finding this Resident as well as others rummaging through their personal belongings at times, and waking up to find this resident and other residents entering their rooms at night while they are in bed, which was startling to them. No supervision was quantifiable nor measurable in the care plan for this Resident. Who will supervise, when to supervise, and how to supervise this Resident, were not included and were not person centered. This oversight indicated staff was unaware of this Resident's specific needs and how to meet them. In conclusion, the facility failed to maintain adequate supervision of Resident #13, and #3, resulting in at least one known repeated assault by Resident #3. On 2-6-19, and 2-7-19, at the end of day debrief, the facility failure was reviewed with the Administrator, and the Corporate Registered Nurse/ interim Director Of Nursing. No further information was provided by them. 2. Resident #3 was not supervised as indicated by his care plan and the care plan was not measurable relating to supervision. Resident #3 was admitted to the facility on [DATE]. Diagnoses included; mood affective disorder, diabetes, depression single episode, dementia with behavioral disturbance, hypertension and vascular disease. Resident #3's most recent Minimum Data Set Assessment was a quarterly assessment with an assessment reference date of 11-1-18. He was coded with a Brief Interview of Mental Status score of 7, or moderate cognitive impairment. He required only supervision and set up help from staff for all activities of daily living (ADLs), and ambulated independently with a wheel chair. The Resident was coded as Verbal behaviors directed at others 4-6 days out of 7 days. Resident #3 was observed multiple times during the three days of survey independently wheeling himself in unattended hallways, and common areas where Residents were present. Resident #3 did not engage with surveyors, but watched cautiously each time they approached him, and gave only short answers when spoken to, then turned and left the area each time. The Resident was found to be appropriate in his answers and oriented. The Resident did not smile as he was greeted with a smile. Review of social work notes revealed that on 8-7-18 there was an altercation in the activity room with another resident. On 9-5-18, the social work professional documented Resident is a safety risk for this environment due to the random outbursts of aggression and the safety risk for staff and other residents. Review of Nursing progress notes revealed the following incidents of Resident #3's aggressive and abusive behavior in reverse chronological order; 1-28-19 the Resident continues to have behavior issues to include kicking out room mate, and verbal. 1-22-19 This trailer is mine, and my girlfriend comes here, you don't live here! (yelling at room mate) 12-22-18 Resident going into dining room, another resident in front of him moving too slow, Resident #3 pushed the resident hard into a table and Resident #3 had to be pushed in his wheel chair away from the resident due to verbal anger. 10-28-18 Resident #3 became impatient for other residents to enter the dining room in wheel chairs which caused him to have to wait, he yelled move the old B ch out of the way, and a second resident tried to calm him and Resident #3 threatened to hit her, and swung his arm out without making contact. 10-28-18 Resident #3 and a second resident (Resident #3's girlfriend) blocked the door to the TV room and would not allow a third resident to leave the room, Resident #3 yelled out that. he was not going to move, he was waiting for dinner, and the third resident would have to wait to leave the room. 9-4-18 assault on Resident #13, and nursing documented that Resident #3's behaviors seemed to be escalating. 8-14-18 refusing care and cursing at staff. 8-8-18 Altercation spoken of by social worker. 7-31-18 assault on Resident #13. 7-27-18 Resident #3 Shoved another Resident into a third resident upsetting several residents causing an argument between Resident #3 and a fourth resident who witnessed the incident. 7-18-18 Resident observed in dining room cursing and yelling at residents. 6-15-18 yelling at room mate & verbally aggressive. This entails 8 months of continued verbal and physical abuse aimed at multiple residents in the facility. A review of Resident #3's comprehensive care plan included interventions for behaviors. Those include as follows: Monitor for adverse signs of psyche med use - instituted 10-8-18, psyche nurse practitioner to evaluate and treat as necessary instituted 10-8-18, allow to vent feelings instituted 9-7-18, establish trusting relationship and allow time to speak and make choice, maintain calm environment, use soft voice, be welcoming instituted 9-7-18, assist to dining room, redirect if encounter conflict, help problem solve, distract instituted 12-24-18, monitor resident when out of room watching for aggressive physical or verbal behaviors towards other residents should resident exhibit aggressive behaviors remove other resident involved and 1:1 redirection may be provided instituted 9-5-18, monitor resident routinely while in common areas redirect resident to his room should he exhibit aggressive behavior instituted 8-1-18, remove self from harmful behavior exhibited by resident and attempt to perform activity at another time instituted 5-28-18, redirect with therapy or activity of choice if he becomes verbally aggressive instituted 2-27-18, assess record effectiveness of psyche drug treatment instituted 1-11-18. This Resident has been known by the facility as verbally and physically abusive to other residents for a period greater than one year as per the clinical record, On 2-6-19 at 3:30 p.m., a CNA in the hallway by Resident #3's room was asked if the Resident was difficult to care for, she stated, He is pretty mean, and scary at times, and if you don't give him what he wants immediately he gets mad and goes off. On 2-6-19, and 2-7-19, at the end of day debrief, the facility failure develop and implement the care plan of Resident #3 was reviewed with the Administrator, and the Corporate Registered Nurse/ interim Director Of Nursing. No further information was provided by them. 3. For Resident #10, the facility staff failed to develop a comprehensive care plan to include feeding assistance, supervision, cueing and oversight. Resident #10 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #10's diagnoses included Gastro-esophageal Reflux Disease, Generalized Muscle Weakness, Other Chronic Pain, Inflammatory polyneuropathy, Functional dyspepsia, Sarcoidosis, Hypertension, Major Depressive Disorder, Hypokalemia, Heart Disease, and Diabetes Mellitus Type Two. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 8/11/18, coded Resident #10 as requiring the extensive assistance of 2 people for bed mobility, transfers, and dressing. For eating, Resident #10 was coded as requiring supervision to include cueing and oversight. In addition, she was also coded as being on 2 opioid medications (narcotic pain medication that cause drowsiness), and having Shortness of Breath. Resident #10 was on the following physician-ordered medications: (Oxycodone, Tramadol, Elavil, Baclofen, and Neurontin). On 2/5/19 at 12:00 Noon, a review was conducted of the facility kitchen with the Dietary Manager (Employee E). The temperature logs were reviewed. The food temperatures had not been taken for the breakfast or lunch meals. In addition, coffee and hot water logs had not been done since January 2019. At that time the coffee and hot water temperatures were recorded as being between 175- 180 degrees Fahrenheit. When asked if the hot liquid temperatures were ever taken, the Dietary Manager stated, Oh, it's always extremely hot. On 2/5/19 at 12:30 P.M., an observation was conducted of Resident #10 in the dining room during lunchtime, for approximately 30 minutes. There were approximately 20 residents eating in the dining room. The two Certified Nursing Assistants were at other tables feeding other residents. Resident #10 sat at a table with two other residents. There were no facility staff present who provided supervision, including cueing and oversight for any of the three residents at the table. At 12:35 P.M., a staff person who was serving hot liquids, including coffee and hot chocolate to several of the residents, served Resident a cup of hot chocolate that had steam coming out of it at a brisk pace. She did not take the temperature prior to serving it. The cup did not have a lid on it. The facility cook (Employee D) was asked to take the temperature of Resident #10's hot chocolate. It took her approximately 5 minutes to obtain an thermometer and arrive at Resident #10's table. The surveyor obtained Resident #10's permission to allow the cook to take the temperature of her hot chocolate. The cook stated that the temperature was 158.35 degrees. At 12:50 P.M. the cook (Employee D) tested the water in the thermos that was used to make Resident #10's hot chocolate. It was 164 degrees Fahrenheit. In addition, at 1:00 P.M. the Dietary Manager (Employee E) stated that the hot water thermos that was in the kitchen had a temperature of 178.2. The Burn Care Foundation accessed on 2/12/19 at 11:56 A.M. at the website http://www.burncarefoundation.org/safety/hot-water-exposure.html provided the following information on burns: Exposure to 131° F water for 17 seconds would cause a second degree burn and exposure of 30 seconds would cause a third degree burn Exposure to 140° F water for 3 seconds would cause a second degree burn and exposure of 5 seconds would cause a third degree burn The following definition of scald was accessed on 2/11/19 at 12:00 P.M. at the Merriam Webster website found at https://www.merriam-webster.com/dictionary/scald: SCALD: To burn with or as if with hot liquid or steam. On 2/5/19, the facility was asked to provide a list of all residents who had received a Hot Liquid Assessment. Resident #10's name was not on the list. In addition, a review was conducted of Resident #10's clinical record. Both her paper chart, and computer chart were reviewed, including all documentation since the previous survey. Resident #10 had not received a Hot Liquid Assessment. Resident #10's care plan did not address feeding assistance, including supervision, cueing and oversight. It did address dehydration. It read: Resident is at risk for dehydration related to use of diuretic for hypertension. Assist with fluids for dehydration. On 2/7/19 at approximately 4:00 P.M., an interview was conducted with the MDS consultant (Employee K). When asked if she had ever worked with Resident #10, she stated that she hadn't worked with her. The MDS consultant was asked how often and under what circumstances Resident #10 required feeding assistance. She stated, When in doubt, provide the help. You can't supervise the resident if you're not there with her. On 2/7/19, after the last meeting with the facility prior to exit, the Director of Nursing (Employee B) stated that Resident #10 had a Hot Liquid Assessment done on 5/2/18, which stated that Resident #10 did not require supervision for eating/drinking. When asked where the assessment had been located since it was not in the clinical record, the DON stated, I don't know. When asked why the assessment conflicted with the MDS assessment, the DON stated, I don't know. When asked to explain what the dehydration care plan meant by the phrase, Assist with fluids for dehydration, the DON repeated the phrase twice. On 2/7/19 a review was conducted of facility documentation, revealing a Hot Liquid Assessment Policy dated 4/6/18. It read, Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. Assessments will be completed with residents on admission/readmission, quarterly and with significant changes by a licensed nurse. On 2/7/19 at 4:30 P.M. the facility Administrator (Employee A) was notified of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 53, the facility staff failed to document the administration of multiple medications as ordered by the physician. Resident # 53 was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to Gastrointestinal hemorrhage, Muscle Weakness, Multiple fractures of ribs, left side, Malignant neoplasm of bronchus or lung, Malignant neoplasm of Kidney, long term use of anticoagulants, chest pain, fracture of sternum and Dementia without behavioral disturbance. Resident # 53's most recent Minimum Data Set (MDS) was a 30 day assessment with an Assessment Reference Date (ARD) of 1/15/2019. The MDS coded Resident # 53 with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating no cognitive impairment. Resident # 53 required supervision with no set up or physical help to set up help only assistance for activities of daily living except required supervision with assistance of one staff person for bed mobility and always continent of bowel and bladder. Review of the clinical record was conducted on 2/5/2019 at 2:30 PM. Review of the MAR (Medication Administration Record) revealed documentation of Late Administration for medications numerous times. The Late Administration: Charted Late documentation included but not limited to: February 2019 MAR- Metoprolol 25 milligrams by mouth once a day-Scheduled at 7:30 AM-Late 3 times Late Administration: Charted Late: 2/2/19, 2/3/19, 2/4/19 Levothyroxine 25 micrograms by mouth once a day, Scheduled at 7:00 AM, 4 times Late Administration:Charted Late: 2/2/19, 2/3/19, 2/4/219, 2/5/19 Ferrous Sulfate 325 milligrams one tablet by mouth before meals Scheduled 7:30 AM, 11:30 AM, 4:30 PM- 7 times Late Administration : Charted Late: 2/1/19 11:30 AM, 2/1/19 4:30 PM, 2/2/19 7:30 AM, 2/2/19 11:30 AM, 2/3/19 7:30 AM, 2/3/19 11:30 AM, 2/4/19 7:30 AM, 2/4/19 4:30 AM, 2/5/19 4:30 PM Voltaren gel 1% 4 gram aliquot topical twice a day before and after Physical Therapy: Late Administration 2/2/19, 2/4/19 January 2019 MAR - Aspirin delayed release 81 milligrams by mouth once a day- two times-Late Administration: Charted Late, Comment: Busy Atorvastatin 20 milligrams by mouth at bedtime- 4 times Late Administration: Charted Late Comment-given, Comment okay (3 separate times) 1/14/19, 1/15/19, 1/21/19, 1/22/19 Carbidopa-levodopa extended release 25-100 milligrams one tablet per day- 2 times Late Administration: Charted Late: Comments, busy and given) 1/1519, 1/22/19 Ferrous Sulfate 325 milligrams three times per day before meals: 59 times Late Administration Charted Late Comments: busy, n/a (not applicable), done, ok and given Folic Acid 1 milligram by mouth once a day- 2 times Late Administration Comments: busy, given) 1/15/19, 1/22/19 Gabapentin 100 milligrams by mouth twice a day, 4 times Late Administration Comments: busy, given x 3) 1/15/19, 1/16/19, 1/22/19, 1/28/19 Isosorbide 30 milligrams by mouth twice a day, 4 times Late Administration Comments: busy, given x 3) 1/15/19, 1/16/19, 1/22/19, 1/28/19 Levothyroxine 25 micrograms once a day. Scheduled at 7:00 AM- 28 times Late Administration-charted late every day in January except 1/5/19 and 1/25/19 Megestrol Suspension 40 milligrams per milliliter give one milliliter three times per day 24 times Late Administration: Charted Late: Comments: ok, n/a, given, done, ok, administered Megestrol Suspension 40 milligrams per milliliter give one milliliter three times per day: 4 times Not administered due to Drug unavailable. 1/14/2019 at 1:00 PM, 1/29/2019 at 5:00 PM, 1/31/2019 at 1:00 PM, 1/31/2019 at 5:00 PM Metoprolol 25 milligrams by mouth once a day Scheduled at 7:30 AM 24 times Late Administration: Charted Late Comments: n/a, busy, administered, done and given. Omeprazole delayed release 40 milligrams by mouth once a day 2 times Late Administration: Charted Late 1/15/19 and 1/22/19 Review of the Medication Administration Records revealed documentation that several medications were not available from the Pharmacy during December 2018 to January 2019. Percocet 5-325 milligrams Schedule II one tablet by mouth twice a day for pain. 1/29/2019 5:00 PM to 9:00 PM-Not Administered: Drug/Item Unavailable . Comment: Patient reports no pain. Eliquis 5 milligrams one tablet by mouth twice a day. (Anticoagulant) 12/8/2018 5:0 PM - 9:00 PM- Not Administered: Drug/Item Unavailable 12/9/2018 7:30-11:30 AM- Not Administered: Drug/Item Unavailable Flomax 0.4 milligrams by mouth once a day; 12/1/2018 7:30 AM-11:30 AM Not Administered: Drug/Item Unavailable Isosorbide dinitrate 30 milligrams by mouth twice a day- 12/21/2018 7:30 AM-11:30 AM-Not Administered: Drug/Item Unavailable Review of the Facility's Medication Administration Policy and Procedure date 8/28/2018. stated: Approved by Executive Director of Clinical Operations. Professional Reference Fundamentals of Nursing, 9th Edition by [NAME], [NAME], [NAME], Hall . Purpose: To administer medications safely to residents according to physicians orders. Policy: Medications shall be prepared, administered and charted by the same person as ordered by the physician. Under Specific Procedures/Requirements 1. Medications are given at the time ordered or within (1) hour before or after the time designated. 2. The medication administration shall be charted as soon after administration as possible. 3. During medication administration, the nurse verifies the resident's identity, the medication order matches the drug and dose from the pharmacy, and the route and time of the order to ensure resident safety. Review of the Progress Notes revealed documentation of an eMar Further review of the Progress Notes revealed other documentation of medications not available from the pharmacy. On 2/6/2019 at 9 AM, an interview was conducted with LPN (Licensed Practical Nurse) B who stated the staff should notify the Pharmacy when medications are not available. On 2/7/2019 at 9:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) C, who gave a demonstration regarding the process for charting medications. She stated that medications are charted as prep, then given then prepped and given and then the nurse must press the Complete button at the bottom of the screen. She stated that, if a medication is given more than one hour late, the nurse is given a choice via a drop down box regarding the reason for late administration. The choices are Administered Late, Charted Late, Drug not Available , Resident unavailable. On 2/7/2019 at 1:45 PM, an interview was conducted with the Administrator who stated the Pharmacy should have medications available for administration as per Physicians Orders. The Administrator was asked to present a copy of the Stat Box medications list to determine if the missing medications were available in that supply. The Administrator stated medications should be given as ordered by the Physician and documented immediately after administration. The Administrator stated not documenting at the time of administration could increase the risk of errors. Review of the Interim/Stat Box contents list revealed the Medication, Folic Acid 1 milligram was available to the staff. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, [NAME]-[NAME], p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. During the end of day debriefing on 2/7/2019, the Facility Administrator, Director of Nursing and Corporate Nurse were informed of the findings. The Administrator stated the Pharmacy should ensure medications were available for administration as ordered by the physician and nurses should administer medications as ordered by the physician and document immediately after administration. No further information was provided. 3. For Resident # 27, the facility staff failed to document the administration of multiple medications as ordered by the physician. Resident # 27, a female, was admitted to the facility 3/24/2007. Her diagnoses included but were not limited to: Hemiplegia and hemiparesis following Cerebrovascular disease affecting left non-dominant side (stroke), Anxiety Disorder, Disorder, Gastroesophageal reflux Disease, Diabetes, Hypertension and muscle weakness. Resident # 27's most recent MDS with an ARD of 12/15/2018 was coded as a quarterly assessment. Resident # 27's BIMS (Brief Interview for Mental Status) Score was 12 out of a possible 15, indicating moderate cognitive impairment. Resident # 27 was coded as needing extensive assistance of one staff member to perform her activities of daily living except supervision for eating and total assistance of one staff person for bathing . Resident # 27 was coded as being able to hear, speak, understand, and be understood. Resident # 27 was always incontinent of bowel and occasionally incontinent of bladder. Review of the clinical record was conducted on 2/6/2019 at 12:25 PM. Review of the January 2019 Medication Administration Records revealed documentation that medications were administered late numerous times. Amlodipine 5 milligrams one tablet by mouth once a day, scheduled at 9:30 AM- 8 times Late Administration-1/7, 1/11, 1/13. 1/19, 1/21, 1/27, 1/28, 1/29/19 Azelastine drops 0.05% one drop each to each eye, ophthalmic twice a day, scheduled at 9:30 AM- Late Administration 11 times Novolog Insulin 12 units subcutaneously before meals. Late Administration 52 times during the month of January 2019, including 7 times with documentation of Administered late, Comment: Busy Glipizide extended release 24 hour; 5 milligrams one tablet by mouth once a day scheduled time 9:30 AM. 7 times Late Administration: (3 times Administered Late, Comment: busy, busy, breakfast 4 times-charted late Comments computer issues, administered on time, and busy. Guidance for nursing standards for the administration of medication is provided by Fundamentals of Nursing, 7th Edition, [NAME]-[NAME], p. 705: Professional standards, such as the American Nurses Association's Nursing : Scope and Standards of Nursing Practice (2004) apply to the activity of medication administration. To prevent medication errors, follow the six rights of medications. Many medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration. The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation. During the end of day debriefing on 2/7/2019, the Facility Administrator, Director of Nursing and Corporate Nurse were informed of the findings. The Administrator stated the Pharmacy should ensure medications were available for administration as ordered by the physician and nurses should administer medications as ordered by the physician and document immediately after administration. No further information was provided. Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow the professional standards for the administration and documentation of medication administration in a timely manner for 3 Residents (Residents # 41, 53, and 27) in a survey sample of 27 residents. 1. For Resident #41, the facility staff failed to administer insulin in a timely manner on many days during the months of December, 2018 and January, 2019. 2. For Resident # 53, the facility staff failed to document the administration of multiple medications as ordered by the physician. 3. For Resident # 27, the facility staff failed to document the administration of multiple medications as ordered by the physician. The Findings included: 1. For Resident #41, the facility staff failed to administer insulin in a timely manner on many days during the months of December 2018 and January 2019. Resident #41 was a [AGE] year old who was admitted to the facility on [DATE]. Resident #41's diagnoses included Hypertension, Chronic Obstructive pulmonary Disease, and Type Two Diabetes Mellitus with Diabetic Nephropathy. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 1/2/19 was reviewed. Id coded Resident #41 as having a Brief Interview of Mental Status Score of 15, indication that she had intact cognition. On 2/5/19 at 2:40 P.M., an interview was conducted with Resident #41. She complained about her insulin not being administered in a timely manner. Resident #41 stated, The nurses are always late giving me my insulin. On 2/5/19 a review was conducted of Resident #41's clinical record, revealing the following signed physician's orders dated December, 2018 and January, 2019: Basaglar KwikPen U-100 Insulin Administer 30 units every night. For December, according to the Medication Administration Record, the 8:00 P.M. medication was administered late on the following dates/times: 12/2/18 at 9:53 P.M. 12/3/18 at 9:24 P.M. 12/4/18 was charted on 12/6/18 at 12:38 A.M. 12/11/18 at 10:43 P.M. 12/19/18 at 10:14 P.M. During January 2019, the 5:00 P.M. medication was administered late on the following dates/times: 1/4/19 at 10:26 P.M. 1/5/19 at 9:56 P.M. On 2/5/19 a review was conducted of facility documentation, revealing a Medication Administration Policy dated 8/26/18. It read, Purpose: To administer medications safely to residents according to physician orders. The medication administration shall be charted as soon after administration as possible. On 2/5/19 at 2:10 P.M., an interview was conducted with Resident #41's nurse. Licensed Practical Nurse (LPN B). When asked why she had administered Resident #41's insulin late on several occasions, she stated, The Aids are always calling me away to help them with lifts, transfers, dressing, bathing, etc. Also at times we only have 4 aides instead of 6 aids for the facility. Guidance for professional standards of nursing for documentation of medication administration was identified. Document all medications administered in the patient's MAR or EMAR. If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. [NAME] Solutions Safe Medication Administration Practices, General 10/02/2015. On 2/06/19 at 3:32 P.M., an interview was conducted with the facility Administrator, who is also a Registered Nurse. The Administrator stated that the expectation is that they document administration right after they give it. If they have total recollection they can go back and document a late entry. Each nurse is responsible to give meds to 22 residents. The nursing standard is to document when you give the medication. When asked why timely documentation was important, the Administrator stated, so that you know exactly what you are administering. This is to decrease the mistakes. The Administrator stated that the facility used [NAME] for their nursing standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #25 the facility failed to give Metoprolol Succinate according to physician parameters and failed to administer insulin. Resident #25 an [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Dementia, with behavioral disturbance, depression, insomnia, atrial fibrillation, heart failure and diabetes. Resident # 25's most recent (Minimum Data Set) MDS (Brief Interview of Mental Status) BIMS Score was 14 indicating mild cognitive impairment. On 2/5/2019 during initial tour resident # 25 stated she liked the facility and the nurses but sometimes her medications were late but she didn't like to complain because she knew they were busy. On 2/6/2019 a clinical record review was conducted and it was found that Resident #25 had an order that stated: Metoprolol Succinate tablet extended release 24 hr.; 50 (Milligram) MG; Amount to administer 50 MG daily; oral Special Instructions: Hold for (Systolic blood pressure) SBP of less than 100 or (Heart Rate) HR less than 60 On 1/08/19 Resident #25 was not given her Metoprolol Succinate extended release tablet 50 MG. The reason sited on the (medication administration record) MAR stated Not Administered: Other Comment: not given due to low B/P. The recorded blood pressure for that day was 119/54 and heart rate of 74. On 1/24/19 the same medication was held and MAR stated Not Administered: Other Comment: not given due to low B/P. The recorded blood pressure for that day was 108/50 and heart rate was 85. Employee C (DON in training) was interviewed on 2/7/19 and she stated that Systolic blood pressure means the top number or first number in the blood pressure and HR were the initials for Heart rate. She stated further that she had no information why the medication was held there were no nursing notes about it being held other than the blood pressure. She stated that the medication should have been given because the parameters were clear on when to hold the medication. The MAR also documented the Resident as having an order that stated: Tresiba Flex Touch U-100 (Insulin Degludec) Insulin Pen; 100 units/ml [Milliliter]; Amount to administer; 15 units; subcutaneous Frequency; Once an evening. For Type 2 Diabetes. The insulin was scheduled to be given at 7:00 PM. On 1/18/2019 the medication was given at 10:13 PM and under reasons/comments it stated Late Administration. On 2/7/29 Employee C was asked to provide any information on this and stated I have no information on why it was late there are no nursing notes to elaborate on why it was late. On 2/7/2019 the Administrator was made aware of this issue and no further information was provided. Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure that four Residents were free from significant medication error (Residents # 53, 27, 52, and 25 ) in a survey sample of 27 Residents. 1. For Resident #53, the facility failed to administer anticoagulant medication as ordered by a physician. 2. For Resident #27, the facility failed to administer insulin as ordered by a physician, was administered late numerous times 3. For Resident #52, the facility staff failed to ensure that a significant medication error did not occur due to unavailable insulin for a period of 14 days. 4. For Resident #25 the facility failed to give Metoprolol Succinate according to physician parameters and failed to administer insulin. Findings Included: 1. For Resident #53, the facility failed to administer anticoagulant medication as ordered by a physician. Resident # 53 was an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to Gastrointestinal hemorrhage, Muscle Weakness, Multiple fractures of ribs, left side, Malignant neoplasm of bronchus or lung, Malignant neoplasm of Kidney, long term use of anticoagulants, chest pain, fracture of sternum and Dementia without behavioral disturbance. Resident # 53's most recent Minimum Data Set (MDS) was a 30 day assessment with an Assessment Reference Date (ARD) of 1/15/2019. The MDS coded Resident # 53 with a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating no cognitive impairment. Resident # 53 required supervision with no set up or physical help to set up help only assistance for activities of daily living except required supervision with assistance of one staff person for bed mobility and always continent of bowel and bladder. Review of the clinical record was conducted on 2/5/2019 at 2:30 PM. Review of the MAR (Medication Administration Record) revealed documentation of the Anticoagulant Eliquis not being administered on two consecutive days Eliquis 5 milligrams one tablet by mouth twice a day. (Anticoagulant) 12/8/2018 5:0 PM - 9:00 PM- Not Administered: Drug/Item Unavailable 12/9/2018 7:30-11:30 AM- Not Administered: Drug/Item Unavailable Valid physician orders were evident for the medications in question. Review of the facility's policy entitled, Medication Administration revealed that all medications are to be given according to the prescriber's order and signed/documented by the administering individual as soon as the medication is given. When interviewed on 2/6/19 at 2:00 PM, the DON (director of nursing) stated that she had identified the failure of the staff to ensure medications and treatments were documented as being administered. The DON stated the facility had implemented a new policy that allowed the nurses up to 8 hours to document the administration of medications. The DON stated the nurses were often busy and could not document at the time of administration of medications but the medications were given on time. The DON stated she was aware that the nursing standard was for medications to be documented immediately after administration. On 2/6/19 at 4:30 PM, an interview with the Administrator who stated her expectation was for staff to administer medications and treatments per physician's orders and to document them as having been administered, immediately following administration. The administrator and DON were informed of the failure of the staff to ensure significant medications were administered and documented, on 2/7/2019 at 4:00 PM. No further information was provided by the facility. 2. For Resident # 27, the facility failed to administer insulin as ordered by a physician, was administered late numerous times. Resident # 27, a female, was admitted to the facility 3/24/2007. Her diagnoses included but were not limited to: Hemiplegia and hemiparesis following Cerebrovascular disease affecting left non-dominant side (stroke), Anxiety Disorder, Disorder, Gastroesophageal reflux Disease, Diabetes, Hypertension and muscle weakness. Resident # 27's most recent MDS with an ARD of 12/15/2018 was coded as a quarterly assessment. Resident # 27's BIMS (Brief Interview for Mental Status) Score was 12 out of a possible 15, indicating moderate cognitive impairment. Resident # 27 was coded as needing extensive assistance of one staff member to perform her activities of daily living except supervision for eating and total assistance of one staff person for bathing . Resident # 27 was coded as being able to hear, speak, understand, and be understood. Resident # 27 was always incontinent of bowel and occasionally incontinent of bladder. Review of the clinical record was conducted on 2/6/2019 at 12:25 PM. Review of the February 2019 Medication Administration Records (MAR) revealed the following documentation: Basaglar KwikPen Insulin 32 units subcutaneous once a morning scheduled at 7:30 AM Not Administered on 12/28/2018- no blood sugar documented. Novolog Insulin 12 units subcutaneous before meals, 7:30 AM, 11:30 AM , 4:30 PM - Late 9 times in February 2019- 2/1/19-11:30 AM given at 1:58 PM, 2/1/19 4:30 PM, 2/2/19 at 7:30 AM, 2/3/19 at 4:30 PM, 2/4/19 at 7:30 AM, 2/4/19 at 4:30 PM, 2/5/19 at 7:30 AM, 2/5/19 at 11:30 AM, 2/5/19 at 4:30 PM Review of January 2019 MAR revealed the following documentation: Basaglar KwikPen Insulin 32 units subcutaneous once a morning scheduled at 7:30 AM- Late Administration 1/31/19 Basaglar KwikPen Insulin 32 units subcutaneous in the evening scheduled at 6:30 PM: Late Administration: 1/31/19 Novolog Insulin 12 units subcutaneous before meals, 7:30 AM, 11:30 AM , 4:30 PM- Late 2 times: 1/31/19 7:30 AM, 1/31/19 4:30 PM Review of December 2018 MAR revealed the following documentation: Basaglar KwikPen Insulin 32 units subcutaneous once a morning scheduled at 7:30 AM Not Administered on 12/28/2018- no blood sugar documented. Basaglar KwikPen Insulin 32 units subcutaneous once a morning scheduled at 7:30 AM-16 times Late Administration: 12/4/18, 12/6/18, 12/7/18, 12/9/18, 12/10/18, 12/11/18, 12/12/18, 12/13/18, 12/14/18, 12/17/18, 12/21/18,12/23/18, 12/24/18, 12/25/18, 12/26/18, 12/27/18, Basaglar KwikPen Insulin 32 units subcutaneous in the evening scheduled at 6:30 PM: 14 times Late Administration- 12/3/18, 12/4/18, 12/6/18, 12/7/18, 12/12/18, 12/13/18, 12/14/18, 12/15/18, 12/21/18, 12/24/18, 12/25/18, 12/27/18, 12/28/18, 12/29/18 Novolog Insulin 12 units subcutaneous before meals, 7:30 AM, 11:30 AM , 4:30 PM- Late Administration: 12/28/18 11:30 AM Valid physician's orders were evident for the medications in question. Review of the facility's policy entitled, Medication Administration revealed that all medications are to be given according to the prescriber's order and signed/documented by the administering individual as soon as the medication is given. When interviewed on 2/6/19 at 2:00 PM, the DON (director of nursing) stated that she had identified the failure of the staff to ensure medications and treatments were documented as being administered. The DON stated the facility had implemented a new policy that allowed the nurses up to 8 hours to document the administration of medications. The DON stated the nurses were often busy and could not document at the time of administration of medications but the medications were given on time. The DON stated she was aware that the nursing standard was for medications to be documented immediately after administration. On 2/6/19 at 4:30 PM, an interview with the Administrator who stated her expectation was for staff to administer medications and treatments per physician's orders and to document them as having been administered, immediately following administration. The administrator and DON were informed of the failure of the staff to ensure significant medications were administered and documented, on 2/7/2019 at 4:00 PM. No further information was provided by the facility. 3. For Resident #52, the facility staff failed to ensure that a significant medication error did not occur due to unavailable insulin for a period of 14 days. Resident #52 was an [AGE] year old who was admitted to the facility on [DATE]. Resident #52's diagnoses included: Diabetes Mellitus Type Two, Hyperlipidemia, Dementia, Seizure Disorder, Traumatic Brain Injury, Anxiety Disorder, and Post Traumatic Stress Disorder. The Minimum Data Set, which was a Quarterly Assessment with an Assessment Reference Date of 1/15/19, was reviewed. It coded Resident #52 as having a Brief Interview of Mental Status Score of 2, indicating severe cognitive impairment. On 2/6/19 a review was conducted of Resident #52's clinical record, revealing the following signed physician order, Bydureon Injection 2 MG subcutaneously one time a day every week on Monday. The Medication Administration Record for January, 2019 was reviewed. On Monday, 1/28/19 11:53 A.M. it read, Not Administered Drug item unavailable In addition, Resident #52's nursing progress notes were reviewed. There was no documentation of the physician being notified that the medication was unavailable, or that the facility staff decided to allow Resident #52 to go without his medication for an extra week, for a total of 14 days between doses. On 02/06/19 at 4:53 P.M., an interview was conducted with Resident #52's Registered Nurse (Employee C). She stated, It was delivered on the night of the 1/24/19. He didn't get the dose that morning we decided to wait until the following Monday to give it to him. She further stated that she could not find any documentation that the doctor had been notified. On 2/6/19 at 5:00 P.M. the facility Administrator (Employee A) was notified of the findings. No further information was received.