Based on interview, clinical record review, and facility documentation, the facility staff failed to ensure proper notification to the resident representative for 1 Resident (#21) in a survey sample of 12 Residents. The findings included: For Resident #21 the facility staff failed to notify family and attending physician of Resident #21 missing her dialysis appointment. On 2/21/23 a review of the clinical record revealed a progress note that read as follows: 12/30/21 3:55 PM - Resident refused to go to dialysis today. She was asked four different times and continued to refuse. The dialysis center was contacted and said they would let the doctor know. The clinical record did not document notification of the Resident Representative or MD on 12/30/21. There was no documentation at all for 12/31/21. On 2/22/23 at approximately 2:00 PM an interview was conducted with DON who stated that it is the expectation that the nurse documents notification of MD and Resident Representative. When asked if it is expected that the nurse document the Resident going out of the building for dialysis or other appointments, she stated that it was. When asked if the facility staff should notify the attending if dialysis was missed, she stated that they should. Employee E stated that staff are supposed to fill out an rCares form if there is a transportation issue so that corporate can track it and file complaints with the transportation company. The Administrator submitted 2 rCares forms dated are 12/22/21 and 1/18/22. A review of the clinical record revealed that there was no progress note documentation for missing dialysis on 12/22/21 or the notification of MD and RR. On 2/23/23 during the end of day meeting the concerns were shared with the Administrator and 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 staff failed to ensure that Residents who require dialysis receive such services for 1 Resident (#21) in a survey sample of 12 Residents. The findings included: The facility staff failed to ensure that Resident #21 had transportation to dialysis appointments. On 2/22/23 during clinical record review it was found that Resident #21 missed several dialysis appointments due to lack of transportation. The facility submitted 2 rCares forms for Resident #21 about not being picked up for Dialysis during the timeframe of 12/1/21 - 1/25/22. The dates of the rCares submitted are 12/22/21 and 1/18/22. In addition, there is documentation in the progress notes that read: 1/15/22 1:08 PM - resident did not received dialysis this shift due to transportation issues, dialysis rescheduled for Monday the 17th with a chair time of 3:15 PM, transportation center to pick up resident between 2:00 - 2:15 PM. On 1/17/22 at 4:53 PM the progress note read: Noted that resident has not yet been picked up. Call being place [sic] to transportation company at [phone number redacted] for ETA. Informed that the appointment was not set up and that she is not set for Tues with her normal time. [MD name redacted] here and will be notified. Primary nurse and DON aware. [MD name redacted] to call and discuss with family. Hospital records were obtained, and the Resident was sent to the ER on [DATE] and returned the same night. The hospital note read: [MD name redacted] calling from [facility name redacted] is sending pt. to [hospital name redacted] for evaluation and treatment, she was seen at the same this morning issues are positive blood cultures, missed dialysis, missed antibiotics, Severe aortic stenosis. Missed dialysis and overdue by 2 days. Patient was seen in this facility on 1/21/22 and discharged after discussion with Nephrology about need for dialysis. They said she could go to regularly scheduled dialysis. [Facility name redacted] states they have appropriate transportation and tomorrow is patients scheduled dialysis. Excerpts from the progress note on 1/24/22 at 12:23 AM read: This nurse arrived for second shift and was informed of resident's situation and that she would be non-emergent brought to the [hospital name redacted] ED. She did not have dialysis. Resident clearly retaining fluid - face swollen - this nurse was told she did not have dialysis in approximately 2 weeks. emergency room note for 1/24/22 at 11:43 PM read: 83 yr. old female presents via EMS (Emergency Medical Services) for evaluation of possible dialysis. Patient is a resident of [facility name redacted] and has missed her last 2 episodes due to transportation issues. Staff noted today increased swelling in face. On 2/23/23 at 10:30 AM a telephone interview with the Medical Director who stated that he was aware they have had transportation issues with getting this patient to dialysis and that they did send her out to the hospital ER for evaluation and treatment when she needed it. On 2/23/23 at approximately 2:00 PM an interview was conducted with the Administrator who stated that during the timeframe in question there were a lot of problems with transportation. The facility also submitted an email statement that read: The process for delays and no shows is once we are made aware we then call the payer and file a complaint and then document the complaint number in the transfer center documentation. Their communication to me is that once a vendor has a certain number of complaints the contract is terminated. Please make sure the facilities are putting transfer center as the responsible facility or we do not get the r Care. We get this report weekly. I have also been in contact with several individuals in Richmond DMAS concerning this issue and patients who have life sustaining treatments such as dialysis. Challenge is our more rural areas and lack of vendors. A facility document named SNF Outpatient Dialysis Service Agreement. Page 3 paragraph 4 read: 4. The Nursing Facility shall be responsible for arranging for suitable and timely transportation of the ESRD Residents to and from the ESRD Dialysis Unit, including the selection of mode of transportation, qualified personnel to accompany the ESRD Residents, transportation equipment usually associated with this type of transfer or referral in accordance with the applicable federal and state laws and regulations and all costs or transportation expenses associated with such transfer. The Nursing Facility shall be responsible for ensuring that the ESRD Residents are medically stable to undergo such transportation and medically suitable to receive treatment at the ESRD Dialysis Unit. On 2/23/23 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility failed to report an incident of neglect, which was also an unusual occurence for 1 Resident (Resident #54) in a survey sample of 31 Residents. On 6/11/21, Resident #54, who was a full code was found unresponsive. Four staff members, (CNA A, CNA B, LPN A, RN A), all of which were CPR certified, neglected to provide any type of emergency medical care, to include CPR. The staff response was neglegnt, as well as an unusual occurence; and the facility staff failed to report the event to the OLC (Office of Licensure and Certification), APS (Adult Protective Services), and other authorities as required. The findings included: Resident #54, diagnosis included but were not limited to: CAD (coronary artery disease), HTN (hypertension), old myocardial infarction, diabetes, and anxiety disorder. Resident #54's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4/8/21 was coded as a quarterly assessment. Resident #54 was coded as having had cognitive impairment and moderately impaired cognitive skills for daily decision making. He was also coded as having required extensive assistance of one staff member for activities of daily living. On 7/7/21, during a clinical record review it was determined that Resident #54 had elected to be a Full Code, wishing to have CPR in the event of cardio pulmonary arrest. Resident #54, had a physician order entered into his electronic clinical record on 1/19/21, the day of admission that read, Full Code. The Social Worker, Employee H, entered a progress note into the clinical record on 1/19/21 at 16:14, that read, Resident is a FULL CODE. Review of the careplan for Resident #54 revealed an entry that read, Resident and RR [responsible representative] desire FULL CODE status, the associated goal for this careplan read, Resident's FULL CODE status designation, will be honored, through next review. Review of the nursing notes dated 6/11/21 at 6:30 AM, an entry read, resident was noted to be shivering stated was cold temp 99.0 rectal denied discomfort or pain given blanket and will continue to observe. The next entry read, resident expired 0930, no heart nor lung sounds heard upon auscultation, no response to verbal or painful stimuli that was entered at 9:48 AM, on 6/11/21, by RN A. There was no evidence in the clinical record of CPR being initiated, 911 being called, or any emergency medical treatment being provided to Resident #54 when he was found unresponsive and without vital signs. Throughout the entire clinical record, there was no evidence to suggest that any emergency medical treatment, to include but not limited to, CPR was attempted or initiated on Resident #54. On 7/7/21 at 3:19 PM, an interview was conducted with CNA A. CNA A was asked about the events involving Resident #54 on 6/11/21. CNA A stated, she had his meal tray and when she attempted to deliver it she didn't find Resident #54 in the common areas, where he normally sits. CNA A then stated, I went and asked [CNA B name redacted] where he was, she said he wasn't feeling well so he was still in bed. CNA A proceeded to state she went to take the tray into the room and he wouldn't answer, I'm still fairly new and had never experienced anything like that so I went and got [CNA B name redacted]. She (CNA B) went in, checked his pulse and tried to wake him, she said oh my God, I think he's gone and went to get [LPN A name redacted], I didn't go back, until I helped [CNA B name redacted] clean him up afterwards. CNA A confirmed that she neglected to initiate CPR despite being CPR certified. CNA A went on to state, they did a huddle afterwards and asked questions but it hasn't been talked about since that day. On 7/7/21 at 3:22 PM, an interview was conducted with CNA B. CNA B stated, [CNA A name redacted] asked where he was and went to take his breakfast tray to him, then she came to me and said I'm trying to wake him and he won't wake up, so I went in. I could tell he was deceased so I went to get the nurse. [LPN A name redacted] came into the room and she looked him over, she was checking him and [RN A name redacted] came to check for a pulse, they said he wasn't alive, he's gone, that was it, so I verified they were done and [CNA A name redacted] and I cleaned him up, gave him a bath and changed him. I didn't even think to check he wasn't a DNR [do not resuscitate], had I known he was a full code I would have started CPR. It was about 3-4 extra people here that day from corporate and they came and said he was a full code and we had to start CPR. No body started CPR until after I had cleaned him and he had been laying there an hour. When asked where the breakdown was, CNA B stated, initially it should have started with the CNA that found him not responding, but I also dropped the ball. On 7/7/21 an interview was conducted with LPN A. LPN A confirmed that Resident #54 was a full code and CPR should have been performed. LPN A further acknowledged that despite several staff who were CPR certified responding to check Resident #54 CPR was not immediately initiated and RN A pronounced the Resident deceased . In the afternoon of 7/7/21, an interview was conducted with the facility Administrator and Corporate Clinical Director/Employee D. When asked if this event on 6/11/21, involving Resident #54 was considered an unusual occurrence, the Administrator said yes. When asked if a FRI (facility reported incident) report had been submitted, the Corporate Clinical Director stated, we decided not to do a FRI after we talked to our counterparts [later identified as Corporate Office Staff/ Employees E and Employee F]. On 7/8/21 the facility Administrator provided the survey team with a FRI that had been submitted to the OLC (Office of Licensure and Certification), APS (Adult Protective Services), and the Ombudaman on 7/7/21. This report read, July 7, 2021 re: First and Final Facility Reported Incident of June 11, 2021. Findings: After investigation, it was determined that CPR was not initiated to the Resident timely. Actions: All corrective actions will be completed 7/23/21. On 7/8/21 at 8:50 AM, an interview was conducted with the facility Administrator. The Administrator was asked to define neglect, she stated, it is any action, it can be many things, not providing medications, food, safe situations, not providing care someone needs. She was asked if, the failure to provide CPR or emergency medical treatment to a Resident who is not responsive is considered negligent, she stated, I would not say that, I would say it was a lack of education. When asked if she would describe her interactions with staff following the incident, the Administrator stated and described her interactions with CNA A as a welfare check, I wanted to see how she was and talk about the situation. The Administrator further acknowledged that the facility staff was still conducting investigations as of 7/7/21. On 7/9/21 at 9:02 AM, an interview was conducted with Employee H, the Social Worker. Employee H, the social worker defined neglect as, not being tended to, not providing what is needed. Employee H was asked, if a Resident is a full code and is found unresponsive and staff do not perform CPR, is that neglect? Employee H said, yeah. She was asked if this has happened and she immediately said yes and called the name of Resident #54. When asked to recall the events on 6/11/21, with regards to Resident #54. She stated, when I came in that morning some said [Resident #54 name redacted] had died, my first thought was, Oh my God, did they do CPR. I said, I hope they did CPR, he's a full code. I don't remember who I said it to, but I think others were realizing it at the same time, when I went down there [to his room] people were scattering and there was a lot of confusion. On 7/9/21 1:28 PM, an interview was conducted with the survey team and the Medical Director. During this conversation the Medical Director stated that CPR had not been initiated immediately as it should have been. He confirmed that Resident #54 was a full code and staff had not performed any emergency medical treatment measures until at least 30 minutes later after realizing he was a full code. The Medical Director went on to state that he fully anticipated such an event should have been reported to the health department and an investigation conducted. He stated that the facility has a good leadership team and he doesn't have to ask that a FRI be submitted, they automatically send them when needed and he expected a FRI to be submitted following this incident as well as an in-depth investigation conducted. The Medical Director did confirm that he had attended an Ad Hoc QA meeting on 7/9/21, where the incident was discussed but was not aware of the details of a full investigation or root cause analysis being conducted. The facility policy titled, Abuse Prevention and Management Policy with a review date of 2/19/21, read, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . 4. Investigation. Designated staff will immediately review and investigate all allegations or observations of abuse. a.) The results of all investigations are to be communicated to the administrator or his or her designated representative and to other officals in accordance with State law, including to the State Survey Agency, within 5 working days of the incident .b) The organizaiton will conduct analysis for trends and patterns related to incidents .c) Outside investigative bodies, such as the local police will be contacted as directed by the administrator or his or her designee d) The Quality Assurance/Performance Improvement Committee will monitor trends and patterns for needed changes in facility policy, practice or protocols. No further information was provided.

Based on staff interview, facility documentation review, and clinical record review, the facility failed to investigate an incident of neglect, which was also an unusual occurence, for 1 Resident (Resident #54) in a survey sample of 31 Residents. On 6/11/21, Resident #54, who was a full code was found unresponsive. Four staff members, (CNA A, CNA B, LPN A, RN A), all of which were CPR certified, neglected to provide any type of emergency medical care, to include CPR. The staff response was neglegnt, as well as an unusual occurence; and the facility staff failed to conduct an investigation of the event. The findings included: Resident #54, diagnosis included but were not limited to: CAD (coronary artery disease), HTN (hypertension), old myocardial infarction, diabetes, and anxiety disorder. Resident #54's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4/8/21 was coded as a quarterly assessment. Resident #54 was coded as having had cognitive impairment and moderately impaired cognitive skills for daily decision making. He was also coded as having required extensive assistance of one staff member for activities of daily living. On 7/7/21, during a clinical record review it was determined that Resident #54 had elected to be a Full Code, wishing to have CPR in the event of cardio pulmonary arrest. Resident #54, had a physician order entered into his electronic clinical record on 1/19/21, the day of admission that read, Full Code. The Social Worker, Employee H, entered a progress note into the clinical record on 1/19/21 at 16:14, that read, Resident is a FULL CODE. Review of the careplan for Resident #54 revealed an entry that read, Resident and RR [responsible representative] desire FULL CODE status, the associated goal for this careplan read, Resident's FULL CODE status designation, will be honored, through next review. Review of the nursing notes dated 6/11/21 at 6:30 AM, an entry read, resident was noted to be shivering stated was cold temp 99.0 rectal denied discomfort or pain given blanket and will continue to observe. The next entry read, resident expired 0930, no heart nor lung sounds heard upon auscultation, no response to verbal or painful stimuli that was entered at 9:48 AM, on 6/11/21, by RN A. There was no evidence in the clinical record of CPR being initiated, 911 being called, or any emergency medical treatment being provided to Resident #54 when he was found unresponsive and without vital signs. Throughout the entire clinical record, there was no evidence to suggest that any emergency medical treatment, to include but not limited to, CPR was attempted or initiated on Resident #54. On 7/7/21 at 3:19 PM, an interview was conducted with CNA A. CNA A was asked about the events involving Resident #54 on 6/11/21. CNA A stated, she had his meal tray and when she attempted to deliver it she didn't find Resident #54 in the common areas, where he normally sits. CNA A then stated, I went and asked [CNA B name redacted] where he was, she said he wasn't feeling well so he was still in bed. CNA A proceeded to state she went to take the tray into the room and he wouldn't answer, I'm still fairly new and had never experienced anything like that so I went and got [CNA B name redacted]. She (CNA B) went in, checked his pulse and tried to wake him, she said oh my God, I think he's gone and went to get [LPN A name redacted], I didn't go back, until I helped [CNA B name redacted] clean him up afterwards. CNA A confirmed that she neglected to initiate CPR despite being CPR certified. CNA A went on to state, they did a huddle afterwards and asked questions but it hasn't been talked about since that day. On 7/7/21 at 3:22 PM, an interview was conducted with CNA B. CNA B stated, [CNA A name redacted] asked where he was and went to take his breakfast tray to him, then she came to me and said I'm trying to wake him and he won't wake up, so I went in. I could tell he was deceased so I went to get the nurse. [LPN A name redacted] came into the room and she looked him over, she was checking him and [RN A name redacted] came to check for a pulse, they said he wasn't alive, he's gone, that was it, so I verified they were done and [CNA A name redacted] and I cleaned him up, gave him a bath and changed him. I didn't even think to check he wasn't a DNR [do not resuscitate], had I known he was a full code I would have started CPR. It was about 3-4 extra people here that day from corporate and they came and said he was a full code and we had to start CPR. No body started CPR until after I had cleaned him and he had been laying there an hour. When asked where the breakdown was, CNA B stated, initially it should have started with the CNA that found him not responding, but I also dropped the ball. On 7/7/21 an interview was conducted with LPN A. LPN A confirmed that Resident #54 was a full code and CPR should have been performed. LPN A further acknowledged that despite several staff who were CPR certified responding to check Resident #54 CPR was not immediately initiated and RN A pronounced the Resident deceased . On 7/7/21, during the afternoon, an interview was conducted with the facility Administrator and Corporate Clinical Director/Employee D. When asked if this event on 6/11/21, involving Resident #54 was considered an unusual occurrence, the Administrator said yes. When asked if a FRI (facility reported incident) report had been submitted, the Corporate Clinical Director stated, we decided not to do a FRI after we talked to our counterparts [later identified as Corporate Office Staff/ Employees E and Employee F]. On 7/8/21 the facility Administrator provided the survey team with a FRI that had been submitted to the OLC (Office of Licensure and Certification), APS (Adult Protective Services), and the Ombudaman on 7/7/21. This report read, July 7, 2021 re: First and Final Facility Reported Incident of June 11, 2021. Findings: After investigation, it was determined that CPR was not initiated to the Resident timely. Actions: All corrective actions will be completed 7/23/21. On 7/8/21 at 8:50 AM, an interview was conducted with the facility Administrator. The Administrator was asked to define neglect, she stated, it is any action, it can be many things, not providing medications, food, safe situations, not providing care someone needs. When asked if she would describe her interactions with staff following the incident, the Administrator stated and described her interactions with CNA A as a welfare check, I wanted to see how she was and talk about the situation. The Administrator further acknowledged that the facility staff was still conducting investigations as of 7/7/21. On 7/9/21 at 9:02 AM, an interview was conducted with Employee H, the Social Worker. Employee H, the social worker defined neglect as, not being tended to, not providing what is needed. Employee H was asked, if a Resident is a full code and is found unresponsive and staff do not perform CPR, is that neglect? Employee H said, yeah. She was asked if this has happened and she immediately said yes and called the name of Resident #54. When asked to recall the events on 6/11/21, with regards to Resident #54. She stated, when I came in that morning some said [Resident #54 name redacted] had died, my first thought was, Oh my God, did they do CPR. I said, I hope they did CPR, he's a full code. I don't remember who I said it to, but I think others were realizing it at the same time, when I went down there [to his room] people were scattering and there was a lot of confusion. On 7/9/21 1:28 PM, an interview was conducted with the survey team and the Medical Director. During this conversation the Medical Director stated that CPR had not been initiated immediately as it should have been. He confirmed that Resident #54 was a full code and staff had not performed any emergency medical treatment measures until at least 30 minutes later after realizing he was a full code. The Medical Director went on to state that he fully anticipated such an event should have been reported to the health department and an investigation conducted. He stated that the facility has a good leadership team and he doesn't have to ask that a FRI be submitted, they automatically send them when needed and he expected a FRI to be submitted following this incident as well as an in-depth investigation conducted. The Medical Director did confirm that he had attended an Ad Hoc QA meeting on 7/9/21, where the incident was discussed but was not aware of the details of a full investigation or root cause analysis being conducted. The facility policy titled, Abuse Prevention and Management Policy with a review date of 2/19/21, read, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . 4. Investigation. Designated staff will immediately review and investigate all allegations or observations of abuse. a.) The results of all investigations are to be communicated to the administrator or his or her designated representative and to other officals in accordance with State law, including to the State Survey Agency, within 5 working days of the incident .b) The organizaiton will conduct analysis for trends and patterns related to incidents .c) Outside investigative bodies, such as the local police will be contacted as directed by the administrator or his or her designee d) The Quality Assurance/Performance Improvement Committee will monitor trends and patterns for needed changes in facility policy, practice or protocols. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility documentation and clinical record review the facility staff failed to accurately reflect status of resident on assessments for 1 Resident (#42) in a survey sample of 31 Residents. The findings included: For Resident #42 the facility documentation and assessments do not accurately reflect the Resident's condition. Resident #42, a [AGE] year old man admitted to the facility on [DATE] with diagnoses of but not limited to wedge compression fracture 5th lumbar vertebra, Brown-Sequard Syndrome, autonomic neuropathy, muscle spasm, fracture of neck, non-displaced fracture of 5th cervical vertebra, and injury of cervical spinal cord. Resident #42's most recent MDS ( minimum data set) with an ARD (assessment reference date) of 6/16/21, a Quarterly Review coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 14 indicating no cognitive impairment. The MDS also coded the Resident as requiring extensive assistance of 2 staff physical assistance and the mechanical lift for all transfers, and extensive assistance of 2 staff for all aspects of ADL care. He can feed himself can bear some weight with the sit to stand lift however he is unable to stand or walk, and has an electric wheelchair for mobility. On 7/6/21 at approximately 1:00 PM during initial tour of the facility, Resident #42 was observed sitting in his room in a shower chair about to be transported by mechanical lift to his wheelchair. It was noted that the resident had a towel at his heel with blood on it. After his being transferred an interview was conducted with #42 who stated, The nurses and staff here are great but the Doctor comes in with his Hollywood attitude and talks about his electric car outside my door for 30 minutes but doesn't have time to look at my wounds? That's just not right. He came in here the other day and said he would be right back and came back over an hour later and told me he would see me next week. I told him to get out of here if he couldn't see me now. The Resident explained that he has been at the facility since March and has developed wounds on his right and left foot and his calf and blisters on different parts of his body at different times. He said Right now I have 3 areas I'm concerned about my right calf and my feet. The one wound on my leg was really bad at one point the smell was horrible, but it's getting better now. On 7/7/21 a review of the clinical record revealed the following: MDS on admission dated 3/19/21 Section M - 0210 - Does the resident have any unhealed pressure ulcers stage 1 or higher - 0. NO MDS (Quarterly) dated 6/16/21 read: Section M 0300 F. Number of unstageable wounds due to slough or eschar - 4 M 0300 G - Number of unstageable wounds with suspected deep tissue injury in evolution -1 M 1030 - Total number of venous and arterial ulcers - 0 The information on all skin and wound issues for this resident was submitted by the facility as a time line. They also submitted the Wound assessment sheets to coincide with each listed wound. Per the document entitled Wounds, Resident #42 developed wounds as follows: Assessment # 47937912 - 3/24/21 at 11:48 AM - blisters to right wrist (1.5 cm x .5 cm) Assessment # 47978458 - 3/27/21 at 12:38 PM - Blister to right outer anterior wrist Assessment # 47978470 - 3/27/21 at 12:41 PM- blisters to right elbow (2 cm x 1.5 cm) Assessment # 47978479 - 3/3:27 PM/21 at 12:44 -Blisters to left groin Assessment # 48035076 - 3 /31/21 at 3:32 PM -DTI Sacrum Assessment # 48035080 - 3/31/21 at 3:35 PM - Deep Tissue Injury to R Sacrum Assessment # 48035084 - 3/31/21 at 3:38 PM- Deep Tissue Injury to Sacrum area Assessment # 48122818 - 4/7/21 at 12:35 PM - DTI left Heel - (found at DTI 7 cm x 6 cm) Assessment # 48196729 - 4/12/21 at 9:59 AM - Blister right upper thigh (recorded as Stage II partial thickness 0.9 cm x 0.6 cm) Assessment # 41896745 - 4/12/21 at 10:03 AM - Blister unstageable Assessment # 48196760 - 4/12/21 at 10:08 AM - DTI right upper posterior calf (found 4/9/21 6 cm x 2 cm) Assessment # 48298406 - 4/19/21 at 3:25 PM - open area in DTI unstageable calf (2.5 x .5) [no depth recorded to this open area] Assessment # 48601073 - 5/12/21 at 1:47 PM -DTI to Right Heel (1 cm x 1 cm) Assessment # 48601161 - 5/12/21 at 1:52 PM - DTI to 5th toe (1.0 cm x 0.5 cm) Assessment # 48601204 -5/12/21 at 1:57 PM - Blister stage II to left upper thigh (3.0 x 0.5 cm) Assessment # 48601263 - 5/12/21 at 2:06 PM - DTI's and blister Assessment # 48650949 - 5/16/21 at 2:29 PM - Blister due to catheter tubing (recorded as Stage II partial thickness 1 cm x 2 cm no depth recorded) Assessment # 48670103 - 5/17/21 at 2:45 PM _ Blister upper left thigh Assessment # 48670743 - 5/17/21 at 2:59 PM - Blister to lateral left thigh (recorded as Stage II partial thickness 7 cm x 0.5 cm no depth recorded) A review of the Wound Assessment Sheets on page 2 of each wound sheet labeled all of the wounds listed above as Vascular in nature. All assessments for wounds to include the initial assessments were conducted and signed off by LPN B. On 7/8/21 at 10:13 AM an interview was conducted with the DON (employee B) who stated that skin assessments are performed weekly. She was asked who was in charge of doing the wound assessments and wound care she stated LPN B is our Wound Champion and she advises the other nurses. When asked if the facility has a wound protocol she stated yes they did. She stated that LPN B would do the initial assessment and that she has credentials for wound care. She further stated that if the wound does not get better or if it worsens the provider (MD or NP) will come and look at it. On 7/8/21 at approximately 10:30 an interview was conducted with the Clinical Services Director (employee D) who stated that we have a Wound Champion and indicated LPN B was that person. When asked if it was the expectation that LPN B would have an RN sign off on the initial assessments and staging of the wounds she stated that it would be an expectation. On 7/8/21 at approximately 11:00 AM an interview with the Wound Champion LPN B who stated that when the Resident developed blisters the doctor told her it was probably vascular, which is why she wrote vascular on the wound assessment sheets. When asked if she was the person who did the initial assessments and staging she stated that she was. At 11:30 AM the wounds were observed by Surveyor and LPN B. The areas are in various stages of the healing, the calf wounds have merged into 1 wound, and the left foot has heavy amount of drainage the right heel wound is dry and scabbed over. LPN B stated I started using calcium alginate today due to copious amount of drainage from the left heel. On 7/9/21 during the end of day meeting the Administrator was made aware of the concerns and no new information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility documentation and clinical record review the facility staff failed to develop and implement a comprehensive care plan that is patient centered with measurable goals and objectives for 1 Resident (#42) in a survey sample of 31 Residents. The findings included For Resident #42 the facility staff failed to develop and implement a comprehensive care plan that is patient centered with measurable goals and objectives. For Resident #42 the facility documentation and assessments do not accurately reflect the Resident's condition. Resident #42, a [AGE] year old man admitted to the facility on [DATE] with diagnoses of but not limited to wedge compression fracture 5th lumbar vertebra, Brown-Sequard Syndrome, autonomic neuropathy, muscle spasm, fracture of neck, non-displaced fracture of 5th cervical vertebra, and injury of cervical spinal cord. Resident #42's most recent MDS ( minimum data set) with an ARD (assessment reference date) of 6/16/21, a Quarterly Review coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 14 indicating no cognitive impairment. The MDS also coded the Resident as requiring extensive assistance of 2 staff physical assistance and the mechanical lift for all transfers, and extensive assistance of 2 staff for all aspects of ADL care. He can feed himself can bear some weight with the sit to stand lift however he is unable to stand or walk, and has an electric wheelchair for mobility. On 7/6/21 at approximately 1:00 PM during initial tour of the facility, Resident #42 was observed sitting in his room in a shower chair about to be transported by mechanical lift to his wheelchair. It was noted that the resident had a towel at his heel with blood on it. After his being transferred an interview was conducted with #42 who stated, The nurses and staff here are great but the Doctor comes in with his Hollywood attitude and talks about his electric car outside my door for 30 minutes but doesn't have time to look at my wounds? That's just not right. He came in here the other day and said he would be right back and came back over an hour later and told me he would see me next week. I told him to get out of here if he couldn't see me now. The Resident explained that he has been at the facility since March and has developed wounds on his right and left foot and his calf and blisters on different parts of his body at different times. He said Right now I have 3 areas I'm concerned about my right calf and my feet. The one wound on my leg was really bad at one point the smell was horrible, but it's getting better now. On 7/7/21 at approximately 1:15 PM an interview was conducted with LPN B who stated the purpose of the care plan was to direct the care of the patient. To address each of his needs and to inform the staff of how A review of the care plan revealed the care plan objectives were not specific and did not address all aspects of care often the discipline (who was to perform the care) was left blank and the frequency of the interventions was also left blank, excerpts are as follows: Use preventive measures for positioning and pressure relief in accordance with facility policy. STATUS: Active (Current) EFFECTIVE: 3/19/2021 - Present CREATED: 3/22/2021 3:27:24 PM [RN name redacted] Frequency Column left blank Discipline Column left blank. Encourage resident to re-position or provide assistance with turning and repositioning as needed STATUS: Active (Current) EFFECTIVE: 3/19/2021 - Present CREATED: 3/22/2021 3:27:24 PM [RN name redacted] Frequency Column left blank Discipline Column left blank. Encourage resident to re-position or provide assistance with turning and repositioning as needed STATUS: Active (Current) EFFECTIVE: 3/19/2021 - Present CREATED: 3/22/2021 3:27:24 PM (RN name redacted) Frequency Column left blank Discipline Column left blank. Apply skin barrier cream per order/protocol STATUS: Active (Current) EFFECTIVE: 3/19/2021 - Present CREATED: 3/22/2021 3:27:24 PM (RN, name redacted) Frequency Column left blank Discipline Column left blank. Staff education concerning he is to be transferred in and out of his Power chair using the mechanical lift. STATUS: Active (Current) EFFECTIVE: 4/2/2021 - Present CREATED: 4/5/2021 4:59:55 PM [RN name redacted] Frequency - column left blank Discipline Nursing CREATED: 4/5/2021 4:59 Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown. STATUS: Active (Current) EFFECTIVE: 3/24/2021 - Present CREATED: 3/24/2021 7:17:48 AM (RN name redacted) Frequency Column left blank Discipline Column left blank. Elevate RLE, positional changes frequently due to edema STATUS: Active (Current) EFFECTIVE: 3/24/2021 - Present CREATED: 3/24/2021 8:30:36 AM Frequency Column left blank Discipline Column left blank. Place low air loss mattress to bed to assist with pressure reduction. STATUS: Active (Current) EFFECTIVE: 6/9/2021 - Present CREATED: 6/10/2021 11:45:14 AM (RN name redacted) Frequency Column left blank Discipline Column left blank. A review of the physicians orders do not show any boots for heel protection however it does reflect an order on 6/22/21 for circular foot lift pillow to right lower extremity as tolerated this was after the wound appeared. On 7/9/21 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to provide care in accordance with professional standards of practice for 4 Residents (Resident #54, Resident #42, Resident #7, Resident #23) in a survey sample of 31 Residents. 1. For Resident #54, who was a full code, the facility staff failed to provide any emergency medical treatment, including CPR, when he was found unresponsive. 2. For Resident #7, the facility failed to administer narcotic pain medication timely as ordered by a physician. 3. For Resident #23, the facility failed to administer 5 medications, including a narcotic pain medication timely as ordered by a physician. 4. For Resident #42 the facility failed to provide care according to professional standards of care by having an LPN perform the wound assessments and staging, which is out of the scope of practice for an LPN. The findings included: 1. For Resident #54, who was a full code, the facility staff failed to provide any emergency medical treatment, including CPR as per professional standards when he was found unresponsive. Resident #54, diagnosis included but were not limited to: CAD (coronary artery disease), HTN (hypertension), old myocardial infarction, diabetes, and anxiety disorder. Resident #54's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of [DATE] was coded as a quarterly assessment. Resident #54 was coded as having had cognitive impairment and moderately impaired cognitive skills for daily decision making. He was also coded as having required extensive assistance of one staff member for activities of daily living. On [DATE], during a clinical record review it was determined that Resident #54 had elected to be a Full Code, wishing to have CPR in the event of cardio pulmonary arrest. Resident #54, had a physician order entered into his electronic clinical record on [DATE], the day of admission that read, Full Code. The Social Worker, Employee H, entered a progress note into the clinical record on [DATE] at 16:14, that read, Resident is a FULL CODE. Review of the careplan for Resident #54 revealed an entry that read, Resident and RR [responsible representative] desire FULL CODE status, the associated goal for this careplan read, Resident's FULL CODE status designation, will be honored, through next review. Review of the nursing notes dated [DATE] at 6:30 AM, an entry read, resident was noted to be shivering stated was cold temp 99.0 rectal denied discomfort or pain given blanket and will continue to observe. The next entry read, resident expired 0930, no heart nor lung sounds heard upon auscultation, no response to verbal or painful stimuli that was entered at 9:48 AM, on [DATE], by RN A. There was no evidence in the clinical record of CPR being initiated, 911 being called, or any emergency medical treatment being provided to Resident #54 when he was found unresponsive and without vital signs. Throughout the entire clinical record, there was no evidence to suggest that any emergency medical treatment, to include but not limited to, CPR was attempted or initiated on Resident #54. On [DATE] at 3:19 PM, an interview was conducted with CNA A. CNA A was asked about the events involving Resident #54 on [DATE]. CNA A stated, she had his meal tray and when she attempted to deliver it she didn't find Resident #54 in the common areas, where he normally sits. CNA A then stated, I went and asked [CNA B name redacted] where he was, she said he wasn't feeling well so he was still in bed. CNA A proceeded to state she went to take the tray into the room and he wouldn't answer, I'm still fairly new and had never experienced anything like that so I went and got [CNA B name redacted]. She (CNA B) went in, checked his pulse and tried to wake him, she said oh my God, I think he's gone and went to get [LPN A name redacted], I didn't go back, until I helped [CNA B name redacted] clean him up afterwards. CNA A confirmed that she neglected to initiate CPR despite being CPR certified. CNA A went on to state, they did a huddle afterwards and asked questions but it hasn't been talked about since that day. On [DATE] at 3:22 PM, an interview was conducted with CNA B. CNA B stated, [CNA A name redacted] asked where he was and went to take his breakfast tray to him, then she came to me and said I'm trying to wake him and he won't wake up, so I went in. I could tell he was deceased so I went to get the nurse. [LPN A name redacted] came into the room and she looked him over, she was checking him and [RN A name redacted] came to check for a pulse, they said he wasn't alive, he's gone, that was it, so I verified they were done and [CNA A name redacted] and I cleaned him up, gave him a bath and changed him. I didn't even think to check he wasn't a DNR [do not resuscitate], had I known he was a full code I would have started CPR. It was about 3-4 extra people here that day from corporate and they came and said he was a full code and we had to start CPR. No body started CPR until after I had cleaned him and he had been laying there an hour. When asked where the breakdown was, CNA B stated, initially it should have started with the CNA that found him not responding, but I also dropped the ball. On [DATE] an interview was conducted with LPN A. LPN A confirmed that Resident #54 was a full code and CPR should have been performed. LPN A further acknowledged that despite several staff who were CPR certified responding to check Resident #54 CPR was not immediately initiated and RN A pronounced the Resident deceased . Review of employee records revealed that all four of the responding staff (CNA A, CNA B, LPN A and RN A) held current and active CPR certification from the American Heart Association, which included training in when to initiate CPR. On [DATE] 1:28 PM, an interview was conducted with the survey team and the Medical Director. During this conversation the Medical Director stated that CPR had not been initiated immediately as it should have been. He confirmed that Resident #54 was a full code and staff had not performed any emergency medical treatment measures until at least 30 minutes later after realizing he was a full code. On [DATE] the facility Administrator provided the survey team with a FRI (Facility Reported Incident) that had been submitted to the OLC (Office of Licensure and Certification), APS (Adult Protective Services), and the Ombudaman on [DATE]. This report read, [DATE] re: First and Final Facility Reported Incident of [DATE]. Findings: After investigation, it was determined that CPR was not initiated to the Resident timely. The facility policy titled, Cardio-Pulmonary Resuscitation (CPR) with a revision date of [DATE], read Prior to the arrival of emergency medical services (EMS), the staff must initiate CPR when cardiac arrest (cessation of respirations and/or pulse) occurs for residents unless: A Resident has a valid DNR order, or A Resident presents with a completed, Durable Do Not Resuscitate Order form, or A resident presents with a POST form indicating Do not Attempt Resuscitation, or A Resident presents with approved jewelry indicating Do Not Resuscitate, or A physician orders otherwise, A resident shows American Heart Association signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care 2015. Obvious signs of clinical death, e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition. *** Only a physician can pronounce if unanticipated death. Not an RN, NP or PA. On [DATE], the facility staff provided the survey team with the training from the American Heart Association that is used during CPR training of their staff. The American Heart Association defines the following Critical Skills in their Basic Life Support training, which each of the responding staff had successfully completed. It read, 1. Assesses victim and activates emergency response system (this must precede starting compressions) within 30 seconds. After determining the scene is safe: checks for responsiveness by tapping and shouting, shouts for help/directs someone to call for help and get AED/defibrillator, checks for no breathing or no normal breathing, checks carotid pulse. 2. Performs high-quality chest compressions (initiates compressions immediately after recognition of cardiac arrest). 3. Provides 2 breaths by using a barrier device. 4. Performs same steps for compressions and breaths for cycle 2. 5. AED use. 6. Resumes compressions. The Administrator and DON (Director of Nursing) were informed of the facility staff's negligence to provide emergency medical treatment to include CPR for Resident #54 being considered failure to follow professional standards on [DATE] at 12 noon, during a mid-day debriefing. During this meeting the Corporate Clinical Director asked if all tags surrounding this incident could be considered for past non-compliance. However, this request for past non-compliance is not able to be upheld due to the facility was still conducting their investigation during the survey, had not completed their plan of correction prior to the start of the survey, and the QA (Quality Assurance) committee had not meet until [DATE]. No further information was provided. 4. For Resident #42 the facility failed to provide care according to professional standards of care by having an LPN perform the wound assessments and staging, which is out of the scope of practice for an LPN. For Resident #42 the facility documentation and assessments do not accurately reflect the Resident's condition. Resident #42, a [AGE] year old man admitted to the facility on [DATE] with diagnoses of but not limited to wedge compression fracture 5th lumbar vertebra, Brown-Sequard Syndrome, autonomic neuropathy, muscle spasm, fracture of neck, non-displaced fracture of 5th cervical vertebra, and injury of cervical spinal cord. Resident #42's most recent MDS ( minimum data set) with an ARD (assessment reference date) of [DATE], a Quarterly Review coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 14 indicating no cognitive impairment. The MDS also coded the Resident as requiring extensive assistance of 2 staff physical assistance and the mechanical lift for all transfers, and extensive assistance of 2 staff for all aspects of ADL care. He can feed himself can bear some weight with the sit to stand lift however he is unable to stand or walk, and has an electric wheelchair for mobility. On [DATE] at approximately 1:00 PM during initial tour of the facility, Resident #42 was observed sitting in his room in a shower chair about to be transported by mechanical lift to his wheelchair. It was noted that the resident had a towel at his heel with blood on it. After his being transferred an interview was conducted with #42 who stated, The nurses and staff here are great but the Doctor comes in with his Hollywood attitude and talks about his electric car outside my door for 30 minutes but doesn't have time to look at my wounds? That's just not right. He came in here the other day and said he would be right back and came back over an hour later and told me he would see me next week. I told him to get out of here if he couldn't see me now. The Resident explained that he has been at the facility since March and has developed wounds on his right and left foot and his calf and blisters on different parts of his body at different times. He said Right now I have 3 areas I'm concerned about my right calf and my feet. The one wound on my leg was really bad at one point the smell was horrible, but it's getting better now. On [DATE] a review of the clinical record revealed the following: MDS on admission dated [DATE] Section M - 0210 - Does the resident have any unhealed pressure ulcers stage 1 or higher - 0. NO MDS (Quarterly) dated [DATE] read: Section M 0300 F. Number of unstageable wounds due to slough or eschar - 4 M 0300 G - Number of unstageable wounds with suspected deep tissue injury in evolution -1 M 1030 - Total number of venous and arterial ulcers - 0 The information on all skin and wound issues for this resident was submitted by the facility as a time line. They also submitted the Wound assessment sheets to coincide with each listed wound. Per the document entitled Wounds, Resident #42 developed wounds as follows: Assessment # 47937912 - [DATE] at 11:48 AM - blisters to right wrist (1.5 cm x .5 cm) Assessment # 47978458 - [DATE] at 12:38 PM - Blister to right outer anterior wrist Assessment # 47978470 - [DATE] at 12:41 PM- blisters to right elbow (2 cm x 1.5 cm) Assessment # 47978479 - 3/3:27 PM/21 at 12:44 -Blisters to left groin Assessment # 48035076 - 3 /31/21 at 3:32 PM -DTI Sacrum Assessment # 48035080 - [DATE] at 3:35 PM - Deep Tissue Injury to R Sacrum Assessment # 48035084 - [DATE] at 3:38 PM- Deep Tissue Injury to Sacrum area Assessment # 48122818 - [DATE] at 12:35 PM - DTI left Heel - (found at DTI 7 cm x 6 cm) Assessment # 48196729 - [DATE] at 9:59 AM - Blister right upper thigh (recorded as Stage II partial thickness 0.9 cm x 0.6 cm Assessment # 41896745 - [DATE] at 10:03 AM - Blister unstageable Assessment # 48196760 - [DATE] at 10:08 AM - DTI right upper posterior calf (found [DATE] 6 cm x 2 cm) Assessment # 48298406 - [DATE] at 3:25 PM - open area in DTI unstageable calf (2.5 x .5) [no depth recorded to this open area] Assessment # 48601073 - [DATE] at 1:47 PM -DTI to Right Heel (1 cm x 1 cm) Assessment # 48601161 - [DATE] at 1:52 PM - DTI to 5th toe (1.0 cm x 0.5 cm) Assessment # 48601204 -[DATE] at 1:57 PM - Blister stage II to left upper thigh (3.0 x 0.5 cm) Assessment # 48601263 - [DATE] at 2:06 PM - DTI's and blister Assessment # 48650949 - [DATE] at 2:29 PM - Blister due to catheter tubing (recorded as Stage II partial thickness 1 cm x 2 cm no depth recorded) Assessment # 48670103 - [DATE] at 2:45 PM _ Blister upper left thigh Assessment # 48670743 - [DATE] at 2:59 PM - Blister to lateral left thigh (recorded as Stage II partial thickness 7 cm x 0.5 cm no depth recorded) A review of the Wound Assessment Sheets on page 2 of each wound sheet labeled all of the wounds listed above as Vascular in nature. All assessments for wounds to include the initial assessments were conducted and signed off by LPN B. On [DATE] at 10:13 AM an interview was conducted with the DON (employee B) who stated that skin assessments are performed weekly. She was asked who was in charge of doing the wound assessments and wound care she stated LPN B is our Wound Champion and she advises the other nurses. When asked if the facility has a wound protocol she stated yes they did. She stated that LPN B would do the initial assessment and that she has credentials for wound care. She further stated that if the wound does not get better or if it worsens the provider (MD or NP) will come and look at it. On [DATE] at approximately 11:00 AM an interview with the Wound Champion LPN B who stated that when the Resident developed blisters the doctor told her it was probably vascular, which is why she wrote vascular on the wound assessment sheets. When asked if she was the person who did the initial assessments and staging she stated that she was. Excerpts from the VA Code 54.1 3000 LPN's Role are as follows: Practical nursing or licensed practical nursing is performed under the direction or supervision of a licensed medical practitioner, a professional nurse, registered nurse or registered professional nurse or other licensed health professional authorized by regulations of the Board. According to the Virginia Department of Health Professions Website [www.dhp.virginia.gov] Assessments: RN vs. LPN LPN - focused assessment -gathers data to contribute to assessment and reports findings/results to RN. RN - comprehensive, initial & ongoing - synthesizes the information based on professional nursing judgment and knowledge base. On [DATE] at approximately 10:30 an interview was conducted with the Clinical Services Director (employee D) who stated that we have a Wound Champion and indicated LPN B was that person. When asked if it was the expectation that LPN B would have an RN sign off on the initial assessments and staging of the wounds she stated that it would be an expectation. The facility submitted copies of the Credentials for LPN B they are as follows: Certificate of Participation dated [DATE] - Nursing insight Pressure Ulcers Taking a Comprehensive look Certificate of Completion dated [DATE] - Pressure Ulcers and Differentiation of Non- Pressure Areas: Measuring and Documenting Certificate of completion dated [DATE] - Wound Dressing Consideration and Categories Certificate of Completion [DATE] - The Skin and Pressure Injuries (1.0 Training hours) Certificate of Completion dated [DATE] - Wound dressing Consideration and Categories On [DATE] during the end of day conference 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 maintain professional standards of practice for medication administration involving two Residents (Residents #7, and #23) in a survey sample of 31 Residents. 2. For Resident #7, the facility failed to administer narcotic pain medication timely as ordered by a physician. 3. For Resident #23, the facility failed to administer 5 medications, including a narcotic pain medication timely as ordered by a physician. The findings included: 2. Resident #7, was admitted to the facility on [DATE]. Diagnoses included; Parkinson's disease, and right shoulder dislocation with pain, contracture right hand, osteoarthritis, and chronic back pain. Resident #7's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-14-21 was coded as a quarterly assessment. Resident #7 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or, no cognitive impairment. Resident #7 was also coded as requiring extensive to total assistance of staff to perform activities of daily living, such as bed mobility, transferring, hygiene, locomotion, and toileting. On 7-6-21 from 1:00 p.m., until 2:00 p.m., medication pour and pass observations were conducted with Licensed Practical Nurse (LPN) A. Resident #7 received medications at 1:40 p.m. The Resident received tramadol, a narcotic pain reliever and LPN A stated these are the morning meds, I am just getting them finished. Review of the Medication Administration Record (MAR) revealed that no time was documented as to the exact time the medication was administered, therefore, the oncoming evening nurse could administer the narcotic pain medication again as soon as 3:00 p.m., and the Resident could experience over sedation. Review of Resident #7's clinical record revealed valid physician's orders for the pain medication given late. That order was as follows: Tramadol 50 milligrams one tablet by mouth three times per day. Those 3 times per day to give the medication, were each listed as a range of time, and are as follows. (1) 8:00 a.m. to 10:00 a.m., (2) 4:00 p.m. to 5:00 p.m., and (3) 9:00 p.m. to 10:00 p.m. Review of the facility's policy entitled, Medication Administration revealed that all medications are to be given according to the prescriber's order timely, and signed/documented by the administering individual as soon as the medication is given. The facility staff stated Mosby's as their clinical standard of practice reference. The reference review revealed the following excerpt; 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. When interviewed on 7-6-21 at 4:00 p.m., the DON (director of nursing), and Corporate Liason stated that the range was going to be changed, and the medications were administered late, which could cause over sedation if given too closely together, and could allow break through pain for the Resident if spaced too far apart. The DON stated her expectation was for staff to administer medications and treatments per physician's orders and to administer them timely. The administrator and DON were informed of the failure of the staff to ensure significant medications were administered timely, on 7-6-21 at 4:00 p.m. No further information was provided by the facility. 3. Resident #23, was admitted to the facility on [DATE]. Diagnoses included; Acute respiatory failure with hypoxia, sacral pressure ulcer, protein deficiency, diabetes, and cardiac/heart disease. Resident #23's most recent MDS (minimum data set) with an ARD (assessment reference date) of 5-12-21 was coded as a significant change assessment. Resident #23 was coded as having a BIMS (brief interview of mental status) score of unable to complete, or, severe cognitive impairment. Resident #23 was also coded as requiring extensive to total assistance of staff to perform activities of daily living, such as bed mobility, transferring, hygiene, locomotion, and toileting. On 7-6-21 from 1:00 p.m., until 2:00 p.m., medication pour and pass observations were conducted with Licensed Practical Nurse (LPN) A. Resident #23 received medications at 1:30 p.m. The Resident received the following 5 medications which were ordered to be administered more than once per day, and were to be given during a range of time. They are as follows; 1. Albuterol metered dose inhaler one to two puffs three times per day at 8:00 a.m. to 10:00 a.m., 12:00 p.m. to 2:00 p.m., and 6:00 p.m. to 8:00 p.m. 2. Flonase nasal steroid one spray in each nare twice per day at 8:00 a.m. to 10:00 a.m., and 6:00 p.m. to 8:00 p.m. 3. Liquicell protein 30 milliliters twice per day at 8:00 a.m. to 10:00 a.m., and 6:00 p.m. to 8:00 p.m. 4. Metoprolol heart medication 50 milligrams twice per day at 8:00 a.m. to 10:00 a.m., and 6:00 p.m. to 8:00 p.m. 5. Hydrocodone narcotic pain reliever 5 milligrams/325 milligrams twice per day at 8:00 a.m. to 10:00 a.m., and 6:00 p.m. to 8:00 p.m. Other medications were also administered at the time, however, they were only ordered to be administered once per day, and so were not added to the deficient practice. LPN A stated these are the morning meds, I am just getting them finished. Review of the Medication Administration Record (MAR) revealed that no time was documented as to the exact time the medication was administered, therefore, the oncoming evening nurse could administer the medications early or late, and the Resident could experience poor respiratory, and cardiac results, over sedation, and or lack of pain control. Review of Resident #23's clinical record revealed valid physician's orders for the multiple significant medications given late. Review of the facility's policy entitled, Medication Administration revealed that all medications are to be given according to the prescriber's order timely, and signed/documented by the administering individual as soon as the medication is given. The facility staff stated Mosby's as their clinical standard of practice reference. The reference review revealed the following excerpt; 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. When interviewed on 7-6-21 at 4:00 p.m., the DON (director of nursing), and Corporate Liason stated that the range was going to be changed, and the medications were administered late, which could cause non-therapeutic side effects, over sedation if given too closely together, and could allow break through pain for the Resident if spaced too far apart. The DON stated her expectation was for staff to administer medications and treatments per physician's orders and to administer them timely. The administrator and DON were informed of the failure of the staff to ensure significant medications were administered timely, on 7-6-21 at 4:00 p.m. No further information was provided by the facility.

2. On 06/11/21, Resident #54, who was a full code was found unresponsive. Four staff members, (CNA A, CNA B, LPN A, RN A), all of which were CPR certified, neglected to provide any type of emergency medical care, to include CPR. This was neglegnt, as well as an unusual occurence; and the facility staff failed to implement their abuse policy in such an event by failing to conduct an investigation and report the incident, until after the survey began. Resident #54, diagnosis included but were not limited to: CAD (coronary artery disease), HTN (hypertension), old myocardial infarction, diabetes, and anxiety disorder. Resident #54's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 4/8/21 was coded as a quarterly assessment. Resident #54 was coded as having had cognitive impairment and moderately impaired cognitive skills for daily decision making. He was also coded as having required extensive assistance of one staff member for activities of daily living. On 7/7/21, during a clinical record review it was determined that Resident #54 had elected to be a Full Code, wishing to have CPR in the event of cardio pulmonary arrest. Resident #54, had a physician order entered into his electronic clinical record on 1/19/21, the day of admission that read, Full Code. The Social Worker, Employee H, entered a progress note into the clinical record on 1/19/21 at 16:14, that read, Resident is a FULL CODE. Review of the careplan for Resident #54 revealed an entry that read, Resident and RR [responsible representative] desire FULL CODE status, the associated goal for this careplan read, Resident's FULL CODE status designation, will be honored, through next review. Review of the nursing notes dated 6/11/21 at 6:30 AM, an entry read, resident was noted to be shivering stated was cold temp 99.0 rectal denied discomfort or pain given blanket and will continue to observe. The next entry read, resident expired 0930, no heart nor lung sounds heard upon auscultation, no response to verbal or painful stimuli that was entered at 9:48 AM, on 6/11/21, by RN A. There was no evidence in the clinical record of CPR being initiated, 911 being called, or any emergency medical treatment being provided to Resident #54 when he was found unresponsive and without vital signs. Throughout the entire clinical record, there was no evidence to suggest that any emergency medical treatment, to include but not limited to, CPR was attempted or initiated on Resident #54. On 7/7/21 at 3:19 PM, an interview was conducted with CNA A. CNA A was asked about the events involving Resident #54 on 6/11/21. CNA A stated, she had his meal tray and when she attempted to deliver it she didn't find Resident #54 in the common areas, where he normally sits. CNA A then stated, I went and asked [CNA B name redacted] where he was, she said he wasn't feeling well so he was still in bed. CNA A proceeded to state she went to take the tray into the room and he wouldn't answer, I'm still fairly new and had never experienced anything like that so I went and got [CNA B name redacted]. She (CNA B) went in, checked his pulse and tried to wake him, she said oh my God, I think he's gone and went to get [LPN A name redacted], I didn't go back, until I helped [CNA B name redacted] clean him up afterwards. CNA A confirmed that she neglected to initiate CPR despite being CPR certified. CNA A went on to state, they did a huddle afterwards and asked questions but it hasn't been talked about since that day. On 7/7/21 at 3:22 PM, an interview was conducted with CNA B. CNA B stated, [CNA A name redacted] asked where he was and went to take his breakfast tray to him, then she came to me and said I'm trying to wake him and he won't wake up, so I went in. I could tell he was deceased so I went to get the nurse. [LPN A name redacted] came into the room and she looked him over, she was checking him and [RN A name redacted] came to check for a pulse, they said he wasn't alive, he's gone, that was it, so I verified they were done and [CNA A name redacted] and I cleaned him up, gave him a bath and changed him. I didn't even think to check he wasn't a DNR [do not resuscitate], had I known he was a full code I would have started CPR. It was about 3-4 extra people here that day from corporate and they came and said he was a full code and we had to start CPR. No body started CPR until after I had cleaned him and he had been laying there an hour. When asked where the breakdown was, CNA B stated, initially it should have started with the CNA that found him not responding, but I also dropped the ball. On 7/7/21 an interview was conducted with LPN A. LPN A confirmed that Resident #54 was a full code and CPR should have been performed. LPN A further acknowledged that despite several staff who were CPR certified responding to check Resident #54 CPR was not immediately initiated and RN A pronounced the Resident deceased . On the afternoon of 7/7/21, an interview was conducted with the facility Administrator and Corporate Clinical Director/Employee D. When asked if this event on 6/11/21, involving Resident #54 was considered an unusual occurrence, the Administrator said yes. When asked if a FRI (facility reported incident) report had been submitted, the Corporate Clinical Director stated, we decided not to do a FRI after we talked to our counterparts [later identified as Corporate Office Staff/ Employees E and Employee F]. The Administrator was asked if the event had been discussed with the Medical Director and she stated, no, I have not talked with him about it. When asked if the facility QA (Quality Assurance) team had met to discuss the event, the Administrator stated, no we had our quarterly meeting in May and we did an Ad hoc meeting in June just to approve the facility assessment because it wasn't done when we met in May. The Administrator was asked if any type of root cause analysis had been conducted and she stated, no. She did indicate all staff were educated. On 7/8/21 the facility Administrator provided the survey team with a FRI that had been submitted to the OLC (Office of Licensure and Certification), APS (Adult Protective Services), and the Ombudaman on 7/7/21. This report read, July 7, 2021 re: First and Final Facility Reported Incident of June 11, 2021. Findings: After investigation, it was determined that CPR was not initiated to the Resident timely. Actions: All corrective actions will be completed 7/23/21. Additionally, the facility provided evidence that only the staff working the day of the incident had been trained, not 100% of clinical staff. On 7/8/21 at 8:50 AM, an interview was conducted with the facility Administrator. The Administrator was asked to define neglect, she stated, it is any action, it can be many things, not providing medications, food, safe situations, not providing care someone needs. She was asked if, the failure to provide CPR or emergency medical treatment to a Resident who is not responsive is considered negligent, she stated, I would not say that, I would say it was a lack of education. When asked if she would describe her interactions with staff following the incident, the Administrator stated and described her interactions with CNA A as a welfare check, I wanted to see how she was and talk about the situation. The Administrator further acknowledged that the facility staff was still conducting investigations as of 7/7/21. On 7/9/21 at 9:02 AM, an interview was conducted with Employee H, the Social Worker. Employee H, the social worker defined neglect as, not being tended to, not providing what is needed. Employee H was asked, if a Resident is a full code and is found unresponsive and staff do not perform CPR, is that neglect? Employee H said, yeah. She was asked if this has happened and she immediately said yes and called the name of Resident #54. When asked to recall the events on 6/11/21, with regards to Resident #54. She stated, when I came in that morning some said [Resident #54 name redacted] had died, my first thought was, Oh my God, did they do CPR. I said, I hope they did CPR, he's a full code. I don't remember who I said it to, but I think others were realizing it at the same time, when I went down there [to his room] people were scattering and there was a lot of confusion. On 7/9/21 1:28 PM, an interview was conducted with the survey team and the Medical Director. During this conversation the Medical Director stated that CPR had not been initiated immediately as it should have been. He confirmed that Resident #54 was a full code and staff had not performed any emergency medical treatment measures until at least 30 minutes later after realizing he was a full code. The Medical Director went on to state that he fully anticipated such an event should have been reported to the health department and an investigation conducted. He stated that the facility has a good leadership team and he doesn't have to ask that a FRI be submitted, they automatically send them when needed and he expected a FRI to be submitted following this incident as well as an in-depth investigation conducted. The Medical Director did confirm that he had attended an Ad Hoc QA meeting on 7/9/21, where the incident was discussed but was not aware of the details of a full investigation or root cause analysis being conducted. The facility policy titled, Abuse Prevention and Management Policy with a review date of 2/19/21, read, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . 4. Investigation. Designated staff will immediately review and investigate all allegations or observations of abuse. a.) The results of all investigations are to be communicated to the administrator or his or her designated representative and to other officals in accordance with State law, including to the State Survey Agency, within 5 working days of the incident .b) The organizaiton will conduct analysis for trends and patterns related to incidents .c) Outside investigative bodies, such as the local police will be contacted as directed by the administrator or his or her designee d) The Quality Assurance/Performance Improvement Committee will monitor trends and patterns for needed changes in facility policy, practice or protocols. 6. The Administrator and DON (Director of Nursing) were informed of the facility staff's negligence to provide emergency medical treatment to include CPR for Resident #54 being considered negligent on 7/8/21 at 12 noon during a mid-day debriefing. During this meeting the Corporate Clinical Director asked if this could be considered for past non-compliance. However, this request is not able to be upheld as the facility was still conducting their invesigiation during the survey and had not completed their plan of correction prior to the start of the survey. No further information was provided. Based on staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to implement their abuse policy for 7 certified nursing assistants (CNA) (CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, and CNA I) out of a staff sample size of 16 CNA's and for one Resident (Resident #54) out of a sample size of 31 residents. 1. For CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, the facility staff failed to complete license verification upon hire. For CNA I, the facility staff failed to verify CNA I's license renewal which resulted in CNA I working at the facility without verifying license renewal (and having an expired license on file). 2. On 06/11/21, Resident #54, who was a full code was found unresponsive. Four staff members, (CNA A, CNA B, LPN A, RN A), all of which were CPR certified, neglected to provide any type of emergency medical care, to include CPR. This was neglegnt, as well as an unusual occurence; and the facility staff failed to implement their abuse policy in such an event by failing to conduct an investigation and report the incident, until after the survey began. The findings included: 1. For CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, the facility staff failed to complete license verification upon hire. For CNA I, the facility staff failed to verify CNA I's license renewal which resulted in CNA I working at the facility without verifying license renewal (and having an expired license on file). On 07/07/21 at approximately 11:45 A.M., the employee files were reviewed with Employee G, Business Office Director, and this surveyor. When asked about the process for on-boarding new employees, Employee G stated that a recruiter does the on-boarding and checking results. Employee G then called Employee I, a Human Resources Generalist at another facility within their corporation. When asked about the expectation for license verification for new hires, Employee I stated that license verification should be completed before the new employee begins interacting with Residents. When asked why that was important, Employee I stated for resident safety. Upon review of the employee files, there were 6 CNA's (CNA C, CNA D, CNA E, CNA F, CNA G, CNA H) that did not have license verification upon hire. When Employee G was asked about the expectation for completing licensure verification, Employee G stated the licensure verification should be completed before they hired. When asked why, Employee G stated it was important to make sure they don't have anything on their license. On 07/07/2021 at approximately 12:15 P.M., the review of CNA I's employee file revealed the following: CNA I was employed with the facility from 12/02/2019 through 05/23/2021. A license verification was completed on 11/12/19. Under the header, Expire Date, it was documented, 03/21/2020. Another license verification was completed on 05/26/2020 (56 days after the license expiration date). Under the header, Expire Date, it was documented, 03/31/2021. A third license verification was completed on 04/19/2021 (19 days after the previous license expiration date). Employee G confirmed that the license renewal verifications for CNA I were completed late. On 07/08/2021 at approximately 9:15 A.M., the Director of Nursing (DON) was notified of findings and provided a copy of the staffing schedule for April 2020 as requested. The DON and this surveyor observed that CNA I was scheduled to work in April and May of 2020. When asked about the expectation for license verification, the DON indicated that staff should not work unless their license is verified. When asked why this was important, the DON stated to make sure they are licensed and competent. On 07/08/2021, the facility's policy entitled, Abuse Prevention and Management Policy was reviewed. Under the header, Specific Procedure/Requirements in Section 1 (b) (i) documented, State licensure and certification agencies, and applicable registries, will be contacted, prior to hire, to validate current licensure or certification requirements and to determine if the potential employee is in good standing with the registry. On 07/09/2021 at approximately 2:45 P.M., the administrator and DON were notified of findings and submitted no further documentation or information by the end of survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure two Residents were free from significant medication errors (Residents #7, and #23) in a survey sample of 31 Residents. 1. For Resident #7, the facility failed to administer narcotic pain medication timely as ordered by a physician. 2. For Resident #23, the facility failed to administer 5 medications, including a narcotic pain medication timely as ordered by a physician. The findings included: 1. Resident #7, was admitted to the facility on [DATE]. Diagnoses included; Parkinson's disease, and right shoulder dislocation with pain, contracture right hand, osteoarthritis, and chronic back pain. Resident #7's most recent MDS (minimum data set) with an ARD (assessment reference date) of 4-14-21 was coded as a quarterly assessment. Resident #7 was coded as having a BIMS (brief interview of mental status) score of 15 out of a possible 15, or, no cognitive impairment. Resident #7 was also coded as requiring extensive to total assistance of staff to perform activities of daily living, such as bed mobility, transferring, hygiene, locomotion, and toileting. On 7-6-21 from 1:00 p.m., until 2:00 p.m., medication pour and pass observations were conducted with Licensed Practical Nurse (LPN) A. Resident #7 received medications at 1:40 p.m. The Resident received tramadol, a narcotic pain reliever and LPN A stated these are the morning meds, I am just getting them finished. Review of the Medication Administration Record (MAR) revealed that no time was documented as to the exact time the medication was administered, therefore, the oncoming evening nurse could administer the narcotic pain medication again as soon as 3:00 p.m., and the Resident could experience over sedation. Review of Resident #7's clinical record revealed valid physician's orders for the pain medication given late. That order was as follows: Tramadol 50 milligrams one tablet by mouth three times per day. Those 3 times per day to give the medication, were each listed as a range of time, and are as follows. (1) 8:00 a.m. to 10:00 a.m., (2) 4:00 p.m. to 5:00 p.m., and (3) 9:00 p.m. to 10:00 p.m. Review of the facility's policy entitled, Medication Administration revealed that all medications are to be given according to the prescriber's order timely, and signed/documented by the administering individual as soon as the medication is given. When interviewed on 7-6-21 at 4:00 p.m., the DON (director of nursing), and Corporate Liason stated that the range was going to be changed, and the medications were administered late, which could cause over sedation if given too closely together, and could allow break through pain for the Resident if spaced too far apart. The DON stated her expectation was for staff to administer medications and treatments per physician's orders and to administer them timely. The administrator and DON were informed of the failure of the staff to ensure significant medications were administered timely, on 7-6-21 at 4:00 p.m. No further information was provided by the facility. 2. Resident #23, was admitted to the facility on [DATE]. Diagnoses included; Acute respiatory failure with hypoxia, sacral pressure ulcer, protein deficiency, diabetes, and cardiac/heart disease. Resident #23's most recent MDS (minimum data set) with an ARD (assessment reference date) of 5-12-21 was coded as a significant change assessment. Resident #23 was coded as having a BIMS (brief interview of mental status) score of unable to complete, or, severe cognitive impairment. Resident #23 was also coded as requiring extensive to total assistance of staff to perform activities of daily living, such as bed mobility, transferring, hygiene, locomotion, and toileting. On 7-6-21 from 1:00 p.m., until 2:00 p.m., medication pour and pass observations were conducted with Licensed Practical Nurse (LPN) A. Resident #23 received medications at 1:30 p.m. The Resident received the following 5 medications which were ordered to be administered more than once per day, and were to be given during a range of time. They are as follows; 1. Albuterol metered dose inhaler one to two puffs three times per day at 8:00 a.m. to 10:00 a.m., 12:00 p.m. to 2:00 p.m., and 6:00 p.m. to 8:00 p.m. 2. Flonase nasal steroid one spray in each nare twice per day at 8:00 a.m. to 10:00 a.m., and 6:00 p.m. to 8:00 p.m. 3. Liquicell protein 30 milliliters twice per day at 8:00 a.m. to 10:00 a.m., and 6:00 p.m. to 8:00 p.m. 4. Metoprolol heart medication 50 milligrams twice per day at 8:00 a.m. to 10:00 a.m., and 6:00 p.m. to 8:00 p.m. 5. Hydrocodone narcotic pain reliever 5 milligrams/325 milligrams twice per day at 8:00 a.m. to 10:00 a.m., and 6:00 p.m. to 8:00 p.m. Other medications were also administered at the time, however, they were only ordered to be administered once per day, and so were not added to the deficient practice. LPN A stated these are the morning meds, I am just getting them finished. Review of the Medication Administration Record (MAR) revealed that no time was documented as to the exact time the medication was administered, therefore, the oncoming evening nurse could administer the medications early or late, and the Resident could experience poor respiratory, and cardiac results, over sedation, and or lack of pain control. Review of Resident #23's clinical record revealed valid physician's orders for the multiple significant medications given late. Review of the facility's policy entitled, Medication Administration revealed that all medications are to be given according to the prescriber's order timely, and signed/documented by the administering individual as soon as the medication is given. When interviewed on 7-6-21 at 4:00 p.m., the DON (director of nursing), and Corporate Liason stated that the range was going to be changed, and the medications were administered late, which could cause non-therapeutic side effects, over sedation if given too closely together, and could allow break through pain for the Resident if spaced too far apart. The DON stated her expectation was for staff to administer medications and treatments per physician's orders and to administer them timely. The administrator and DON were informed of the failure of the staff to ensure significant medications were administered timely, on 7-6-21 at 4:00 p.m. No further information was provided by the facility.

**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 offer the COVID immunization for 8 Residents (Resident #3, #21, #22, #27, #28, #32, #38, #43) in a survey sample of 31 Residents. The facility staff failed to provide evidence that they offered the COVID vaccination to 8 Residents when they were eligible, despite the facility having vaccines available to administer. The findings included: On 7/7/21 at approximately 11:00 AM, Surveyor A met with the facility Director of Nursing (DON) who is also serving as the facility's Infection Preventionist. During this review Surveyor A asked for a copy of the immunization logs for staff and Residents with regards to COVID immunizations. On 7/7/21, a review of the clinical records were performed to find evidence of immunizations, to include the COVID vaccine. Surveyor A was having difficulty finding the information and asked the facility staff for assistance. The facility staff were reminded at the end of the day meeting on 7/7/21 and again on 7/8/21, that evidence of the vaccine being offered, administered or declined was needed for Residents #3, #21, #22, #27, #28, #32, #38, #43. On 7/8/21 at 5:53 PM, the facility DON provided the survey team with the following data: 1. Resident #3 is currently hospitalized and unable to be asked about/offered the COVID vaccine. 2. Resident #21 refused the vaccine on 7/8/21. No further evidence was provided to indicate Resident #21 had been offered the vaccine previously. Resident #21 was admitted to the facility on [DATE]. 3. Resident #22 refused the vaccine on 7/8/21. No further evidence was provided to indicate Resident #21 had been offered the vaccine previously. Resident #21 was admitted to the facility on [DATE]. 4. Resident #27 indicated 7/8/21 will discuss with extended family. Resident #27 was admitted to the facility on [DATE] and there was no evidence that the COVID vaccine had been discussed or offered previously. 5. Resident #28 on 7/7/21, consented to receive the first dose of the COVID vaccine on 7/9/21. 6. Resident #32 refused the vaccine on 7/8/21. No further evidence was provided to indicate Resident #32 had been offered the vaccine previously. Resident #32 was admitted to the facility on [DATE]. 7. Resident #38 on 7/8/21 consented to receive the first dose of the COVID vaccine on 7/9/21. There was no evidence provided to suggest that Resident #38 had been offered or educated on the COVID vaccine prior to 7/8/21, despite she had resided in the facility since 5/27/21. 8. Resident #43 refused the vaccine on 7/8/21. No further evidence was provided to indicate Resident #43 had been offered the vaccine previously. Resident #43 was admitted to the facility on [DATE]. On 7/9/21 at 10:02 AM, an interview was conducted with the DON. The DON was advised that the documents she submitted suggested that the above referenced Residents had not been offered the vaccine until 7/7 and 7/8. The DON stated that [Resident #28 name redacted] was not eligible for the vaccine in January when they held their vaccine clinic, because she had been COVID positive in December 2021. Surveyor A asked for evidence that following her 90 days of recovery she was offered the vaccine. The DON stated that she didn't have any further information. She said I know they are offered it on admission and verbally declined but I can't find it. The DON further stated that when vaccines are offered that she does expect this to be documented in the clinical record. On 7/9/21, during the interview with the DON she was made aware of the concerns regarding the lack of evidence of the COVID vaccine had been offered on the 8 Residents aforementioned. On 7/9/21 at 12:22 PM, the facility DON confirmed, COVID vaccine supply is stored centrally at one of our hospitals, and we request doses weekly, which are delivered on Fridays. We have had no difficulty obtaining vaccines for residents or staff who have agreed to receive the vaccine. Review of the facility policy titled COVID- Vaccine Documentation it read, COVID-19 Vaccinations will be offered to residents/representatives and staff and all staff and residents/representatives will be educated on the COVID-19 vaccine they are offered in a manner they can understand including information on the benefits and risks consistent with the CDC and/or FDA information Staff and residents/representatives will be provided the opportunity to refuse the vaccine and/or change their decision about vaccination at any time. Residents: 1. All current residents will be offered the COVID-19 vaccinations well as corresponding fact sheets to the specific vaccination they will receive. 2. During the nursing admission assessment, residents will be provided education on the COVID-19 vaccinations and dates vaccine will be offered at the facility 3. Documentation is maintained in the resident's electronic medical record or in the paper chart. A. Resident vaccination information will be documented on the [Company name initials redacted] COVID-19 Vaccine Record. B. COVID-19 Vaccine Education, Consent/Declination Form will be reviewed with the Resident and/or Resident representative as appropriate. No further information was provided to the survey team prior to exit.