**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to send a copy of the Resident's Care Plan to include their goals for 1 of 50 residents (Resident #324) after being transferred and admitted to the hospital on [DATE]. The findings included: Resident #324 was originally admitted to the nursing facility on 04/02/22. Diagnosis for the resident included but are not limited to Gastrostomy and Trachoestomy. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change with an Assessment Reference Date (ARD) of 02/23/23 coded Resident #324 with a 10 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The Discharge MDS assessments was dated for 12/10/22 - discharge return anticipated. Resident #324 was re-admitted to the nursing facility on 12/22/22. A review of Resident #324's clinical record indicated the resident was transferred to the local hospital on [DATE] related to clogged G-tube. On 06/23/23 at approximately 12:46 p.m., an interview was conducted with License Practical Nurse (LPN) #6. She stated she sent Resident #324 out to the hospital on [DATE] for a clogged G-tube. After the LPN reviewed the resident's clinical record, she stated she would get back to the surveyor related to the resident's care plan being sent upon transfer or shortly after. On the same day at approximately 1:11 p.m., an interview was conducted with the Director of Nursing. She stated LPN #6 informed her she was unable locate in the resident's clinical record that Resident #324's person-centered care plan was sent when discharged and admitted to the hospital on [DATE]. The DON stated if the resident's clinical record did not indicate the care plan was ever sent when discharge or shortly after, then the care plan was never sent to the receiving provider. On 06/23/23 at 2:06 p.m., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services Nursing were informed of the above findings. The DON stated the purpose of sending the residents care plan is for the receiving provider to maintain continuity of care. Definitions -A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach (https://medlineplus.gov). -A tracheostomy is surgery to create a hole in your neck that goes into your windpipe. If you need it for just a short time, it will be closed later. Some people need the hole for the rest of their life. The hole is needed when your airway is blocked, or for some conditions that make it hard for you to breathe. You may need a tracheostomy if you are on a breathing machine (ventilator) for a long time; a breathing tube from your mouth is too uncomfortable for a long-term solution. The tracheostomy provides a way for your health care providers to gradually remove the ventilator if possible (https://medlineplus.gov).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to provide evidence that one of two residents (Resident (R) 102) reviewed for hospital transfers, out of a total sample of 50 residents, documentation that the resident and/or the resident representative were provided a written notice of transfer when the residents were transferred to the hospital. Findings included: Review of the facility policy Resident Discharge/Transfer Letter Policy, dated 04/19/2023 (sic), revealed, Policy: The Facility will complete discharge letters appropriately and according to all federal, state, and local regulations. Procedure: .D) Discharge notices must have the following components: 1. The reason for discharge/transfer, to include appropriate verbiage listed above. 2. The effective date of transfer/discharge. 3. The location to which the resident is transferred/discharge, this must be a specific address which has accepted the resident and is an appropriate location. 4. A statement that the resident has the right to appeals the action to the state. 5. The name, address, and telephone number of the Local and State long term care ombudsman. 6. The mailing address and telephone number of agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Assistance and [NAME] of Rights Act. 7. The mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. E) Social Service or designee will assure the original discharge/transfer letter is given to resident or guardian/sponsor, if applicable. 1. Copies will be sent to the Department of Health, Ombudsman Office and filed in the business file and/or scanned into the electronic chart with administrator/designee signature, with the certified receipt if applicable. 2. For emergency transfers, one list can be sent to the Ombudsman at the end of the month. F) Social service of designee will document in the chart all discharge/transfer reasons, any notices given to the resident or the guardian/sponsor, and discharge planning. Review of R102's undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R102 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute respiratory failure, anxiety disorder, dependence on respirator (ventilator) status, atrial fibrillation, end stage renal disease, morbid obesity, gastrostomy, tracheostomy status. Review of the EMR Progress Notes, located under the Notes tab, revealed an Alert note dated 03/03/23 While in dialysis, resident voiced that he was having chest pain and sob [shortness of breath]. Resident was taken back to his room. While transferring resident to his room, resident skin color noted to be pale, and lips were cyanotic . By the time staff attempted to assist resident with transferring to his bed, Resident became unresponsive . 911 was called. Resident was transported over to Sentara [NAME] (hospital).Further review of the EMR Progress Notes revealed a respiratory therapy note, dated 03/08/23, documented R102 was readmitted to the facility from the hospital. Further review of the record revealed no documentation that written notice of transfer was provided to the resident and/or the resident's representative. In an interview on 06/23/23 at 10:30 AM, the Administrator stated, Residents and their representatives are only given verbal notifications of resident transfers, and nothing is provided to them in writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold policy upon discharge/transfer for 1 of 50 resident's (Resident #324) that was transferred to the local hospital on [DATE]. The findings included: Resident #324 was originally admitted to the nursing facility on 04/02/22. Diagnosis for the resident included but are not limited to Gastrostomy and Trachoestomy. The most recent Minimum Data Set (MDS - an assessment protocol) a significant change with an Assessment Reference Date (ARD) of 02/23/23 coded Resident #324 with a 10 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The Discharge MDS assessments was dated for 12/10/22 - discharge return anticipated. Resident #324 was re-admitted to the nursing facility on 12/22/22. A review of Resident #324's clinical record indicated the resident was transferred to the local hospital on [DATE] related to clogged G-tube. On 06/23/23 at approximately 12:46 p.m., an interview was conducted with License Practical Nurse (LPN) #6. She stated she sent Resident #324 out to the hospital on [DATE] for a clogged G-tube. After the LPN reviewed the resident's clinical record, she stated she would get back to the surveyor related to the Bed-Hold policy being sent when transferred. On the same day at approximately 1:11 p.m., an interview was conducted with the Director of Nursing. She stated LPN #6 informed her she was unable locate in the resident's clinical record the Bed-Hold Policy was sent when discharged to the hospital on [DATE]. The DON stated if the resident's clinical record did not indicate the Bed-Hold policy was ever issued to the resident and or their representative on the day of discharge, then the Bed-Hold policy was never provided. On 06/23/23 at 2:06 p.m., the Administrator, Director of Nursing and Regional Director of Clinical Services Nursing were informed of the above findings. No further information was provided prior to exit. The facility policy titled Bed Hold Notice stated the notice is to be provided to the resident and his/her representative at the time of transfer. In the case of an emergency, the paperwork should be provided within 24 hours. Definitions -A gastrostomy feeding tube insertion is the placement of a feeding tube through the skin and the stomach wall. It goes directly into the stomach (https://medlineplus.gov). -A tracheostomy is surgery to create a hole in your neck that goes into your windpipe. If you need it for just a short time, it will be closed later. Some people need the hole for the rest of their life. The hole is needed when your airway is blocked, or for some conditions that make it hard for you to breathe. You may need a tracheostomy if you are on a breathing machine (ventilator) for a long time; a breathing tube from your mouth is too uncomfortable for a long-term solution. The tracheostomy provides a way for your health care providers to gradually remove the ventilator if possible (https://medlineplus.gov).

Based on staff interview and clinical record review the facility staff failed to ensure a resident received a comprehensive Minimum Data Set (MDS) assessment not less than once every 12 months, within 366 days for 1 of 50 residents (Resident #41), in the survey sample. The findings included: Resident #41 was originally admitted to the facility 5/120/21 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included a seizure disorder, TBI, schizophrenia disorder, and high blood pressure. The quarterly MDS assessment with an assessment reference date (ARD) of 1/24/23 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. During a review of the facility task, Resident assessments triggered Resident #41 for not having a Minimum Data Set (MDS) assessment completed for over 120 days. A review of completed MDS assessment for the resident revealed the following quarterly MDS assessments were completed 1/24/23, 10/29/22, 7/29/22 and a comprehensive MDS assessment was dated 4/28/22 therefore a comprehensive MDS assessment was due April 2023 because each resident must receive a comprehensive Minimum Data Set (MDS) assessment not less than once every 12 months, within 366 days. The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless a Significant Change in Status Assessment or a Significant Correction to Prior Comprehensive Assessment has been completed since the most recent comprehensive assessment was completed. Its completion dates (MDS/Care Area Assessment(s)/care plan) depend on the most recent comprehensive and past assessments ' ARDs and completion dates. (CMS's RAI Version 3.0 Manual, Chapter 2 Page 2-21) An interview was conducted with the MDS Coordinator on 6/22/23 at approximately 5:00 p.m. The MDS Coordinator stated after reviewing it was determined that Resident #41's MDS assessment wasn't completed timely and a new MDS assessment had been opened since it was brought to her attention On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information, but none was provided, and no other concerns were voiced from them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information gleamed during the closed record review and staff interview the facility staff failed to complete a Death in Facility tracking record for Resident #47. Resident #47 was originally admitted to the facility [DATE] after an acute care hospital stay. The current diagnoses included chronic respiratory failure, a seizure disorder, mini stroke and diabetes. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #47's cognitive abilities for daily decision making were intact. The closed record was categorized as hospitalization. A review of the discharge MDS revealed it was coded discharged return not anticipated. During the review of the clinical record a nurse's note date [DATE] at 4:50 a.m. read, the resident was transferred from the facility to the emergency department of a local hospital. Another nurse's note dated [DATE] at 5:31 a.m. read, a nurse telephoned the hospital for information regarding Resident #49 and was told by the hospital personnel that the resident expired at 5:12 a.m., in the emergency department. An interview was conducted with the MDS Coordinator on [DATE] at approximately 5:00 p.m. The MDS Coordinator stated she gained additional information about Resident #47's status and she determined the resident was not admitted to the hospital therefore the Death in facility tracking record should have been completed instead of a discharge assessment return not anticipated. Death in Facility refers to when the resident dies in the facility or dies while on a leave of absence (LOA) (see LOA definition). The facility must complete a Death in Facility tracking record. No Discharge assessment is required. (CMS's RAI Version 3.0 Manual, Chapter 2 Page 2-10) Leave of Absence (LOA), which does not require completion of either a Discharge assessment or an Entry tracking record, occurs when a resident has a: · Temporary home visit of at least one night; or · Therapeutic leave of at least one night; or · Hospital observation stay less than 24 hours and the hospital does not admit the resident. (CMS's RAI Version 3.0 Manual, Chapter 2 Page 2-13) On [DATE] at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information, but none was provided and no concerns were voiced from them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and a clinical record review the facility's staff failed to develop a person-centered comprehensive care plan to include a seizure disorder for 1 of 50 residents (Resident #27), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 4/7/23 after an acute care hospital stay. The resident was discharged to a local hospital on 5/30/23 and returned to the facility on 6/8/23. The current diagnoses included chronic respiratory failure, status post a subdural hematoma, a seizure disorder and pressure ulcers. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/13/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. A review of the clinical record revealed a nurse's noted dated 5/30/23 at 2:26 p.m. It read an order was received from the physician to send Resident #27 to a local emergency room for seizures, altered mental status, a rapid heart rate and fever. The resident's vitals were as follows: blood pressure 150/85, heart rate 127, and temperature 100.8. The hospital's Discharge summary dated [DATE] read the resident had a past medical history significant for a seizure disorder and she was maintained on Keppra (an anticonvulsive). The hospital's discharge summary further read the resident was sent to the emergency room after staff witnessed seizure-like activity at the facility and the emergency room staff noted that she was actively seizing. The resident was treated with intravenous (IV) Ativan and a loading dose Keppra unsuccessfully therefore IV propofol was started with cessation of the seizure activity. A review of the physician's order summary revealed the resident was receiving Levetiracetam oral Tablet 750 MG (Levetiracetam), give two tablets via G-Tube two times a day for seizures. A review of the active care plan revealed there was not a seizure disorder care plan to ensure safety during and after seizures, preventing injury, and minimizing the frequency and severity of seizures through appropriate medication management and caregiver education. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 6/22/23 at approximately 1:36 p.m. LPN #1 stated it is the responsibility of the nursing staff to keep each resident's care plan updated and a care plan is necessary to define how to care for the resident. On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information, but none was provided and no concerns were voiced from them.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to revise the resident's person-centered care plan to include the application and removal of a right leg immobilize for 1 of 50 residents (Resident #75), in the survey sample. The findings included: Resident #75 was originally admitted to the facility 03/29/22. Diagnosis for Resident #75 included but not limited to difficulty in walking and muscle weakness. The most recent Minimum Data Set (MDS - an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 05/24/23 coded Resident #75 with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. On 06/22/23 at approximately 11:33 a.m., Resident #75 observed sitting in her wheelchair with immobilize to right knee. On the same day at 4:05 p.m., right knee leg brace remained in place. Resident #75 observed sitting in her wheelchair on 06/22/23 at 11:33 a.m., with right knee immobilizer in place. The resident stated she always wears the brace when out of bed. She stated the immobilizer is applied by the Certified Nursing Assistant (CNA), therapy but on occasion, she will apply the knee immobilizer. She stated she has worn a brace since being admitted to the facility in March 2022. A review of Resident #75's care plan did not include the wear of a right leg/knee splint/immobilizer. The Director of Nursing (DON) was interviewed on 06/23/23 at 1:00 p.m. She stated Resident #75's person-centered care plan should have been revised to include the use of right knee device. On 06/23/23 at 2:06 p.m., the Administrator, Director of Nursing and Regional Director of Clinical Services Nursing were informed of the above findings. No further information was provided prior to exit. The facility policy titled Splint Issuance policy revised 03/11/22. It is the facility's policy that splints shall be issued or fabricated with a provider's order and therapist must evaluate to determine need for splint, fit and issuance. -Procedure: 2. Patient splint schedule will be communicated to the multidisciplinary team and documented in the care plan. Comprehensive Care Planning revised 07/19/19. It is the facility policy for the interdisciplinary plan of care will be established for every resident and updated in accordance with state and federal regulatory requirements and on an as needed basis.

Based on observation, staff interview, and clinical record review the facility's staff failed to ensure appropriate care and services were provided to prevent/reduce complications while utilizing an indwelling catheter for 1 of 50 residents (Resident #27), in the survey sample. The findings included: Resident #27 was originally admitted to the facility 4/7/23 after an acute care hospital stay. The resident was discharged to a local hospital on 5/30/23 and returned to the facility on 6/8/23. The current diagnoses included chronic respiratory failure, status post a subdural hematoma, a seizure disorder and pressure ulcers. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/13/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. In section H0100 of the MDS assessment the resident was coded for utilizing an indwelling catheter. During the tour on 6/20/23 at approximately 1:25 p.m., Resident #27's indwelling catheter's bedside drainage bag was observed resting on the floor, again on 6/21/23 at approximately 12:15 p.m., the indwelling catheter's bedside drainage bag was resting on the floor and on 6/23/23 at approximately 1:35 p.m., an observation was made with Registered Nurse #1 (RN) of Resident #27's indwelling catheter bedside drainage bag resting on the floor. RN #1 donned a pair of gloves, adjusted the bed so the catheter drainage bag was no longer resting on the floor. RN #1 put the drainage bag inside a privacy cover and stated he would educate staff to ensure all catheter drainage bags are emptied prior to weighing the bag down and to make sure the drainage bag didn't rest on the floor. On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information and the Director of Nursing stated they had begun educating the staff regarding best practices when use of an indwelling catheter is necessary. The Centers for Disease Control recommendations to maintain unobstructed urine flow for an individual utilizing an indwelling catheter; Maintain the bag below the level of the bladder. Ensure that the bag is emptied prior to transport. Use a catheter securement device to anchor the catheter. Keep the urine bag off the floor. (https://www.cdc.gov/infectioncontrol/pdf/strive/CAUTI104-508.pdf)

Based on observations, staff interview, and clinical record review, the facility staff failed to ensure staff reviewed the risks and benefits of bed rail use with the Resident and/or Resident Representative prior to installation, provide documentation that the facility staff attempted alternatives or that they obtained consent for the use of bed rails prior to use for 1 of 50 residents (Resident #27), in the survey sample. Findings include: Resident #27 was originally admitted to the facility 4/7/23 after an acute care hospital stay. The resident was discharged to a local hospital on 5/30/23 and returned to the facility on 6/8/23. The current diagnoses included chronic respiratory failure, status post a subdural hematoma, a seizure disorder and pressure ulcers. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/13/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of two or more people with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing. During the tour on 6/20/23 at approximately 1:25 p.m., Resident #27 was observed in bed with the head of the bed at approximately 45 degrees, bilateral bed rails were attached to the bed and in an upright position and a fall mat was on the floor on the resident's right side. The resident didn't respond when spoken to and there was no identified body movement. On 6/21/23 at approximately 12:15 p.m., the resident was again observed in bed facing the window, with bilateral bed rails in an upright position. On 6/23/23 at approximately 1:35 p.m., an observation was made with Registered Nurse #1 (RN) of Resident #27 in bed with bed rails were attached to the bed and in an upright position. The active care plan dated 4/25/23 had a problem which read resident has an ADL self care performance deficit related to disease process. The interventions included provide two person staff assistance with repositioning and turning in bed and provide two person assistance with transfers daily. There was not any care plan documentation for use of bed rails. A review of the clinical record failed to reveal an assessment for use of bed rails, neither was there documentation that staff reviewed the risks and benefits of bed rail use with the Resident and/or Resident Representative prior to installation of the bed rails, or documentation that the facility staff attempted alternatives prior to use of bed rails use or that they obtained consent for the use of bed rails prior to use. An interview was conducted with the Director of Nursing on 6/23/23 at approximately 11:40 a.m. The Director of Nursing stated there was not a side rail assessment, risk and benefit information provided to the Resident and/or Resident Representative, or documentation of alternative attempted prior to use of the bed rails and there was not a signed consent for bed rails. On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information. They provided no additional information and voiced no further concerns.

Based on observations, resident interview, and staff interview, the facility staff failed to maintain an effective pest control program so that the facility was free of gnats which was voiced by 1 of 50 residents (Resident #273), in the survey sample. The findings included: Resident #273 was originally admitted to the facility 6/1/2023 after an acute care hospital stay. The resident discharged from the facility on 6/21/23. The diagnoses included; a urinary tract infection (UTI), status post a kidney transplant and kidney stones. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/7/2023 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #273's cognitive abilities for daily decision making were intact. On 6/20/23 at approximately 1:53 p.m. an interview was conducted with Resident #273 in her room. The resident was reclined in on her bed, talking about the events which brought her to the facility and the plan for her to be discharged home 6/21/23 at 3:00 p.m. The resident stopped mid-sentence to ask the surveyor if she saw the gnats in her room. The resident stated she needs to drink a lot of water to aid in passing the kidney stones but the gnats go down the straw into her water so she doesn't always have water to drink. Resident #273 also stated the gnats were in her room when she was admitted to present time. The resident also said when she removes the top from her meal tray she has to fight the gnats off to consume the meal. The resident further stated what is homelike about that. An interview was conducted with the Director of Maintenance on 6/23/23 at approximately 12:15 p.m. The Director of Maintenance stated they had a problem with gnats but it is no longer a concern. He also stated the gnats were associated to the resident having flowers and plants in the facility and he thinks if they keep them out the problem will be totally resolved. The Director of Maintenance stated, I asked the pest control company come in today (6/23/23) because he was asked today about the gnat situation in the facility. The pest control technician used a special aerosol was gnats today and prior to that he believes the special aerosol was used last month. Over the four days of the survey (6/20/23 - 6/23/23) the survey team identified gnats throughout the facility including the conference room. On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information but no additional information was provided, and no further concerns were voiced.

Based on observations, resident interview, and staff interview, the facility staff failed to maintain a clean comfortable homelike environment for 1 of 50 residents (Resident #273), in the survey sample. The findings included: Resident #273 was originally admitted to the facility 6/1/2023 after an acute care hospital stay. The resident discharged from the facility on 6/21/23. The diagnoses included; a urinary tract infection (UTI), status post a kidney transplant and kidney stones. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/7/2023 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #273's cognitive abilities for daily decision making were intact. On 6/20/23 at approximately 1:53 p.m. an interview was conducted with Resident #273 in her room. The resident was reclined in on her bed, talking about the events which brought her to the facility and the plan for her to be discharged home 6/21/23 at 3:00 p.m. The resident stopped mid-sentence to ask the surveyor if she saw the gnats in her room. The resident stated she needs to drink a lot of water to aid in passing the kidney stones but the gnats go down the straw into her water so she doesn't always have water to drink. Resident #273 also stated the gnats were in her room when she was admitted to present time. The resident also said when she removes the top from her meal tray she has to fight the gnats off to consume the meal. The resident further stated what is homelike about that. An interview was conducted with the Director of Maintenance on 6/23/23 at approximately 12:15 p.m. The Director of Maintenance stated they had a problem with gnats but thought it was no longer a concern. He also stated the gnats were associated to the resident having flowers and plants in the facility and he thought if they keep them out the problem would be totally resolved. The Director of Maintenance stated, I asked the pest control company come in today (6/23/23) because he was asked today about the gnat situation in the facility. The pest control technician used a special aerosol was gnats today and prior to that he believes the special aerosol was used last month. Over the four days of the survey (6/20/23 - 6/23/23) the survey team identified gnats throughout the facility including the conference room. On 6/23/23 at approximately 2:05 p.m., the above findings were shared with the Administrator, Director of Nursing, a Corporate Consultant, and the Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information but no additional information was provided, and no further concerns were voiced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review and facility policy review, the facility failed to protect seven out of seven residents (Resident (R) 71, R2, R64, R324, R225, R63, R56) reviewed for abuse, specifically the misappropriation of resident's property out of a total sample of 50 residents. This failure has the potential for misappropriation of property for other residents. Findings included: Review of the facility policy, Virginia Resident Abuse Policy dated 10/03/2022 (sic), revealed, Policy: This Facility will not tolerate . misappropriation of resident property by anyone. It is the facility's policy to investigate all allegations, suspicions and incidents of .misappropriation of resident property .Procedure: 7) Investigate: Once the Administrator and DON (Director of Nursing) are notified, an investigation of the allegation or suspicion will be conducted .The person investigating the incident should generally take the following actions: i. Interview the resident, the accused, and all witnesses . c. Documentation. Evidence of the investigation should be documented. 8) Reach a Conclusion: After completion of the investigation, all of the evidence should be analyzed, and the Administrator (or his/her designee) will make a determination regarding whether the allegation or suspicion is substantiated, and, for Injuries of Unknown Source, a determination regarding the probable source of the injury. 1. Review of R71's undated admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R71 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included malignant neoplasm of lower lobe right lung, atrial fibrillation (irregular heartbeat), congestive heart failure, vascular dementia, cerebral infarction (stroke). Review of the facility's investigation revealed an unnamed and undated document that indicated R71 was missing 22 oxycodone tablets. Review of R71's EMR under the Orders tab revealed a Physician Order for oxycodone-acetaminophen tablet 5-325mg (milligram), give 1 tablet by mouth every 12 hours for RA (rheumatoid arthritis) pain, start 07/12/22. 2. Review of R2's undated admission Record, located in the EMR under the Profile tab revealed R2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified intestinal obstruction, major depressive disorder, chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity cerebral infarction (stroke). Review of the facility's investigation revealed an unnamed and undated document that indicated R2 was missing 23 hydrocodone tablets. Review of R2's EMR under the Orders tab revealed a Physician Order for hydrocodone-acetaminophen tablet 5-325mg, give 1 tablet by mouth every 12 hours as needed for chronic back pain, start 10/17/22. 3. Review of R64's undated admission Record, located in the EMR under the Profile tab revealed R64 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included aphasia (disorder affecting communication) following cerebral infarction (stroke), malignant neoplasm of left breast, epilepsy. Review of the facility's investigation revealed an unnamed and undated document that indicated R64 was missing 9cc (cubic centimeters) liquid morphine. Review of R64's EMR under the Orders tab revealed a Physician Order for morphine sulfate 100mg CR (prolong release), give 0.5 ml (milliliter) by mouth every 3 hours as needed for pain, give sublingually for moderate to severe pain, start 10/21/22. 4. Review of R324's undated admission Record, located in the EMR under the Profile tab revealed R324 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute respiratory failure with hypoxia (in sufficient oxygen levels) tracheostomy, gastrostomy. Review of the facility's investigation revealed an unnamed and undated document that indicated R324 was missing 275cc liquid oxycodone. Review of R324's EMR under the Orders tab revealed a Physician Order for oxycodone hcl (hydrochloride) solution 5mg/5ml, give 5ml via PEG (percutaneous endoscopic gastrostomy) tube every 6 hours as needed for pain, start 11/29/22. 5. Review of R225's undated admission Record, located in the EMR under the Profile tab revealed R225 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included congestive heart failure, chronic kidney disease, chronic pain, acute respiratory failure with hypoxia. Review of the facility investigation revealed an unnamed and undated document revealing R225 was missing 10 oxycodone tablets. Further review of R225's EMR under the Orders tab revealed R225 was ordered oxycodone-acetaminophen tablet 5-325mg, give 1 tablet by mouth every 4 hours as needed for moderate to severe pain, start 12/07/22. 6. Review of R63's undated admission Record, located in the EMR under the Profile tab revealed R63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, major depressive disorder, morbid obesity, dementia, asthma, adjustment disorder. Review of the facility's investigation revealed an unnamed and undated document revealing R63 was missing 144 Percocet tablets. Further review of R63's EMR under the Orders tab revealed a Physician Orders that indicated Percocet tablet 5-325mg (oxycodone-acetaminophen), give 1 tablet by mouth every 6 hours as needed for pain, start 10/31/22. 7. Review of R56's undated admission Record, located in the EMR under the Profile tab revealed R56 was admitted to the facility on [DATE] with diagnoses which included nontraumatic intracerebral hemorrhage, dementia, congestive heart failure, chronic obstructive pulmonary disease. Review of the facility investigation revealed an unnamed and undated document that indicated R56 was missing 102 Percocet tablets. Further review of R56's EMR under the Orders tab revealed R56 was ordered Percocet tablet 5-325mg, give 1 tablet by mouth every 8 hours as needed for jaw pain, start 10/21/21. In an interview on 06/22/23 at 3:30 PM, the Regional [NAME] President of Operations (RVPO) stated, on 01/02/23 a nurse reported a medication card of Percocet (an opioid pain medication) was missing from the medication cart. As a result of this discovery a full facility audit was performed, and additional medications were discovered to be missing. A full investigation was carried out, staff were interviewed, and residents were given head to toe assessments. All affected residents were assessed for pain, no residents were found to be in distress or reporting signs or symptoms of pain. No resident was found to have missed any doses of pain medication and the missing medications were replaced. Suspected staff provided written statements and have resigned from the facility. Agency staff suspected have not returned to the facility. The cameras in the facility did not work so there was no video evidence to review. There have been previous incidents of missing medication in the facility and no suspect has been identified after the investigations were completed. The police were notified along with other appropriate agencies. Increased audits of medications are being conducted. Review of the facility incident investigation confirmed the incident occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility staff failed to protect resident from public view during care for 1 resident (Resident #2), of 43 residents in the survey sample. The facility staff failed to ensure Resident #2's privacy was maintained during tracheostomy care. The findings included: Resident #2 was originally admitted to the facility on [DATE]. Diagnosis for Resident #2 included but are not limited to *Tracheostomy, Ventilator and Persistent Vegetative State. Resident #2's Minimum Data Set (MDS-an assessment protocol), a quarterly assessment with an Assessment Reference Date of 09/09/19, coded Resident #2 requiring total dependence of two with dressing, bed mobility, bathing, and toilet use, total dependence of one with hygiene and eating. On 12/12/19 at approximately 8:30 a.m., the Respiratory Therapist (RT) performed tracheostomy care with two surveyors present. While tracheostomy care was being provided on Resident #2's, the privacy curtain was not pulled nor was her door closed to provide privacy. The RT performed tracheostomy care as follows: -Removed gauze from around trach, removed inner trach cannula, inner cannula trach replaced, gloves removed then washed her hands. -RT left the room, remove a split gauze from the treatment cart, came back into the room; door remained open and curtain still not pulled for privacy. -Washed hands, donned a new pair of gloves, cleaned around trach site with wet saline gauze. -Placed a new split gauze around Resident #2's trach. -Suctioned Resident #2, gloves removed, hands washed. -Applied new gloves; listen to breathe sounds, then position Resident #2's head for comfort. During the tracheostomy care procedure, the resident could be viewed by anyone walking past the doorway because the privacy curtain was not pulled and the door was left opened. On 12/12/19, immediately following tracheostomy care, the RT was asked, Should the door be closed or the curtain pulled while providing trach care on Resident #2 she replied, Yes, I should have closed the door or pulled the curtain. The RT was asked, What is the purpose for pulling the curtain or closing the door while providing tracheostomy care on (Resident #2), she replied, Normally, we do pull the curtain for privacy. An interview was conducted with Director of Nursing (DON) and Regional Director [NAME] President of Operations on 12/12/19 at approximately 2:01 p.m. The DON said the therapist should have pulled the curtain and close the door as necessary to provide dignity and privacy of the resident. A briefing was held with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/12/19 at approximately 6:53 p.m. The facility did not present any further information about the findings. The facility's policy titled Resident's Privacy (Revised 04/2015). -Purpose: All personnel will provide resident privacy to the maximum extent possible, in order to maintain the privacy of their bodies. -Procedure include but not limited to: -Residents shall be examined and treated in a manner that maintains the privacy of their bodies. -A closed door, drawn curtain, or both, shield the resident from passersby, as well as their roommate. -Resident's should be draped and dressed appropriately at all times to avoid exposure of embarrassment. -Privacy is also maintained during toileting, bathing, and other activities of personal hygiene. -Protecting the resident's privacy is a very important aspect of resident care and a right guaranteed by the Resident's [NAME] of Rights. Definitions: -Tracheostomy is a hole that surgeons make through the front of the neck and into the windpipe (trachea). A tracheostomy tube is placed into the hole to keep it open for breathing (Mayoclinic.com). -Ventilator is a machine that supports breathing. Ventilators: Get oxygen into the lungs, remove carbon dioxide from the body (Carbon dioxide is a waste gas that can be toxic), help people breathe easier and breathe for people who have lost all ability to breathe on their own (nih.gov). -Persistent Vegetative State is a person with overwhelming damage to the cerebral hemispheres commonly pass into a chronic state of unconsciousness (ie, loss of self-awareness) called the vegetative state. When such cognitive loss lasts for more than a few weeks, the condition has been termed a persistent vegetative state, because the body retains the functions necessary to sustain vegetative functions (nih.gov).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policies by failing to submit to the appropriate state agencies, a five day follow up investigation to a FRI (facility reported incident) that was reported on 1/7/19, for one of 43 residents in the survey sample, Resident #84. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses that included but were not limited to hemiplegia (one sided paralysis) and aphasia (loss of ability to express speech) status post stroke, and type two diabetes. Resident #84 passed away on 10/15/19, therefore a closed record review was conducted. Resident #84's most recent comprehensive MDS (minimum data set) assessment was an significant change assessment with an ARD (assessment reference date) of 10/15/19. Resident #84 was coded as being severely impaired in cognitive function scoring 99 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #84 was coded as being totally dependent on staff with ADLS (activities of daily living). Review of the facility FRIs (facility reported incidents) revealed a FRI that was submitted to the State Survey Agency on 1/7/19 regarding Resident #84. The following FRI was documented in part, Standard Notes: Allegations of neglect in care of resident. Investigation Pending. An APS (Adult Protective Service) report was attached to the FRI. The following was documented: Caller reports for client who resides at (Name of Nursing Facility) and has for the last 6 years. Caller states client has a history of stroke, diabetes, is currently a feeding tube and has difficulty communicating. Caller is concerned the facility is not giving the client the appropriate level of care and may be neglecting client. Caller states that she herself recently had back surgery and was unable to visit with the client for quite some time, until recently when she visited after the holidays. Caller states that when she saw the client in her room, that client's face appeared very swollen, to which she assumes is from an abscess on her tooth from almost a year ago that she has repeatedly asked the facility to address. Caller states that when she went to speak with someone from the front desk about the client's care, that she was informed no information would be provided to her as she was now banned from the facility. Caller states she is unsure how or why this has happened as she is the one who had been taking client to all her necessary medical appointments in the past and visited with her at that day. Caller states she has left several messages for the staff at the facility but that no one will get back to her or return her calls . Review of Resident #84's clinical record revealed that Resident #84 had complaints of mouth pain on 10/3/19. The following nursing note was documented in part, Resident stated she was in pain and pointed to her mouth. Review of Resident #84's October 2018 nursing notes revealed she had an abscess to her tooth on 10/4/19. The following note was documented: Resident started on ABT (antibiotic) clindamycin (antibiotic)(1) for abscesses (sic). Review of Resident #84's October 2018 MAR (medication administration record) revealed that the Resident was started on Clindamycin on 10/4/19 and had ended on 10/10/19. There was no evidence that Resident #84 had any further concerns related to a tooth abscess once antibiotics were completed on 10/10/19. A nursing note dated 11/13/18, documented an incident between Resident #84's daughter (complainant) and the facility. The note documented the following: pt daughter (Name of patient's daughter) was notified that this nurse was not able to give her pt information because she was not on the face sheet as the POA (power of attorney). I notified her it was (Name of social service agency). The daughter began to threaten staff so I called 911. The daughter told (Name of social service agency) and the police that the pt (patient) had feces going up back and her face was swollen. I notified (Name of case manager), the feces and swollen face was not true. I notified (Name of case manager) that she became angry when we did not give her information from the patient's chart .The police arrived and I escorted them to the pt (patient's) room to show them that the patient face was not swollen and she was not in feces. The police agreed that she look fine. We then notified the police that (Name of daughter) will not be allowed back on property until she speaks with management on Monday. The officers (stated) they will her know that she is not allowed back on the property at this time and she will have to leave until she speaks with management. Further review of Resident #84's clinical notes revealed an incident with Resident #84's daughter (another daughter) being disruptive on 12/25/18. The following note was documented: Pts (patients) daughter, (Name of Patient's Daughter) was escorted to N4 (unit 4) nursing station to speak with me about her concerns with her mothers care, or lack thereof. She wanted a state complaint form to fill out. When I turned my back to find one she turned to her companion and said, I hate this b****, I've had to deal with her before. A call was made to DON (Director of Nursing), (name of DON), and a message was left to please call back with information on where to find forms. Called and spoke with (Name of Unit Manager) who informed this RN (Registered Nurse) that there was a No trespassing letter addressed to (Name of daughter). I signed the letter and showed it to the daughter. Told her that she would need to leave now. She left relatively quiet after telling pt, I Will be back to see you tomorrow. She left the building along with her two daughters. She has asked if they had to leave also. I told her the letter only stated that SHE could be here. Two hours later, I was asked to come to N3 (nursing station) 3 again to a belligerent family member. Upon arrival to pts room, pts granddaughter, (Name of granddaughter) was seated outside the room. I went into the room and spoke first with the LPNs (Licensed Practical Nurses) and CNas (Certified Nursing Assistants) caring for the patient. It was said that the daughter said derogatory remarks in their presence and called them bitches. I informed her that it was not ok for her to insult or threaten my staff and that as much as I sympathized with her concerns, she would need to leave the building. She stated she would leave as soon as she said goodbye to the patient. Finally, after saying goodbyes spending more than 5 minutes saying her goodbyes and loudly assuring the pt she would be back to visit her tomorrow, the young lady left the building .only two people have been approved by (social service agency) to visit pt, (Name of two family members) . All other visitors can be turned away and told to contact (social service agency). Further review of the FRIs revealed no evidence that a five-day follow up to the investigation was submitted to the appropriate state agencies for the above allegation of neglect. On 12/10/19 at approximately 12:00 p.m., ASM (administrative staff member) #3, the Regional Director of Clinical Services stated that the facility had changed companies in July of 2019 and any resident records, FRI'S, and grievances prior to July of 2019, would be hard to obtain. ASM #3 would have to ask the old company to send over documents. ASM #3 was asked to provide the follow up to the FRI submitted on 1/7/19 for Resident #84. On 12/12/19 at 9:52 a.m., ASM #3 stated that she was not able to provide evidence that the follow up investigation was sent to the appropriate state agencies. ASM #3 stated that she was the DON (Director of Nursing) with the old company at the time of the above incident. ASM #3 stated that she knew an investigation was conducted but could not speak to the follow-up FRI. When asked the process for reporting an allegation of abuse, ASM #3 stated that an allegation of abuse should be reported immediately, usually within 2 hours if abuse is founded to the appropriate state agencies such as police, APS (Adult Protective Services), and (Name of State Survey Agency) etc. ASM #3 stated that an investigation would be initiated and the results would be sent to the same state agencies within five working days. ASM #3 was made aware of the above concerns. On 12/12/19 at the pre-exit meeting (6:55 p.m.) ASM (administrative staff member) #1, the Administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. No further information was presented prior to exit. No further information was presented prior to exit. The facility's abuse policy documented in part, the following .Final Report will be submitted to the applicable State agency, after the investigation is completed, but no later than (5) working days from the alleged occurrence. (1) This information was obtained from the National Institutes of Health. https://www.ncbi.nlm.nih.gov/books/NBK519574/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, it was determined that facility staff failed to submit the results of an investigation within 5 working days of an allegation of neglect reported on 1/7/19 to the appropriate state agencies for one of 43 residents in the survey sample, Resident #84. The findings included: Resident #84 was admitted to the facility on [DATE] with diagnoses that included but were not limited to hemiplegia (one sided paralysis) and aphasia (loss of ability to express speech) status post stroke, and type two diabetes. Resident #84 passed away on 10/15/19 therefore, a closed record review was conducted. Resident #84's most recent comprehensive MDS (minimum data set) assessment was an significant change assessment with an ARD (assessment reference date) of 10/15/19. Resident #84 was coded as being severely impaired in cognitive function scoring 99 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #84 was coded as being totally dependent on staff with ADLS (activities of daily living). Review of the facility FRIs (facility reported incidents) revealed a FRI that was submitted to the State Survey Agency on 1/7/19 regarding Resident #84. The following FRI documented in part, Standard Notes: Allegations of neglect in care of resident. Investigation Pending. An APS (Adult Protective Service) report was attached to the FRI. The following was documented: Caller reports for client who resides at (Name of Nursing Facility) and has for the last 6 years. Caller states client has a history of stroke, diabetes, is currently a feeding tube and has difficulty communicating. Caller is concerned the facility is not giving the client the appropriate level of care and may be neglecting client. Caller states that she herself recently had back surgery and was unable to visit with the client for quite some time, until recently when she visited after the holidays. Caller states that when she saw the client in her room, that client's face appeared very swollen, to which she assumes is from an abscess on her tooth from almost a year ago that she has repeatedly asked the facility to address. Caller states that when she went to speak with someone from the front desk about the client's care, that she was informed no information would be provided to her as she was now banned from the facility. Caller states she is unsure how or why this has happened as she is the one who had been taking client to all her necessary medical appointments in the past and visited with her at that day. Caller states she has left several messages for the staff at the facility but that no one will get back to her or return her calls . Review of Resident #84's clinical record revealed that Resident #84 had complaints of mouth pain on 10/3/19. The following nursing note was documented in part, Resident stated she was in pain and pointed to her mouth. Review of Resident #84's October 2018 nursing notes revealed she had an abscess to her tooth on 10/4/19. The following note was documented: Resident started on ABT (antibiotic) clindamycin (antibiotic)(1) for abscesses (sic). Review of Resident #84's October 2018 MAR (medication administration record) revealed that the Resident was started on Clindamycin on 10/4/19 and had ended on 10/10/19. There was no evidence that Resident #84 had any further concerns related to a tooth abscess once antibiotics were completed on 10/10/19. A nursing note dated 11/13/18, documented an incident between Resident #84's daughter (complainant) and the facility. The note documented the following: pt daughter (Name of patient's daughter) was notified that this nurse was not able to give her pt information because she was not on the face sheet as the POA (power of attorney). I notified her it was (Name of social service agency). The daughter began to threaten staff so I called 911. The daughter told (Name of social service agency) and the police that the pt (patient) had feces going up back and her face was swollen. I notified (Name of case manager), the feces and swollen face was not true. I notified (Name of case manager) that she became angry when we did not give her information from the patient's chart .The police arrived and I escorted them to the pt (patient's) room to show them that the patient face was not swollen and she was not in feces. The police agreed that she look fine. We then notified the police that (Name of daughter) will not be allowed back on property until she speaks with management on Monday. The officers (stated) they will her know that she is not allowed back on the property at this time and she will have to leave until she speaks with management. Further review of Resident #84's clinical notes revealed an incident with Resident #84's daughter (another daughter) being disruptive on 12/25/18. The following note was documented: Pts (patients) daughter, (Name of Patient's Daughter) was escorted to N4 (unit 4) nursing station to speak with me about her concerns with her mothers care, or lack thereof. She wanted a state complaint form to fill out. When I turned my back to find one she turned to her companion and said, I hate this b****, I've had to deal with her before. A call was made to DON (Director of Nursing), (name of DON), and a message was left to please call back with information on where to find forms. Called and spoke with (Name of Unit Manager) who informed this RN (Registered Nurse) that there was a No trespassing letter addressed to (Name of daughter). I signed the letter and showed it to the daughter. Told her that she would need to leave now. She left relatively quiet after telling pt, I Will be back to see you tomorrow. She left the building along with her two daughters. She has asked if they had to leave also. I told her the letter only stated that SHE could be here. Two hours later, I was asked to come to N3 (nursing station) 3 again to a belligerent family member. Upon arrival to pts room, pts granddaughter, (Name of granddaughter) was seated outside the room. I went into the room and spoke first with the LPNs (Licensed Practical Nurses) and CNas (Certified Nursing Assistants) caring for the patient. It was said that the daughter said derogatory remarks in their presence and called them bitches. I informed her that it was not ok for her to insult or threaten my staff and that as much as I sympathized with her concerns, she would need to leave the building. She stated she would leave as soon as she said goodbye to the patient. Finally, after saying goodbyes spending more than 5 minutes saying her goodbyes and loudly assuring the pt she would be back to visit her tomorrow, the young lady left the building .only two people have been approved by (social service agency) to visit pt, (Name of two family members) . All other visitors can be turned away and told to contact (social service agency). Further review of the FRIs revealed no evidence that a five-day follow up to the investigation was submitted to the appropriate state agencies for the above allegation of neglect. On 12/10/19 at approximately 12:00 p.m., ASM (administrative staff member) #3, the Regional Director of Clinical Services stated that the facility had changed companies in July of 2019 and any resident records, FRI'S, and grievances prior to July of 2019, would be hard obtain. ASM #3 would have to ask the old company to send over documents. ASM #3 was asked to provide the follow up to the FRI submitted on 1/7/19 for Resident #84. On 12/12/19 at 9:52 a.m., ASM #3 stated that she was not able to provide evidence that the follow up investigation was sent to the appropriate state agencies. ASM #3 stated that she was the DON (Director of Nursing) with the old company at the time of the above incident. ASM #3 stated that she knew an investigation was conducted but could not speak to the follow-up FRI. When asked the process for reporting an allegation of abuse, ASM #3 stated that an allegation of abuse should be reported immediately, usually within 2 hours if abuse is founded to the appropriate state agencies such as police, APS (Adult Protective Services), and (Name of State Survey Agency) etc. ASM #3 stated that an investigation would be initiated and the results would be sent to the same state agencies within five working days. ASM #3 was made aware of the above concerns. On 12/12/19 at the pre-exit meeting (6:55 p.m.) ASM (administrative staff member) #1, the Administrator, and ASM #2, the DON (Director of Nursing) were made aware of the above concerns. No further information was presented prior to exit. No further information was presented prior to exit. The facility's abuse policy documented in part, the following .Final Report will be submitted to the applicable State agency, after the investigation is completed, but no later than (5) working days from the alleged occurrence. (1) This information was obtained from the National Institutes of Health. https://www.ncbi.nlm.nih.gov/books/NBK519574/

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #63 was originally admitted to the facility on [DATE]. Resident #63 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnoses included but not limited to, Nontraumatic Subarachnoid Hemorrhage, Unspecified and Persistent Vegetative State. Resident #63's Annual Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 11/18/2019 coded Resident #63 as severely impaired cognitive skills for daily decision making. In addition, the Minimum Data Set coded Resident #63 as requiring total assistance of 1 with dressing and bathing and total dependence of 2 with bed mobility, eating, toilet use and personal hygiene. On 12/11/2019 the Regional Director of Clinical Services was asked for evidence that Resident #63's care plan goals were sent with the resident upon discharge to the hospital on [DATE]. On 12/11/2019 at approximately 3:55 p.m., an interview was conducted with the Regional Director of Clinical Services and she stated, I am unable to provide any evidence that the care plan goals were sent to the hospital when (Resident Name) was discharged on 10/08/2019. On 12/12/2019 at 1:30 p.m., during a briefing an interview was conducted with the Director of Nursing and when she was asked what her expectations are of the nurses when residents are sent to the hospital she stated, I expect the nurses to send the resident care plan goals to the hospital. The Administrator, Director of Nursing and Regional Director of Clinical Services were informed of the finding on 12/12/2019 at 6:55 p.m. at the pre-exit meeting. The facility did not present any further information about the finding. 2. The facility staff failed to ensure that Resident #71's Plan of Care Summary to include his care plan goals was sent upon transfer/discharge to the hospital on [DATE]. Resident #71 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnoses for Resident #71 included but not limited to, Essential Hypertension and Major Depressive Disorder. The current Minimum Data Set (MDS), an annual assessment with an Assessment Reference Date (ARD) of 06/13/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The Discharge MDS assessment was dated for 08/15/19 and included: discharged with return anticipated. On 08/15/19, according to the facility's documentation, Resident #71 was sent to the local emergency room (ER). Resident picked up at 6:05 PM and daughter notified right after. There was no documentation indicating the care plan goals were sent with the resident upon transfer to the hospital. A pre-exit meeting was held with the administrator, Director of Nursing and Corporate Nurse Consultant on 12/12/19 at approximately 3:05 p.m. No further comments were made. Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to send the required documentation to include care plan goals upon transfer to the hospital, for 3 of 43 residents in the survey sample, Residents # 61, #71, #63. The findings included: 1. Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to spinal cord compression, dependence on ventilator, trachesostomy and gastronomy status (feeding tube). Resident #61's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 9/17/19. Resident #61 was coded as being severely impaired in cognitive function scoring 09 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #61 was coded as being dependent on staff for all ADLS (activities of daily living). Review of Resident #61's clinical record revealed that she had been transferred to the hospital on [DATE]. The following nursing note was documented in part: Resident noted to be jerking and throwing arms about, sweating and noted a pasty bowel movement, amber urine and skin to touch. Noted secretions from mouth. Noted some red tinge coming from trach . Review of Resident #61's SNF/NF (skilled nursing facility/nursing facility) transfer form failed to evidence that care plan goals were sent with Resident #61 at the time of hospital transfer. On 12/11/19 at 5:08 p.m., an interview was conducted with Registered Nurse (RN) #2. When asked what documents were sent with Residents upon transfer to the hospital, RN #2 stated that nurses were supposed to send the face sheet, medication list, transfer summary, advanced directives, and the bed hold policy. RN #2 stated that nurses should be documenting in a nursing note what documents were sent with the resident at the time of transfer. RN #2 stated that nursing staff should also be checking off the Acute Care Transfer list. RN #2 showed this writer that the Acute Care Transfer List was a check off list of documents sent with the resident to the hospital. Care plan goals was not an option on this list. RN #2 stated that nurses usually write in CP goals on the sheet. RN #2 stated however the checklist was mostly adhered to during the day shifts. Facility staff could not present an Acute Care Transfer List for Resident #61. On 12/12/19 at the pre-exit meeting (6:55 p.m.) ASM (administrative staff member #1, the Administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was presented prior to exit.

Based on clinical record review, staff interview and facility documentation the facility staff failed to ensure 1 of 43 residents (Resident #54) in the survey sample received a complete and accurate assessment. The findings included: The facility staff failed to ensure Resident #54's, MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 11/14/19 was coded correctly under Section N (Medications) for the use of Anti-depressant. Resident #54 was admitted to the facility 1/10/19. Diagnosis for Resident #54 included but not limited to Depression disorder. Resident #54's MDS, an annual assessment with an Assessment Reference Date (ARD) of 11/14/19 coded resident with a BIMS score of 15 out of a possible 15 indicating no cognitive impairment. Review of Resident #54's quarterly MDS with an ARD of 11/14/19 was coded 7 for receiving antianxiety medications and was coded 0 for days receiving antidepressant medications. The section N on the MDS under medications received read as follows: Indicate the number of DAYS the resident receiving the medication during the last 7 days, enter 0 if medication was not received by the resident during the last 7 days. Resident #54's comprehensive care plan documented the resident with use of anti-depressant medication. The goal: will show decreased episodes of sign and symptoms of depression through the next review date (02/17/19). Some of the intervention to manage goal included give antidepressant medications as ordered by the physician. Monitor/document side effects and effectiveness. The physician order read: Starting on 08/28/19, Celexa 40 mg -give 1 tablet by mouth one time a day for depression. Review of Resident #54's November 2019, Medication Administration Record (MAR) revealed the medication Celexa was administered daily for daily for the look back period of 7 days for the MDS with an ARD date of 11/14/19. An interview was conducted with MDS Coordinator #1 on 12/12/19 at approximately 8:17 a.m. She reviewed the MDS with an ARD date of 11/14/19 then reviewed the MAR for November 2019. The MDS Coordinator stated, The MDS was coded incorrectly. She said the medication Celexa is an antidepressant; not antianxiety medication. She stated, I will modify the 11/14/19, MDS now. A briefing was held with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/12/19 at approximately 6:53 p.m. The facility did not present any further information about the findings. CMS's RAI Version 3.0 Manual (Chapter 1: Resident assessment Instrument (RAI) 1). 1.3 Completion of the RAI (1) the assessment accurately reflects the resident's status. Goals: The goal of the MDS 3.0 revision are to introduce advances in assessment measures, increase the clinical relevance of items, improve the accuracy and validity of the tool, increase the resident's voice by introducing more resident interview items. Providers, consumers, and other technical experts in the nursing home care requested that MDS 3.0 revision focus on improving the tool's clinical utility, clarity, and accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to develop a care plan for the prevention of pressure ulcers/injury for 1 of 43 residents (Resident #30) in the survey sample. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (PVD), right below the knee amputation (BKA), *unstageable left heel pressure ulcer, type 2 diabetes, stage 3 renal disease, stroke and Alzheimer's disease. Resident #30 was readmitted to the nursing facility on 10/15/19 with additional diagnoses that included post fall, urinary tract infection (UTI), generalized muscle weakness and gastro-esophageal reflux disease (GERD). *According to the NPUAP (National Pressure Ulcer Advisory Panel)/NPIAP (National Pressure Injury Advisory Panel) an unstageable pressure ulcer/injury is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (slough is non-viable tissue comprised of dead white blood cells, fibrin, cellular debris and liquefied devitalized tissue and requires debridement) or eschar (eschar is composed of necrotic granulation tissue, muscle, fat, tendon or skin. Eschar is used to describe leathery, dry hard eschar tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar should not be moved on an ischemic limb or heel (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5098472/). Resident #30's admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 00 out of a possible score of 15 which indicated the resident was severely impaired in the necessary skills for daily decision making. The resident was not coded to reject care to include activities of daily living (ADL) assistance. The resident required extensive assistance from one staff for bed mobility (how the resident moves to and from a lying position, turns side to side, and positions body while in bed or alternative sleep furniture). The resident was assessed totally dependent on two staff for transfers, dressing and personal hygiene and bathing. She was coded totally dependent on one staff for locomotion on the unit and toilet use. The resident used a manual wheelchair as the primary mobility device and was dependent on staff actively propel the resident in the wheelchair. The resident was coded to require set up and supervision from one staff for eating. The resident was assessed at risk for the development of pressure ulcers and had one unhealed unstageable pressure ulcer, and no venous or arterial ulcers. Pressure reducing devices for the bed was coded, as well as pressure ulcer care, and nutritional and hydration intervention to manage skin problems. The resident was assessed always incontinent of bowel and bladder. The resident was 5 feet 6 inches tall and weighed 171 pounds. She was not terminal or on hospice care. Resident #30's 5 day scheduled assessment dated [DATE] coded a change in bed mobility to require the assistance of two staff. Resident #30 was not care planned for the prevention of pressure ulcers although she was assessed upon admission, as well as on the Braden Scale Pressure Ulcer Risk assessments to be at risk for them. The care plan dated 10/15/19 identified Resident #30 had actual unstageable pressure ulcers on the left heel and left toe. This care plan was revised on 12/11/19 for an acquired unstageable pressure ulcer on the sacrum. The Braden Scale Pressure Ulcer Risk Assessments dated 9/26/19 indicated the resident was at moderate risk for the development of pressure ulcers with a score of 14, on 10/3/19 at low risk with a score of 15, on 10/22/19 with a score of 14, on 10/29/19 at very high risk with a score of 9, on 11/5/19 at high risk with a score of 12 and on 12/6/19 at very high risk with a score of 9. On 12/10/19 during the orientation/screening of the residents on North 4 at 11:00 a.m., Resident #30 was observed in a blue geri-lounger with pillows wedged in the chair on each side of the resident. The resident remained in the chair until 2:30 p.m. It was not known how long the resident was up in the chair prior to start of this observation, at 11:00 a.m. The resident was wearing a brief and a thin piece of *Dycem was in the seat of the chair, as shown to this surveyor by a Certified Nursing Assistant (CNA). The nurse's notes dated 12/11/19 at 2:22 a.m. indicated that Resident #30 was in the chair when the nurse came on her shift at 7:00 p.m. *Dycem® is a non-slip, rubber-like plastic material used to stabilize surfaces. Reusable. Cut to most any size or shape with scissors. Cleans with soap and water. Matting is 1/32 thick. Pads are 3/16 thick. Not made of natural rubber latex (https://Dycem-ns.com/). Dycem does not provide pressure relief. The care plans presented on 12/12/19 at approximately 10:00 a.m. did not include a care plan with goals and approaches to prevent pressure ulcers/injury for Resident #30. On 12/12/19 at 6:53 p.m., a debriefing was held with the Administrator, Director of Nursing, Regional Director of Clinical Services and Regional Administrator. No further information was provided prior to survey exit. The facility policy continued: The first step in prevention will be through identification of the resident at risk of developing pressure ulcers. This will be followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions . Monitor every shift to ensure that measures are in place as specified on the care plan to prevent skin breakdown . According to the Joint Commission, they support the following pressure ulcer prevention strategies based on the NPUAP's (National Pressure Ulcer Prevention Advisory Panel) also known as NPIAP (National Pressure Injury Advisory Panel): *Definition of pressure ulcer/injury-A pressure ulcer/injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The injury can present as intact skin or an open ulcer and may be painful. -Multiple disciplines and teams involved in developing and implementing care plans with teamwork, communication and expertise involved in developing and implementing the care plan, therefore improvement in pressure injury prevention, optimizing overall care and increasing attention to these issues can prevent the next pressure injury and save the next patient. Prioritize and address identified issues. Make sure they are aware of the plan of care and that all care is documented in the patient's record. Retrieved from https://www.jointcommission.org>Quick_Safety_Issue_25_July_20161Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to develop a care plan for the prevention of pressure ulcers/injury for 1 of 43 residents (Resident #30) in the survey sample.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and clinical record review the facility staff failed to revise the comprehensive care plan to reflect the resident's current weight bearing status for 1 of 43 residents in the survey sample, Resident #49. The findings included: Resident #49 was admitted to the facility on [DATE]. Diagnoses included but were not limited to, Other Fracture of Right Lower Leg, Subsequent Encounter For Closed Fracture with Routine Healing and Other Fracture of Left Lower Leg, Subsequent Encounter For Closed Fracture with Routine Healing. Resident #49's Quarterly Minimum Data Set (MDS - an assessment protocol) with an Assessment Reference Date of 11/06/2019 coded Resident #49 with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #49 as requiring limited assistance of 1 with bed mobility, transfer, walk in room, dressing and toilet use and independent with set up help only with eating, personal hygiene and bathing. On 12/12/2019 at approximately 10:00 a.m., review of Resident #49's clinical record revealed the following: Review of Resident #49's comprehensive care plan revealed focus areas and is documented as follows: (Resident Name) has an ADL (Activity of Daily Living) Self Care Performance Deficit r/t (Related To) inability to bear weight to BLE (Bilateral Lower Extremities). Date Initiated: 08/07/2019 Revision on : 08/08/2019; Alteration in musculoskeletal status r/t ORIF (Open Reduction Internal Fixation) to bilateral ankles and NWB (Non-Weight Bearing) orders. Date Initiated: 08/07/2019 Revision on: 08/13/2019; (Resident Name) is at risk for falls due to BLE Fracture and presence of External Fixators. Date Initiated: 08/07/2019 Revision on: 10/22/2019; (Resident Name) has acute pain r/t Bilateral Ankle Fracture and External Fixators. Date Initiated: 08/07/2019 Revision on: 10/22/2019. Review of Resident #49's Physician Order Listing Report revealed the following: Bilateral Fixator removed via (Name of Hospital abbreviation). Please have therapy eval (evaluate) post surgery x1. One time only for Post Surg (Surgery) for 1 Day. Order Status: Completed Revision Date: 10/28/2019 Last Order Date: 10/28/2019. Review of Resident #49's Physician Orders dated 11/12/2019 revealed the following: 1. Please apply bilateral canvas lace up ankle braces; 2. May weight bear to tolerance. Review of Resident #49's Physician Order Listing Report revealed the following: Non-Weight Bearing To Bilateral Lower Extremities every shift. Order Status: Discontinued Revision Date: 11/13/2019 Last Order Date: 08/23/2019. On 12/12/2019 at 12:55 p.m., an interview was conducted with Registered Nurse (RN) #1, MDS Coordinator, was asked to review the residents current orders and comprehensive care plan. When asked if the residents comprehensive care plan reflected the residents current status, MDS Coordinator stated, No, the care plan needs to be updated. (Resident Name) does not have external fixators and his weight bearing status has changed. When asked if the residents ankle braces should be care planned, MDS Coordinator stated, Yes. When asked what is the purpose of a comprehensive care plan, Licensed Practical Nurse #2, MDS Coordinator, stated, The care plan serves as a blue print for nursing. On 12/12/2019 at 1:30 p.m., during briefing an interview was conducted with the Director of Nursing (DON), when she was asked what her expectations were of the MDS Coordinators updating comprehensive care plans, DON stated, I expect that the care plan will reflect the residents current status. The Administrator, Director of Nursing and Regional Director of Clinical Services was informed of the finding on 12/12/2019 at 6:55 p.m., at the pre-exit meeting. The facility did not present any further information about the finding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that facility staff failed to provide fingernail care to a dependent resident for one of 43 residents in the survey sample, Resident #52. The findings included: Resident #52 was admitted to the facility on [DATE] with diagnoses that included but were not limited to post stroke, weakness following cerebrovascular disease (stroke) and diabetes type two. Resident #52's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 11/11/19. Resident #52 was coded as being moderately impaired in cognitive function scoring 13 out of 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #52 was coded in Section G Functional Status as having impairments to one side of his upper and lower extremities. On 12/10/19 at 11:24 a.m., an interview was conducted with Resident #52. Resident #52 had stated that he wanted his finger nails cut and that staff were aware. Resident #52 could not state who he expressed his concern to. Resident #52 also stated that he was not sure how long it had been since his nails were cut. Observation of Resident #52's nails was also conducted. Resident #52's finger nails to both hands were approximately 1/2 inch long. Resident #52 also stated that he had weakness to his right arm and sometimes wore a brace. On 12/11/19 at 10:42 a.m., a second observation was made of Resident #52's fingernails. His fingernails were still approximately 1/2 inch long. A nursing assistant had just left Resident #52's room. Resident #52 stated that he was just dressed by the aide for his appointment soon. Review of Resident #52's ADL (activities of daily living) care plan dated 9/2/19 documented the following: The resident has an ADL self care performance deficit related to weakness following cerebrovascular accident .check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Review of Resident #52's December 2019 CNA (Certified Nursing Assistant) - ADL tracker form revealed that Resident #52 frequently refused bath days but would accept partial baths. There was no evidence that nail care was provided. Review of Resident #52's clinical record failed to evidence that he recently refused fingernail care. On 12/11/19 at 3:05 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. When asked if Resident #52 was able to cut his own fingernails, LPN #1 stated that he wasn't. When asked who was responsible for ensuring fingernails were cut, LPN #1 stated that if a resident was diabetic, nurses were responsible for providing nail care. LPN #1 stated that if Residents are not diabetic, the CNAs would offer and perform nail care during baths, and showers as part of ADL care. LPN #1 stated that nurses should also offer whenever they see that fingernails are long. When asked if Resident #52 had recently requested for his nails to be cut, LPN #1 stated that he usually tells staff when he wants to see podiatry. When asked if she had Resident #52 that day, LPN #1 stated that she had worked with Resident #52 since 7 a.m. that morning. When asked if she noticed his nails, LPN #1 stated his hands were underneath the blanket and that she didn't check his nails. When asked the process if a resident refuses nail care, LPN #1 stated that she would make several attempts to offer nail care and document in a nursing note if the resident continues to refuse care. On 12/11/19 at 3:13 p.m., LPN #1 followed this writer to Resident #52's room. LPN #1 confirmed that his nails were long. At that time Resident #52 stated that he has asked a staff member the day prior (12/10/19) to cut his nails and no one did. He could not recall who he had told. On 12/11/19 at 3:19 p.m., an interview was conducted with CNA #1, Resident #52's nursing aide. When asked who was responsible for providing fingernail care, CNA #1 stated that the nursing aides were responsible if the resident was not diabetic. CNA #1 stated that they will offer weekly to trim nails if needed and try to ensure they are clean on a daily basis. CNA #1 stated that she did not notice Resident #52's nails that day. CNA #1 stated that she did not offer to cut his nails that day but that he was also diabetic. On 12/12/19 at 10:45 a.m., an interview was attempted with the CNA who worked 12/10/19. She could not be reached. On 12/12/19 at 11:41 a.m., an interview was attempted with the nurse who worked 12/10/19. She could not be reached. On 12/12/19 at the pre-exit meeting (6:55 p.m.) ASM (administrative staff member) #1, the Administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was presented prior to exit. Facility policy, Nail Care, documented in part, the following: Nursing staff will administer nail care in order to provide cleanliness and prevent infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility documentation review, the facility staff failed to develop and implement preventative measures to prevent the formation of a new pressure ulcer to an at risk resident prior to identification at an advanced stage, for 1 or 43 residents (R#30) in the survey sample. Resident #30's sacral/coccyx pressure ulcer was first identified on 12/6/19 by the nursing staff as an unstageable pressure ulcer. The findings include: Resident #30 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease (PVD), right below the knee amputation (BKA), *unstageable left heel pressure ulcer, type 2 diabetes, stage 3 renal disease, stroke and Alzheimer's disease. Resident #30 was readmitted to the nursing facility on 10/15/19 with additional diagnoses that included post fall, urinary tract infection (UTI), generalized muscle weakness and gastro-esophageal reflux disease (GERD). The resident was a full code. She was not terminal or on hospice care. *According to the NPUAP (National Pressure Ulcer Advisory Panel)/NPIAP (National Pressure Injury Advisory Panel) an unstageable pressure ulcer/injury is an obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (slough is non-viable tissue comprised of dead white blood cells, fibrin, cellular debris and liquefied devitalized tissue and requires debridement) or eschar (eschar is composed of necrotic granulation tissue, muscle, fat, tendon or skin. Eschar is used to describe leathery, dry hard eschar tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar should not be moved on an ischemic limb or heel (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5098472/). Resident #30's admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 00 out of a possible score of 15 which indicated the resident was severely impaired in the necessary skills for daily decision making. The resident was not coded to reject care to include activities of daily living (ADL) assistance. The resident required extensive assistance from one staff for bed mobility (how the resident moves to and from a lying position, turns side to side, and positions body while in bed or alternative sleep furniture). The resident was assessed as totally dependent on two staff for transfers, dressing and personal hygiene and bathing. She was coded totally dependent on one staff for locomotion on the unit and toilet use. The resident was coded to require set up and supervision from one staff for eating. Resident # 30 was assessed as at risk for the development of pressure ulcers and had one unhealed unstageable pressure ulcer, and no venous or arterial ulcers. Pressure reducing devices for the bed was coded, as well as pressure ulcer care, and nutritional and hydration intervention to manage skin problems. The resident was assessed as always incontinent of bowel and bladder. The resident was 5 feet 6 inches tall and weighed 171 pounds. Resident #30's 5 day scheduled assessment dated [DATE] coded a change in bed mobility to require the assistance of two staff. The resident weight had increased to 187 pounds. The care plan dated 10/15/19 identified ADL, self care performance deficit related to Alzheimer's dementia and right BKA and history of stroke as a focus areas. The goals set by the staff for the resident was that the resident would not decline in current level of function and that she would be free from the signs and symptoms of complications from the stroke. Some of the approaches the staff would use to accomplish these goals included observe skin for redness, open area, scratches, cuts, bruises and report changes to nurse per protocol and prn (as needed) and out of bed as tolerated. The care plan indicated the resident was totally dependent on staff for positioning and repositioning. The care plan dated 10/15/19 identified Resident #30 had a left heel, left toe unstageable pressure ulcer and was revised on 12/11/19 for an acquired unstageable pressure ulcer on the sacrum. The goal set by the staff was that the resident's pressure ulcer would show signs of healing and remain free of infection. The approaches to accomplish this goal included medications and supplements to promote wound healing, serve diet as ordered and monitor intake and record and pressure relieving/reducing device (mattress). The resident was not care planned to have significant weight loss. Resident #30 did not have a plan of care for the prevention of pressure ulcers even though she was assessed upon admission, as well as on the Braden Scale Pressure Ulcer Risk assessments, to be at risk for them. The Braden Scale Pressure Ulcer Risk assessment dated [DATE] indicated the resident was at moderate risk for the development of pressure ulcers with a score of 14 based on the following (this assessment tool did not take into account existing pressure ulcers-the unstageable left heel upon admission): -The resident could not always communicate discomfort or the need to be turned; or, had some sensory impairment which limits ability to feel pain or discomfort in one or two extremities. -The resident was chairfast in wheelchair. -Rarely moist-skin usually dry, linen requires changing at intervals. -The resident was completely immobile and did not make even slight changes in body or extremity position without assistance. -The resident rarely eats a complete and generally eats only half of the food offered. -Potential problem with friction or shearing. Moves feebly and during a move skin probably slides to some extent against sheets, chair, restraints or other devices. The Braden Scale Pressure Ulcer Risk assessment dated [DATE] indicated the resident was at low risk with a score of 15 for the development of pressure ulcers based on the following changes: -The resident occasionally moist, requiring an extra linen change at least once a day. -Mobility is very limited, makes occasional slight changes in body position, but unable to make frequent or significant changes independently. -Nutrition is adequate, eats over half of most meals. The Braden Scale Pressure Ulcer Risk assessment dated [DATE] indicated the resident was at moderate risk for the development of pressure ulcers with a score of 14 based on the following changes: -Resident requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. The Braden Scale Pressure Ulcer Risk assessment dated [DATE] indicated the resident was at very high risk for the development of pressure ulcers with a score of 9 based on the following changes: -Completely limited to painful stimuli, due to diminished level. -Constantly moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. The Braden Scale Pressure Ulcer Risk assessment dated [DATE] indicated the resident was at high risk for the development of pressure ulcers with a score of 12 based on the following changes: -Slightly limited in sensory perception, responds to verbal commands, but cannot always communicate discomfort or the need to be turned; or, has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. The Braden Scale Pressure Ulcer Risk assessment dated [DATE] indicated the resident was at very high risk for the development of pressure ulcers with a score of 9 based on the following changes: -Completely limited to painful stimuli. -Very moist, skin is often, but not always moist. Linen must be changed at least once a shift. -Completely immobile, does not make even slight changes in body or extremity position without assistance. -Rarely eats a complete meal, eats half of food offered. Resident #30 had physician orders dated 9/21/19 for Prostat (protein supplement for wound healing) once a day and increased to twice a day on 11/14/19, and a multi-vitamin once a day ordered on 9/19/19, changed to Theragran-M (multi-vitamins with minerals). On 12/10/19 during the initial screening of the residents on North 4 at 11:00 a.m., Resident #30 was observed in a blue geri-lounger with pillows wedged in the chair on each side of the resident. The resident remained in the chair until 2:30 p.m. It was not known how long the resident was up in the chair prior to start of this observation, at 11:00 a.m. The resident was wearing a brief and a thin piece of *Dycem was in the seat of the chair, as shown to this surveyor by a Certified Nursing Assistant (CNA). The nurse's notes dated 12/11/19 at 2:22 a.m. indicated that Resident #30 was in the chair when the nurse came on her shift at 7:00 p.m. *Dycem® is a non-slip, rubber-like plastic material used to stabilize surfaces. Reusable. Cut to most any size or shape with scissors. Cleans with soap and water. Matting is 1/32 thick. Pads are 3/16 thick. Not made of natural rubber latex (https://Dycem-ns.com/). Dycem does not provide pressure relief. The Bi-Weekly skin checks that were presented to this surveyor, performed by a licensed nurse, identified the admitted (9/19/19) left unstageable heel ulcer, but NO NEW PRESSURE ULCERS per the skin checks on 10/21/19, 10/24/19, 10/26/19, 10/28/19, 10/29/19, 11/3/19, 11/5/19, 11/7/19, 11/19/19, 11/21/19, 11/25/19. 11/28/19, 12/1/19, 12/3/19, 12/6/19 (timed at 7:25 p.m.). On 12/9/19 (timed at 6:20 p.m.) the coccyx pressure ulcer was recorded. The nurse's notes dated 12/6/19 at 5:09 p.m. indicated a new pressure wound .Stage: unst (unstageable) wound location coccyx; length 4.0 centimeters (cm); width 3.5 cm; depth 0.1 cm; area is in house acquired. Skin impairment was not present upon admission. 12/6/19 drainage type: No drainage wound has slough. No odor periwound (perimeter of the wound) appearance is red .Treatment: cleanse coccyx area with wound cleanser and apply *Santyl and cover . This nurse's note was signed by Licensed Practical Nurse (LPN) #8. *Santyl is a topical debridement agent Collagenase Santyl® Ointment is a sterile enzymatic debriding ointment which possesses the unique ability to digest collagen in necrotic tissue (https://www.rxlist.com/santyl-drug.htm#description). On 12/11/19 at 12:23 p.m., LPN #8 performed wound care to the sacral/coccyx pressure ulcer assisted by the Registered Nurse (RN) Supervisor #2. The sacral/coccyx wound bed exhibited light brown/yellowish slough with redness around the perimeter of the wound. The resident had a large soft dark brown liquid stool that had oozed into and under the dressing prior to its removal, as well as in the front peritoneal area and vaginal folds. The RN Supervisor #2 used a basin of soapy water and many wash cloths and towels to remove the exorbitant amount of stool prior to performing the dressing change. The resident was also observed dribbling urine throughout the dressing change procedure with continued oozing of stool. On 12/11/19 at 4:00 p.m., an interview was conducted with the Director of Nursing (DON). The Weekly Wound Assessments were reviewed with her and at this time an inquiry was made regarding any further information, documentation that would refute that the sacral wound pressure ulcer was first identified by the nursing staff at an advanced stage on 12/6/19. She pointed to the Weekly Wound Assessment document date of 12/6/19 that indicated the pressure ulcer was unstageable, in house acquired with slough in the wound bed and no documentation to support otherwise. On 12/12/19 at 1:00 p.m., an interview was conducted with the North 4 RN Unit Manager. When asked if she had any other documentation that showed there was an area on the resident's sacrum prior to it being assessed as unstageable on 12/6/19. She stated copies of skin assessments, wound assessments and nurse's notes were what she had to go on and there was nothing she could find identified prior to 12/6/19 on the resident's sacrum/coccyx and that they were given to this surveyor. When asked if it was acceptable to first identify a pressure ulcer at an advanced stage, she responded, Not preferable. She stated on 10/1/19, Resident #30 was placed on a specialty mattress 10/1/19, but there was no pressure reduction of relieving device/cushion placed in her geri-chair. The Unit Manager stated, We only use a piece of *Dycem to keep her in place in the chair with pillows to wedge on each side of her body otherwise she would wiggle or slide down, she is in a Geri-Chair. We recline her a little. When asked if they consulted Occupational Therapy (OT) for residents with positioning challenges, to come up with something that would fit in the Geri-chair that would provide pressure relief/reduction, to which she responded, No we haven't. During the above interview, the North 4 RN Unit Manager stated the nursing staff get the resident up every day for a couple of hours and she is checked every 2 hours for incontinence. She stated the CNAs were to report all changes in skin integrity to the licensed nurse. When asked if there were any Stop and Watch forms on file filled out by any CNAs that would evidence any areas or changes in the resident's sacrum/coccyx before 12/6/19, the Unit Manager stated there were not any and she knew that when CNA #3 saw the pressure area on 12/6/19, she did not fill one out, but went straight to the nurse to let her know. On 12/12/19 at 1:25 p.m., during an interview with LPN #8, she stated the wound was in house acquired and first found by Certified Nursing Assistant (CNA) #3. She stated, (CNA #3's name) came to tell me when she checked the resident's brief, she found this pressure area. She stated she is routinely assigned to Resident #30 and it was the first she heard or knew about an area on the resident's coccyx. She stated she assessed the resident, called the physician with the assessment of the wound (described in the aforementioned nurse's note dated 12/6/19 at 4:10 p.m.) and received orders for treatment. The verbal Physician orders were verified dated 12/6/19 to cleanse the wound with with wound cleanser or normal saline, pat dry, apply Santyl, cover with a dry sterile dressing daily and PRN until healed as needed for wound care, and every shift for pressure injury. Record review revealed the Physician's Assistant (PA) examined the wound on 12/11/19 and ordered that the same dressing change procedure be followed as ordered on 12/6/19 except that wound be cleansed with normal saline, not wound cleanser and a nickel thick amount of Santyl be applied to the wound bed. On 12/12/19 at 2:00 p.m., an interview was conducted with CNA #3. She stated, I was pulled to the unit at 1:00 p.m. that day (12/6/19). I wasn't working over there (North 4). When I turned her over to check her to see if she was wet that was when I saw this large area in the middle of her bottom. I went immediately to (LPN #8's name) and told her. The CNA that had the resident on 12/5/19 from 7:00 p.m. to 7:00 a.m. (12/6/19) did not respond to the surveyors telephone calls prior to survey exit. On 12/12/19 at 4:21 p.m., a telephone interview was conducted with CNA #5. She stated she took care of the resident on Tuesday 12/10/19 from 7:00 a.m. to 7:00 p.m. and stated she gets her up in the chair daily. She stated the resident did not have a pressure relief cushion, just a sheet of Dycem to keep her in place. She stated, The resident did not have a pressure ulcer on her bottom when she came in. She came in with that heel, but there was nothing on her bottom when I had her on 12/5/19 from 7:00 a.m. to 7:00 p.m. I checked her every two hours and she was clear. If I see something, I tell the nurse. On 12/12/19 at 6:00 p.m., the resident was observed in bed and it was asked to see the chair Resident #30 was normally placed in, both RN supervisors #2 and #4 stated the chair was behind the door in the resident's room. It was at this time, this writer validated it was the same chair as previously observed the resident in on 12/10/19 at 11:00 a.m. No cushions, or pressure relief/reduction devices were observed. On 12/12/19 at 6:53 p.m., a debriefing was held with the Administrator, Director of Nursing, Regional Director of Clinical Services and Regional Administrator. Concerns about identification of the sacrum/coccyx pressure ulcer was reviewed with all those in attendance. The Administrative Team concurred that the expectation of the nursing staff would be to check the resident every two hours or as needed for incontinence, provide incontinence care as necessary and reposition at least every two hours, in bed and in the chair. It was also stated and agreed by the Administrative Team in attendance, that the CNAs are to report any changes in skin integrity to the nurse immediately, if found during their checks or care. Additionally, it was stated that the Bi-Weekly skin checks and the one dated 12/6/19 at 7:25 p.m. (after the sacrum/coccyx pressure ulcer was identified) indicated the resident had no new identified skin issues. The observations of the resident were discussed during the debriefing. It was stated by the surveyor that the resident was up in her chair with only a sheet of Dycem and pillows wedged on both sides, which rendered the resident totally immobile, and without a pressure relief device/cushion, placed the resident at an increased risk for breakdown with direct sustained pressure to the coccyx area. The Regional Director of Clinical Services stated that she knew that she could provide information that Resident #30's pressure ulcer could have developed in a few hours. The survey team gave the facility staff the opportunity to present credible evidence that an unstageable pressure ulcer could develop within a few hours. The Administrator, DON and Regional Director of Clinical Services returned at 7:30 p.m., but was not able to present any supporting articles or research that indicated an unstageable pressure ulcer could develop in a few hours. The resident was not terminal or in hospice care. The facility's policy and procedure titled Pressure Ulcer Policy/Wound Management dated as revised on 1/18/17 indicated the following: It is the policy of (Name of Health Care Corporation) based on the comprehensive assessment of the resident; the facility must ensure that a resident receives care consistent with professional standards of practice, to prevent pressure ulcer and does not develop pressure ulcers unless the clinical condition demonstrates that they were unavoidable; and that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The facility policy continued: The first step in prevention will be through identification of the resident at risk of developing pressure ulcer. This will be followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. Upon admission and at least quarterly, resident will be assessed for risk of developing pressure ulcers by utilizing a standardized tool. The Braden score is completed on admission and for the next three weeks (to ensure any change is identified), quarterly, with significant changes in cognition or functional ability or acute illness as determined by facility nursing administration .Assessments are head to toe assessments .Monitoring includes evaluate and document when there are identified changes. Monitor every shift to ensure that measures are in place as specified on the care plan to prevent/promote skin breakdown. Twice a week, on bath/shower days, the nursing assistant will report any reddened and/or areas of concern to the licensed nurse. The licensed nurses will completed a head to toes body review as well. This head to toe body review in addition to the nursing assistant's skin review .The interdisciplinary team will review residents with pressure ulcers during the weekly NAR (Nutritional at Risk) committee/resident review committee. The DON/designees will report findings to the quarterly Quality Improvement Committee. According to the Joint Commission, they support the following pressure ulcer prevention strategies based on the NPUAP's (National Pressure Ulcer Prevention Advisory Panel) also known as NPIAP (National Pressure Injury Advisory Panel): *Definition of pressure ulcer/injury-A pressure ulcer/injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The injury can present as intact skin or an open ulcer and may be painful. -Multiple disciplines and teams involved in developing and implementing care plans with teamwork, communication and expertise involved in developing and implementing the care plan, therefore improvement in pressure injury prevention, optimizing overall care and increasing attention to these issues can prevent the next pressure injury and save the next patient. Prioritize and address identified issues. Make sure they are aware of the plan of care and that all care is documented in the patient's record. -Risk Assessment should be considered as the starting point. The earlier a risk is identified, the more quickly it can be addressed. -Refine the assessment by identifying other risk factors, including existing pressure injuries and other diseases, such as diabetes and vascular problems. Repeat the assessment on a regular basis and address changes as needed. -Skin Care. Protecting and monitoring the condition of the patient's skin is important for preventing pressure sores and identifying *Stage 1 sores early so they can be treated before they worsen. *A Stage 1 pressure ulcer is intact skin with a localized area of non-blanchable erythema (swelling), which may appear differently in darkly pigmented skin. Presence of blanchable swelling or changes in sensation, temperature or firmness may precede visual changes. -Inspect the skin upon admission and at least daily for signs of pressure injuries. -Assess pressure points. -Clean the skin promptly after episodes of incontinence -Avoid positioning the patient on an area of pressure injury. -Positioning and Mobilization. Immobility can be a big factor in causing pressure injuries. -Turn and reposition at-risk patients, if not contraindicated. -Plan a scheduled frequency of turning and repositioning the patient. -Consider using pressure-relieving devices when placing patients on any support surface (chair and bed or alternate sleeping surfaces). Retrieved from https://www.jointcommission.org>Quick_Safety_Issue_25_July_20161

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and clinical record review the facility staff failed to ensure 1 of 43 residents (Resident #35) in the survey sample, who were unable to carry out activities of daily living, received the necessary services to maintain toenail care. The findings included: The facility staff failed to ensure that podiatry services was provided to Resident #35. Resident #35 was admitted to the facility on [DATE]. Diagnosis for Resident #35 included but not limited to Alzheimer's disease. The most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 10/23/19 coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 06 out of a possible score of 15, which indicated severe cognitive impairment for daily decision-making. Resident #35 was coded total dependence of one with dressing, hygiene, bathing and toilet use, limited assistance of one with transfer and bed mobility with Activities of Daily Living (ADL) care. Resident #35's comprehensive care plan with a revision date of 09/18/19 documented Resident #35 with ADL self-performance deficit related to Alzheimer's Dementia and muscle weakness. The goal: will improve current level of function through next review date (12/18/19). Some of the intervention/approaches to manage goal included to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. An interview was conducted with Resident #35 on 12/11/19 at approximately 9:00 a.m. Resident #35 stated, My toenails need to be cut but I cannot get one to cut them. The resident also said the staff does not wash my feet; my feet are dirty. On 12/11/19 at approximately 9:14 a.m., the Unit Manager (UM) and surveyor assessed the resident's toenails. The nurse removed the sock from the resident's left foot with the following observed: all toenails were long, thick and curved to the side. The nurse removed the sock from the right foot; the 1st, 3rd, 4th, and 5th digit were long, thick and curved to the side. The 2nd digit was long, thick and had cured backward almost coming in contact with the top of the toe. The resident asked for the UM to check in between then stated, They don't wash my feet; my feet are dry and dirty. The nurse assessed in between resident toes; observed was a brown substance in between the 2nd, 3rd and 4th digit on the left foot and 3rd and 4th digit to the right foot. The nurse was asked if Resident #35 was ever placed on the podiatry list to be seen, she replied, I don't know but I will make sure she is put on the podiatry list. The nurse was asked, Does Resident #35 need her toenails cut and trimmed she replied, Yes. On 12/11/19 at approximately 12:35 p.m., the Unit Secretary on Unit 4, stated, Someone (not sure who) gave me Resident #35's name to have her placed on the podiatry list to be seen because her toenails need to be cut and trimmed. She said this is the first time anyone has every mention to her that Resident #35 required podiatry services. On 12/11/19 at approximately 1:00 p.m., the Unit Secretary provided a podiatry list for October and November 2019, which did not include Resident #35. The Unit Secretary she had contacted the podiatry office requesting for Resident #35 to be seen as soon as possible. On the same day at approximately 3:10 p.m., the Unit Secretary stated, The podiatrist will be her tomorrow (12/12/19) to see Resident #35. On 12/12/19 at approximately 10:50 a.m., an interview was conducted with the Registered Nurse (RN), Nurse Supervisor on North 4 unit. She said the certified nursing assistants should be checking the resident's fingernail and toenails daily while providing ADL care and on their shower days. She said the nurses should be checking the resident's toenails when performing the resident's weekly skin assessments. She said for a resident, who is non-diabetic, the nurses can cut their toenails if they are not too thick. Review of Resident #35's clinical record did not reveal refusal of toenail care. Review of Resident #35's current Physician Order Sheet (POS) included the following order but not written until 12/12/19: may see podiatrist as needed. On 12/12/19, according to the clinical record, Resident #35 was seen by the podiatrist on 12/12/19. The progress report included the following documentation: Chief complaint: -Painful, elongated and thicken toenails. -Toenails: thicken, debris, painful, brittle and difficulty walking. -Dermatological: scaly. Diagnosis/Treatment: -Onychomycosis to left and right toenails. -Painful: left and right toenails. -Debrided painful dystrophic nails. Orders written: -Aquaphor ointment. A briefing was held with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/12/19 at approximately 6:53 p.m. The facility did not present any further information about the findings. The facility did not have a policy directly related to podiatry services or foot care but did provide a policy titled Nail Care (Revision date: 01/2014). -Policy: Nursing staff will administer nail care in order to provide cleanliness and prevent infection. Definitions: Alzheimer's is the common form of dementia. A progressive disease beginning with mild memory loss possibly leading to loss of the ability to carry on a conversation and respond to the environment (Source: http://www.cdc.gov/aging/aginginfo/alzheimers.htm).

Based on observation and staff interview, the facility staff failed to a system in place to control, account for, and periodically reconcile, the controlled medication Ativan. The findings included: On 12/12/2019 at approximately 10:00 a.m., a tour of the medication storage room on North 3 Unit revealed a small refrigerator which contained an affixed small metal lock box on the bottom base of the refrigerator. LPN (Licensed Practical Nurse) #1 was asked to describe the purpose of the lock box located within the refrigerator. LPN#1 responded, I'm not going to open that lock box. I don't think there is anything in there. Surveyor asked LPN #1 to open the lock box, revealing six vials of Ativan in the box. LPN #1 was asked to show evidence of accounting for the medication and she stated, We don't have a system to count it. An interview was conducted with the Director of Nursing on 12/12/2019 at approximately 3:00 p.m. and when asked about the accounting of Ativan on North 3 unit, she replied, Those are for emergency usage. An interview was held with North 3 LPN #7, the Unit Manager and when asked about the accounting of Ativan on North 3 unit, LPN #7 replied, The Ativan should have been included with the count. The facility Administrator was informed of the findings during a briefing on 12/12/2019 at approximately 4:45 p.m. On 12/12/2019 at approximately 6:04 p.m., an email from the pharmacy contractor was submitted relaying, Per (Corporation name) request, I delivered two lorazepam injections for house stock to be used in the event of an emergency .The pharmacy is in the process of searching for the proof of delivery ticket. I will forward a copy to the community once it has been retrieved. No additional documentation was provided prior to the survey exit. The Facility policy on Inventory Control of Controlled Substances dated 12/01/07 states: 1.2 Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on the Controlled Substance Count Verification/Shift Count Sheet set forth in Appendix 15: Shift Verification of Controlled Substances (may also be called Controlled Substance Disposition Record.) 2. Facility should ensure that facility staff count all Schedule III-V controlled substances in accordance with facility policy and applicable law. 3. Facility should periodically count controlled substances stored in emergency kits, refrigerators or kept in other storage areas. The Facility policy on Emergency Mediation Supplies dated 12/01/2007 states: 1.3 Facility should maintain a list of inventory in the Emergency Medication Supply in a location easily retrievable for quick reference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility staff failed to ensure 1 (Resident #335's) of 43 residents in the survey sample's medical records were readily accessible. The findings included: Resident #335 was admitted to the facility on [DATE] with diagnoses of pressure ulcer on the sacral region, unspecified stage and Multiple Sclerosis. Resident #335 was discharged on 11/29/18, therefore a closed record review was attempted. On 12/11/19 at approximately 1:45 PM, the Corporate Nurse Consultant was asked for Resident # 335's clinical record to include nurses notes, MDS (Minimum Data Set), and skin assessments. All requested medical records were received except the nurses notes. The Corporate Nurse Consultant explained that they could only access records from July 1, 2019 forward since the facility was bought out by another company. She stated the previous company did not give them access to the medical records prior to July 1st; the records had to be requested from the prior facility corporation. A pre-exit meeting was held with the Administrator, Director of Nursing and Corporate Nurse Consultant on 12/12/19 at approximately 3:05 p.m. No further information was presented by the facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to notify a representative of the Office of the State Long-Term Care Ombudsman of discharges to the hospital for 6 residents (Residents #63, #27, #71, #61, #37 and #62) of 43 residents in the survey sample. This deficiency is cited as Past Non-Compliance. The findings included: On 12/12/19 at approximately 3:13 PM an interview was conducted with the Corporate Nurse Consultant concerning the above. She stated, Ombudsman notification will fall under our past non compliance. A document was received shortly thereafter concerning discharge notices not being sent to the local state ombudsman by the previous director of social services for September or October. Corrective Action: The discharge notices will be sent to the ombudsman for those not previously sent. The Ombudsman was notified and he did confirm that he had not received notices for the past couple of months, but said that he is fine with us sending over a spread sheet monthly. How will the facility identify other like residents that have the potential to be affected and what corrective action will be done? An audit was completed of past residents to see if the notices were sent, those not sent are being sent to the ombudsman. What will you do to prevent this from reoccurring or what systematic change will you implement? The spread sheet will be reviewed monthly. How will you monitor and maintain ongoing compliance? The discharge spreadsheets will be reviewed in the monthly QAPI meeting to ensure they are being completed. QAPI: The issue was discussed on 12/06/19 as the new director of social services discovered that the notices had not been sent for the previous months. 1. Resident #63 was originally admitted to the facility on [DATE]. Resident #63 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. On 12/11/2019 at approximately 5:02 p.m., an interview was conducted with the Director of Social Services and when he was asked if the Ombudsman was notified of Resident #63's discharge to the hospital on [DATE], the Director of Social Services stated, I've only been here in this position for about two weeks and I contacted the previous Social Worker concerning discharge notices and she stated that she had faxed the list of residents who had been discharged in September and October to the Ombudsman but she did not have confirmation that they were sent to the Ombudsman. Going forward I will obtain confirmations when the Ombudsman is made aware of discharges. The Administrator, Director of Nursing and Regional Director of Clinical Services was informed of the finding on 12/12/2019 at 6:55 p.m. at the pre-exit meeting. The facility did not present any further information about the finding. 3. Resident #71 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnosis for Resident #71 included but not limited to Essential Hypertension and Major Depressive Disorder. The Discharge MDS assessment was dated for 08/15/19 - discharged with return anticipated. On 08/15/19, according to the facility's documentation, Resident #71 was sent to the local emergency room (ER). Resident picked up at 6:05 PM and daughter notified right after. On 12/12/19 an interview was conducted with the facility Director of Social Services (Other Staff #1). He stated that Resident #71's name was not on the list that was sent out to the local ombudsman. A pre-exit meeting was held with the Administrator, Director of Nursing and Corporate Nurse Consultant on 12/12/19 at approximately 3:05 p.m. No further comments were made. 6. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #62's transfer and admission to the hospital on [DATE]. Resident #62 was originally admitted to the facility on [DATE]. Diagnosis for Resident #62 included but not limited to acute and chronic respiratory failure with hypoxia. The Discharge MDS assessments was dated for 08/11/19 - discharged with return anticipated. An interview was conducted with the Director of Social Worker (DSW) on 12/11/19 at approximately 10:00 a.m. He said that he has only been employed at the facility for 2 weeks. The DSW stated, I have search the entire Social Worker's office and I am unable to provide evidence that the Ombudsman was notified of Resident #62's transfer to the hospital on [DATE]. A briefing was held with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/12/19 at approximately 6:53 p.m. The facility did not present any further information about the findings. The facility's policy titled Discharge or Transfer Letter Policy (Revised October 5, 2017). -Policy: The facility will complete discharge letters appropriately and according to all federal, state, and local regulations. -Procedure include but not limited to: E. Social Service or designees will assure the original letter is given to resident or guardian/sponsor, if applicable. -Copies will be sent to Department of Health, Ombudsman Office and filed in the business file and/or scanned into Point [NAME] Care (PCC) documents tab with administrator/designees signature. -For emergency transfers, one list can be sent to the Ombudsman at the end of month. 4. Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to spinal cord compression, dependence on ventilator, trachesostomy and gastrostomy status (feeding tube). Review of Resident #61's clinical record revealed that she was transferred to the hospital on 8/9/19. There was no evidence that the long term care ombudsman was made aware of this transfer on 8/9/19. Review of Resident #61's clinical record revealed that she had been transferred to the hospital for a second time on 11/23/19. There was no evidence that the long term care ombudsman was made aware of this transfer on 11/23/19. On 12/11/19 at 3:36 p.m., an interview was conducted with OSM (other staff member) #1, the Director of Social Work. When asked who was responsible for notifying the long term care ombudsman when a resident is sent out to the hospital for an acute care transfer, OSM #1 stated that the social worker was responsible for notifying the long term care ombudsman on a monthly basis of all discharges including acute transfers to the hospital. OSM #1 stated that he had only been employed with the facility for approximately two weeks. OSM #1 stated he was also in training the first week. OSM #1 stated that the only list of discharges he could find from the previous social worker was from March of 2019. On 12/11/19 at 4:51 p.m., OSM #1 confirmed that he could find evidence that the long term care ombudsman was notified when Resident #61 was sent to the hospital on 8/9/19 and 11/23/19. On 12/12/19 at the pre-exit meeting (6:55 p.m.) ASM (administrative staff member) #1, the Administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was presented prior to exit. 5. Resident #37 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to persistent vegetative state, post stroke, dependence on ventilator, tracheostomy and gastrostomy status (feeding tube). Review of Resident #37's clinical record revealed that she was sent out to the hospital on 9/19/19. There was no evidence that the long term care ombudsman was made aware of this transfer on 9/19/19. On 12/11/19 at 3:36 p.m., an interview was conducted with OSM (other staff member) #1, the Director of Social Work. When asked who was responsible for notifying the long term care ombudsman when a resident is sent out to the hospital for an acute care transfer, OSM #1 stated that the social worker was responsible for notifying the long term care ombudsman on a monthly basis of all discharges including acute transfers to the hospital. OSM #1 stated that he had only been employed with the facility for approximately two weeks. OSM #1 stated he was also in training the first week. OSM #1 stated that the only list of discharges he could find from the previous social worker was from March of 2019. On 12/11/19 at 4:51 p.m., OSM #1 confirmed that he could find evidence that the long term care ombudsman was notified when Resident # 37 was sent to the hospital on 9/19/19. On 12/12/19 at the pre-exit meeting (6:55 p.m.) ASM (administrative staff member) #1, the Administrator, ASM #2, the DON (Director of Nursing) and ASM #3, the Regional Director of Clinical Services were made aware of the above concerns. No further information was presented prior to exit. 2. Resident #27 was admitted with diagnoses of dyspnea, gastro-esophageal reflux disease, emphysema, anxiety, atrial fibrillation and chronic obstructive pulmonary disease. Resident #27 was discharged to the hospital on [DATE]. There were no clinical records indicating the facility staff contacted the State Long Term Care Ombudsman of the discharge. During an interview on 12/11/19 at 11:10 A.M. with the facility's Social Worker, he stated, The facility had not contacted the State Long Term Care Ombudsman regarding discharge to the hospital for Resident #27.

Based on observation, staff interviews, and review of the facility's policy, the facility staff failed to ensure food was stored under sanitary conditions. The finding included; On 12/10/19 at approximately 10:50 AM an initial tour of the kitchen was conducted with the Food Service Director (FSD). The following was observed during the tour: Located in the walk-in freezer-one opened and not sealed 5 lb. bag (1/2 full) of Chicken tenders with no opened date listed. Located in dry storage one opened bag of [NAME] Sugar (1/2 full) with no opened date. Located in the kitchen on the shelf was one bag of Red Raspberry Gelatin dessert mix. (1/4 mix left in bag) and one opened bag of [NAME] sauce with no opened date listed. Located in the reach in freezer was one opened, unsealed, and unlabeled bag of frozen vegetables with no opened date. Located in the reach in freezer was a 2 lb opened (sealed) brown bag of french fries with no opened date. The bag was not labeled with what the product was. One opened, 12 ounce bag of dry gravy mix (1/4 full) with no opened date. Policy: Storage of Refrigerated Foods. Date Reviewed: 2/19/19. Date Revised: 2/19/19. Refrigerated items must have a label showing the name of the food and date it should be consumed, or discarded. On 12/11/19 at approximately 5:10 PM an interview was conducted with the Food Service Director (FSD) concerning the opened items listed above. She was asked what should have been done concerning the unlabeled/undated foods? She stated, They should have been labeled with an opened date. A pre-exit meeting was held with the Administrator, Director of Nursing and Corporate Nurse Consultant on 12/12/19 at approximately 3:05 p.m. No further comments were made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a information obtained during a complaint investigation, resident, staff and family interviews, review of the clinical record and review of the facility's policy; the facility staff failed to keep the physician and/or designee informed of events which may require an intervention for 1 of 58 residents (Resident #118), in the survey sample. The facility staff failed to notify Resident #118's physician and/or designee of missed Physical Therapy (PT) appointments. The findings included: Resident #118 was originally admitted to the facility 8/10/16. The admission diagnoses included Parkinson's disease, Major Depressive disorder, Unspecified Psychosis, an anxiety disorder, and an Adjustment disorder with mixed Disturbance of emotions and conduct. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #118's cognitive abilities for daily decision making were intact. In section D (Mood), the resident was coded for feeling downed, depressed and hopeless and in section E (Behaviors), the resident was coded for exhibiting physical and verbal behaviors directed towards others 1-3 days each week. The resident was also coded indicating the behaviors didn't put the resident at risk for illness/injury, not significantly interfering with resident care, activities or social interactions, and the resident was coded to indicate the behaviors didn't put others at significant risk for physical injury or as causing disruption to the living environment. The resident was also coded for rejection of care 1-3 days each week. In section G (Physical functioning), the resident was coded as requiring supervision of 1 person with wheelchair locomotion, limited assistance with transfers, extensive assistance of 1 person with bed mobility, personal hygiene, dressing and toileting and total care with bathing. The clinical record revealed Resident #118 had a physician's order dated 4/3/18, for physical therapy (PT) services; heat therapy to the left posterior shoulder, for muscle pain; limiting range of motion. Resident #118 stated during an interview on 6/20/18, at approximately 10:30 a.m., that she was told by the facility physical therapist they saw no improvement in her and they couldn't help her therefore; the Neurologist recommended she see a community based physical therapist. The resident further stated, during the initial visit approximately 4/26/18, her needs were assessed and the therapist developed a treatment plan and a schedule of future appointments. The appointments were later changed to Tuesdays and Thursdays at 10:00 a.m. A copy of the scheduled appointments were sent to the nursing facility and the Unit Secretary arranged transportation for travel to and from the community based PT office. Resident #118 stated facility staff accompanied her to the initial appointment and no one informed her that was not the plan for future PT appointments. The resident also stated she frequently reminded staff she preferred and required 2 staff during care and 1-2 staff for non activities of daily living. Resident #118 stated the facility staff was aware she has only 3 relatives locally and they are unable to accompany her to appointments because her daughter is visually impaired and requires assistance and her 2 granddaughters have commitments to their jobs and families. She stated on one occasion her sister traveled from South Carolina to accompany her on an appointment. The resident further stated because of her family's obligations and inability to aide her with needed services she elected to remain in the nursing facility. During the 6/20/18 interview at approximately 10:30 a.m., Resident #118 stated, the first official day of therapy was 6/5/18. The resident stated she got ready for the appointment, went to the nurse's station and was told by the Unit secretary and the information was confirmed by the Unit Manager that the Administrator and Director of Nursing stated said she was to go alone to the appointment because she had no cognitive deficits or other limitations preventing her from going unaccompanied. The resident then, stated the Assistant Administrator told her go ahead and try going by yourself. The resident stated, she was reluctant but left the facility without facility staff accompanying her, she arrived to the PT office, the driver assisted her inside, she had therapy, the office staff called the transport company to pick her up and she asked the office staff to sit her outside the office so the transport driver could see her upon arrival. Resident #118 stated she waited approximately 20-30 minutes outside the PT office but; the transport company didn't arrive therefore; she used her cell phone to call the nursing facility and alerted them that the transport company hadn't returned to transport her back to the nursing facility. Resident #118 stated the nursing facility staff told her to calm down because she couldn't understand what she was saying, then the nurse stated (name of resident), the transport company says you have already been picked up. Resident #118 stated she asked the Unit Secretary each Monday and Wednesday after the 6/5/18 event, who would be accompanying me to the community PT office on Tuesday and Thursday; if the Unit Secretary stated no one, she stated she told her to cancel the appointment because she felt unsafe going unaccompanied. An interview was conducted with the Unit Secretary 6/20/18 at approximately 11:15 a.m. The Unit Secretary stated prior to 6/5/18 she accompanied Resident #118 to appointments in the community if family was unable to attend. The Unit Secretary stated she didn't work 6/5/18 and there was no one to accompany the resident to the appointment therefore she was sent alone. The Unit Secretary stated she was told the resident returned to the facility 6/5/18 crying and upset. A nurses's note dated 6/14/18 read; Resident scheduled to go out for therapy today. She refused to go because a staff member is unable to accompany her. She is alert and oriented with a BIMS score of 15. This resident makes all her needs known. She is her own responsible party. (name of resident) is able to self maneuver herself in her wheelchair. Staff offered to get her ready for this appointment but she still refused to go. An interview was conducted with Licensed Practical Nurse (LPN) #5 on 6/22/18 at approximately 1:10 p.m. LPN #5 stated she was aware it was Resident #118's preference for a staff member to accompany her on appointments in the community and she was aware on 6/5/18, Resident #118 returned to the facility upset because the transportation driver didn't pick the resident up until approximately 2 hours after transport was called to return the resident back to the facility. LPN #5 stated she informed the resident that hand to hand transport; (transportation driver takes the resident inside the office and picks the resident up inside the office) was requested on her behalf therefore what occurred on 6/5/18, should not happen again, but the resident stated she would not go again unless she was accompanied because she didn't feel safe. LPN #5 stated she kept the Administrator and Director of Nursing informed of the resident's preference to be accompanied by a staff member and of each episode of refusal to attend appointments when there wasn't a staff member to accompany her. LPN #5 stated the Administrator and Director of Nursing stated each time Resident #118 was alert, oriented, had a BIMS score of 15 and a cell phone therefore; capable of going unaccompanied. During the interview with LPN #5 on 6/22/18 at approximately 1:10 p.m., she stated the physician hadn't been notified of the missed PT appointments. On 6/25/18 at approximately 11:30 a.m., the Unit secretary provided the surveyor with the appointment scheduling forms for Resident #118's past community PT appointment; some of the forms had a note written across the top that stated, canceled appointment due to resident's request. The Unit Secretary stated the resident canceled the appointments because staff was not available to accompany her and it was the resident's preference to have an escort. On 6/28/18 at approximately 3:50 p.m., the above findings were shared with the Administrator, Director of Nursing, Director of Operations, 2 visiting Administrators and the Dietitian. An opportunity was given to the facility staff to provide additional information but; none was presented. The facility policy titled Life Care - Notification of Changes of Condition with an original date of 10/7/1995 and revision date of 6/23/16 read, in part, as follows, .2. The nurse on duty will notify the Practitioner and Resident/Legal Representative/Family Member when a significant change in the resident's physical, mental or psychosocial status (i.e., deterioration in health, mental or psychosocial status is either life threatening conditions or clinical complications). Based on clinical record review, staff interview, resident interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed for 2 (Resident #176 and #118) of 61 residents in the survey sample to notify the physician and/or resident's family of a change of conditions 1. For Resident #176, the facility staff failed to notify the resident's family of a fall. 2. For Resident #118, the facility staff failed to notify the physician and/or designee of missed Physical Therapy (PT) appointments. The findings included: Resident # 176 was admitted to the facility on [DATE] with diagnoses of depression, insomnia, and bradycardia. Resident #176 had an unwitnessed fall on 2/27/18. An Initial Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Hearing, Speech, and Vision as having minimal hearing difficulty. In the area of Cognitive Patterns this resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 9. Resident #176 was assessed in the area of Activates of Daily Living (ADL) for transfer as requiring limited assistance of one staff person. Resident #176 was not assessed in the area of locomotion or walking. This resident was assessed in the area of Mobility Devices as using a walker and wheelchair for mobility. A Care Plan dated 2/27/18 assessed Resident #176 in the areas of bed mobility as being at risk for falls. This resident was care planned for short term memory impairment - unable to recall after 5 minutes. Interventions- Re-orient to time, location, events and activities. Problem- Transfer (to/from bed, chair, wheelchair, standing position. Intervention- remind resident to call for assistance before moving from bed to chair and from chair to bed. A review of the clinical records dated 2/27/18 at 7:46 A.M. indicated: Patient had unwitnessed fall this am. Pt attempted to return to bed from wheelchair. Pt reports that He forgot to lock the wheelchair and landed on his butt. Pt denies pain. The review of the clinical records and staff interview indicated the family was not notified. A physician's progress note dated 2/28/18 at 9:21 A.M. indicated: Patient's wife requests consultation with the provider today to discuss her husband's recent fall, which occurred this morning around 0645 (6:45 A.M.). He was trying to transition to his bed from W/C, and forgot to lock the wheels. As he attempted to stand, the wheelchair rolled and he fell to the floor on his buttocks. The fall was unwitnessed. He is unsure how long he laid on the floor before help arrived, but does not believe it was more than a few minutes. He denies injury or worsening of pain since the fall. He is a high risk patient and fall prevention protocols are in place. During an interview on 6/ 27/18 at 10:00 A.M. with the Director of Nursing (DON) she stated, the family was not notified of the fall. A request was made for a notification policy during the survey and no-policy was provided. The facility staff failed to notify Resident #176 family of a fall. Complaint Deficiency

Based on observation, resident interview, staff interview, facility documentation review, the facility staff failed to ensure the Privacy of Residents related to leaving a team assignment face up on 1 medication cart of 10 med carts (Cart 2 Unit 2) The findings included: During a medication administration observation on 6/20/18 at approximately 11:11 AM, Registered Nurse #1 left her medication cart to retrieve a supply of insulin syringes and left her Patient Assignment face up on her medication cart. The Patient Assignment included medical information (diagnoses) on the Residents that anyone passing the medication cart may have seen. RN #1 on 6/20/18 at approximately 11:12 AM, when asked about the Resident Assignment being left face up, she stated, Oh that is a HIPPA (Health Insurance Portability and Accountability Act) issue. Other than the Surveyor remaining at the medication cart, no one saw the information. In addition, during medication pass, RN #1 was heard giving a medical update to a family member in the hall way where any resident or visitors in the Resident rooms could have heard the medical information shared. The information included a resident had become lethargic and was sent to the hospital. The Facility Policy titled, HIPAA - Notice of Privacy Practices with a revision date of 2/2015, documented the following: (Facility) will maintain a Notice of Privacy Practices (NPP) statement. The statement will provide individual's information as to how (Facility) will may use and disclose protected health information about the individual, as well the individual's rights and the covered entity's obligations with respect to that information. (Facility) will provide its patients/members and anyone who requests the (Facility) NPP. The Administrator was notified of the findings during a meeting on 6/20/18 at approximately 5:45 PM. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, staff interviews and facility document review, the facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of hospital discharges for 2 of 61 residents in the survey sample, Resident #42 and 91. 1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #42's transferred and admitted to the hospital on [DATE]. 2. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #91 transferred and admitted to the hospital on [DATE]. The finding include: 1. Resident #42 was originally admitted to the facility on [DATE]. Diagnosis for Resident #42 included but not limited to *Chronic Respiratory Failure with *hypoxia -dependent on respiratory (*Ventilator). *Respiratory Failure is the inability of the cardiovascular and pulmonary systems to maintain adequate exchange of oxygen and carbon dioxide in the lungs (Mosby's Dictionary of Medicine, Nursing & Health Professions, 7th Edition). *Hypoxia is diminished availability of oxygen to the body tissues (Reference: http://medical-dictionary.thefreedictionary.com/hypoxia) *Ventilator is a machine that supports breathing (Source: http://www.nhlbi.nih.gov/health/health-topics/topics/vent). The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 04/06/18 coded the resident with as comatose - persistent vegative state/no discernible consciousness. The Discharge MDS assessments was dated for 5/19/18 - discharged with return anticipated. The clinical note revealed the following: on 5/19/18, Resident #42 was noted with increased respiratory rate. The other vital signs were stable. The respiratory department recommended for resident to be sent out for evaluation; on call physician notified with new orders to send out for evaluation. The above findings were shared with the Administrator 6/20/18 at approximately 430 p.m. No additional information was provided. An interview was conducted with the Part-time Social Worker on 6/20/18 at approximately 5:30 p.m. She stated, The Ombudsman was only being notified of the residents who where discharged home and not to the hospital. The facility's policy: Life Care - Bed Hold (Revision: 1/17/17). -Purpose: To define requirements regarding bed hold when a resident or patient is admitted to an acute care setting on therapeutic leave. -Performed by: Business Office / Social Services -Procedure: Before a facility transfers or discharges, a resident the facility must notify the resident and the resident's representative(s) and the reasons for the move in writing and in a language and manner, they understand. The facility must send a copy of the notice to the State Long-Term Ombudsman. Contents of the notice include but not limited too: -Notice must be at least 30 days -Specific reason for the transfer or discharge -Effective date of transfer or discharge -Location to which resident is to be transferred or discharged -A statement of the residents appeal right to State 2. The facility staff failed to provide notice of discharge to Resident #91 and send a copy of the notice to a representative of the Office of the Long Term care Ombudsman. Resident #91 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, dysphagia, legal blindness, depression type two diabetes, Parkinson's Disease and peripheral vascular disease. A 5/2/18 re-entry Minimum Data Set (MDS) assessed this resident as having impaired vision. In the area of Cognitive Patterns this resident was assessed as being severely impaired cognitive skills for daily decision making. In the area of Activities of Daily Living (ADL) this resident was assessed as being unable to transfer, unable to walk. Resident #91 required extensive assistance with one person assist with dressing. This resident required total dependence in the areas of eating, toileting and personal hygiene. A Care Plan dated 5/15/18 indicated: Resident #91 demonstrated impaired in cognitive skills for daily decision making due to Parkinson's Disease. A review of the clinical records indicated Resident #91 was discharged to the hospital on 4/25/18. An interview was conducted with the Part-time Social Worker on 6/20/18 at approximately 5:30 p.m. She stated, The Ombudsman was only being notified of the residents who where discharged home and not to the hospital. The facility staff failed to send a copy the discharge notice to the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility documentation review the facility staff failed send or provide a copy of the Bed-Hold Policy for 1 resident (Resident #42) of 61 residents in the survey sample, after being transferred to the hospital on 5/19/18. The facility staff failed to provide the resident #42 or the resident's representative with a written copy of the bed hold policy. The finding include: Resident #42 was originally admitted to the facility on [DATE]. Diagnosis for Resident #42 included but not limited to Chronic Respiratory Failure with *hypoxia dependent on a ventilator-a machine that supports breathing (Source: http://www.nhlbi.nih.gov/health/health-topics/topics/vent). *Hypoxia is diminished availability of oxygen to the body tissues (Reference: http://medical-dictionary.thefreedictionary.com/hypoxia) The current Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 04/06/18 coded the resident with as comatose - persistent vegative state/no discernible consciousness. The Discharge MDS assessments was dated for 5/19/18 - discharged with return anticipated. The clinical note revealed the following: on 5/19/18, Resident #42 was noted with increased respiratory rate. The other vital signs were stable. The respiratory department recommended for resident to be sent out for evaluation; on call physician notified with new orders to send out for evaluation. An interview was conducted with the Part-time Social Worker on 6/20/18 at approximately 5:30 p.m. She stated, I was unable to locate any written documentation in the resident's medical record to validate that the resident or their representative were made aware of the bed hold policy. The above findings were shared with the Administrator 6/20/18 at approximately 430 p.m. No additional information was provided. The facility's policy: Life Care - Bed Hold (Revision: 1/17/17). -Purpose: To define requirements regarding bed hold when a resident or patient is admitted to an acute care setting on therapeutic leave. -Performed by: Business Office / Social Services -Procedure: Before a facility transfers or discharges, a resident the facility must notify the resident and the resident's representative(s) and the reasons for the move in writing and in a language and manner, they understand.

Based on staff interview and clinical record review the facility staff failed to assure one resident (Resident #1) of 61 residents in the survey sample, was assessed at least quarterly utilizing the Minimum Data Set (MDS). For Resident #1, the facility staff failed to complete a quarterly MDS assessment within the required 92 days. The findings included: Resident #1 was admitted to the nursing facility 7/27/07. The diagnoses for Resident #1 included but not limited to Type II Diabetes. Resident #1's last Minimum Data Set (MDS) was a Comprehensive Assessment with an Assessment Reference Date of 01/29/18 coded Resident #1 Brief Interview for Mental Status (BIMS) scoring a 11 out of a possible 15 indicating moderate cognitive impairment. In addition the MDS coded Resident requiring supervision with one assist with bed mobility, transfer, dressing, toilet use and personal hygiene. An interview was conducted with MDS Coordinator on 6/26/18 at approximately 11:00 a.m., who stated, Resident #1 popped up on the Missing OBRA Assessment Report. She should have had a quarterly assessment completed before 4/30/18 - her quarterly assessment should have been signed and locked by day 92 which would have been 4/30/18. The Omnibus Budget Reconciliation Act (OBRA) of 1987 requires long-term care facilities to complete an ongoing OBRA assessments for each resident within 92 days of the ARD of the most recent MDS assessment. (RAI manual, MDS 3.0 chapter 2 pages 2-16). The above findings were shared with the Administrator 6/25/18 at approximately 8:30 a.m. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to accurately reflect, via the required Minimum Data Set (MDS) assessment, the resident's status for 1 of 61 residents (Resident #18) in the survey sample. The facility staff failed to accurately assess the resident's sacral pressure upon re-admission to the facility on [DATE]. The findings included: Resident #18 was originally admitted to the nursing facility on 11/9/17 with diagnoses that included right subdural hematoma, severe traumatic brain injury, closed facial fractures and mandible fracture, vegetative state, and enteral feedings via a gastrostomy tube (GT). The resident was seen in the Emergency Department (ED) on 11/10/17 and readmitted on [DATE] Resident #18 was readmitted to the nursing facility on 12/5/17 with an *unstageable sacral pressure ulcer. The facility staff failed to accurately assess and initiate an effective pressure ulcer treatment protocol, instead the ulcer was assessed as a *Stage I. In addition the facility staff failed to assess the wound every 7 days per facility protocol until 13 days later at which time the wound had progressively worsened and ultimately led to wound management by a specialized physician. Minimum Data Set (MDS) assessment analysis: The MDS assessment in effect at the time of Resident #18 initial, first entry dated 11/9/17 indicated no skin issues. In correlation with this MDS assessment, the hospital Discharge summary dated [DATE] also indicated no skin issues. The discharge MDS assessment dated [DATE] with return anticipated, one day in the building, the resident was assessed to have one *Stage II pressure ulcer. The hospital wound care notes dated 11/23/17 indicated the resident's sacral ulcer progressed to a *Stage III and on 12/3/17 the hospital wound care notes indicated the pressure ulcer had further progressed to 4x3 centimeter unstageable, open with slough (soft adherent necrotic tissue). Resident #18 was coded with short and long term memory problems and severely impaired in the skills for daily decision making. The resident was non-verbal and not able to understand staff. The resident was totally dependent on one staff for all activities of daily living (ADL). The resident was re-admitted to the nursing facility on 12/5/17. The admission MDS assessment with an assessment reference date of 12/12/17 indicated the resident had a one Stage I sacral pressure ulcer. The facility admission nursing note entered by Licensed Practical Nurse (LPN) #6 dated 12/5/17 indicated Resident #18 had one Stage I pressure ulcer 2 cm by 1 cm. The significant change in status MDS assessment dated [DATE] assessed the resident as having two pressure ulcers: one unstageable pressure ulcer with slough and/or eschar (hard black adherent necrotic tissue), as well as one unstageable deep tissue injury (*DTI). The quarterly MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] assessed Resident #18 as having one Stage IV pressure ulcer. During an interview with the facility MDS coordinator and the Regional Corporate MDS coordinator on 6/26/18 at 3:00 p.m., they stated they get their information from the nurse's notes in order to complete the MDS and although they felt the most recent MDS' dated 3/26/18 and 6/18/18 were accurate representations of Resident #18 current sacral wound, the admission nurse's note assessment of the sacral wound as a Stage I was not accurate, thus the 12/12/17 MDS assessment was not an accurate assessment of the sacral wound. They stated they follow through with care planning based on the MDS assessment. The re-admission nursing assessment dated [DATE] scored the resident with a 6 on the Braden Scale Pressure Sore Risk assessment which indicated the resident was at very high risk for the development of pressure ulcers. The care plan dated 12/14/17 indicated the resident had a Stage I pressure ulcer and the goal set by the staff for the resident was that it would decrease over the review period (3/12/18). Some of the interventions to accomplish this goal include assess and record the size of the ulcer, perform a complete assessment and record, perform nutritional screening and assessment and to implement the protocol for Stage I pressure ulcer and was at risk for having pressure ulcers. The nursing staff were to use pillows and or wedges to reduce pressure on heels and pressure points, and turn and position, as well as a pressure reducing mattress (standard mattress for all residents) and pad when sitting. The nursing staff would also check skin for redness, skin tears, swelling or additional breakdown. The resident was incorrectly care planned in the area of actual alteration in skin integrity and should have been care planned for an unstageable pressure ulcer to the sacrum. On 6/28/18 at 3:35 p.m., the aforementioned issues were shared during a debriefing with the Administrator, Director of Operations and Director of Nursing (DON). The DON stated the MDS coordinators use the RAI 3.0 manual to code MDS assessments. No further information was provided prior to exit. RAI manual 3.0 SECTION M: SKIN CONDITIONS Intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Be certain to include in the assessment process, a holistic approach. It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound. *Category/ Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org). *Category/ Stage I is Pressure Injury: Non-blanchable erythema of intact skin (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org). *Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation. Bruising indicates deep tissue injury (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/). *Category/Stage III: Full thickness skin loss: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/). *DTI (Deep Tissue Injury) - depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org).

**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 develop and implement a comprehensive person centered care plan for two Residents (Residents #95, & #72) of the 61 residents in the survey sample. 1. Resident #95's care plan did not include person centered interventions for weight loss. 2. For Resident #72 the facility staff failed to care plan the Resident for constipation. Findings included: 1. Resident #95 was admitted to the facility on [DATE]. Current diagnoses included; Altered mental status, nutrition deficiency, vitamin D deficiency, and urinary tract infection. The current MDS (Minimum Data Set) was a significant change assessment with an ARD (assessment reference date) of 5-11-18. Staff assessment of mental status coded the Resident with severely impaired cognition. The Resident was coded as having no behaviors, and needing extensive to total assistance of 1-2 staff members for all activities of daily living. he Resident was also coded as needing to be fed. The MDS coded the Resident as having no swallowing disorder, no weight loss, and on a mechanically altered diet, and edentulous (no teeth). The quarterly assessment due for this assessment reference date was changed to a significant change assessment due to Resident's weight and overall decline, as stated in nursing notes by MDS staff on 5-23-18. On 6-19-18 at approximately 12:00 p.m. during initial tour of the facility Resident #95 was sitting in a reclined chair, in the dining area of the south unit with a meal tray in front of her and she was staring at the food, which was an untouched pureed diet. A staff member was asked if the Resident would feed herself, and she replied, I don't know, but I will help her, and she began to feed the Resident. On 2-9-18 the Resident went out to the hospital after a fall and laceration to the head which was repaired in the emergency room, and the Resident was readmitted to the facility the same day. The Resident had a wet cough and refused to eat throughout the next 24 hours and was again sent to the emergency room. The Resident returned on 2-15-18 (5 days later) and was given a pureed diet and was being fed. On 2-15-18 The Resident had a Pre-Albumin blood test, and the result was low at 13 (malnutrition). Normal range is 15-36, and the Resident was diagnosed with under weight, inadequate caloric intake, at risk of further weight loss, weight loss 6.8% in less than 30 days. No further nutrition assessment occurred until 3 months later on 5-14-18 and the Resident had lost 9.8% of her weight by 3-13-18. On 2-18-18 a Speech therapy consult was ordered by the physician, and was begun on 2-20-18. The consult states No recent weight loss. On 2-25-18 the Resident's weight had dropped 8 lbs (pounds) since the 2-1-18 weight, and on 2-26-18 the doctor ordered Pro-stat AWC 17 grams- 100 kcal (calories) per 30 ml (milliliters) liquid for nutritional deficiency one time daily. On 2-27-18 The physician changed the pro-stat order to increase it to three times per day, as documented in the physician progress notes, instead of once per day. That order was never instituted, and the Resident remained on Pro-stat once per day through the time of survey. The diet order was also changed this day and was Mechanical soft ground with thin liquids. The Resident's weights were documented in the facility for 2018 as follows; 1-2-18 120 lbs 2-1-18 120.20 lbs 2-25-18 112 lbs 3-1-18 110 3-13-18 108.2 3-20-18 108 3-29-18 108.2 4-2-18 108.2 5-4-18 109.4 6-7-18 108.5 The Resident's current care plan dated 5-16-18 with a quarterly revision goal date of 8-8-18 was reviewed. The document was compared to many areas in the clinical record including physician orders, the 2 nutrition assessments, nursing notes, both MDS assessments, and speech therapy notes, which all indicated the Resident needed to be fed by staff. The care plan still documented an intervention that the resident would feed herself. The care plan also documented the intervention of supplements per doctor's orders would be administered, which also did not happen, as Pro-stat was only given once per day and not three times per day as had been ordered. The Resident was ordered by a physician to have a mechanical ground diet with honey thickened liquids, and was observed consuming a pureed diet at lunch on 6-19-18 during initial tour of the facility, which was also an intervention on the care plan, and an error. The care plan was not measurable and was not implemented to show correct treatments, physician orders, and assessed needs. The interventions did not list the type or amount of supplements to be administered, What the Resident's food preferences were, whether to feed the Resident or not, or what swallowing strategies to use for this Resident. The care plan was not comprehensive, and did not assist in correcting the significant weight loss for Resident #95, which is the purpose of a comprehensive care plan, to list needs and describe care interventions for those needs. On 6-21-18 at the end of day debrief at 4:00 p.m.The Director of Nursing, and Administrator were made aware of the issues, and asked to bring any information available to explain the lack of services provided for this Resident. No further information was supplied by the time of exit on 6-28-18. 2. Resident #72 was admitted to the facility on [DATE]. Diagnoses for Resident #72 included but were not limited to; Traumatic Brain Injury, constipation, and quadriplegia. Resident #72's most recent Minimum Data Set (an assessment protocol) was a quarterly assessment, with an Assessment Reference Date of 5-3-18. The MDS coded Resident #72 as alert, oriented to person, place, time and situation, with no cognitive impairment. The Minimum Data Set further coded Resident #72 as being totally dependent, on 1-2 staff members for all Activities of Daily Living care. The Resident was coded as at risk for skin breakdown, and having currently, 2 acquired wounds, while in the facility. They were; (1) unstageable deep tissue injury on the right buttock, and (2) a stage 3 wound on the lower right leg shin. On initial tour of the facility on 6-19-18 at approximately 11:30 a.m. Resident #72 was interviewed and observed. The Resident was laying in a Clinitron Bed which is a specialty skin pressure removal bed used for individuals with skin breakdown from pressure. The Resident was asked if he was comfortable with his feet pushed against the foot board, and he responded that he slid down in the bed often, and had to wait for nurses to pull him up. He stated he loved the bed, however, needed to be pulled up to get his feet right every couple hours. The Resident was asked if he had eaten his lunch, and he stated he had an upset stomach, and had no appetite. He was asked if this happened often, and he stated no, but for the last week he had not felt well because of constipation. He was asked if he was given medication for that problem, and he stated that staff had a hard time getting it for him, and he had to suffer and wait days sometimes to get the medicine. A review of Resident #72's clinical record was conducted during the survey. The review revealed current physician orders for Magnesium Citrate oral solution one bottle one time daily starting 6-14-18. The Medication Administration Record (MAR) was reviewed and revealed a medication note documented by a nurse stating medication is unavailable, not administered, will be delivered 6-15-18. Nursing progress notes were reviewed and revealed the medication was given 6-15-18. The current care plan starting 5-8-18 was reviewed and revealed no care plan for constipation. The facility administration was informed of the findings during an end of day briefing on 6-21-18 at approximately 4:00 p.m. The facility did not present any further information about the findings up to the time of exit on 6-28-18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and closed record review the facility staff failed to meet professional standards of quality for 2 (Residents #477 and #95) of 61 residents in the survey sample. 1. The facility staff failed to meet professional standards of quality when an LPN (Licensed Professional Nurse) delegated the application of a hot compress to a CNA (certified nursing assistant) which resulted in second degree burns on Resident #477's hand. 2. The facility staff failed implement a physician's order to increase Pro-stat from once per day to three times per day for Resident #95; and provided the wrong diet to the Resident on 6-19-18 for the lunch meal. Findings included: 1. Resident #477 was admitted to the facility on [DATE] with diagnoses that include and were not limited to: Osteomyelitis of the vertebra (infection in the bones of neck), bilateral upper extremities paralysis, Type 2 diabetes, drug abuse, respiratory failure, viral hepatitis C, cystitis (urinary tract infection), urinary retention, and encephalopathy (damage or malfunction of the brain). A complaint investigation was conducted and the complainant had documented that the resident complained of pain to his left hand. He requested a warm compress. The CNA [certified nursing assistant] heated a washcloth in the microwave and placed it in a plastic bag and applied it to the resident's [#477] hand. The resident sustained blisters to his left second, third and fifth digits [fingers]. He was sent to the hospital for evaluation and treatment. On 6/20/18 at 11:30 AM a review of an investigative summary regarding the burn injury to Resident #477 prepared by the facility was reviewed and noted: Investigation (Assessment) On October 28, 2917 [2017], [Resident #477] complained of pain to his left hand. His assigned nurse requested the CNA to apply warm compress to [Resident #477's] left hand. The CNA heated the wet washcloth in the microwave and placed cloth into a plastic bag and applied to patient's hand. The staff members involved were immediately removed from the schedule while the facility conducted an investigation. Conclusion/Recommendations: A licensed staff nurse delegated a non-licensed staff a task that is not in accordance to their scope of practice, by applying a warm compress to a resident. On 6/21/18 at 1:00 PM a review of the facility document titled Incident Abstract Report related to the burn injury was completed. The report was dated 10/31/17 and documented Event Description Nursing issues: heating pad protocol, catheter care, personal care, The report asks the question did the deviation reach the patient to which Y Yes - Reached Patient was documented. On 6/25/18 at 1:42 PM an attempt was made to call LPN #2 (licensed practical nurse) who was caring for Resident #477 on the date of the burn injury with a message left for LPN #2 to return call regarding burn injury incident for Resident #477. On 6/25/18 at 4:50 PM a telephone interview was conducted with CNA #1 who was caring for Resident #477 on 10/28/17. He stated the LPN #2 told him to apply heat to Resident #477's left hand. CNA #1 stated he heated a wet washcloth in the microwave oven for 30 seconds and placed the cloth in a plastic bag, and he placed a towel on Resident #477's hand. CNA #1 was asked if he had been trained in the use of heat for residents and he stated he had not. When asked what prompted him to apply the hot pack to Resident #477 he stated the nurse told me to do it, I just do what she tells me to do. I had done it couple of times before. CNA #1 was asked if he was aware that Resident #477 had very limited movement in his upper extremities which made it more difficult for him to move away from the hot washcloth. CNA #1 stated he was aware that Resident #477 has limited movement in his hands and arms. On 6/26/18 at approximately 1:00 PM a second attempt to call LPN #2 was made and a message was left for her to return the call regarding the burn incident for Resident #477. No return call were received prior to the end of the survey. On 6/26/18 at 1:51 PM an interview was conducted with RN #1 in regard to LPN #2. RN #1 confirmed that she authored the disciplinary action and termination for LPN #2 related to her failure to follow facility policy. When asked specifically what LPN #2 had failed to do RN #1 responded that it is against policy to put any wet item into the microwave and then apply it to a patient. Only food goes into the microwave. RN #1 further explained that there is a sticker on the all the microwaves about what can be put into the microwave. RN #1 confirmed that the warning sticker has been on the microwaves since she started employment at the facility in August of 2017, 2 months prior to the burn injury to Resident #477. During the same interview RN #1 was asked what actions she would have expected to take place if a warm compress was indicated for a resident. RN #1 responded that the nurse should have notified the physician about what was going on with the resident. RN #1 stated that if an order had been obtained for a warm compress from the physician we could have gone to the hospital to get a real heat pack instead of a washcloth. RN #1 added that LPN #2 should not have instructed CNA #1 to apply the heat, and that CNA #1 needed to question anything he is asked to do if he has a concern about being correct or not company policy. RN #1 was asked if the application of heat was within the scope of practice for a CNA she state no, it is not, the LPN should never have instructed him to do that. RN #1 stated that CNA #1 had been suspended for 3 days, in serviced upon his return and was placed on probation for a year following the incident. When asked what the in servicing was for she replied that CNA's should question anything that seems wrong or does not follow company policy. On 6/26/18 at 1:55 PM an observation of the microwave ovens behind the nurse's station on Units 1, 3, and 4 noted each had a red sticker prominently placed on the microwave door which measured approximately 4 inched square. The red sticker reads: Microwave is for heating food and drinks only. Please DO NOT heat any medical supplies in this microwave. Those actions have the potential to burn our patients. On 6/26/18 at 3:30 PM review of in service records titled SBAR CNA scope of practice and was dated 11/1/17 was conducted. It read: S - Situation CNA's may perform duties beyond their scope of practice which endangers residents and CNA's. B - Background Recently an unorthodox hot pack was administered by a CNA who did not realize this action was beyond his/her scope of practice, a resident became injures from this action. A - Assessment CNA's are encouraged [to] have a questioning attitude. And not to perform any action that requires a nurse to assess the patient first. If there is a risk for harm ask your supervisor! R - Recommendation If you are performing an unfamiliar task, ask your supervisor if this is appropriate for you to be doing? We want to be flexible and help others; however, we must think about resident safety first! On 6/27/18 at 4:10 PM an interview was conducted with the DON (Director of Nursing) RN #2. When asked what her expectation of the nursing staff if warm compress was indicated for a resident to which she replied if someone needs heat we would call the doctor to clarify the order. Now we have disposable hot packs. When asked if staff had been trained on the application of warm compresses she stated the licensed nursing staff has now been in serviced. The DON was asked if CNA's were ever allowed to apply hot compresses to a resident she replied no. The Commonwealth of Virginia REGULATIONS GOVERNING THE PRACTICE OF NURSING VIRGINIA BOARD OF NURSING, Revised Date: April 8, 2015 Title of Regulations: 18 VAC 90-20-10 et seq. Statutory Authority: §§ 54.1-2400 and Chapter 30 of Title 54.1 of the Code of Virginia addresses the scope of practice for a Licensed Professional Nurses was conducted and noted: The following sections of the Board of Nursing Regulations govern what nursing tasks can be appropriately delegated by a Registered Nurse to unlicensed persons (which may include CNAs). PART VII. DELEGATION OF NURSING TASKS AND PROCEDURES. 18VAC90-20-420. Definitions. Delegation means the authorization by a nurse to an unlicensed person to perform selected nursing tasks and procedures in accordance with this part. 18VAC90-20-460. Nursing tasks that shall not be delegated. A. Nursing tasks that shall not be delegated are those which are inappropriate for a specific, unlicensed person to perform on a specific patient after an assessment is conducted as provided in 18VAC90-20-440. B. Nursing tasks that shall not be delegated to any unlicensed person are: 1. Activities involving nursing assessment, problem identification, and outcome evaluation which require independent nursing judgment; Regulations governing the scope of practice for a Certified Nursing Assistant was conducted. According to Regulations Governing Certified Nursing Assistants the Virginia Board of Nursing set forth regulations titled: 18 VAC 90-25-10 et seq. Statutory Authority: §§ 54.1-2400 and Chapter 30 of Title 54.1 of the Code of Virginia Revised Date: July 1, 2017 18VAC90-25-100. Disciplinary provisions for nurse aides. For the purpose of establishing allegations to be included in the notice of hearing, the board [Board of Nursing] has adopted the following definitions: 2. Unprofessional conduct shall mean, but shall not be limited to: a. Performing acts beyond those authorized for practice as a nurse aide or an advanced certified nurse aide as defined in Chapter 30 (§54.1-3000 et seq.) of Title 54.1 of the Code of Virginia, and beyond those authorized by the Drug Control Act (§ 54.1-3400 et seq.) or by provisions for delegation of nursing tasks in 18VAC90-20-420 et seq. The facility staff failed to meet professional standards of quality when an LPN delegated the application of a hot compress to a CNA which resulted in second degree burns to Resident #477. 2. Resident #95 was admitted to the facility on [DATE]. Current diagnoses included; Altered mental status, nutrition deficiency, vitamin D deficiency, and urinary tract infection. The current MDS (Minimum Data Set) was a significant change assessment with an ARD (assessment reference date) of 5-11-18. Staff assessment of mental status coded the Resident with severely impaired cognition. The Resident was coded as having no behaviors, and needing extensive to total assistance of 1-2 staff members for all activities of daily living. he Resident was also coded as needing to be fed. The MDS coded the Resident as having no swallowing disorder, no weight loss, and on a mechanically altered diet, and edentulous (no teeth). The quarterly assessment due for this assessment reference date was changed to a significant change assessment due to Resident's weight and overall decline, as stated in nursing notes by MDS staff on 5-23-18. On 6-19-18 at approximately 12:00 p.m. during initial tour of the facility Resident #95 was sitting in a reclined chair, in the dining area of the south unit with a meal tray in front of her and she was staring at the food, which was an untouched pureed diet. A staff member was asked if the Resident would feed herself, and she replied, I don't know, but I will help her, and she began to feed the Resident. On 2-9-18 the Resident went out to the hospital after a fall and laceration to the head which was repaired in the emergency room, and the Resident was readmitted to the facility the same day. The Resident had a wet cough and refused to eat throughout the next 24 hours and was again sent to the emergency room. The Resident returned on 2-15-18 (5 days later) and was given a pureed diet and was being fed. On 2-15-18 The Resident had a Pre-Albumin blood test, and the result was low at 13 (malnutrition). Normal range is 15-36, and the Resident was diagnosed with under weight, inadequate caloric intake, at risk of further weight loss, weight loss 6.8% in less than 30 days. No further nutrition assessment occurred until 3 months later on 5-14-18 and the Resident had lost 9.8% of her weight by 3-13-18. On 2-18-18 a Speech therapy consult was ordered by the physician, and was begun on 2-20-18. The consult states No recent weight loss. On 2-25-18 the Resident's weight had dropped 8 lbs (pounds) since the 2-1-18 weight, and on 2-26-18 the doctor ordered Pro-stat AWC 17 grams- 100 kcal (calories) per 30 ml (milliliters) liquid for nutritional deficiency one time daily. On 2-27-18 The physician changed the pro-stat order to increase it to three times per day, as documented in the physician progress notes, instead of once per day. That order was never instituted, and the Resident remained on Pro-stat once per day through the time of survey. The diet order was also changed this day and was Mechanical soft ground with thin liquids. The Resident's weights were documented in the facility for 2018 as follows; 1-2-18 120 lbs 2-1-18 120.20 lbs 2-25-18 112 lbs 3-1-18 110 3-13-18 108.2 3-20-18 108 3-29-18 108.2 4-2-18 108.2 5-4-18 109.4 6-7-18 108.5 The Resident's current care plan was reviewed, and even though many areas in the clinical record including nursing notes, the MDS, and speech therapy notes indicated the Resident needed to be fed by staff, the care plan still documented an intervention that the resident would feed herself. The care plan also documented the intervention of supplements per doctor's orders would be administered, which also did not happen, as Pro-stat was only given once per day and not three times per day as had been ordered. The Resident was ordered to have a mechanical ground diet with honey thickened liquids, and was observed consuming a pureed diet at lunch on 6-19-18 during initial tour of the facility. No nutrition evaluation was completed from 2-26-18, until 5-14-18 (approx 3 months later) and the Resident had already experienced a 9.8% weight loss between 2-1-18 and 3-13-18. (approx 6 weeks). On 6-21-18 at the end of day debrief at 4:00 p.m. the Director of Nursing, and Administrator were made aware of the issues, and asked to bring any information available to explain the lack of professional services provided for this Resident. No further information was supplied by the time of exit on 6-28-18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and family and staff interview, the facility staff failed to provide one resident (Resident #103) with physician ordered oxygen in the survey sample of 61 residents. The findings included: Resident #103 was admitted to the facility on [DATE] with diagnoses which included hypertension, GERD, hemiplegia, Chronic Respiratory Failure, Tracheostomy, Gastrostomy Status, Pneumothorax, seizures, and CVA. The facility staff failed to provide physician ordered. A re-entry Minimum Data Set (MDS) dated [DATE] for Resident #103 indicated this resident is not able to communicate with speech. This resident is not able to make self understood or understand others. In the area of Cognitive Patterns for daily decision making this resident is assessed as being severely impaired. In the area of Activities of Daily Living (ADL) this resident is assessed as being totally dependent on staff. In the area of Special Treatments, Procedures, and Programs -Respiratory Treatment- this resident was assessed for receiving oxygen therapy, suctioning and tracheostomy care. A Care Plan dated 5/30/18 indicated: Problem- Resident is at risk for ineffective airway clearance due to tracheostomy as a result of acute respiratory failure. Intervention- Provide humidified oxygen to maintain O2 (oxygen) level as ordered. Assess for evidence of respiratory distress, trachypnea, nasal flaring and increased use of accessory muscles. Assess for changes in mental status; lethargy, confusion, restlessness and irritability. Provide humidified oxygen to maintain FiO2 (fraction of inspired oxygen) at 28%. A Physician's order indicated: oxygen orders per protocol continuous. Tracheal Suctioning PRN and chronic trach collar with humidification to keep o2 saturations greater than 95%, Therapeutic Range: Pulse Oximetry Every shift due to demonstrated unstable oxygen saturation levels. During a family interview on 6/19/18 at 4:30 P.M. Resident #103's sister stated: On April 10, 2018 her sister was sent out on a doctors appointment and didn't have an oxygen tank with her. The sister stated, upon arrival to the appointment she noticed her sister not breathing well and gasping for air. She stated, she asked the transportation driver where was her oxygen tank and why didn't they bring her oxygen? The family member stated, the driver informed her that the Respiratory Therapist (RT) stated, she did not need it because she was going around the corner for her doctors appointment. During an interview on 6/26/18 at 2:15 P.M. with the Respiratory Therapy Manager, she stated, Resident #103 was sent out to an appointment without her oxygen on 4/10/18. The Respiratory Therapy Manager stated as a result of the incident a Medical Transport Checklist for Transfer Care of Ventilated Patients was developed. The check off list included the following guide lines: 1. Paramedic verifies o2 tank is greater than 1500 PSI is attached to ventilator on/before arrival to unit. 2200 psi if o2 if patient greater than 50% Fio2. 2. Paramedic verifies that suction is set -up/functioning in ambulance. (Ask them) 3. Paramedic requests Respiratory Therapist (RT) to bedside upon transport's arrival unless RT already present, for verbal hand-off of ventilator settings and any other significant patient information. Trach size______ Back ups given_______ . 5. Transport team places patient on Cardiac Monitor / Spo2 (saturated percent of oxygen) monitor. The facility staff failed to provide Resident #103 with physician's ordered oxygen.

**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 meet the nutritional needs of one resident (Resident #95) of the 61 residents in the survey sample. For Resident #95, the facility staff failed to provide the ordered diet on 6-19-18, failed to provide the Pro-stat supplement as ordered, provide ongoing nutritional assessments, and failed to revise the care plan with feeding needs, during a significant weight loss. Findings included: Resident #95 was admitted to the facility on [DATE]. Current diagnoses included; Altered mental status, nutrition deficiency, vitamin D deficiency, and urinary tract infection. The current MDS (Minimum Data Set) was a significant change assessment with an ARD (assessment reference date) of 5-11-18. Staff assessment of mental status coded the Resident with severely impaired cognition. The Resident was coded as having no behaviors, and needing extensive to total assistance of 1-2 staff members for all activities of daily living. he Resident was also coded as needing to be fed. The MDS coded the Resident as having no swallowing disorder, no weight loss, and on a mechanically altered diet, and edentulous (no teeth). The quarterly assessment due for this assessment reference date was changed to a significant change assessment due to Resident's weight and overall decline, as stated in nursing notes by MDS staff on 5-23-18. On 6-19-18 at approximately 12:00 p.m. during initial tour of the facility Resident #95 was sitting in a reclined chair, in the dining area of the south unit with a meal tray in front of her and she was staring at the food, which was an untouched pureed diet. A staff member was asked if the Resident would feed herself, and she replied, I don't know, but I will help her, and she began to feed the Resident. On 2-9-18 the Resident went out to the hospital after a fall and laceration to the head which was repaired in the emergency room, and the Resident was readmitted to the facility the same day. The Resident had a wet cough and refused to eat throughout the next 24 hours and was again sent to the emergency room. The Resident returned on 2-15-18 (5 days later) and was given a pureed diet and was being fed. On 2-15-18 The Resident had a Pre-Albumin blood test, and the result was low at 13 (malnutrition). Normal range is 15-36, and the Resident was diagnosed with under weight, inadequate caloric intake, at risk of further weight loss, weight loss 6.8% in less than 30 days. No further nutrition assessment occurred until 3 months later on 5-14-18 and the Resident had lost 9.8% of her weight by 3-13-18. On 2-18-18 a Speech therapy consult was ordered by the physician, and was begun on 2-20-18. The consult states No recent weight loss. On 2-25-18 the Resident's weight had dropped 8 lbs (pounds) since the 2-1-18 weight, and on 2-26-18 the doctor ordered Pro-stat AWC 17 grams- 100 kcal (calories) per 30 ml (milliliters) liquid for nutritional deficiency one time daily. On 2-27-18 The physician changed the pro-stat order to increase it to three times per day, as documented in the physician progress notes, instead of once per day. That order was never instituted, and the Resident remained on Pro-stat once per day through the time of survey. The diet order was also changed this day and was Mechanical soft ground with thin liquids. The Resident's weights were documented in the facility for 2018 as follows; 1-2-18 120 lbs 2-1-18 120.20 lbs 2-25-18 112 lbs 3-1-18 110 3-13-18 108.2 3-20-18 108 3-29-18 108.2 4-2-18 108.2 5-4-18 109.4 6-7-18 108.5 The Resident's current care plan was reviewed, and even though many areas in the clinical record including nursing notes, the MDS, and speech therapy notes indicated the Resident needed to be fed by staff, the care plan still documented an intervention that the resident would feed herself. The care plan also documented the intervention of supplements per doctor's orders would be administered, which also did not happen, as Pro-stat was only given once per day and not three times per day as had been ordered. The Resident was ordered to have a mechanical ground diet with honey thickened liquids, and was observed consuming a pureed diet at lunch on 6-19-18 during initial tour of the facility. No nutrition evaluation was completed from 2-26-18, until 5-14-18 (approx 3 months later) and the Resident had already experienced a 9.8% weight loss between 2-1-18 and 3-13-18. (approx 6 weeks). On 6-21-18 at the end of day debrief at 4:00 p.m.The Director of Nursing, and Administrator were made aware of the issues, and asked to bring any information available to explain the lack of services provided for this Resident. No further information was supplied by the time of exit on 6-28-18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interview the facility staff failed to provide one resident (Resident #103) with Respiratory care in accordance with professional standards of practice and the person centered care plan, in the survey sample of 61 residents. The findings included: Resident #103 was admitted to the facility on [DATE] with diagnoses which included hypertension, GERD, hemiplegia, Chronic Respiratory Failure, Tracheostomy, Gastrostomy Status, Pneumothorax, seizures, and CVA. The facility staff failed to provide Respiratory care and services in accordance with the residents care needs. A re-entry Minimum Data Set (MDS) dated [DATE] for Resident #103 indicated this resident is not able to communicate with speech. This resident is not able to make self understood or understand others. In the area of Cognitive Patterns for daily decision making this resident is assessed as being severely impaired. In the area of Activities of Daily Living (ADL) this resident is assessed as being totally dependent on staff. In the area of Special Treatments, Procedures, and Programs -Respiratory Treatment- this resident was assessed for receiving oxygen therapy, suctioning and tracheostomy care. A Care Plan dated 5/30/18 indicated: Problem- Resident is at risk for ineffective airway clearance due to tracheostomy as a result of acute respiratory failure. Intervention- Provide humidified oxygen to maintain O2 (oxygen) level as ordered. Assess for evidence of respiratory distress, trachypnea, nasal flaring and increased use of accessory muscles. Assess for changes in mental status; lethargy, confusion, restlessness and irritability. Provide humidified oxygen to maintain FiO2 at 28%. A Physician's order indicated: oxygen orders per protocol continuous. Tracheal Suctioning PRN and chronic trach collar with humidification to keep O2 saturations greater than 95%, Therapeutic Range: Pulse Oximetry Every shift due to demonstrated unstable oxygen saturation levels. During a family interview on 6/19/18 at 4:30 P.M. Resident #103's sister indicated: On April 10, 2018 her sister was sent out on a doctors appointment and didn't have an oxygen taken with her. The sister stated, upon arrival to the appointment she noticed her sister not breathing well and gasping for air. She stated, she asked the transportation driver where was her oxygen tank and why didn't they bring her oxygen? The family member stated, the driver informed her that the Respiratory Therapist (RT) stated, she did not need it because she was going around the corner for her doctors appointment. During an interview on 6/27/18 at 10:15 A.M. with the Respiratory Therapist he stated. Resident #103 was sent out to a doctors appointment on 4/10/18 without her oxygen. The Respiratory Therapist stated, transportation came and transported the resident out before he could put her on oxygen. When asked was it the facilities responsibility to ensure that Resident #103 was prepared to go on her doctors visit, he stated, Yes. An appointment Scheduling form dated 4/10/18- Time: 3:15 P.M. Indicated: Resident #103 Had an appointment a a local hospital for Podiatry care (swollen left big toe). During an interview on 6/26/18 at 2:15 P.M. with the Respiratory Therapy Manager, she stated, Resident #103 was sent out to an appointment without her oxygen on 4/10/18. The Respiratory Therapy Manager stated as a result of the incident a Medical Transport Checklist for Transfer Care of Ventilated Patients was developed. The check off list included the following guide lines: 1. Paramedic verifies o2 tank is greater than 1500 PSI is attached to ventilator on/before arrival to unit. 2200 psi if o2 if patient greater than 50% Fio2 (fraction of inspired oxygen). 2. Paramedic verifies that suction is set -up/functioning in ambulance. (Ask them) 3. Paramedic requests Respiratory Therapist (RT) to bedside upon transport's arrival unless RT already present, for verbal hand-off of ventilator settings and any other significant patient information. Trach size______ Back ups given_______ . 5. Transport team places patient on Cardiac Monitor / Spo2 (saturated percentage of oxygen) monitor. The facility staff failed to provide Resident #103 with physician's ordered respiratory care (oxygen).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and clinical record review the facility staff failed to provide pain management for 1 resident (Resident # 5) in the survey sample of 61 Residents. For Resident # 5 facility staff failed to provide pain management according to physician's orders. The finding included: Resident #5 a 66 yr. old female was admitted on [DATE] with diagnoses of but not limited to anemia, CAD (coronary artery disease), hypertension (high blood pressure), CVA (stroke), and depression and psychotic disorder. Resident # 5's most recent MDS (Minimum Data Set) was coded as an annual an ARD (assessment reference date) of 6/4/18. She was coded as having a BIMS (Basic Interview of Mental Status) score of 15, indicating no cognitive impairment. She was coded as needing physical assistance of 1 staff member for activities of daily living as well as being always incontinent of bowel and bladder as well as being totally dependent on staff for bathing. She was coded as being at risk for pressure ulcers however she was also coded as having no open areas or pressure ulcer On 6/22/18 at 1030 AM a review of Resident #5's clinical record was conducted it was found that Resident #5 had a physician's order for pain management. Resident #5 was to receive the scheduled pain medication, Oxycodone (narcotic pain medication) 5 mg (milligram) 1 tablet 3 times per day The MAR (Medication Administration Record) for May 2018 was reviewed and revealed the resident was not administered 12 consecutive doses of the scheduled narcotic pain medication. The notes on the MAR state the reason as medication not available as well as awaiting hard script from MD. The MAR also showed that the Resident had PRN (as needed) orders for Tylenol as well as Ibuprofen that could have been utilized for pain however were not signed off as given or as offered and refused. Interview on 6/26/18 at 9:30 AM resident stated she receives pain medicine because her knees hurt every time she moves or is turned in the bed. I have arthritis all over my other joints too, its painful business that arthritis. On 6/26/18 and interview with the DON (director of nursing) who stated During the time the medication was not given the doctor had been contacted by the staff and had not yet sent over the hard script [paper prescription] which is why she missed the medication. She further stated it is the expectation of the nurses that they utilize the stat box to pull meds from if the patient does not have them in their drawer. She also stated the nurses should have continued to call the physician for the prescription. She went on to say if there is no more of a particular drug in the stat box they could use the stat box on another units and fax the pharmacy to refill the stat box. Administration notified on 6/26/18 at 2:45 p.m. and no further information was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility staff failed to provide on communication with the dialysis facility for one resident (Resident #110) in the survey sample of 61 residents. The findings included: Resident #110 was admitted to the facility on [DATE] with diagnosis of colon cancer, failure to thrive, type two diabetes, depression, end stage renal disease and anemia. The facility staff failed to have ongoing communication with the dialysis facility regarding dialysis care and services. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Hearing, Speech and Vision as having highly impaired Vision. In the area of Cognitive Patterns this resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 15. In the areas of Activities of Daily Living (ADL) this resident was assessed as requiring limited assist of one person for bed mobility, not able to walk in room, eats with supervision of set-up and one person assist, requires extensive assistance with one person for person hygiene. In the area of Special Treatments, Procedures and Programs this resident was assessed as receiving dialysis services. A Care Plan dated 6/12/18 indicated: Dialysis Monday, Wednesday, and Friday. Interventions- allow to verbalize feelings of disease process. provide for assist with adls and comfort measures as needed. Physician's orders dated June 2018 indicated: Dialysis Monday, Wednesday, and Friday. A review of the facility's leave of absence flow sheet indicated this resident went out to dialysis 30 times from 3/19/18 until 6/25/18. A review of the Hemodialysis Communication form for this resident documented on communication with the dialysis facility on 6/20/18, 5/14/18, 5/11/18, 5/9/18, 5/2/18, and 4/25/18. During an interview on 6/27/18 at 11:45 A.M. with the Director of Nursing (DON) she stated, the facility and dialysis center do not always communicate. A facility Dialysis Care policy indicated: Policy: The facility will provide patients and residents who require renal dialysis services that are consistent with professional standards of practice. Procedures: This agreement will address at least: Interchange of information necessary for the resident's care. Facility staff failed to provide on ongoing communication with the dialysis facility.

Based on a information obtained during a complaint investigation, resident, staff and family interviews, and review of the clinical record, the facility staff failed to ensure residents who displays or has a history of a mental disorder and trauma receives the care and services necessary to reach and maintain the highest level of mental and psychosocial functioning for 1 of 61 residents (Resident #118), in the survey sample. The facility staff failed to acknowledge, assess, develop and implement a person centered plan for the underlying cause of displayed expressions of distress exhibited by Resident #118 on 6/5/18 and 6/12/18, and to ensure Resident #118 received appropriate, individualized treatment, services and assistance to meet her needs during community physical therapy appointments; which resulted in a decline in her psychosocial well-being. The findings included; Resident #118 was originally admitted to the facility 8/10/16. The admission diagnoses included Parkinson's disease, Major Depressive disorder, Unspecified Psychosis, an anxiety disorder, and an Adjustment disorder with mixed Disturbance of emotions and conduct. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #118's cognitive abilities for daily decision making were intact. In section D (Mood), the resident was coded for feeling downed, depressed and hopeless and in section E (Behaviors), the resident was coded for exhibiting physical and verbal behaviors directed towards others 1-3 days each week. The resident was also coded indicating the behaviors didn't put the resident at risk for illness/injury, not significantly interfering with resident care, activities or social interactions, and the resident was coded to indicate the behaviors didn't put others at significant risk for physical injury or as causing disruption to the living environment. The resident was also coded for rejection of care 1-3 days each week. In section G (Physical functioning), the resident was coded as requiring supervision of 1 person with wheelchair locomotion, limited assistance with transfers, extensive assistance of 1 person with bed mobility, personal hygiene, dressing and toileting and total care with bathing. A facility reported incident which occurred 2/3/17, revealed Resident #118 had a history which included an allegation of sexually assault by a certified nursing assistant during peril-care therefore; a plan of care was developed to have a second staff member accompany the assigned caregiver during provision of care and the resident agreed to counseling services. The clinical record contained progress notes revealing Resident #118, was receiving psychological services for 1 hour each week from 1/2/18 through 3/5/18. The 3/5/18 progress note stated the resident would be seen next week but no further visits were made with the resident. An interview was conducted with the Administrator 6/19/18, at approximately 1:30 p.m. The Administrator disclosed the Licensed Clinical Social Worker (LCSW), providing the therapy no longer practiced in the nursing facility and the Resident #118's services had not been assigned to another practitioner. The LCSW progress notes stated the therapist was working with Resident #118 on the following targeted symptoms; helplessness, interpersonal problems, marital/family problems, nervousness, worry, stress, anxiety, grief, loss issues, hopelessness, irritability, pain, paranoia, suspiciousness and negative thinking. The Resident's top targeted symptoms were; anxiety, suspiciousness and unusual thought content. Her mood was described as worried, helpless, anxious, worthless and irritable and her insight was described as limited. The clinical record revealed Resident #118 had a physician's order dated 4/3/18, for physical therapy (PT) services; heat therapy to the left posterior shoulder, for muscle pain; limiting range of motion. The clinical record also revealed Resident #118 missed community PT appointments; 6/7/18, 6/14/18, 6/19/18 and 6/22/18, because facility staff was not available to accompany her. The resident's person centered care plan dated 6/5/18; had a problem titled locomotion on/off the unit (name of resident) requires assistance. The goal read; (name of resident) will participate in unit activities/social interactions 3-5 times per week over the next 90 days, 9/1/18. The interventions read; Assist (name of resident) to desired location. (name of resident) requires wheel chair and staff assistance. Another person centered care plan problem read; (name of resident) has a diagnosis of an anxiety disorder. The goal read; Periods of distress/anxiety will be reduced over the next 90 days, 9/1/18. The interventions included; Assess and record behaviors. Assess need for as needed antianxiety medication if interventions do not relieve anxiety. Conduct 1:1 visits with (name of resident). Help (name of resident) identify specific thoughts/ideas that cause anxiety. Reassure (name of resident) during distress/anxiousness. Speak in a calm voice. Validate feelings. The resident also had a person centered care plan problem which read; Behavioral symptoms; (name of resident) has verbal and physical behavioral symptoms directed at others. The goal read the number of verbal incidents will be decreased over the next 90 days, 9/1/18. The interventions included; Encourage caregivers to participate in activities with (name of resident) to promote positive interactions. Gently remind (name of resident) screaming/cursing is not appropriate. Record behaviors on the Behavior Tracking form. Monitor pattern or behavior (time of day, precipitating factors, specific staff or situations). Respond in a calm voice, maintain eye contact, Remove from area if (name of resident) is verbally and physically abusive to others. Talk with family and friends to identify potential sources/reasons. Conduct 1:1 sessions with (name of resident), encourage resident to verbalize feelings in an appropriate manner and provide realistic feedback. Review of the Care Plan confirmed that the facility staff had not developed an individualized care plan that addressed Resident 118's anxieties surrounding attending community appointments unaccompanied. Resident #118 stated during an interview on 6/20/18, at approximately 10:30 a.m., that she was told by the facility physical therapist they saw no improvement in her and they couldn't help her therefore; the Neurologist recommended she see a community based physical therapist. The resident further stated, during the initial visit approximately 4/26/18, her needs were assessed and the therapist developed a treatment plan and a schedule of future appointments. The appointments were later changed to Tuesdays and Thursdays at 10:00 a.m. A copy of the scheduled appointments were sent to the nursing facility and the Unit Secretary arranged transportation for travel to and from the community based PT office. Resident #118 stated facility staff accompanied her to the initial appointment and no one informed her that was not the plan for future PT appointments. The resident also stated she frequently reminded staff she preferred and required 2 staff during care and 1-2 staff for non activities of daily living. Resident #118 stated the facility staff was aware she has only 3 relatives locally and they are unable to accompany her to appointments because her daughter is visually impaired and requires assistance and her 2 granddaughters have commitments to their jobs and families. She stated on one occasion her sister traveled from South Carolina to accompany her on an appointment. The resident further stated because of her family's obligations and inability to aide her with needed services she elected to remain in the nursing facility. During the 6/20/18 interview at approximately 10:30 a.m., Resident #118 stated, the first official day of therapy was 6/5/18. The resident stated she got ready for the appointment, went to the nurse's station and was told by the Unit secretary and the information was confirmed by the Unit Manager that the Administrator and Director of Nursing stated said she was to go alone to the appointment because she had no cognitive deficits or other limitations preventing her from going unaccompanied. The resident then, stated the Assistant Administrator told her go ahead and try going by yourself. The resident stated, she was reluctant but left the facility without facility staff accompanying her, she arrived to the PT office, the driver assisted her inside, she had therapy, the office staff called the transport company to pick her up and she asked the office staff to sit her outside the office so the transport driver could see her upon arrival. Resident #118 stated she waited approximately 20-30 minutes outside the PT office but; the transport company didn't arrive therefore; she used her cell phone to call the nursing facility and alerted them that the transport company hadn't returned to transport her back to the nursing facility. Resident #118 stated the nursing facility staff told her to calm down because she couldn't understand what she was saying, then the nurse stated (name of resident), the transport company says you have already been picked up. Resident #118 stated, she became very upset, began crying and thought she needed to go back inside the office but; she was unable to self propel herself back inside the PT office therefore; she asked a male stranger, passing by to assist her back into the office. The resident explained if there are no rails she is unable to pull the wheelchair along and the wheelchair just goes around in circles. The resident also stated, upon returning inside the office, she informed the office staff she had been outside waiting but the transport company had not come. The resident stated the office staff said, The van didn't pick you up! and proceeded to telephone the transport company again, after approximately 25 more minutes the transport van still had not arrived therefore; the PT office staff telephoned the nursing facility and inform them the resident was still at the PT office because the transport company hadn't returned to transport her back to the facility. Resident #118 stated, approximately 2 1/2 hours after her therapy session ended the transport company arrived to transport her back to the nursing facility. The resident stated she was still very upset and continued to cry on the van and an individual told her to stop crying for she was now safe and on her way home. Resident #118 also stated during the 6/20/18, interview that on 6/12/18, she got ready to go to the PT office for therapy, the Unit secretary accompanied her to the transport van, watched her get belted in but didn't enter the van so she asked the transport driver what time will you return to pick me up. The resident stated, the transport driver answered I can't give you a time, and she began crying, swinging her arms and yelling, I'm not going, get me out of here, I'm not going by myself to be left and told I've been picked up. I'm afraid to go alone, not knowing when I will picked up, disabled and confined to this wheelchair, that not safe. Resident #118 stated the transport driver unbelted her and she was assisted back into the nursing facility. Resident #118 stated she asked the Unit Secretary each Monday and Wednesday after the 6/5/18 event, who would be accompanying her to the community PT office on Tuesday and Thursday; if the Unit Secretary stated no one, she stated she told her to cancel the appointment because she felt unsafe going unaccompanied. An interview was conducted with the Unit Secretary 6/20/18 at approximately 11:15 a.m. The Unit Secretary stated prior to 6/5/18 she accompanied Resident #118 to appointments in the community if family was unable to attend. The Unit Secretary stated she didn't work 6/5/18 and there was no one to accompany the resident to the appointment therefore she was sent alone. The Unit Secretary stated she was told the resident returned to the facility 6/5/18 crying and upset. A nurses's note dated 6/14/18 read; Resident scheduled to go out for therapy today. She refused to go because a staff member is unable to accompany her. She is alert and oriented with a BIMS score of 15. This resident makes all her needs known. She is her own responsible party. (name of resident) is able to self maneuver herself in her wheelchair. Staff offered to get her ready for this appointment but she still refused to go. An interview was conducted with Licensed Practical Nurse (LPN) #5 on 6/22/18 at approximately 1:10 p.m. LPN #5 stated she was aware it was Resident #118's preference for a staff member to accompany her on appointments in the community and she was aware on 6/5/18, Resident #118 returned to the facility upset because the transportation driver didn't pick the resident up until approximately 2 hours after transport was called to return the resident back to the facility. LPN #5 stated she informed the resident that hand to hand transport; (transportation driver takes the resident inside the office and picks the resident up inside the office) was requested on her behalf therefore what occurred on 6/5/18, should not happen again, but the resident stated she would not go again unless she was accompanied because she didn't feel safe. LPN #5 stated she kept the Administrator and Director of Nursing informed of the resident's preference to be accompanied by a staff member and of each episode of refusal to attend appointments when there wasn't a staff member to accompany her. LPN #5 stated the Administrator and Director of Nursing stated each time Resident #118 was alert, oriented, had a BIMS score of 15 and a cellphone therefore; capable of going unaccompanied. LPN #5 was asked during the 6/22/18 interview at approximately 1:10 p.m., if she or the Interdisciplinary Team (IDT) had addressed Resident #118 displayed behaviors (crying, swinging her arms, yelling and demanding to get off the transport van) regarding attending community appointments unaccompanied, after the 6/5/18 and 6/12/18 events. The response was no. LPN #5 was also asked if the resident's Social Worker, Mental Health Counselor or physician had been notified about the resident's voiced fears, exhibited behaviors and frequent refusal to keep appointments if not accompanied by staff member. The response was no. LPN #5 was asked if a care plan had been developed to address Resident #118's new problem of fear to leave the facility unaccompanied had been documented so the staff could consistently implement the interventions and the IDT could evaluate the interventions to ensure the resident's needs are met. The response was I'm not sure. During an interview with the social workers on 6/24/18 at approximately 3:20 p.m. The social workers stated they hadn't been notified Resident #118 had voiced fears and displayed behaviors regarding attending community appointments unaccompanied by staff. The social workers stated they would immediately follow-up with the resident and get back with the surveyor. The following day 6/25/18 at approximately 12:30 p.m., the social worker presented a progress note documenting her conversation with Resident #118. The document stated the resident explained what occurred 6/5/18 and how the social worker would attempt to obtain volunteers to accompany the resident to future appointments. The progress note stated the resident didn't express fear during the ordeal and the it didn't state the social addressed the behaviors displayed by the resident 6/5/18, 6/12/18 and thereafter by refusing to attend appointments unaccompanied. An interview was conducted with the PT office Operations Coordinator on 6/25/18 at approximately 10:25 a.m. The Operations Coordinator stated, Resident #118 arrived to the office at approximately 9:30 a.m. accompanied by the transportation drive only, on 6/5/18, the therapy session concluded at approximately 10:45 a.m., the resident was assisted to the lobby and the transport company was telephoned by the PT office staff. The Operations Coordinator further stated, the resident asked to be assisted outside the office to wait for the transport van and the staff did, after approximately 20 minutes the resident returned inside the PT office stating the transportation van had not come therefore; the PT staff again called the transport company and the resident continued to wait in the lobby. The Operations Coordinator stated after another 20 minutes the nursing facility was telephone and the Operations Coordinator spoke with an individual who identified themselves as a supervisor but, the Operations Coordinator couldn't recall the supervisor's name. The Operations Coordinator stated the nursing facility supervisor stated the resident had been picked up and the PT staff informed the nursing facility supervisor the resident was still at the PT office, crying and upset. The Office Coordinator stated the PT office has limited staff and they are not equipped to provide care for the client after the therapy session ends. An interview was conducted with the Administrator 6/27/18 at approximately 1:55 p.m. The Administrator stated the facility had no formal assessment to determine who can go to a community appointment unaccompanied but she felt a resident with a BIMS of 15, capable of making sound decisions, can do a lot for herself as well as maneuver the wheelchair, and has a cell phone, can travel into the community unaccompanied. The Administrator further stated the appointments they did send staff with the resident was solely common courtesy and not based upon resident needs. The Administrator also stated she never understood what the resident meant when she frequently stated she was to have at least 2 persons with her. The Administrator didn't consider the resident's mental disorders or previous traumatic event the resident considered sexual assault or the intervention instituted after the alleged sexual assault event. Neither did the Administration consider that the psychological counseling was discontinued abruptly and the indicators of increased anxiety, fear and more trauma was not acknowledged, assessed, and care planned. The facility didn't have a policy for determining a resident's needs for community appointments but a document was drafted 6/25/18 explaining their process. The document was titled (Name of Facility) Social worker's Outlined Process for Appointments. It read; at Bullet #3, The Unit securities also discuss the coordination with families and resident's to ensure communication and coordination is agreed upon by both family designee and or resident. Bullet #4 read; If the resident is a Long Term Care resident the Unit Securities will schedule appointments with specialized providers and will set transportation based on transportation needs. Bullet #5 read; as a courtesy, resident is reviewed by nursing for mobility and BIMS to see if a need for additional assistance at appointments. Bullet #6 read; If assistance at appointments is needed, family or caregivers are contacted first and then if needed, staff may attend the appointment with the resident which usually is the unit security or designee. Bullet #7 Social Worker staff also support staff with reaching out to family designee and or resident to discuss barriers with transportation. On 6/28/18 at approximately 3:50 p.m., the above findings were shared with the Administrator, Director of Nursing, Director of Operations, 2 visiting Administrators and the Dietitian. The Administrator stated she didn't feel the facility was responsible for a resident because transportation didn't pick her up when she thought they should have. The facility staff provided a staff member to accompany Resident #118 to community PT appointments during the last week of this survey, after it had been brought to their attention by the surveyor that the resident was refusing appointments because the facility felt she should go unaccompanied. The Administrator stated again the resident was accompanied because of common courtesy. Complaint deficiency

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #118 was originally admitted to the facility 8/10/16. The admission diagnoses included Parkinson's disease, Major Depressive disorder, Unspecified Psychosis, an anxiety disorder, and an Adjustment disorder with mixed Disturbance of emotions and conduct. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #118's cognitive abilities for daily decision making were intact. In section D (Mood), the resident was coded for feeling downed, depressed and hopeless and in section E (Behaviors), the resident was coded for exhibiting physical and verbal behaviors directed towards others 1-3 days each week. The resident was also coded indicating the behaviors didn't put the resident at risk for illness/injury, not significantly interfering with resident care, activities or social interactions, and the resident was coded to indicate the behaviors didn't put others at significant risk for physical injury or as causing disruption to the living environment. The resident was also coded for rejection of care 1-3 days each week. In section N0410 A. antipsychotic medication was coded as 0, antianxiety was codes as 1, and antidepressant was coded as 7. In section N0450 A. Antipsychotic was coded as 'No, B. GDRs was not coded, C. Date of last GDR was not coded. D. physician documentation of GDR clinically indicated, not coded, E. date physician documented GDR as clinically was not answered. The clinical record revealed Resident #118 had a physician's order dated 2/9/17, for Seroquel 100 milligram (mg) tablet; 1 tablet orally at the hour of sleep for a diagnosis of unspecified psychosis, a physician's order dated 8/4/17, for Duloxetine 30 mg delayed released capsule; 1 capsule orally two times daily for an anxiety disorder and a physician's order dated 2/27/18, for Alprazolam 0.25 mg tablet; 1 tablet orally as needed every day for an anxiety disorder. Seroquel is an antipsychotic medicine that works in the brain.(https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0011909/?report=details) Duloxetine is a drug used to treat depression and urinary urge incontinence (leakage of urine) and it can be also be useful for certain types of pain . (https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0010059/?report=details) Alprazolam (Xanax) is used to relieve symptoms of anxiety, including anxiety caused by depression. It is also used to treat panic disorder in some patients. (https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0008896/?report=details) The resident had person centered care plan problems which included; (name of resident) has a diagnosis of an anxiety disorder. The goal read; Periods of distress/anxiety will be reduced over the next 90 days, 9/1/18. The interventions included; Assess and record behaviors. Assess need for as needed antianxiety medication if interventions do not relieve anxiety. Conduct 1:1 visits with (name of resident). Help (name of resident) identify specific thoughts/ideas that cause anxiety. Reassure (name of resident) during distress/anxiousness. Speak in a calm voice. Validate feelings; Behavioral symptoms; (name of resident) has verbal and physical behavioral symptoms directed at others. The goal read the number of verbal incidents will be decreased over the next 90 days, 9/1/18. The interventions included; Encourage caregivers to participate in activities with (name of resident) to promote positive interactions. Gently remind (name of resident) screaming/cursing is not appropriate. Record behaviors on the Behavior Tracking form. Monitor pattern or behavior (time of day, precipitating factors, specific staff or situations). Respond in a calm voice, maintain eye contact, Remove from area if (name of resident) is verbally and physically abusive to others. Talk with family and friends to identify potential sources/reasons. Conduct 1:1 sessions with (name of resident), encourage resident to verbalize feelings in an appropriate manner and provide realistic feedback; Resident receives an antipsychotic medication. The goal read; Minimize/avoid harmful side effects during the next 90 days, 9/1/18. The interventions included; Complete AIMS assessment. Notify physician if resident appears to be drowsy or shows decrease in usual functioning. Monitor for side effects and adverse reactions. Monthly review by registered pharmacist. Labs per physician's order; (name of resident) is receiving an antidepressant drug on a regular basis. The goal read; Symptoms of depression will be controlled/managed with minimal side effects over the next 90 days, 9/1/18. The interventions included; Conduct 1:1 visit with (name of resident) to discuss current status and adjustment to lifestyle changes. Monitor for side effects of medication; constipation, dry mouth, anxiety, agitation, headaches, falls. Report promptly to the physician. Plan (name of resident) and the physician for a trial period of dose reduction. Record behaviors on the Behavior Tracking Record. Observe (name of resident) for changes in mood/behavior, sleep patterns, fatigue, appetite, ability to concentrate, participation in activities, crying. An Interview was conducted with the Director of Nursing on 6/25/18 at approximately 2:25 p.m. The Director of Nursing stated the facility staff was unable to provide documentation the physician had attempted gradual dose reduction (GDR)/rationale for not attempting GDRs, or justification of continuous use and duration of as needed Xanax. On 6/28/18 at approximately 3:50 p.m., the above findings were shared with the Administrator, Director of Nursing, Director of Operations, 2 visiting Administrators and the Dietitian. An opportunity was given to the facility staff to provide additional information but; none was presented. The facility's Pharmacy service policy with a revision dated of 10/26/17 read at bullet #5; Provide GDR and other recommendations surrounding psychotropic and antipsychotic medications. Bullet #7 read; If a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. The facility's Psychoactive Medications policy with a revision date of 1/17/17 read; The facility will develop and maintain a system for assuring the proper use and monitoring of psychoactive agents. Psychoactive agents can only be used on receipt of a physician's order to eliminate or reduce identified behavioral symptoms or to treat a specific diagnosis. Page 2 of the facility's policy included the following; Residents who receive an antipsychotic medication to treat a psychiatric condition will be monitored. Define and document specific behavioral problems within the nursing notes using the terminology in chart. Set reasonable and measurable objectives and reflect these in the resident's care plan. Occurrences of specific behaviors and incidences of adverse effects will be monitored daily and totaled monthly on the Psychoactive Drug Monitoring Form. Each occurrence or lack of occurrence will be noted for each day and shift. Physicians will routinely comment on progress of resident in medical progress notes. Based on record review and staff interview, the facility staff failed to attempt gradual dose reductions of psychoactive medications for two residents (Resident #63 and 118) in the survey sample of 61 resident. 1. For Resident #63, the facility staff failed to attempt gradual dose reductions or document why gradual dose reductions are not indicated for ordered doses of Seroquel. 2. For Resident #118, the facility staff failed to attempt gradual dose reductions or document why gradual dose reductions were not indicated for ordered doses of Seroquel and Duloxetine; and to not prescribe as needed Xanax for greater than 14 days without documenting the rationale and duration of use in the medical record. The findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance, epilepsy disorienting, anxiety and anemia. The facility staff failed to provide a Gradual Dose Reduction (GDR) for psychotropic medications for Resident #63. Resident #63 had Quarterly Minimum Data Set (MDS) May 15, 2018 which assessed this resident as not able to make self understood and does note understand others. In the area of vision this resident was assessed as being highly impaired. In the area of Cognitive Skills for daily Decision Making this resident was assessed as being severely impaired. In the area of Activities of Daily Living (ADL) this resident was assessed as being totally dependent of staff in areas of daily living. This resident was not assessed in the area of medications for documented GDR. A Care Plan dated 5/8/18 indicated: Antipsychotic medication- Interventions- Monitor for side effects (insomnia, agitation, nervousness, dizziness, rash, Tardive dyskinesia, hypertension, drowsiness, anxiety, tachycardia, leg pain, upper respiratory infection, metabolic syndrome, weight gain, increased blood sugar. Monthly review by Registered Pharmacist. A facility Monthly Antipsychotic Report dated May 2018 indicated: Name-Resident #63 - Drug - Seroquel - Diagnosis-Anxiety disorder- Start Date- 1/15/18 - Last GDR Request- 5/31/18. A physician's order dated June 2018 indicated: Quetiapine 25 mg tablet (2 tablets) . Frequency- two times daily starting 1/15/18. A Consultant Pharmacist Communication to Physician dated 5/31/18 indicated: Antipsychotic Gradual Dose Reduction. Drug Seroquel (Quetiapine) 50 mg BID - Last GDR -None (Seroquel was started on 1/15/18. last GDR request: None. Diagnosis: Anxiety. A facility policy for Psychotropic Medications indicated: Gradual Dose Reduction-must be attempted in tow separate quarters within the first year of initiation of an agent. with at least a month in between attempts. unless clinically contraindicated. During an interview on 6/27/18 at 11:00 A.M. with the Director of Nursing (DON) she stated, Gradual Dose Reductions had been performed for Resident #63. The facility staff failed to attempt a GDR for the psychoactive medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On [DATE] at approximately 1:05 a.m., this surveyor observed the treatment cart lock on Unit North 3 with a set of nursing keys left unsupervised. After 3 minutes, License Practical Nurse (LPN) #7 came to the treatment cart and stated, I left me keys in my treatment cart, I went to assist a resident and just forgot to take them out. An interview was conducted with Director of Nursing (DON) who stated, I expect for all nurses to make sure they remove their keys from the lock of the treatment or medication cart, push the button and make sure the cart is to locked then put their keys in their pocket before leaving the treatment or medication cart. The treatment or medication cart should never be left with the keys still in the lock unsupervised. The facility's policy titled Life care - Storage of Medications (Revision: [DATE]). -Policy statement: Medications, treatments, and biologicals are stored safety, securely, and properly following manufacture's recommendations or facility policy. The medication supply is accessible only to licenses nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. -Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medications supplied are locked or attended by persons with authorized access. Policy Life Care - Medication Administration (Revision [DATE]). Policy statement: Medications will be administered in accordance with prescribed orders, manufactures specifications regarding the preparation and administration of the drug or biological and accepted professional standards and principles. -General Guidelines to include but not limited to: The key must be in the possession of the medication nurse, med tech, or charge nurse at all times. Based on observation, resident interview, staff interview, facility documentation review, clinical record review, the facility staff failed to ensure Insulin was stored correctly with both an open and a correct expiration date on 1 of 10 medication carts (Unit 4 Cart 2, and failed to ensure one PPD (purified protein derivative-tuberculosis skin test) vial was stored correctly with both an open and expiration date on 1 of 3 medication storage rooms (South 1 Medication Storage Room) and failed to ensure one treatment cart was secure by LPN #7 after leaving her keys in the treatment cart lock when not in direct supervision of the nurse. The findings included: 1. On [DATE] at approximately 12:08 PM an observation was made of the Facility's Unit 4 Cart 2. A Humalog 100 ml (milliliter) opened vial was observed with an open date of [DATE] with an expiration date marked [DATE]. When RN #1 was asked what she thought was wrong with the labeling she stated, They marked it for 30 days instead of 28. The Clinical Manager stated that it was tabled incorrectly as insulin is to be expired 28 days after opening.Correct An observation on the South 1 Medication Storage room was made on [DATE] at approximately 3:30 PM. An opened PPD vial was observed in the Medication storage room refrigerator. The PPD vial had an open date; however had no marked expiration date. LPN #1 stated that it would expire as the Manufacturer's Expiration date stated in the year 2019. The Facility Policy titled, Storage of Medications with a revision date of [DATE], documented the following: Policy Statement: Medications, treatments, and biologicals are stored safely, securely, and properly following manufacturer's recommendations or facility policy. The Facility Policy titled, Medication: Expiration Dates with a revision date of [DATE], documented the following: PPD-30 days from opening Insulin Once opened, ALL insulin kept in the refrigerator or in the medication cart expires 28 days after opening. The Administrator was notified of the findings during a meeting on [DATE] at approximately 5:45 PM. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 28 an 84 yr. old female was admitted to the facility on [DATE] with diagnoses of, but not limited to, Hypertension, Gastroesophageal Reflux Disease, CVA (stroke), and has colostomy. Resident # 28's most recent MDS (Minimum Data Set) was coded as an annual an ARD (assessment reference date) of 3/30/18. She was coded as having a BIMS (Basic Interview of Mental Status) score of 14, indicating no cognitive impairment. She was coded as needing extensive assistance of 2 staff members for activities of daily living as being always incontinent of urine and as having a colostomy. She was coded as being at risk for pressure ulcers however she was also coded as having no open areas or pressure ulcers. On 6/19/18 a review of clinical record revealed that the resident was noted to have two open areas to the lateral side of abdomen 1.4 centimeters (cm) x 2.6 cm x 0.1 cm. and medial measuring 0.6 cm x 1.4 cm x 0.1 cm. On 04/24/18 resident was noted to have these wounds on 4/24/18. On 6/6/18 a Note from Nurse Practitioner was reviewed and read: ASP [asked to see patient] regarding painful area on her back. Pt states she has been having pain on her back for the last few weeks. She says she asked the staff to look at it while she was being bathed and was told there was nothing there. However, today when she was getting washed up the aide advised her she saw something and went to get a nurse. She asked if I would also take a look. She stated it's painful and has a burning quality and exacerbates when she lays on it. It can also itch. She has not tried anything to get relief. Care plan for resident #28 was not revised to include pain, shingles, or the identified open areas on the abdomen. On 6/21/18 at 2:00 PM the DON (Director of Nursing) was interviewed . The DON stated she recognized the care plan had not been updated and no interventions were added for Shingles Pain and the pressure areas that were identified. Administration was notified of these issues on 6/20/18 and no new information was provided. 3. Resident #11 is a 71 yr. old female admitted to the facility on [DATE] with diagnoses of but not limited to Atrial Fibrillation, CAD (coronary artery disease), deep vein thrombosis, hypertension (high blood pressure), diabetes, aphasia ( inability to speak), CVA (stroke), seizure disorder, Hemiplegia (one sided weakness) and anxiety disorder. Resident # 11's most recent MDS dated [DATE] was coded as a quarterly. She was coded as having a BIMS score of 0, indicating severe cognitive impairment. She was coded as needing extensive assistance of 2+ staff members for all activities of daily living. She is transferred using a mechanical lift and 2 staff members. MDS also codes Resident in the section Makes self understood Rarely/Never Understood she is also coded under Ability to Understand Others as Rarely/Never Understood On 6/21/18 at 1:00 PM a review of clinical record revealed that on the 6/7/18 the nurse charted Resident A x O x 2 [alert and oriented x 2] able to make needs known. On 6/10/18 another nurse documented Resident in bed alert and verbally responsive able to make needs known. On 6/13/18 the MDS coordinator charted Care plan meeting with IDT [interdisciplinary team]. Care plan reviewed and up to date. No resident attendance due to cognitive deficit. No family RSVP. On 6/21/18 at 1:00 PM A review of Resident Care #11's care plan revealed that under the focus area of activities it states Resident #11 is capable of self-directed activities of choice. On 6/26/18 at 1:00 PM interview with DON was conducted and she was asked about the discrepancy between the MDS and the care plan as well as the nurses notes. She stated that the MDS was correct and the patient cannot say anything but yes. She doesn't always mean yes she sometimes just says yes. She further stated that one of the nurses did not usually work on 1 south had documented incorrectly that she was alert and orientated and verbally responsive. The other nurse was also incorrect in his documentation. The DON went on further to say the documentation that sates Resident did not attend the care plan was correctly documented by the MDS coordinator, however the care plan was incorrect in stating that Resident is sometimes understood and is capable of self-directed activities of choice. Administration was made aware of the issues with the care plans and no further information was provided. 4. Resident #5 a 66 yr. old female was admitted on [DATE] with diagnoses of but not limited to anemia, CAD (coronary artery disease), hypertension (high blood pressure, CVA (stroke), depression and psychotic disorder. Resident # 5's most recent MDS (Minimum Data Set) dated 6/4/18 was coded as quarterly. She was coded as having a BIMS (Basic Interview of Mental Status) score of 15, indicating no cognitive impairment. She was coded as needing physical assistance of 1 staff member for activities of daily living. She was coded as being at risk for pressure ulcers however she was also coded as having no open areas or pressure ulcers. She is also coded as being always incontinent of bowel and bladder. On 6/21/18 a clinical record review was conducted and it was found that for the month of May 2018 the Medication Administration Record (MAR) was missing documentation of administration for 12 doses of routinely scheduled narcotic pain medication. (May 6th at 6:00 AM -until May 10th 6:00 AM) Care plan was not updated to include during this time. Resident #5 had orders for (as needed) PRN Tylenol and Ibuprofen that was utilized during the three days that she did not receive her scheduled narcotic pain medication. Pain assessments were not conducted during this time. No interventions were put in place. On 6/26/18 and interview with the DON (director of nursing) who stated During the time the medication was not given the doctor had been contacted by the staff and had not yet sent over the hard script [paper prescription] which is why she missed the medication. The DON and unit manager also stated they recognized that pain assessments and interventions were not put in place nor was the care plan updated. On 6/26/18 Administration was made a ware and no new information was provided. Based on medical record review, staff interviews and facility document review the facility staff failed to revise care plans for 5 of the 61 Resident's in the Survey Sample, Residents' #125, #28, #11, #5, and #72. 1. The facility staff failed to revise Resident #125's care plan on 5/21/18 to include the initial physician order for the antipsychotic medication Quetiapine 50 mg (milligram) tablet one time daily. 2. For Resident #28 care plan was not revised to include new wounds and pain from shingles. 3. For Resident #11 care plan has not been updated to accurately reflect Residents current communication abilities. 4. For Resident #5 care plan was not revised to include pain assessments or interventions. 5. For Resident #72 the facility staff failed to revise the care plan for wounds and treatments. The Findings Included: 1. Resident #125 was admitted to the facility on [DATE] with diagnoses to include . (1). Alcohol Abuse, (2). Anxiety Disorder and (3). Vascular Dementia. The most recent comprehensive Minimum Data Set (MDS) was a 5 Day with an Assessment Reference Date (ARD) of 5/28/18. The Brief Interview for Mental Status (BIMS) for Resident #125 was coded as a zero indicating the resident is rarely/never understood. Resident #125 was also coded as having short and long term memory recall and cognitive skills for daily decision making was moderately impaired. Under Section N Medications, N0410 Medications Received Resident #125 was coded as receiving an Antipsychotic for 6 days. The following physician orders for Resident #125 were reviewed and are documented in part, as follows: Quetiapine 50 mg Tablet Oral One Time Daily Order Date: 5/21/2018 Discontinued: 5/21/2018 Quetiapine 50 mg Tablet Oral One Time Daily Order Date: 5/29/2018 Discontinued: 6/7/2018 Quetiapine 50 mg Tablet Oral One Time Daily Order Date: 6/7/2018 Discontinued: 6/12/2018 Quetiapine 25 mg Tablet Oral One Time Daily Order Date: 6/18/2018 Discontinued: 6/22/2018 Quetiapine 25 mg Tablet Oral One Time Daily Order Date: 6/22/2018 Discontinued: 6/22/2018 Resident #125's Medication Administration Records for May and June of 2018 were reviewed and the above orders for Quetiapine were noted and given as ordered. On 6/26/18 Resident #125's Comprehensive Care Plans dated 4/27/18 -5/8/18 and 5/8/18-Present were reviewed. The use of Quetiapine (an antipsychotic) initially ordered on 5/21/18 and still active was not identified on either Care Plan for Resident #125. On 6/27/10 at 10:06 A.M. an interview was conducted with the Director Of Nursing regarding Resident #125's Care Plan not being revised for the medication Quetiapine initially ordered 5/21/18 and still active for the resident and what she would have expected to occur. The Director of Nursing stated, In the morning we print all new orders and in the morning meeting all new orders are discussed. The Clinical Managers then go back and review the new orders and then the MDS nurses update the Care Plan. I would have expected for MDS to have updated the Care Plan and initiate the behavior monitoring sheets the same day the orders were reviewed in morning meeting. The facility policy Comprehensive Care Plan Revision Date: 1/22/2018 was reviewed and documented in part, as follows: Purpose: Establishment, periodic review of current patient-centered plan of care for each resident to assure a systemic, comprehensive approach to assessing, planning, and periodic review in meeting the resident's needs. IDT (Inter-disciplinary) Responsibilities (Activities, Nursing, Dietary, Therapy, MDS, and Social Services): 2. Care plans will be reviewed and updated as needed to reflect changes. A revised Comprehensive Care Plan for Resident #125 was presented to this surveyor on 6/27/18 upon arrival to the facility. The Comprehensive Care Plan dated 5/8/18-Present was reviewed and is documented in part, as follows: Problems: (Name) Resident #125 receives an Antipsychotic medication (started 5/21/18) STATUS: Active (Current) EFFECTIVE: 6/26/2018-Present Goal: Minimize/avoid harmful side effects during the next 90 days. STATUS: Active (Current) GOAL DATE: 9/26/2018 EFFECTIVE: 6/26/2018-Present Interventions: Administer medications as ordered. STATUS: Active (Current) EFFECTIVE: 6/26/2018-Present Monitor for side effects (insomnia, agitation, nervousness, dizziness, rash, tardive dyskinesia, leg pain, upper respiratory infection, metabolic syndrome, weight gain, increased blood sugar, high cholesterol) STATUS: Active (Current) EFFECTIVE: 6/26/2018-Present Review by registered Pharmacist STATUS: Active (Current) EFFECTIVE: 6/26/2018-Present On 6/27/18 at 2:45 P.M. the above information was shared with the Administrator and prior to exit no further information was provided. (1). Alcohol Abuse: a dependency of alcohol. (2). Anxiety Disorder: a disorder in which anxiety is the most prominent feature. The symptoms range from mild, chronic tenseness, with feelings of timidity, fatigue, apprehension, and indecisiveness, to more intense states of restlessness and irritability that may lead to aggressive acts, persistent helplessness, or withdrawal. (3). Vascular Dementia: a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. 5. Resident #72 was admitted to the facility on [DATE]. Diagnoses for Resident #72 included but were not limited to; Traumatic Brain Injury and quadriplegia. Resident #72's most recent Minimum Data Set (an assessment protocol) was a quarterly assessment, with an Assessment Reference Date of 5-3-18. The MDS coded Resident #72 as alert, oriented to person, place, time and situation, with no cognitive impairment. The Minimum Data Set further coded Resident #72 as being totally dependent, on 1-2 staff members for all Activities of Daily Living care. The Resident was coded as at risk for skin breakdown, and having currently, 2 acquired wounds, while in the facility. They were; (1) unstageable deep tissue injury on the right buttock, and (2) a stage 3 wound on the lower right leg shin. On initial tour of the facility on 6-19-18 at approximately 11:30 a.m. Resident #72 was interviewed and observed. The Resident was laying in a Clinitron Bed which is a specialty skin pressure removal bed used for individuals with skin breakdown from pressure. The bed is constantly filled with blowing air which moves tiny soft beads inside the mattress creating a floating sensation for the user, and no steady pressure point on the body of a user. The Resident's feet were uncovered and were noted to be propped on a pillow. The mattress was covered with 2 sheets, and had a border around it which resembled the bumper rail around a billiards or pool table, which set up above the mattress approximately 4-6 inches. With the Resident's calves elevated on the pillow, it allowed the Resident's heels to lie directly on the bumper which was harder than the mattress, and forced the soles of the Resident's feet against the hard plastic foot board of the bed. [NAME] yellow and tan spots of creamy drainage were noted on the bumper of the mattress in the foot area. On the floor, against the wall at the foot of the bed was a pile of 2-3 foam wedges, and 2-3 pillows, which the Resident stated were to position him with while he was in bed. These positioning devices were also stained with the same color drainage observed to be on the bumper at the foot of the bed. The Resident was asked if he was comfortable with his feet pushed against the foot board, and he responded that he slid down in the bed often, and had to wait for nurses to pull him up. He stated he loved the bed, however, needed to be pulled up to get his feet right every couple hours. A review of Resident #72's clinical record was conducted during the survey. The review revealed documents titled Skin. The Director of Nursing (DON) provided these records and stated these are the May and June 2018 weekly skin checks, these are all we have. The documents revealed skin assessments completed by nursing staff on May 1, 7, 14, 21, 28, and 6-18-18. No skin checks were completed from 5-28-18 through 6-18-18. The documents revealed the following; 5-1-18 - 2 different wounds right lower leg, no open lesions on the foot. No preventative, or protective foot care. 5-7-18 - DTI (deep tissue injury) right buttock, 3 areas right lower leg, no open lesions on the foot. No preventative, or protective foot care. 5-14-18 - DTI (deep tissue injury) right buttock, 3 areas right lower leg, no open lesions on the foot. No preventative, or protective foot care. 5-21-18 - DTI (deep tissue injury) right buttock, 2 areas right lower leg, no open lesions on the foot. No preventative, or protective foot care. 5-28-18 - DTI right buttock, and right lower leg, no open lesions on the foot. No preventative, or protective foot care. 6-18-18 - Blister right elbow, right lower leg wound. No preventative, or protective foot care. Nursing progress notes were reviewed and revealed no wound had been identified on the bottom (sole) or plantar surface of the left foot. A nutrition assessment was ordered on 5-24-18 to be completed by the Registered Dietician. The nutrition assessments were reviewed, and the most recent assessment was completed March 2018. The DON was asked to produce the May nutrition assessment, she stated there was none. The current care plan starting 5-8-18 was reviewed and revealed an intervention which read (Resident name) has a Clinitron Air Mattress, ensure air mattress is inflated and operating appropriately. Goal date 7-31-18. No instruction was given in the care plan as to how the bed should be used, what settings should be maintained, what linens could be used, if any, and if other positioning devices should be used with the bed. No direction was given as to use of the bed. Interventions for Floating of legs and heels remained on the care plan, and had not been removed/revised when the Clinitron bed was installed. No foot wound was documented in the care plan. The treatment nurse and Wound doctor were asked if they had been trained on the use of the bed, and they both stated no, however, they stated that the Hill ROM representative came and set up the bed, and if they had a problem the representative would come out and fix it. They were asked what the representatives response time to their call for help would be, and they stated they were unsure. The treatment nurse, and Administrator were asked for the manufacturers instructions guide for use of the bed. The Administrator delivered a 2 page flyer printed from the Hill ROM computer site on 6-21-18, and stated this is all we have. The flyer did not explain how to use the bed. Research of the Clinitron bed was conducted by the surveyor online, on the Hill ROM eLearning site and revealed that only one bed sheet should be used, not 2, and all other support devices such as pillows under feet defeat the therapeutic results of the bed, as they create pressure points, and barriers between the patient, and the bed, which is designed to relieve pressure by coming into contact with the Resident's skin. The site further stated the air wall (bumper) is firm and not fluidized with beads (would create pressure points). The directions for use were detailed and required added education necessary to learn the manipulation of the bed controls, and therapeutic use of the bed. The device was not self explanatory. On 6-21-18 at 9:45 a.m., a wound care observation was conducted with the South unit nursing manager and the wound doctor (other #5). Resident #72 was laying in bed and the doctor and wound nurse were asked why the Resident had drainage on the air wall of the bed. They lifted the Resident's foot and revealed a new wound measuring 1.5 centimeters x 1.8 centimeters circular wound which was 45% necrotic according to the wound doctor. An interview was conducted at that time, and the wound doctor and the wound nurse both stated that pressure ulcers should not be found at necrotic eschar. The wound was not identified nor prevented prior to eschar formation and thus found at unstageable. The wound was further encouraged to form by pressure on the plantar surface of the foot caused by the inappropriate placing of pillows in the bed under both feet for floating purposes which pushed the feet on top of the bumper/air wall surrounding the mattress, and pressing them onto the foot board of the bed causing pressure. The the SOC Quality Assurance & Performance Improvement (QAPI) facility form for wounds was reviewed and revealed the facility Administration was only aware of the right lower leg stage 2 wound, and the unstageable right buttock wound for Resident #72. The form stated that both wounds were avoidable, and facility acquired. It is notable to mention that the Resident had 3 other wounds, 1) Resident's left ankle, lateral left Achilles tendon, and top of left foot at the ankle juncture which had all begun as blisters. These wounds were not mentioned in the QAPI report, nor on the care plan. The facility administration was informed of the findings during an end of day briefing on 6-21-18 at approximately 4:00 p.m. The facility did not present any further information about the findings up to the time of exit on 6-27-18

Based on a complaint investigation, observations, clinical record review, staff and resident interview, the facility staff failed to ensure 1 of 61 residents (Resident #107) in the survey sample were seen by a physician, nurse practitioner or physician assistant every 60 days with 10 day grace period. Resident #107 was not seen every 60 days with 10 day grace period by the physician, nurse practitioner or physician assistant per mandate. Specifically, there was a 5 month gap between physician visits from 9/14/17 to 2/13/18. The findings include: Resident #107 was admitted to the nursing facility on 2/12/15 with diagnoses that included multiple sclerosis, contractures and neurogenic bladder. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 5/25/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident was cognitively intact for the skills in daily decision making. An interview was conducted with Resident #107 on 6/25/18 at 10:30 a.m. She stated she was not being seen by the pervious attending physician on a routine basis at least every 60 days. She stated she changed physicians in February 2018. Upon review of the clinical record from to change of physician on 2/13/18, it was validated that Resident #107 was not seen by a physician or designee every 60 days: -1/19/17 -4/27/17 -6/29/17 -9/14/17 -2/13/18 (new physician) On 6/28/18 at 3:35 p.m., the aforementioned issues were shared with the Administrator, Director of Operations and Director of Nursing (DON). They stated the delay in conducting all visits by the previous attending physician caused the facility to change to another physician group, but the attending physician that failed to conduct Resident #107's visits still sees other Residents in the facility. They stated there were no audits conducted to evaluate all residents in the facility for delay in visits with possible unmet care and services issues. No further information was provided prior to exit. COMPLAINT DEFICIENCY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #5 a 66 yr. old female was admitted on [DATE] with diagnoses of but not limited to anemia, CAD (coronary artery disease), hypertension (high blood pressure), CVA (stroke), and depression and psychotic disorder. Resident # 5's most recent MDS (Minimum Data Set) was coded as an annual an ARD (assessment reference date) of 6/4/18. She was coded as having a BIMS (Basic Interview of Mental Status) score of 15, indicating no cognitive impairment. She was coded as needing physical assistance of 1 staff member for activities of daily living as well as being always incontinent of bowel and bladder as well as being totally dependent on staff for bathing. She was coded as being at risk for pressure ulcers however she was also coded as having no open areas or pressure ulcers. On 6/20/18 a review of resident clinical record was conducted and it was noted that Resident #5 did not get bathed on 6/15/18 it was noted on the TAR (treatment administration record) that Resident did not get bathed due to Insufficient Staffing. On 6/22/18 at 9:45 AM (licensed practical nurse) LPN #4 was contacted via telephone and an interview was conducted with LPN #4 about her documentation of Insufficient Staffing for reason Resident #5 did not get bathed. LPN #4 stated that she correctly documented the events and the resident had not been bathed because the 3-11 staff was short that day and so when she arrived at work at 11:00 PM Residents still were not touched that is they had not been changed or put to bed yet. LPN #4 stated the 11-7 shift was short by 2 (certified nursing assistants) CNA's and that they all had to immediately start changing Residents and putting them to bed. She further elaborated saying We had only 2 CNA's and an orientee however the orientee cannot take her own assignment because she is just learning so the nurses had to help Even with all of us helping everyone was not in bed until around 2:00AM or 3:00 AM. LPN #4 stated We are supposed to have 4 CNA's we are happy if we have 3 but we should have 4. When there is only 2 it is just too much for anyone to do 20 + residents each. It started getting bad in March around the 17th and its steadily getting worse. People are leaving or being let go Review of staffing sheet and staff punch reports reveal the LPN's statement was accurate they should have had 4 CNA's and only had 2 CNA's working on the 15th of June. On 6/26/18 at 10:30 AM DON (director of nursing) was interviewed about staffing and she presented the punch reports and the staffing schedule and stated that they did have call outs on the evening and night shifts on that date. Administration was made aware and no further information was provided. COMPLIANT DEFICIENCY 3. Resident #118 was originally admitted to the facility 8/10/16. The admission diagnoses included Parkinson's disease, Major Depressive disorder, Unspecified Psychosis, an anxiety disorder, and an Adjustment disorder with mixed Disturbance of emotions and conduct. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/30/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #118's cognitive abilities for daily decision making were intact. In section D (Mood), the resident was coded for feeling downed, depressed and hopeless and in section E (Behaviors), the resident was coded for exhibiting physical and verbal behaviors directed towards others 1-3 days each week. The resident was also coded indicating the behaviors didn't put the resident at risk for illness/injury, not significantly interfering with resident care, activities or social interactions, and the resident was coded to indicate the behaviors didn't put others at significant risk for physical injury or as causing disruption to the living environment. The resident was also coded for rejection of care 1-3 days each week. In section G (Physical functioning), the resident was coded as requiring supervision of 1 person with wheelchair locomotion, limited assistance with transfers, extensive assistance of 1 person with bed mobility, personal hygiene, dressing and toileting and total care with bathing. The clinical record revealed Resident #118 had a physician's order dated 4/3/18, for physical therapy (PT) services; heat therapy to the left posterior shoulder, for muscle pain; limiting range of motion. Resident #118 stated during an interview on 6/20/18, at approximately 10:30 a.m., that she was told by the facility physical therapist they saw no improvement in her and they couldn't help her therefore; the Neurologist recommended she see a community based physical therapist. The resident further stated, during the initial visit approximately 4/26/18, her needs were assessed and the therapist developed a treatment plan and a schedule of future appointments. The appointments were later changed to Tuesdays and Thursdays at 10:00 a.m. A copy of the scheduled appointments were sent to the nursing facility and the Unit Secretary arranged transportation for travel to and from the community based PT office. Resident #118 stated facility staff accompanied her to the initial appointment and no one informed her that was not the plan for future PT appointments. The resident also stated she frequently reminded staff she preferred and required 2 staff during care and 1-2 staff for non activities of daily living. Resident #118 stated the facility staff was aware she has only 3 relatives locally and they are unable to accompany her to appointments because her daughter is visually impaired and requires assistance and her 2 granddaughters have commitments to their jobs and families. She stated on one occasion her sister traveled from South Carolina to accompany her on an appointment. The resident further stated because of her family's obligations and inability to aide her with needed services she elected to remain in the nursing facility. During the 6/20/18 interview at approximately 10:30 a.m., Resident #118 stated, the first official day of therapy was 6/5/18. The resident stated she got ready for the appointment, went to the nurse's station and was told by the Unit secretary and the information was confirmed by the Unit Manager that the Administrator and Director of Nursing stated said she was to go alone to the appointment because she had no cognitive deficits or other limitations preventing her from going unaccompanied. The resident then, stated the Assistant Administrator told her go ahead and try going by yourself. The resident stated, she was reluctant but left the facility without facility staff accompanying her, she arrived to the PT office, the driver assisted her inside, she had therapy, the office staff called the transport company to pick her up and she asked the office staff to sit her outside the office so the transport driver could see her upon arrival. Resident #118 stated she waited approximately 20-30 minutes outside the PT office but; the transport company didn't arrive therefore; she used her cell phone to call the nursing facility and alerted them that the transport company hadn't returned to transport her back to the nursing facility. Resident #118 stated the nursing facility staff told her to calm down because she couldn't understand what she was saying, then the nurse stated (name of resident), the transport company says you have already been picked up. Resident #118 stated she asked the Unit Secretary each Monday and Wednesday after the 6/5/18 event, who would be accompanying me to the community PT office on Tuesday and Thursday; if the Unit Secretary stated no one, she stated she told her to cancel the appointment because she felt unsafe going unaccompanied. An interview was conducted with the Unit Secretary 6/20/18 at approximately 11:15 a.m. The Unit Secretary stated prior to 6/5/18 she accompanied Resident #118 to appointments in the community if family was unable to attend. The Unit Secretary stated she didn't work 6/5/18 and there was no one to accompany the resident to the appointment therefore she was sent alone. The Unit Secretary stated she was told the resident returned to the facility 6/5/18 crying and upset. A nurses's note dated 6/14/18 read; Resident scheduled to go out for therapy today. She refused to go because a staff member is unable to accompany her. She is alert and oriented with a BIMS score of 15. This resident makes all her needs known. She is her own responsible party. (name of resident) is able to self maneuver herself in her wheelchair. Staff offered to get her ready for this appointment but she still refused to go. An interview was conducted with Licensed Practical Nurse (LPN) #5 on 6/22/18 at approximately 1:10 p.m. LPN #5 stated she was aware it was Resident #118's preference for a staff member to accompany her on appointments in the community and she was aware on 6/5/18, Resident #118 returned to the facility upset because the transportation driver didn't pick the resident up until approximately 2 hours after transport was called to return the resident back to the facility. LPN #5 stated she informed the resident that hand to hand transport; (transportation driver takes the resident inside the office and picks the resident up inside the office) was requested on her behalf therefore what occurred on 6/5/18, should not happen again, but the resident stated she would not go again unless she was accompanied because she didn't feel safe. LPN #5 stated she kept the Administrator and Director of Nursing informed of the resident's preference to be accompanied by a staff member and of each episode of refusal to attend appointments when there wasn't a staff member to accompany her. LPN #5 stated the Administrator and Director of Nursing stated each time Resident #118 was alert, oriented, had a BIMS score of 15 and a cell phone therefore; capable of going unaccompanied. On 6/25/18 at approximately 11:30 a.m., the Unit secretary provided the surveyor with the appointment scheduling forms for Resident #118's past community PT appointment; some of the forms had a note written across the top that stated, canceled appointment due to resident's request. The Unit Secretary stated the resident canceled the appointments because staff was not available to accompany her and it was the resident's preference to have an escort. The facility didn't have a policy for determining a resident's needs for community appointments but a document was drafted 6/25/18 explaining their process. The document was titled (Name of Facility) Social worker's Outlined Process for Appointments. It read; at Bullet #3, The Unit securities also discuss the coordination with families and resident's to ensure communication and coordination is agreed upon by both family designee and or resident. Bullet #4 read; If the resident is a Long Term Care resident the Unit Securities will schedule appointments with specialized providers and will set transportation based on transportation needs. Bullet #5 read; as a courtesy, resident is reviewed by nursing for mobility and BIMS to see if a need for additional assistance at appointments. Bullet #6 read; If assistance at appointments is needed, family or caregivers are contacted first and then if needed, staff may attend the appointment with the resident which usually is the unit security or designee. Bullet #7 Social Worker staff also support staff with reaching out to family designee and or resident to discuss barriers with transportation. On 6/28/18 at approximately 3:50 p.m., the above findings were shared with the Administrator, Director of Nursing, Director of Operations, 2 visiting Administrators and the Dietitian. An opportunity was given to the facility staff to provide additional information but; none was presented. Based on observations, clinical record review, staff and resident interview, and facility documentation review, the facility failed to ensure sufficient staff was in place to provide nursing and related services to maintain the highest practicable physical, mental and psychosocial well-being for 4 of 61 residents (Resident #124, #23, #118 and #5) in the survey sample. 1. Resident #124 was not provided timely incontinence care due to insufficient staffing on the 3 pm-11 p.m. shift on 6/25/18. She was left soiled and cold for 2.5 hours before she was able to receive incontinence care. 2. Resident #23 was not provided timely incontinence care due to insufficient staff on the 3 p.m.-11p.m. shift on 6/25/18. She was left up in her wheel chair soiled for 5.5 hours. The next shift (11 p.m.-7 a.m.) placed her in bed and provided incontinence care at 12:20 p.m. 3. The facility staff failed to assure there was sufficient staff to accompany Resident #118 to pre-planned Physical Therapy (PT) appointments on 6/7/18, 6/14/18, 6/19/18 and 6/22/18. 4. For resident # 5 facility failed to provide sufficient staff to provide care. The findings include: 1. Resident #124 was admitted to the nursing facility on 10/20/14 with diagnoses that included high blood pressure, diabetes mellitus, paralytic syndrome and history of falling. Resident #124's most recent Minimum Data Set (MDS) assessment was a quarterly dated 6/1/18 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident was intact in the skills need for daily decision making. The resident was not assessed to have any mood or behavioral problems. Resident #124 was coded totally dependent on two staff for transfers, bed mobility and personal hygiene. She was assessed totally dependent on one staff for toilet use and bathing. The resident was impaired on both sides of lower extremities and one side upper extremity. She required stabilization from staff for all surface to surface transfers. The resident was coded as non-ambulatory and used a wheelchair as her primary mobility device. She was able to fully understand staff and was fully understood. The resident was assessed as frequently incontinent of bladder and had a colostomy. The resident was not coded to resist care to include ADL assistance. The care plan dated 6/12/18 indicated Resident #124 was identified with ADL care needs to be provided by staff and some ADLs with supervision, was at risk for falls and would receive the necessary assistance for bladder incontinence. The goals set for the resident by the staff was that the resident would maintain the highest level of psychosocial well-being, transfer with assist without falls and was dependent on staff with assistance for in and out of bed transfers via mechanical lift. Some of the interventions to implement these goals included anticipate her needs, always use mechanical lift with two staff for all transfers and monitor for incontinence, provide hygiene after voiding with mild soap and water, change pads and briefs as needed, as well as check for areas of redness related to urinary incontinence. On 6/26/18 at 10:10 a.m., Resident #124 stated she sat in urine over 5.5 hours waiting to be cleaned up and put to bed on the evening shift (3-11) 6/25/18. She stated she told the Certified Nursing Assistant (CNA) staff around 7:00 p.m., and was told there was not enough staff to put her to bed and clean her up. She said she was not placed back to bed and provided incontinence care until 12:20 a.m. of the next shift (6/26/18). The resident added, I was so hurt because I wearing a designer dress my son gave me and it was ruined sitting in urine. I took it to the activities department to use their washer because I was afraid of the the industrial machines for general wash. I told them to throw away the Hoyer (brand name for mechanical lift pad) pad in the incinerator because it was saturated with urine. On 6/26/18 at 12:30 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #8 who was the staffing scheduler. She stated the CNA that was scheduled for the 3-11 shift on Unit 1 was supposed to work a double which would have been 7-3 and 3-11, but did not show up for the 7-3 shift and thus she did not show up for the 3-11 shift. The LPN stated that left 2 CNAs instead of the required 3 CNAs to provide care and assistance to bed for 45 patients. The LPN was not able to explain why an earlier initiative was not taken to find coverage when the CNA did not show up for the first scheduled 7-3 shift. She stated the licensed nurses can help, but usually are busy passing medications or performing treatments. On 6/28/18 at 3:35 p.m., the aforementioned issues were shared with the Administrator, Director of Operations and Director of Nursing (DON). No further information was provided prior to exit. The facility's policy titled Staffing-Nursing dated 6/29/17 indicated sufficient nursing staff will be employed on a twenty-four hour basis to ensure that nursing and related services are provided to enable each resident to attain or maintain his/her highest practicable physical, mental and psychosocial well-being, as determined by assessments and individual plans of care. Sufficient staff will be employed to ensure direct care needs are met. 2. Resident #23 was admitted to the nursing facility on 8/21/13 with diagnoses that included diabetes mellitus, high blood pressure and major depressive disorder. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 6/15/18 and coded the resident with a score of 15 out of a possible score of 15 which indicated Resident #23 had intact cognitive skills for daily decision making. The resident was not assessed to refuse care to include ADL assistance. The resident was assessed to require extensive assistance from one staff for dressing and was totally dependent on one staff for toilet use and bathing. The care plan dated 6/20/18 indicated Resident #23 had a left ankle fracture with boot in place, was at risk for falls, and that she required assistance from staff for activities of daily living (ADL) needs to include dressing, personal hygiene, bathing and toileting. The goal set for the resident by the staff was that she would be free from further injuries, she would receive assistance from staff to meet all ADL needs. Some of the interventions the staff would use to accomplish these goals included assist as needed for transfers, monitor for incontinence and change briefs and pads as needed, as well as provide hygiene after voiding and bowel movements to prevent skin breakdown and clean and dry skin if wet or soiled. On 6/26/18 at 10:40 a.m., Resident #23 stated on the 3/11 shift at 9:00 p.m. she was set up to have the routine personal care and the Certified Nursing Assistant (CNA) and told by the CNA that she would return at 9:30 p.m. The resident stated she was in bed and had completed some of her peri-care and as per her routine the CNA would return 30 minutes later to wash her buttocks and apply a new brief and bed pad. She stated she called around 9:30 p.m. when the CNA did not return and again at 10:30 p.m. She said she was re-soiled herself, was cold and had stuffed the clean towel between her legs to absorb the urine. The Call Bell Response log verified the call times as stated by the resident. According to the resident, the CNA returned around 11:15 p.m. and finished the ADL care. The resident stated this was not an isolated event and it happens frequently. She said she reports these occurrences to the Director of Nursing (DON), Unit Manager and or the Administrator. On 6/26/18 at 12:30 p.m., an interview was conducted with Licensed Practical Nurse (LPN) #8 who was the staffing scheduler. She stated the CNA that was scheduled for the 3-11 shift on Unit 1 was supposed to work a double which would have been 7-3 and 3-11, but did not show up for the 7-3 shift and thus she did not show up for the 3-11 shift. The LPN stated that left 2 CNAs instead of the required 3 CNAs to provide care and assistance to bed for 45 patients. The LPN was not able to explain why an earlier initiative was not taken to find coverage when the CNA did not show up for the first scheduled 7-3 shift. She stated the licensed nurses can help, but usually are busy passing medications or performing treatments. On 6/28/18 at 3:35 p.m., the aforementioned issues were shared with the Administrator, Director of Operations and Director of Nursing (DON). No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #5 was admitted on [DATE] with diagnoses of but not limited to anemia, CAD (coronary artery disease), hypertension (high blood pressure, CVA (stroke), depression and psychotic disorder. Resident # 5's most recent MDS (Minimum Data Set) was coded as an annual an ARD (assessment reference date) of 6/4/18. She was coded as having a BIMS (Basic Interview of Mental Status) score of 15, indicating no cognitive impairment. She was coded as needing physical assistance of 1 staff member for activities of daily living as well as being always incontinent of bowel and bladder as well as being totally dependent on staff for bathing. On 6/21/18 a clinical record review was conducted and it was found that for the month of May 2018 the (Medication Administration Record) MAR was missing documentation of administration for 12 doses of routinely scheduled narcotic pain medication. The order read Oxycodone (a narcotic pain medication) 5 (mg) Milligram tablets - Give 1 tablet 3 times per day. The following dates and times the medication was not administered according to the MAR. 5/6/18 at 6:00 AM 5/6/18 at 2:00 PM 5/6/20 at 9:00 PM 5/7/18 at 6:00 AM 5/7/18 at 2:00 PM 5/7/18 at 9:00 PM 5/8/18 at 6:00 AM 5/8/18 at 2:00 PM 5/8/18 at 9:00 PM 5/9/18 at 6:00 AM 5/9/18 at 2:00 PM 5/9/18 at 9:00 PM The following notes were added the the last page of the MAR each time a dose was missed. Note to [DATE]/6/18 at 6:00 AM- Not administered-NIS [not in stock] Note to [DATE]/6/18/at 2:00 PM - Not Administered not available needs new script Note to [DATE]/6/18 at 9:00 PM - Not administered not available MD made aware Note to [DATE]/7/18 at 6:00 AM - Not available MD made aware Note to [DATE]/7/18 at 2:00 PM - Not administered awaiting hard script Note to [DATE]/7/18 at 9:00 PM - Not administered Note to [DATE]/8/18 at 6:00 AM - L/M [left message] with MD that resident needs hard script -not administered Note to [DATE]/8/18 at 2:00 PM - Not administered awaiting pharmacy delivery. Note to [DATE]/8/18 at 9:00 PM - NIS [not in stock] - awaiting hard script from MD Note to [DATE]/9/18 at 6:00 AM - Not available awaiting hard script from MD Note to [DATE]/9/18 at 2:00 PM - Not administered awaiting pharmacy delivery Note to [DATE]/9/18 at 9:00 PM - Medication not avail not administered. On 6/26/18 and interview with the DON (director of nursing) who stated During the time the medication was not given the doctor had been contacted by the staff and had not yet sent over the hard script [paper prescription] which is why she missed the medication. She further stated it is the expectation of the nurses that they utilize the stat box to pull meds from if the patient does not have them in their drawer. She also stated the nurses should have continued to call the physician for the prescription. She went on to say if there is no more of a particular drug in the stat box they could use the stat box on another units and fax the pharmacy to refill the stat box. Administration was notified on 6/26/18 at 2:45 PM and no further information was provided. Based on Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to ensure medications were available for administration for two Residents (Resident #72, & #5) of the 61 residents in the survey sample. 1. For Resident #72 the facility staff failed to administer Magnesium Citrate as requested and ordered on 6-14-18. 2. The facility failed to provide Resident #5, with twelve consecutive doses of a scheduled narcotic pain medication. The findings included; 1. Resident #72 was admitted to the facility on [DATE]. Diagnoses for Resident #72 included but were not limited to; Traumatic Brain Injury, constipation, and quadriplegia. Resident #72's most recent Minimum Data Set (an assessment protocol) was a quarterly assessment, with an Assessment Reference Date of 5-3-18. The MDS coded Resident #72 as alert, oriented to person, place, time and situation, with no cognitive impairment. The Minimum Data Set further coded Resident #72 as being totally dependent, on 1-2 staff members for all Activities of Daily Living care. On initial tour of the facility on 6-19-18 at approximately 11:30 a.m. Resident #72 was interviewed and observed. The Resident was laying on a Clinitron Bed which is a specialty skin pressure removal bed used for individuals with skin breakdown from pressure. The Resident was asked if he had eaten his lunch, and he stated he had an upset stomach, and had no appetite. He was asked if this happened often, and he stated no, but for the last week he had not felt well because of constipation. He was asked if he was given medication for that problem, and he stated that staff had a hard time getting it for him, and he had to suffer and wait days sometimes to get the medicine. A review of Resident #72's clinical record was conducted during the survey. The review revealed current physician orders for Magnesium Citrate oral solution one bottle one time daily starting 6-14-18. The Medication Administration Record (MAR) was reviewed and revealed a medication note documented by a nurse stating medication is unavailable, not administered, will be delivered 6-15-18. Nursing progress notes were reviewed and revealed the medication was given 6-15-18. The current care plan starting 5-8-18 was reviewed and revealed no care plan for constipation. The facility administration was informed of the findings during an end of day briefing on 6-21-18 at approximately 4:00 p.m. The facility did not present any further information about the findings up to the time of exit on 6-28-18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, family interview, staff interview, and clinical record review the facility staff failed to ensure 1 Resident (Resident #5) in a survey sample of 61 to be free of significant med error. For Resident # 5 facility staff failed to follow physicians order to administer Oxycodone 5 mg. (narcotic pain medication) as scheduled. The finding included: Resident #5 a 66 yr. old female was admitted on [DATE] with diagnoses of but not limited to anemia, CAD (coronary artery disease), hypertension (high blood pressure, CVA (stroke), depression and psychotic disorder. Resident # 5's most recent MDS (Minimum Data Set) dated 6/4/18 was coded as quarterly. She was coded as having a BIMS (Basic Interview of Mental Status) score of 15, indicating no cognitive impairment. She was coded as needing physical assistance of 1 staff member for activities of daily living. She was coded as being at risk for pressure ulcers however she was also coded as having no open areas or pressure ulcers. She is also coded as being incontinent of bowel and bladder On 6/21/18 a clinical record review was conducted and it was found that for the month of May 2018 the Medication Administration Record (MAR) was missing documentation of administration for 12 doses of routinely scheduled narcotic pain medication. The order read Oxycodone (a narcotic pain medication) 5 (mg) Milligram tablets - Give 1 tablet 3 times per day. The following dates and times the medication was not administered according to the (medication administration record) MAR. 5/6/18 at 6:00 AM 5/6/18 at 2:00 PM 5/6/20 at 9:00 PM 5/7/18 at 6:00 AM 5/7/18 at 2:00 PM 5/7/18 at 9:00 PM 5/8/18 at 6:00 AM 5/8/18 at 2:00 PM 5/8/18 at 9:00 PM 5/9/18 at 6:00 AM 5/9/18 at 2:00 PM 5/9/18 at 9:00 PM The following notes were added the the last page of the MAR each time a dose was missed. Note to [DATE]/6/18 at 6:00 AM- Not administered-NIS [not in stock] Note to [DATE]/6/18/at 2:00 PM - Not Administered not available needs new script Note to [DATE]/6/18 at 9:00 PM - Not administered not available MD made aware Note to [DATE]/7/18 at 6:00 AM - Not available MD made aware Note to [DATE]/7/18 at 2:00 PM - Not administered awaiting hard script Note to [DATE]/7/18 at 9:00 PM - Not administered Note to [DATE]/8/18 at 6:00 AM - L/M [left message] with MD that resident needs hard script -not administered Note to [DATE]/8/18 at 2:00 PM - Not administered awaiting pharmacy delivery. Note to [DATE]/8/18 at 9:00 PM - NIS [not in stock] - awaiting hard script from MD Note to [DATE]/9/18 at 6:00 AM - Not available awaiting hard script from MD Note to [DATE]/9/18 at 2:00 PM - Not administered awaiting pharmacy delivery Note to [DATE]/9/18 at 9:00 PM - Medication not avail not administered. On 6/26/18 and interview with the DON (director of nursing) who stated During the time the medication was not given the doctor had been contacted by the staff and had not yet sent over the hard script [paper prescription] which is why she missed the medication. She further stated it is the expectation of the nurses that they utilize the stat box to pull meds from if the patient does not have them in their drawer. She also stated the nurses should have continued to call the physician for the prescription. She went on to say if there is no more of a particular drug in the stat box they could use the stat box on another units and fax the pharmacy to refill the stat box. Administration notified on 6/26/18 at 2:45 p.m. and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #26 was admitted to the facility on [DATE]. Diagnoses for Resident #26 included, but not limited to: Diabetes. Resident #26's admission Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 6418, coded Resident #26 with a score of 7 out of a possible 15 BIMS (Brief Interview for Mental Status) indicating severe cognitive impairment. Resident #26's 6/14/18 Comprehensive Person Centered Care Plan documented: Focus Area: Potential for hypo/hyperglycemia related to Diabetes Goal: Resident will be without negative outcomes related to hypo/hyperglycemia with goal date of 9/14/18 Interventions: Monitor accuchecks per Medical Doctor order On 6/20/18 at approximately 11:41 AM, an observation was made of RN #1 performing a blood glucose check on Resident #26. RN #1 sanitized the glucometer prior to going into Resident #26's room. RN #1 placed the sanitized glucometer on Resident #26's bed along with the opened bottle of glucometer strips. RN #1 continued to perform Resident's #26's blood glucose test. Upon completion of the test, RN #1 obtained the bottle of glucose strips from the Resident's bed and returned them to the medication cart. RN #1 sanitized the glucometer and left in on top of the medication cart. RN #1 was asked what she thought may be an issue with having the glucometer and glucose testing strips on the Resident's bed. RN #1 stated that it could be an infection control concern and that she should have placed the testing supplies on the Resident's bed side table. The Facility Policy titled, Glucose Monitoring with a revision date of 9/28/17, documented the following: Purpose: Blood for serum glucose levels will be obtained in aseptic manner Cleaning: Clean outside of meter using a disposable bleach wipe or a germicidal disposable wipe (Sani-wipes or (Sani Wipe-Clorox for C-Diff patients). Allow to air dry. Note: Clean and disinfect blood glucose meter after every use with Sani Wipe or (Sani Wipes with Clorox for C-Diff patients.) The Policy titled, Glucose Monitoring did not document any guide for where to place supplies at the bedside Fundamentals of Nursing; Eighth Edition, Page 410, documented the following: Medical Asepsis, or clean technique, includes procedures reducing the number or organisms present and preventing the transfer of organisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. The Administrator was notified of the findings during a meeting on 6/20/18 at approximately 5:45 PM. No further information was provided. Based on staff interview, and facility document review, the facility staff failed to maintain an active facility wide Infection Prevention and Control Program (IPCP) and failed to ensure infection control measures to prevent the potential transmission of infection while performing a blood glucose test on 1 resident of 61 residents in the survey sample (Resident #26) The finding's included; 1. On 6-25-18 at approximately 5:00 p.m., During the end of day debriefing, the Administrator was asked who surveyors should speak with, the next morning in regard to the facility infection control program. The Administrator stated the Director of Nursing (DON) who was no longer employed at the facility had previously been in charge of it, however, since she was no longer there, the new interim DON would be responsible. On 6-26-18 at 10:00 a.m., the Registered Nurse (RN-2) south unit manager and the Corporate Infection Preventionist (Other 3) RN came into the conference room and stated they would be in charge of infection control, not the DON. RN-2 and Other 3 were interviewed in the conference room by surveyors. RN-2 stated she was working in the new roles of south unit nursing manager, facility wound nurse, med and treatment nurse, and now infection control nurse coordinator. The Corporate Infection Preventionist RN was asked for the RN-2's infection control education record, and she stated it had not been completed at this time. RN-2 stated she was hired at the facility in January 2018 (6 months prior to survey) and had never been responsible for an infection control program and she was in training now for it, but had not completed the online training as yet. RN-2 stated the previous Director of Nursing left in May 2016. RN-2 stated she assumed the role. RN-2 was asked what the objectives of the facility infection control program were, and how records were maintained for incidents of infection and what analysis occurs as a result. She was also asked to provide the following items; 1. Corrective actions related to infections, tracking information about their antibiotic stewardship program. 2. The facility process for communicating with acute care institutions when transfers (to and from) occurred, involving, multi-drug resistant organisms ( MDRO's), Labs, diagnoses, discharge summaries, organism colonization, and health care associated infections (HAI's). 3. Protocols for making adjustments to antibiotic therapy. 4. Identify and produce infection assessment tools or management algorithms used for infections. 5. Notes from the QAPI committee on data review, and follow up planning. On 6-26-18 during the interview, the Corporate Infection Control Preventionist and RN-2 stated they did not have those documents, RN A was unable to explain the processes verbally as her training was not yet completed, and they stated they would be unable to produce the documents requested. The Administrator was made aware of the findings. During the end of day debriefing on 6-28-18 at approximately 4:00 PM, the Administrator and Director of Nursing were again informed of the findings. No further information was provided.

Based on staff interview, and facility document review, the facility staff failed to maintain an active antibiotic stewardship program. The finding's include; On 6-25-18 at approximately 5:00 p.m., During the end of day debriefing, the Administrator was asked who surveyors should speak with, the next morning in regard to the facility infection control program. The Administrator stated the Director of Nursing (DON) who was no longer employed at the facility had previously been in charge of it, however, since she was no longer there, the new interim DON would be responsible. On 6-26-18 at 10:00 a.m., the Registered Nurse (RN-2) south unit manager and the Corporate Infection Preventionist (Other 3) RN came into the conference room and stated they would be in charge of infection control, not the DON. RN-2 and Other 3 were interviewed in the conference room by surveyors. RN-2 stated she was working in the new roles of south unit nursing manager, facility wound nurse, med and treatment nurse, and now infection control nurse coordinator. The Corporate Infection Preventionist RN was asked for the RN-2's infection control education record, and she stated it had not been completed at this time. RN-2 stated she was hired at the facility in January 2018 (6 months prior to survey) and had never been responsible for an infection control program and she was in training now for it, but had not completed the online training as yet. RN-2 stated the previous Director of Nursing left in May 2016. RN-2 stated she assumed the role. RN-2 was asked what the objectives of the facility infection control program were, and how records were maintained for incidents of infection and what analysis occurs as a result. She was also asked to provide the following items; 1. Corrective actions related to infections, tracking information about their antibiotic stewardship program. 2. The facility process for communicating with acute care institutions when transfers (to and from) occurred, involving, multi-drug resistant organisms ( MDRO's), Labs, diagnoses, discharge summaries, organism colonization, and health care associated infections (HAI's). 3. Protocols for making adjustments to antibiotic therapy. 4. Identify and produce infection assessment tools or management algorithms used for infections. 5. Notes from the QAPI committee on data review, and follow up planning. On 6-26-18 during the interview, the Corporate Infection Control Preventionist and RN-2 stated they did not have those documents, RN A was unable to explain the processes verbally as her training was not yet completed, and they stated they would be unable to produce the documents requested. The Administrator was made aware of the findings. During the end of day debriefing on 6-28-18 at approximately 4:00 PM, the Administrator and Director of Nursing were again informed of the findings. No further information was provided.