Based on staff interview and facility documentation review, the facility staff failed to develop COVID-19 vaccination policies for staff that include all of the required components, failed to track the immunization status of all facility employees, and failed to ensure 100% of facility staff were vaccinated, the facility vaccination rate was 98.1%. 1. The facility failed to develop COVID-19 policies that included the implementation of additional precautions to mitigate the transmission of COVID-19, for staff who are not fully vaccinated for COVID-19. 2. The facility failed to include 3 staff members of the vaccination tracking and were unaware of their vaccination status. 3. The facility staff failed to ensure 1 staff member had an appropriate request for a medical exemption. 4. The facility staff vaccination rate for COVID-19 was 98.1%. The findings included: 1. The facility failed to develop COVID-19 policies that included the implementation of additional precautions to mitigate the transmission of COVID-19, for staff who are not fully vaccinated for COVID-19. On 3/15/22, the facility administrator submitted a facility policy titled, COVID-19 Immunization of Employees with an effective date of 12/10/20. This policy was reviewed and it read, [Facility name redacted] or its affiliate will offer the COVID-19 immunization, to each employee, each employee receives education regarding the benefits and potential side effects of the immunization. The administration of COVID-19 vaccine is offered to each employee, unless the immunization is medically contraindicated for the employee during this time. The employee has the opportunity to refuse immunization. The facility administrator was asked to double check and ensure they didn't have a more current policy or any revisions. On 3/16/22, the facility staff provided the survey team with the staff vaccination matrix. Review of this document revealed that 11 facility employees had approved exemptions on file for COVID-19 immunization. On 3/16/22, the facility Administrator submitted additional documents that were titled, COVID-19 testing guidance, COVID-19 Screening and Testing Program, and Summary of Recommendations for management of COVID-19 during Omicron Surge. These documents were reviewed. On 3/16/22 at 3:08 PM, a group interview was conducted with the facility Director of Nursing (DON), the Infection Preventionist (Employee D) and RN B, the employee health nurse. RN B confirmed that the facility has 11 employees who have been granted exemptions from COVID-19 immunization. When asked how these employees are handled versus those employees that are fully vaccinated, RN B and Employee D confirmed there are no additional steps taken other than encourage vaccination and they are subjected to routine testing. On 3/17/22 at 9:32 AM, an interview was conducted with Employee J, the human resources representative. Employee J stated that employees who are not vaccinated are subject to testing and have to request an exemption. When asked if she had a policy that stated how to handle these items she said she would check. On 3/17/22 at 10:11 AM, an interview was conducted with Employee K, who has an approved exemption for COVID-19 immunization on file. Employee K was asked what precautions are taken since she isn't vaccinated. Employee K said, I am tested twice a week. Employee K added that, All staff have to wear masks and I know I have to be tested twice a week but other than that nothing. Employee K added that she chooses to wear an N-95 masks and double masks per her personal choice but has not been told of any additional precautions or been told she had to wear an N-95 since she isn't vaccinated. A review of the facility policies related to infection control and COVID-19 was reviewed. These policies included but were not limited to: Infection Prevention and Control Program, COVID-19 Vaccine, COVID-19 Immunization of Employees, COVID-19 Testing Guidance, and COVID-19 screening and testing program. None of the policies addressed: 1. Staff having had at least one dose of a COVID-19 vaccine before being permitted to provide any care, treatment, or other services for the facility. 2. A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19. 3. Contingency plans for staff who are not fully vaccinated for COVID-19. On 3/17/22 at 12:32 AM, Surveyor C received the following information from the facility Administrator. It read, I am following up on a conversation that you had earlier with our Human Resource Director, [name redacted]. All staff, whether COVID-19 vaccinated or unvaccinated are required to wear a surgical mask at [facility name redacted] and are required to follow the same guidelines for hygiene and infection control prevention. COVID-19 unvaccinated staff are required to get tested twice a week at [facility name redacted], as well as report exposure, symptoms, etc. in accordance with CDC recommendations. The facility administrator was made aware of the findings during an end of day meeting held on 3/17/22. No further information was provided. 2. The facility failed to include 3 staff members of the vaccination tracking and were unaware of their vaccination status. On 3/16/22, the facility staff submitted a total of three versions of the staff vaccination matrix. The third submission was confirmed to be final and complete. This matrix was compared to the as worked schedule submitted to the survey team. A total of 11 staff were noted on the as worked schedule and not on the staff vaccination matrix. On 3/16/22 an interview was conducted with RN B, the Employee Health nurse who confirmed she manages the vaccination status of employees. RN B was given all 11 employees names and stated that 10 had resigned or been terminated. She identified one who had been out of work for some time due to chronic medical issues. Time cards for the 11 employees was then requested. Review of the time cards revealed, that Other employee C had worked 3 hours the week of survey and 8 hours the week prior. Other Employee B had worked 3/8/22, 3/9/22, 3/10/22, and 3/16/22. CNA D was noted as having last worked 3/8/22, but was listed as an active employee. The other 8 employees were noted as being no longer employed by the facility. The three staff that were employed during the time of survey who were not on the staff vaccination matrix were added into the total number of employees for calculation of the employee vaccination rate. The facility Administrator and RN B were made aware that they employee vaccination matrix failed to include all staff's vaccination status that are currently working at the facility. No further information was provided. 3. The facility staff failed to ensure 1 staff member had an appropriate request for a medical exemption. On 3/16/22, the facility staff submitted a staff vaccination matrix. From this matrix a sample of 8 employees was selected, which included contracted staff. Employee G was noted as the only person having received a medical exemption for COVID-19 immunization. Employee G's documentation with regards to the exemption was requested and received. Review of Employee G's form titled, Request for Medical Accommodation in connection with COVID-19 Vaccine was conducted. This form read, Provide a brief description of your medical condition/disability and requested accommodation and the employee had written asthma. The form had a question that read, Is the condition/disability temporary or permanent? and Employee G had failed to answer this question. The bottom of the form revealed that human resources had signed off on this and noted approved and dated the form 1/27/22. On 3/17/22 at 11:25 AM, Employee J, the human resources director was interviewed. Employee J was asked if she had any supporting documentation from Employee G's medical provider regarding the request for medical exemption. Employee J said, We do not. Employee J confirmed that she was not the person that approved the exemption request and typically more information would be needed in this case. On 3/17/22, during an end of day meeting, the facility Administrator was made aware of the findings with regards to Employee G. The facility Administrator confirmed that Employee G's request for exemption was inadequate as submitted and should not have been approved as submitted. Therefore, Employee G is considered unvaccinated without an exemption. No further information was submitted. 4. The facility staff vaccination rate for COVID-19 was 98.1%. On 3/16/22, the facility staff submitted a total of three versions of the staff vaccination matrix. The third submission was confirmed to be final and complete. This matrix revealed a total of 210 employees, 11 with exemptions and 199 that were vaccinated. The staff vaccination matrix was compared to the as worked schedule submitted to the survey team. A total of 11 staff were noted on the as worked schedule and not on the staff vaccination matrix. On 3/16/22 an interview was conducted with RN B, the Employee Health nurse who confirmed she manages the vaccination status of employees. RN B was given all 11 employees names and stated that 10 had resigned or been terminated. She identified one who had been out of work for some time due to chronic medical issues. Time cards for the 11 employees was then requested. Review of the time cards revealed, that Other employee C had worked 3 hours the week of survey and 8 hours the week prior. Other Employee B had worked 3/8/22, 3/9/22, 3/10/22, and 3/16/22. CNA D was noted as having last worked 3/8/22, but was listed as an active employee. The other 8 employees were noted as being no longer employed by the facility. The three staff that were employed during the time of survey who were not on the staff vaccination matrix were added into the total number of employees for calculation of the employee vaccination rate. Review of the 8 sampled employee's vaccination records was reviewed. This review revealed, Employee G was noted as the only person having received a medical exemption for COVID-19 immunization. Employee G's documentation with regards to the exemption was requested and received. Review of Employee G's form titled, Request for Medical Accommodation in connection with COVID-19 Vaccine was conducted. This form read, Provide a brief description of your medical condition/disability and requested accommodation and the employee had written asthma. The form had a question that read, Is the condition/disability temporary or permanent? and Employee G had failed to answer this question. The bottom of the form revealed that human resources had signed off on this and noted approved and dated the form 1/27/22. On 3/17/22 at 11:25 AM, Employee J, the human resources director was interviewed. Employee J was asked if she had any supporting documentation from Employee G's medical provider regarding the request for medical exemption. Employee J said, We do not. Employee J confirmed that she was not the person that approved the exemption request and typically more information would be needed in this case. On 3/17/22, during an end of day meeting, the facility Administrator was made aware of the findings with regards to Employee G. The facility Administrator confirmed that Employee G's request for exemption was inadequate as submitted and should not have been approved as submitted. Therefore, Employee G is considered unvaccinated without an exemption. This brought the facility total to: 213 total employees, 10 with approved exemptions, 199 vaccinated; for a vaccination rate of 98.1%, which is deficient. Review of the facility line listing revealed no Resident COVID-19 cases within the past four weeks. On 3/17/22, during an end of day meeting the facility Administrator was made aware of the findings. No further information was provided.

Based on staff interview, facility documentation review and clinical record review, the facility staff failed to offer and provide the flu and /or pneumonia vaccines to 3 Residents (Resident #1, #27, #247) in a survey sample of 5 Resident's reviewed for flu and pneumonia immunizations. The findings included: On 3/15/22, the facility staff were asked to provide any and all evidence regarding flu and pneumonia immunizations for the survey sample of 5 Residents selected for review of immunizations. On 3/16/22, the requested information was reviewed and revealed the following: 1. Resident #1 had no information submitted to indicate that the Resident had received the flu or pneumonia vaccine or had a history of receiving it previously. 2. For Resident #27, the facility submitted a progress note from a medical provider/nurse practitioner that was dated 3/22/21, and read, Legal guardian gave permission for flu immunization. No further information was provided. 3. For Resident #247, the facility submitted no information regarding flu and pneumonia immunizations. On the COVID immunization evidence there was a post-it note that read, No consent on file yet. On 3/16/22 at 3:08 PM, a group interview was conducted with Employee B, the Director of Nursing, Employee D, the Infection Preventionist and RN B, the employee health nurse. During this interview, the Infection Preventionist was informed of the above findings. Employee D stated, we ask for immunization history of Residents on admission and if nothing is on file we get consent and then ask the doctor for an order to vaccinate. Employee D responded, for Resident #1, It was no information available, there was nothing in [the] chart. For Resident #27, Employee D said, is another Resident that recently came back from the hospital. With regards to Resident #247, Employee D said, is a new admit that came in February and we don't have consent on file yet. During an end of day meeting held on 3/16/22 at 4:10 PM, the facility Administrator was made aware of the missing documentation with regards to flu and pneumonia immunizations as noted above. On 3/16/22 at 6:04 PM, additional records were submitted to the Survey team. This included, an excel spreadsheet that indicated the following: 1. Resident #1 had consent(s) on file in the chart. The flu vaccine was last given 10/15/2020. There was no documentation on record for pneumonia immunization for this Resident. 2. Resident #27 had consent(s) on file in the chart for immunizations but no documentation was on file with regards to being previously immunized or offered the flu and pneumonia vaccines. 3. Resident #247, had consent on file in the chart as of 3/16/22. There was no documentation of the Resident having previously been vaccinated for flu or pneumonia and no evidence of it being offered prior to the survey. On 3/17/22 at 9:40 AM, an interview was conducted with the Director of Nursing (DON) and Employee C, the Assistant Director of Nursing (ADON). The ADON said, We do flu vaccines annually. We get consent on admission and the pharmacist will order the flu vaccine, the doctor writes an order and then we give it to the Resident. The ADON said consent for immunizations is usually obtained within the first 48 hours of admission. The ADON confirmed that the immunizations provided are documented in the clinical record. The ADON confirmed the process is the same for the pneumonia vaccines with the exception of it is not given annually. On 3/17/22 at 10:11 AM, an interview was conducted with Employee K, the registered pharmacist. Of note, this facility has an on-site pharmacy. Employee K confirmed that they [the pharmacy] maintains a stock on hand of the flu and pneumonia vaccines that are available to be dispensed immediately for administration. Employee K, the pharmacist said, It is important to get immunized because it prevents against disease. We know our patient population is vulnerable and we want to make sure they are protected. On 3/17/22 at approximately 11:00 AM, an interview was conducted with Employee L, the pharmacy director. Employee L confirmed they have flu and pneumonia vaccines in stock and available for dispensing and administration and have had no difficulty maintaining a stock of these on-hand. A review of the facility policy titled, Influenza Vaccination, was conducted. This policy read, .All persons, upon admission to long term care programs, will be assessed for recent and past flu vaccinations. The influenza vaccine is administered to patients annually .The influenza vaccine may be given at the same time as the pneumococcal vaccine. All patients will be routinely vaccinated, except those with medical contraindication(s) to receipt of influenza vaccine, at one time, annually, before the influenza season. Those patients who are admitted during the winter months after completion of the programs vaccination program, will be offered the vaccine at the time of their admission . Review of the facility policy titled, Influenza and Pneumococcal Vaccine was conducted. This policy read, [Facility name redacted] will offer the influenza and pneumonia immunization, to each resident or the resident's representative receives education [sic] regarding the benefits and potential side effects of the immunization. The administration of influenza and pneumococcal polysaccharide vaccines, is offered to each resident between October 1 through March 31 annually, unless the immunization is medically contraindicated during this time period. The facility Administrator was made aware of the findings during an end of day meeting held on 3/17/22. No further information was submitted.

Based on staff interview and facility documentation review, the facility staff failed to conduct COVID-19 testing as required for 105 facility staff who were not up-to-date with COVID-19 vaccinations, out of a total of 205 employees. The findings included: On 3/15/22, the facility staff submitted evidence of tracking the community transmission rates. This revealed: 12/6/21-3/8/22, the community rate of transmission was noted as high. On 3/13/22, the community rate of transmission was noted as low. The facility submitted evidence that for the week of, 3/7/22-3/13/22, only 17 employees were tested for COVID-19. Review of the facility staff vaccination matrix revealed the following data: 210 total employees, 105 who are up to date with COVID immunizations, 94 who are not up to date (have not received boosters), and 11 with granted/approved exemptions. On 3/16/22 at 3:08 PM, a group interview was held with the Director of Nursing (DON), Employee C the Assistant Director of Nursing (ADON) and RN B, the employee health nurse. The ADON said that she and RN B conduct the employee testing for COVID-19. When asked about the testing conducted in March, she said, The first week of March was our last week of outbreak testing, after that we tested unvaccinated staff as CMS [Centers for Medicare and Medicaid Services] says, twice a week based on community transmissibility level. The ADON and RN B confirmed that only the staff who have been granted exemptions from COVID-19 immunizations, are considered not immunized, and are the only staff subject to routine testing. The ADON and RN B confirmed they were not aware of the new guidance issued that requires staff who are not up to date, meaning have received all recommended booster doses, to also be included in the routine testing. Review of the facility policy titled, Widespread Coronavirus 2019 Testing Plan, was conducted. This policy did not address the requirement for routine testing of staff based on community transmissibility rates. An additional document was provided to the survey team, DBHDS Human Resources Guidance titled, DBHDS COVID 19 Testing Guidance for State Facilities (Effective 01/20/2022). Review of this document also revealed it did not address the routine testing of staff based on the level of community transmission of COVID-19. Review of the CMS (Centers for Medicare and Medicaid Services) QSO-20-38-NH memo with a revision date of 3/10/2022, was conducted. This document read, .Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community. Staff, who are up-to-date, do not have to be routinely tested .Facilities should use their community transmission level as the trigger for staff testing frequency .Level of COVID-19 Community Transmission: high (red)= minimum testing frequency of staff who are not up-to-date: twice a week .If the level of community transmission decreases to a lower level of activity, the facility should continue testing staff at the higher frequency level until the level of community transmission has remained at the lower activity level for at least two weeks before reducing testing frequency. On 3/16/22, during an end of day meeting the facility Administrator was made aware that the facility was not following the most recent CMS guidance regarding testing of staff who are not up to date with all doses of COVID-19 vaccines. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to complete a SNF ABN (Skilled Nursing Facility Advance Beneficiary Notice) for 3 Residents (Resident #300, Resident #301, Resident #23) in a survey sample of 21 Residents. 1. For Resident #300, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #300 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. 2. For Resident #301, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #301 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. 3. For resident #23, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #23 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. The findings included: 1. For Resident #300, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #300 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. Resident #300, was admitted to the facility on [DATE], with a readmission date of 3/6/19. Resident #300's diagnoses included but were not limited to: neurogenic bladder, septicemia, cerebral palsy, seizure disorder, manic depression, and psychotic disorder. Resident #300's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/13/19 was coded as an admission Assessment. Resident #300 was coded as his cognitive skills for daily decision making being severely impaired. The resident was also coded as being totally dependent upon two staff members for bed mobility, transfers, dressing, toileting and bathing. The resident was coded as being totally dependent upon one staff person for eating and personal hygiene. Resident #300 was discharged from a Medicare covered Part A stay on 3/22/19, he remained in the facility. Facility record review of Medicare discharge notices on 3/27/19, revealed the facility mailed a NOMNC (notice of medicare non-coverage) and letter dated 3/18/19 to Resident #300's family member stating that his Medicare covered Part A stay would end on 3/22/19. A copy of the certified mail receipt was attached. The Administrator was asked on 3/27/19 if any other documentation was available regarding the Medicare discharge notices. No further information was provided. On 03/27/19 at 04:03 PM during an interview with Employee I, Utilization Review Coordinator, she stated she is the responsible person for sending the notices and when asked about the notices sent, she stated, This is all that I send. We don't have any other form. The facility staff provided Resident #300 with the NOMNC, which provides notice of the right to an appeal and expedited review of service termination. The facility staff failed to provide Resident #300 with the second required notice, a SNF ABN, which allows the resident an option to continue to receive services, be notified of the expected cost, and have Medicare make the coverage determination once a bill is submitted to Medicare. The Administrator and DON, were informed on 3/27/19 at 4:44pm of the failure of staff to provide Resident #300 with a SNF ABN notice prior to skilled care services ending, which would have allowed Resident #300 or his representative, to make a decision about continuation of services and have Medicare make the coverage determination. No further information was provided. 2. For Resident #301, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #301 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. Resident #301 was admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to, hip fracture, dementia, Parkinson's disease, malnutrition, anxiety and depression. Resident #301's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 11/19/18, was coded as a 14 day assessment. Resident #301 was coded as having a BIMS (Brief Interview for Mental Status) score of 11, indicating moderately impaired cognition. The resident was coded as requiring limited assistance of one staff member for activities of daily living except bathing, which the resident required extensive assistance. Resident #301 was discharged from a Medicare covered Part A stay, and from the facility on 11/19/18. Facility record review of Medicare discharge notices on 3/27/19, revealed the facility mailed a NOMNC (notice of medicare non-coverage) and letter dated 11/13/18 to Resident #301's family member stating that her Medicare covered Part A stay would end on 11/19/18. A copy of the certified mail receipt was attached and a signed return receipt card. The Administrator was asked on 3/27/19 if any other documentation was available regarding the Medicare discharge notices. No further information was provided. On 03/27/19 at 04:03 PM during an interview with Employee I, Utilization Review Coordinator, she stated she is the responsible person for sending the notices and when asked about the notices sent, she stated, This is all that I send. We don't have any other form. The facility staff provided Resident #301 with the NOMNC, which provides notice of the right to an appeal and expedited review of service termination. The facility staff failed to provide Resident #301 with the second required notice, a SNF ABN, which allows the resident an option to continue to receive services, be notified of the expected cost, and have Medicare make the coverage determination once a bill is submitted to Medicare. The Administrator and DON, were informed on 3/27/19 at 4:44pm of the failure of staff to provide Resident #301 with a SNF ABN notice prior to skilled care services ending, which would have allowed Resident #301 or her representative, to make a decision about continuation of services and have Medicare make the coverage determination. No further information was provided. 3. For Resident #23, the facility staff failed to provide a SNF ABN notice prior to skilled care services, paid by Medicare, ended. Resident #23 was not afforded the opportunity to continue skilled care services and have Medicare make a determination about coverage of such services. Resident #23, a [AGE] year old female, was admitted to the facility on [DATE]. Her diagnosis included but were not limited to: quadriplegia, seizure disorder, profound intellectual disabilities, cyst of pancreas and GERD (gastro-esophageal reflux disease). Resident #23's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/21/19, was coded as the resident having severe cognitive impairment for daily decision making. The resident was coded as being totally dependent upon two staff persons for bed mobility, transfers, toilet use and bathing. Resident #23 was discharged from a Medicare covered Part A stay on 1/25/19. Facility record review of Medicare discharge notices on 3/27/19, revealed the facility mailed a NOMNC (notice of medicare non-coverage) and letter dated 1/15/19 to Resident #23's family member stating that her Medicare covered Part A stay would end on 1/25/19. A copy of the certified mail being returned to sender as being undeliverable as addressed, was attached. The Administrator was asked on 3/27/19 if any other documentation was available regarding the Medicare discharge notices. No further information was provided. On 03/27/19 at 04:03 PM during an interview with Employee I, Utilization Review Coordinator, she stated she is the responsible person for sending the notices and when asked about the notices sent, she stated, This is all that I send. We don't have any other form. The facility staff provided Resident #23 with the NOMNC, which provides notice of the right to an appeal and expedited review of service termination. The facility staff failed to provide Resident #23 with the second required notice, a SNF ABN, which allows the resident an option to continue to receive services, be notified of the expected cost, and have Medicare make the coverage determination once a bill is submitted to Medicare. The Administrator and DON, were informed on 3/27/19 at 4:44pm of the failure of staff to provide Resident #23 with a SNF ABN notice prior to skilled care services ending, which would have allowed Resident #23 or her representative, to make a decision about continuation of services and have Medicare make the coverage determination. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #45, the facility staff failed to implement their policy and procedure of abuse for a fracture of unknown origin. Resident #45, was admitted to the facility on [DATE]. Diagnoses included but were not limited to: profound intellectual disability, Down's Syndrome with severe congenital hear disease, pulmonic stenosis, polycythemia secondary to chronic hypoxemia, chronic hypothyroidism, osteoporosis, Hepatitis B carrier, and self injurious behavior. Resident #45's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 12/5/18 was coded as a quarterly assessment. Resident #45 was coded as having severe cognitive impairment. The resident was also coded as requiring limited assistance of two staff members for transfers, and being totally dependent on staff for dressing, toileting and bathing. Resident #45 required supervision of one staff member for eating. During clinical record review on 3/27/19 and 3/28/19, of the nursing notes, physician progress notes, nursing assessments and social worker notes there was no indication of an investigation. Nursing notes read on 8/28/19 resident was observed sitting up in w/c (wheel chair) @ (at) nursing station. Observed rubbing hard headphones against left shoulder area. Small purple bruise noted on left shoulder. Nursing notes dated 9/1/18 read, noted to have 2 new parallel areas of bruising to left shoulder and left anterior chest. Fading bruising remains to top of left shoulder and anterior left chest skin intact. Nursing notes dated 9/5/18 read bruise to l (left) shoulder spreading down to L (left) breast. Nursing notes dated 9/6/18 read, bruising of left shoulder, chest, & lower side remains. Seems to be protective guarding of moving left arm. On 9/7/18 x-ray results revealed a non-displaced acute fracture of distal clavicle. On 3/27/19 at 9am, the Administrator was requested to provide investigation information for Resident #45's injury. A blue folder was provided. The folder contained the following 10 documents. 1. Investigator's summary dated 9/12/18 2. FRI (Facility reported incident) report which was submitted to the office of licensure 3. A facility event report dated 8/28/18 4. Interdisciplinary notes dated 8/27/18-9/9/18 5. Physician interdisciplinary notes dated 8/8/18- 9/10/14 6. Physician orders dated 9/5/18-9/10/18 7. X-ray reports dated 9/7/18 8. Fax confirmation of APS (Adult Protective Services) notification of injury 9. A Letter dated 9/13/18 addressed to Resident #45's guardian with a certified mail receipt and signed return receipt card which notified her an investigation was being performed 10. A letter dated 9/14/18 addressed to Resident #45's guardian which read, based on the preponderance of evidence, the case was found to be unsubstantiated for neglect and the case is now closed. The facility Administrator was asked again on 3/27/19 at 4:44pm and the morning of 3/28/19 to provide any additional investigation information regarding Resident #45. On 03/28/19 at 10:59 AM the Administrator said there is nothing else. On 3/28/19 at 1:19pm a telephone call was made to Employee H, the investigator, and she stated I looked through the chart at the documentation related to the issue. When asked if she interviewed any nursing staff, CNA staff, other residents, or radiology personal; she stated, no ma'am. The resident was unable to be protected from further abuse, as the Administrator and the Director of Nursing stated no staff had been interviewed during the investigation of abuse and neglect for Resident #45. Review of the facility Policy and Procedure titled: Patient Abuse, Neglect, & Injuries of Unknown Origin; Prevention & Investigation of with a revision date of 3/4/19 states, the purpose of the policy is To provide guidance to staff concerning the prevention of patient/resident abuse and/or neglect, and to establish uniform procedures for the reporting and investigation of allegations of patient/resident abuse, neglect, or injuries of an unknown origin. The policy reads: All unexplained fractures are reportable as alleged abuse/neglect. (facility name) has zero tolerance for acts of abuse or neglect. Therefore, whenever an allegation of abuse or neglect is made, (Facility name) shall take immediate steps to protect the safety & welfare of patients/residents who may be victims of the alleged abuse or neglect, conduct a thorough investigation and take any action necessary to prevent future occurrences of abuse or neglect. The facility staff failed to implement their abuse policy in regard to investigating allegations of alleged abuse. The facility Administrator and Director of Nursing were made aware of these findings on 3/28/19 at 2:16pm. No additional information was provided. Based on staff interview, clinical record review, and facility documentation the facility staff failed to implement their abuse and neglect policy. 1. For Resident #35 the facility staff failed to implement abuse and neglect policy for an injury of unknown origin. 2. For Resident #45, the facility staff failed to implement their policy and procedure of abuse for a fracture of unknown origin. The findings include: 1. For Resident #35 the facility staff failed to implement abuse and neglect policy for an injury of unknown origin. Note: This deficiency is the result of an investigation conducted in relation to (Facility Related Incident) FRI send to the Office of Licensure and Certification on 11/3/2017. The FRI indicated that Resident #25 had X-Rays that showed a possible fracture of knee as a result of an injury of unknown origin. Resident #35 a [AGE] year old woman was admitted to the facility on [DATE] with diagnoses of but not limited to Schizophrenia, Involuntary Commitment, G-Tube feeding, Impaired mobility, Bilateral hand contractures, Seizure Disorder, Dialysis Dependent, and depression. On 3/26/19 at 2:00 PM requested investigation for FRI that was sent to OLC. Administrator explained that previous employee responsible for investigations was no longer at facility and that she would try to find the investigation. On 3/27/19 a clinical record review was conducted and it was found that Resident #35 had complained of pain and showed signs of pain such as facial grimaces since 10/24/17. Her attending physician ordered X-Rays on November 2, 2017. According to documents provided by the facility Administrator the results were of the X-Rays were received by Radiology Dept. at the facility and date stamped on Nov. 2, 2017, however MD was not notified by Radiology until Nov. 3, 2017 thus creating a delay in notification to the Office of Licensure and Certification and a delay in treatment. A review of the Abuse and neglect policy provided by the facility page 3 Paragraph E states: E. All allegations of abuse/neglect and incidents of unknown origin (IUO) are reported to the Virginia Department of Health (VDH) in accordance with Centers of Medicare and Medicaid Services (CMS) conditions of Participation as follows: 1. Abuse / Neglect allegations will be reported within 2 hours of discovery. 2. Incident of unknown origin resulted in a serious injury to a patient/resident will be reported within two (2) hours of discovery. 3. Incidents of unknown origin resulting in no apparent injury or minor injury will be reported no later than two (2) hours of discovery. 4. A copy of the report that is faxed to VDH will be emailed to CNE Facility Director, Medical Director, Clinical Director and Risk Manager. The program would not be complete without a procedure for investigating allegations of abuse and neglect that do occasionally occur. Specially trained personnel, who while responding to an allegation, report directly to the Office of Investigations Management at DBHDS, investigate these allegations. The facility Director will maintain the products of these investigations. In an interview with the Administrator she stated that the Radiology dept. at the facility failed to notify the doctor of the results on the day it was received [DATE]. She further stated that the facility launched an investigation and notified the VDH as soon as they had the results of the X-Rays. The Administrator and the Medical Director were made aware of the findings on 3/28/19 during the end of day meeting no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #24, the facility staff failed to report investigation results of an injury of unknown origin to the state agency. Resident #24 was found with bruising to her third and fifth fingers on her right hand. Resident #24, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to vascular dementia, impaired mobility, spastic contracture of hands, motor paralysis lower extremities, and seizure disorder. Resident #24's most recent Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 01/21/2019 and was coded as a quarterly assessment. Resident #24 was not coded for a Brief Interview of Mental Status (BIMS). Cognitive skills for daily decision-making were coded as severely impaired. Functional status for bed mobility, transfers, eating (tube feedings), dressing, and personal hygiene were all coded as total dependence on staff. On 10/26/2018 at 11:47 AM, a facility-reported incident (FRI) was transmitted to the state agency in reference to Resident #24 and an injury of unknown origin. Under the section entitled 'Description of Incident', it was documented, Around 0900 on 10-26-18, staff reported patient had discoloration to right 3rd and 5th fingers. Fifth right knuckle slightly swollen and purple in color. No break in skin. Under the section entitled 'Facility Action Taken', it was documented, NP (nurse practitioner) in to assess patient. xray (sic) right hand (3rd-5th fingers) ordered. Ice to right hand 15 minutes every 4 hours x 24 hours. On 03/28/2019 at 10:00 AM, the Administrator stated that Employee H [employed by an outside agency] was the investigator for Resident #24's injury of unknown origin. A copy of the investigation documentation and a copy of facility investigation protocol was requested. On 03/28/2019 at 12:35 PM, the Administrator provided 2 pages of an email conversation between Employee C (clinical director) and Employee H (investigator). An email dated 10/29/18 at 1:52 PM documented, Hi [Employee H]: Ecchymosis - causes breaking of the capillaries. She had taken Vitamin C to help with this but it was discontinued at some point. It's now been ordered again. Here are some samples of how we write it. The one labeled IUO is how I write it. The other is how [name] wrote it. Either way is fine please let me know if you have any questions. Thanks, [Employee C]. An email dated 10/30/18 at 10:28 AM documented, Good morning [Employee C] I am currently working on the report for [Resident #24] and have a couple questions .what is [MD name]'s title? Is he/she active in [Resident #24]'s treatment? How did he/she learn about [Resident #24]'s injury? In other words, I'm trying to figure out how he ended up telling us about the ecchymosis .Any info you can share would be helpful. [Employee H]. An email dated 10/30/18 at 11:05 AM documented, Hi [Employee H], [MD name] is the Medical Director. So she's not on his direct caseload, but he oversees the care of all the pts (patients) and makes recommendations as needed. He's been here for years and is very familiar with her case. Hope that helps, [Employee C]. On 03/28/2019 at 12:45 PM, the Administrator provided all the documentation associated with the investigation which was seven pages. Included in the packet of papers: 1. Facsimile transmittal sheet dated 10/26/18 that was sent to the state agency on the day of incident 2. Facility Reported Incident Form dated 10/26/18 that was sent to state agency on the day of incident 3. A copy of the nurse's note dated 10/26/18 at 12:00 PM 4. A copy of the NP progress note dated 10/26/18 at 10:15 AM 5. A Facility Event Report dated 10/26/18 6. Handwritten notes by Employee H dated 10/26/18. 7. Typewritten report by Employee H dated 10/26/18 The Facility Event Report was a document with many boxes to select as relevant. The event date was 10/26/18. The event time was 9:50 AM. Unexplained was selected for Type of Event. Bedroom was select for Location. Bruise was selected for Type of Injury. Under the section Describe Event, it was documented, Staff reported patient had discoloration to right 3rd and 5th fingers. Fifth right digit knuckle slightly swollen and purple in color. No break in skin. Under the section Treatment/Interventions, it was documented, NP in to assess patient. New order to x-ray right hand/3rd-5th fingers discoloration to right 3-5th fingers. Ice to right hand 15 min every 4 hours x 24 hours. Nurse was notified on 10/26/18 at 9:55 AM. MD/NP notified 10/26/18 at 10:00 AM. Supervisor was notified 10/26/18 at 11:00 AM. The form was signed by the RN (registered nurse) completing the form. The copy of the handwritten notes by Employee H (investigator) was a lined paper that documented: 10/26/18 [Resident #24's last name] IUO [injury of unknown origin] No known injury/accident-nothing documented [name] - Mdirector Pt has ecchymosis - has had long time Vitamin C for symptoms. quit taking new order. On 03/28/2019 at 1:15 PM, a telephone interview with Employee H was conducted. Employee H verified that the notes listed above were her handwritten notes of the investigation. When asked about her investigation process, she stated that Resident #24 was not able to speak so she reviewed Resident #24's chart. When asked if she spoke with any of the staff or interviewed anyone in the course of her investigation, she stated, No. The typewritten report by Employee H was dated 10/26/2018. Under the section Description of Incident it was documented, Incident of Unknown Origin: Resident was found with bruising to her right hand at approximately 0950 hours in the morning of Friday, 10/26/2018. Interdisciplinary notes from 10-26-18 written by [name] RN stated there was discoloration to right 3rd and 5th fingers with 5th right digit knuckle noted to be slightly swollen and purple in color. There was no break in skin, no active bleeding, no wincing or facial grimacing when palpating the fingers. At approximately 1015 hours, FNP (family nurse practitioner) [name] assessed [Resident #24] and an x-ray of her right hand (3rd and 5th fingers) was ordered. An order for ice to the right hand every 15 minutes every 4 hours for 24 hours was also made. Continue to monitor. Under the section Facility Action Taken it was documented, Facility and Clinical Director were notified on Friday 10/26/2018 and an IUO (injury of unknown origin) investigation was initiated. [State and federal agencies] notified. Reviewed interdisciplinary notes and spoke with nursing staff and [MD name], facility medical director. As the medical director, [name] oversees the patients at [facility] and is very familiar with [Resident #24]. He stated the area appeared to be a result of ecchymosis. A condition [Resident #24] has had for quite some time and has taken vitamin C for in the past to aide (sic) with symptoms. A new order for vitamin C has been made. [Resident #24] has no documented symptoms of pain or distress from the injury. After further investigation, there are no new findings in this case. In summary, the state agency received initial facility-report incident documentation on 10/26/2018 pertaining to Resident #24 and her injury of unknown origin. The facility did not report follow-up investigation results pertaining to Resident #24 and her injury of unknown origin. On 03/28/2019 at approximately 3:45 PM, the Administrator and the DON were notified of findings and they offered no further documentation of information. Based on staff interview, clinical record review, and facility documentation review the facility staff failed to submit a 5 day follow up report to the State Agency for two residents (Resident #2 and #24) in a survey sample of 21 residents. 1. For Resident #2, the facility did not report the results of the investigation of an injury of unknown origin to the State Agency. Resident # 2 was found with a large raised area on the right side of her forehead on 9/29/18. 2. For Resident #24, the facility staff failed to report investigation results of an injury of unknown origin to the state agency. Resident #24 was found with bruising to her third and fifth fingers on her right hand. The findings included: 1. For Resident #2, the facility did not report the results of the investigation of an injury of unknown origin to the State Agency. Resident # 2 was found with a large raised area on the right side of her forehead on 9/29/18. Resident # 2, an [AGE] year old female, was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Profound Intellectual Disability, ITP (Idiopathic Thrombocytopenic Purpura)(low levels of blood cells that prevent bleeding), Dysphagia, Reactive Airway Disease, Seizure Disorder and Aspiration Syndrome. The most recent Minimum Data Set assessment was a Quarterly assessment with an assessment reference date (ARD) of 3/12/19. Resident # 2 was coded as having severe cognitive impairment. Resident # 2 was coded as requiring total assistance of one staff person for Activities of Daily Living except she required total assistance of two staff persons for bathing and transfers. Resident # 2 was coded as always incontinent of bowel and bladder. Review of the clinical record was conducted on 3/27/2019. Review of the Interdisciplinary notes (nurses notes) revealed documentation of: 9/29/2018 at 8:00 AM .0540 (5:40 AM) noted up in chair, has large raised area on right side of forehead [sic], no bleeding, sm (small) amt (amount) of bruising center of area, ice pack applied, helped some, swelling decreased some, chg (charge) nurse aware, doctor notified. will see pt (patient) on rounds. 9/29/2018 at 1400 (2:00 PM) Patient was up in wheelchair at start of dayshift. Patient noted with a 7 cm (centimeter) x 7 cm raised intact area of swelling and bruising to right forehead .Pt seen by Dr. _____(Employee G) on morning rounds. No new orders received. Review of the Physicians Interdisciplinary Notes revealed documentation on 9/29/2018 11:02 AM- c/c (complaint/ concern): right forehead bump-wound swelling and bruised. No neurological deficit, well localized bump with intact skin. Diagnosis: bump on right forehead. (May be related to bang herself.) Prescription: (1) close observation (2) incident report (3) called left message on answering machine for family 10/1/2018 at 1400 (2:00 PM) c/c: forehead bruise-fading but spread to right temple/face bump decrease Diagnosis: right forehead bump- still continuous, purposeless, wide Rx (prescription) observation On 3/27/2019 at 9:18 AM, an interview was conducted with doctor (Employee F) who stated she was Resident # 2's doctor and was told of the injury of unknown origin when she returned to work. Employee F stated another doctor (Employee G) was on call that day. Employee F was informed the surveyor would complete the interview with her after interviewing Employee G. On 3/27/2019 at 9:24 AM, an interview was conducted with the doctor (Employee G) who was on call on 9/29/2018 when the injury of unknown origin was discovered. Employee G stated he was informed of the injury and assessed Resident # 2 when he made rounds. Employee G stated he discovered swelling and a bruise. Employee G stated the lump was a good size and appeared to be hit by something probably in the morning hours. Employee G stated the injury was unwitnessed, an ice pack was applied along with close observation. Employee G stated due to Resident # 2's history of low platelets disease (ITP) any banging or any injuries would cause lots of bruising. On 3/27/2019 at 9:29 AM, a subsequent interview was conducted with Resident # 2's primary doctor (Employee F) who stated Resident # 2 had involuntary movements of her head and that it was possible that she hit her head on the side rails. Employee F stated it was more likely possible that Resident # 2 sustained the injury of unknown origin during a transfer with the hoyer lift. Employee F stated the lump and bruise were indicative of a strong impact to the right side of her forehead. Employee F stated the facility staff have now begun to cradle Resident # 2's head during transfers to prevent her from bumping her head. On 3/27/2019 at 10:20 AM, an interview was conducted with the Director of Nursing (DON) who stated she had been informed by the nursing supervisor on the day the injury of unknown origin was discovered. The DON stated the investigation showed the injury probably happened during the transfer with the hoyer lift. The DON stated the nursing staff on all three shifts were educated on transfer training. Six pages of sign in sheets of training on Transfer Training were presented. Review of the Training Signature Record revealed that training was conducted on various dates and shifts and included Certified Nursing Assistant, Licensed Practical Nurses and Registered Nurses. Review of the facility's investigation report revealed no documentation of the summary of the investigation of the injury of unknown origin being reported to the State Agency. There was an email written on 9/29/2018 by the Director of Nursing to the former risk manager informing him of the injury of unknown origin for Resident # 2. The email stated We have a VDH reportable on IUO for ___(Resident # 2) and would like to report it to you. Please follow up with me on Monday. Report put in ____box. Further review of the facility documentation of the investigation revealed a document that the Administrator stated was the final report submitted to her by the former Risk Manager. The document stated: Aide related to RN (Registered Nurse) that they observed an about 8 cm (centimeter) 'bump' on resident's right forehead. Area assessed; skin intact, swelling viable and skin reddish in color Action Taken: ice pack wrapped in washcloth applied. AR(Authorized Representative)/Family, MD (Medical Doctor), Nurse and Supervisor notified; resident seen by Nurse at time of discovery (0600)(6:00 AM) and MD (1000)(10:00 AM) No new orders at the time of notification. Incident reported to VDH/CMS (Virginia Department of Health/Center for Medicare and Medicaid Services) as IUO (Injury of Unknown Origin); FD (Facility Director) and Advocate notified per report. Investigation initiated Sept. 29, 2018 per report. The report also stated: Patient/Resident unable to respond to interview questions due to intellectual disability. Over the course of the investigation, Resident's aides at the time of discover were interviewed. Both were unable to state how injury occurred but speculated that resident's behavior of moving head from side to side may have contributed to injury, possibly during a transfer using the Hoyer lift. The unit Manager and resident's nurse and aide were interviewed on Oct. 2, 2018, both noted a possible cause of injury the resident's uncontrolled head movements, trashing [sic] from side to side. The nurse manager also remarked on the resident's ITP (Idiopathic Thrombocytopenic Purpura), which allows for easy bruising and extreme bleeding . There is no discernible pattern of occurrence of this incident to the resident or others on her unit. There is no evidence to support or abuse or neglect as a cause of the incident. The type and location of the injury is as previously reported. Resident care is properly addressed in her treatment plan. RM (Risk Management) Assessment: The reported facts and circumstances DO NOT meet the definition of suspicious injury. However, based on the review summarized above, this incident remains unresolved as to cause of injury. While injury is suspected to be accidental in nature, related to the resident's uncontrolled head movement, the actual cause of the injury was unwitnessed and remained unexplained. On 3/27/2019 at 10:36 AM, an interview was conducted with the Administrator and Director of Nursing regarding the process regarding any injuries of unknown origin. The Administrator stated the facility investigates all injuries of unknown origin and completes a summary report within five days. The Administrator stated there had been recent changes in Risk Management personnel and there was difficulty finding documentation of the summary of the investigation of Resident # 2's injury of unknown origin being sent to the State Agency. The Director of Nurses stated the facility's expectation was: the nurse would assess the resident for injuries, start neurological checks, notify the medical doctor, and responsible party. The nurse would start the investigation, notify the Director of Nursing, Administrator. The investigation would include interviewing resident if possible, interviewing staff, inspect to make sure the equipment is operating properly, putting appropriate interventions in place, and update care plans. The Administrator and DON stated the facility would report an injury to the State Agency and a summary of the investigation should be reported within 5 days to the State Agency. Review of the facility abuse policy Patient Abuse, Neglect, & Injuries of Unknown Origin: Prevention, Investigation of: Effective date 3/10/2006, Revised Date: 3/4/2019 revealed C. Injuries of Unknown or Unexplained Origin (IUO) are an indicator that patient/resident abuse/neglect has occurred. A patient/resident injury is considered to be a possible IUO if: 1. The injury's cause can not be reasonably determined. 2. When an incident report is received coding the report event as Unexplained, 3. When an incident report is received without a marked event category. Incident of unknown origin resulting in serious injury to a patient/resident must be reported to the Facility Director and Physician immediately, but no later than two (2) hours of discovery. All incident of unknown origin will be reported to VDH/CMS as follows: * Incident of unknown origin resulting in serious injury to a patient/resident will be reported within two (2) hours of discovery *Incidents of unknown origin resulting in no apparent injury or minor injury will be reported no later than two (2) hours of discovery All unknown patient/resident events must be explained if at all possible by: 1 The supervisor initially receiving the report, 2. The Risk Manager during the initial review of the report, 3. The interdisciplinary treatment team after discussion at daily meetings. 4. By Physician or Nurse in the ID notes. All IUOs will be reported to: 1. The Facility Director 2. The Facility Advocate 3. The patent/resident's Authorized Representative (AR) 4. The Virginia Department of Health (VDH) Any investigation that leads to an allegation of patient/resident abuse/neglect must be reported to the Facility Director immediately. Investigation of the IUO must be completed within five (5) business days of the incident. Results must be reported to the Facility Director and the Virginia Department of Health (VDH) within five (5) business days. On 3/28/19 at 2:00 PM, the Administrator and DON were again informed of the findings. The Administrator stated she did not find any documentation of the final summary being submitted to the State Agency of an injury of unknown origin for Resident # 2. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #45, the facility staff failed to conduct an investigation for a fracture of unknown origin. Resident #45, was admitted to the facility on [DATE]. Diagnoses included but were not limited to: profound intellectual disability, Down's Syndrome with severe congenital hear disease, pulmonic stenosis, polycythemia secondary to chronic hypoxemia, chronic hypothyroidism, osteoporosis, Hepatitis B carrier, and self injurious behavior. Resident #45's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 12/5/18 was coded as a quarterly assessment. Resident #45 was coded as having severe cognitive impairment. The resident was also coded as requiring limited assistance of two staff members for transfers, and being totally dependent on staff for dressing, toileting and bathing. Resident #45 required supervision of one staff member for eating. During clinical record review on 3/27/19 and 3/28/19, of the nursing notes, physician progress notes, nursing assessments and social worker notes there was no indication of an investigation. Nursing notes read on 8/28/19 resident was observed sitting up in w/c (wheel chair) @ (at) nursing station. Observed rubbing hard headphones against left shoulder area. Small purple bruise noted on left shoulder. Nursing notes dated 9/1/18 read, noted to have 2 new parallel areas of bruising to left shoulder and left anterior chest. Fading bruising remains to top of left shoulder and anterior left chest skin intact. Nursing notes dated 9/5/18 read bruise to l (left) shoulder spreading down to L (left) breast. Nursing notes dated 9/6/18 read, bruising of left shoulder, chest, & lower side remains. Seems to be protective guarding of moving left arm. On 9/7/18 x-ray results revealed a non-displaced acute fracture of distal clavicle. On 3/27/19 at 9am, the Administrator was requested to provide investigation information for Resident #45's injury. A blue folder was provided. The folder contained the following 10 documents. 1. Investigator's summary dated 9/12/18 2. FRI (Facility reported incident) report which was submitted to the office of licensure 3. A facility event report dated 8/28/18 4. Interdisciplinary notes dated 8/27/18-9/9/18 5. Physician interdisciplinary notes dated 8/8/18- 9/10/14 6. Physician orders dated 9/5/18-9/10/18 7. X-ray reports dated 9/7/18 8. Fax confirmation of APS (Adult Protective Services) notification of injury 9. A Letter dated 9/13/18 addressed to Resident #45's guardian with a certified mail receipt and signed return receipt card which notified her an investigation was being performed 10. A letter dated 9/14/18 addressed to Resident #45's guardian which read, based on the preponderance of evidence, the case was found to be unsubstantiated for neglect and the case is now closed. The facility Administrator was asked again on 3/27/19 at 4:44pm and the morning of 3/28/19 to provide any additional investigation information regarding Resident #45. On 03/28/19 at 10:59 AM the Administrator said there is nothing else. On 3/28/19 at 1:19pm a telephone call was made to Employee H, the investigator, and she stated I looked through the chart at the documentation related to the issue. When asked if she interviewed any nursing staff, CNA staff, other residents, or radiology personal; she stated, no ma'am. The resident was unable to be protected from further abuse, as the Administrator and the Director of Nursing stated no staff had been interviewed during the investigation of abuse and neglect for Resident #45. Review of the facility Policy and Procedure titled: Patient Abuse, Neglect, & Injuries of Unknown Origin; Prevention & Investigation of with a revision date of 3/4/19 states, the purpose of the policy is To provide guidance to staff concerning the prevention of patient/resident abuse and/or neglect, and to establish uniform procedures for the reporting and investigation of allegations of patient/resident abuse, neglect, or injuries of an unknown origin. The policy reads: All unexplained fractures are reportable as alleged abuse/neglect. (facility name) has zero tolerance for acts of abuse or neglect. Therefore, whenever an allegation of abuse or neglect is made, (Facility name) shall take immediate steps to protect the safety & welfare of patients/residents who may be victims of the alleged abuse or neglect, conduct a thorough investigation and take any action necessary to prevent future occurrences of abuse or neglect. The facility had no formal investigation of the fracture of unknown source, which was an allegation of abuse. The facility didn't have statements from any staff members involved in the care of the individual when the injury was identified. The facility staff failed to provide any protection of Resident #45 during the investigation, and failed to take any measures to prevent reoccurrence. The facility Administrator and Director of Nursing were made aware of these findings on 3/28/19 at 2:16pm. No additional information was provided. Based on staff interviews, clinical record review, and facility documentation, the facility staff failed to thoroughly investigate an injury of unknown origin for 2 residents (Resident #24, Resident #45) out of a sample size of 21 residents. The findings included: 1. For Resident #24, the facility staff failed to fully investigate an injury of unknown origin to ensure Resident #24 was not a victim of abuse. Resident #24 was found with bruising to her third and fifth fingers on her right hand. 2. For Resident #45, the facility staff failed to conduct an investigation for a fracture of unknown origin. The findings include: Resident #24, an [AGE] year old female, was admitted to the facility on [DATE]. Diagnoses include but not limited to vascular dementia, impaired mobility, spastic contracture of hands, motor paralysis lower extremities, and seizure disorder. Resident #24's most recent Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 01/21/2019 and was coded as a quarterly assessment. Resident #24 was not coded for a Brief Interview of Mental Status (BIMS). Cognitive skills for daily decision-making were coded as severely impaired. Functional status for bed mobility, transfers, eating (tube feedings), dressing, and personal hygiene were all coded as total dependence on staff. On 10/26/2018 at 11:47 AM, a facility-reported incident (FRI) was transmitted to the state agency in reference to Resident #24 and an injury of unknown origin. Under the section entitled 'Description of Incident', it was documented, Around 0900 on 10-26-18, staff reported patient had discoloration to right 3rd and 5th fingers. Fifth right knuckle slightly swollen and purple in color. No break in skin. Under the section entitled 'Facility Action Taken', it was documented, NP (nurse practitioner) in to assess patient. xray (sic) right hand (3rd-5th fingers) ordered. Ice to right hand 15 minutes every 4 hours x 24 hours. An NP progress note dated 10/26/18 at 10:15 AM documented, Reported purplish discoloration on Rt (right) 3rd and 5th finger/knuckle area. No reported/known injury. Palm roll was off. Appears slightly swollen. X-ray will be ordered. Ice to area, monitor. Physician's orders dated 10/26/18 at 10:15 AM documented, X-ray right hand (3rd-5th fingers) - discoloration to rt (right) 3-5th fingers. Ice to Rt hand 15 min every 4 hours x 24 hours. A nurse's note dated 10/26/18 at 12:00 PM documented, Alert and responsive. Respirations even and unlabored. Staff reported patient had discoloration to write 3rd and 5th fingers. 5th right digit knuckle slightly swollen and purple in color. No breaks in skin. No active bleeding noted. No wincing or facial grimacing when palpating fingers. Fingers to right hand slightly contracted. Palm roll in place. 1000 VS (10:00 AM vital signs) 97.9 (temperature), 99 (pulse), 17 (respirations), 113 / 67 (blood pressure) O2 sat (oxygen saturation) 95% RA (room air). NP in to assess patient. New order to x-ray right hand 3rd through 5th fingers, discoloration to write three through five fingers. Ice to right hand 15 minutes Q (every) 4 hours x 24 hours. A radiographic report dated 10/26/2018 at 8:01 PM documented, Impression: 1. no definite radiographic evidence of acute fracture or dislocation. If there are persistent symptoms, follow-up x-ray may be obtained as clinically warranted. 2. Old fracture first metacarpal healed with mild deformity. 3. Specifically, 3rd through 5th digits intact. 4. Moderate osteopenia or osteoporosis is demonstrated. 5. Mild degree of osteoarthritis. A nurse's note dated 10/27/18 at 6:00 AM documented, Ice to right hand x 2(every 4 hours) Knuckle next to thumb (index finger) slightly swollen and red to purple in color resp [respirations] even and unlabored skin warm and dry to touch Alert and responsive HOB [elevated] tolerating tube feeding In no acute distress A physician's order dated 10/29/18 at 9:45 AM documented, Vit C 500 mg po [by mouth] daily (via G tube) [gastrostomy tube] daily x 30 days. A physician's progress note dated 10/29/18 at 9:46 a.m. documented, S [subjective]. Bruise noted on right hand last Friday [DATE]. X-ray of the hand - no fracture 0 [objective].Reddish discoloration noted over right hand, [illegible] 5th and 4th metacarpals and between 4th and 3rd metacarpals. The areas have prominent and engorged veins and capillaries with loose skin. [illegible] discoloration looks like ecchymosis from spontaneous rupture of various capillaries. A [assessment]. Ecchymosis, right hand P [plan]. Will add Vit C [vitamin C] to drug regimen. A physician's progress note dated 10/29/18 at 10 a.m. documented, bruise on right hand/ not knuckle. On 03/28/2019, the DON explained that medication orders are renewed every 30 days and are considered active on the date the physician signs the order. Physician's medication orders signed on 09/25/2018, 10/23/2018, and 11/19/2018 documented, Multivitamin/Mineral LIQU [liquid] Take 15 ml [milliliters] daily via G-tube [gastrostomy tube]. A copy of the physician's order when the multivitamin was first initiated was requested. A copy of the multivitamin package insert was also requested. The facility staff provided a copy of a physician's order dated 03/25/2010 at 3:00 PM which documented, MVI [multivitamin] with mineral supplement 15 ml [milliliters] GT [gastrostomy tube] x 30d [days]. Start first dose 03/26/2010. The facility staff also provided a copy of the Supplement Facts for the multivitamin that Resident #24 has been receiving since 2010. Included on the list of vitamins in the multivitamin was Vitamin C 60mg, 150% of the recommended daily value. The Medication Administration Record (MAR) from 09/25/18 through 11/22/18 was reviewed. MVI was administered daily as ordered during that date range. Vitamin C was also administered daily from 10/29/18 through 11/22/18. On 03/28/2019 at 10:00 AM, the Administrator stated that Employee H [employed by an outside agency] was the investigator for Resident #24's injury of unknown origin. A copy of the investigation documentation and a copy of facility investigation protocol was requested. On 03/28/2019 at 12:35 PM, the Administrator provided 2 pages of an email conversation between Employee J (clinical director) and Employee H (investigator). An email dated 10/29/18 at 1:52 PM documented, Hi [Employee H]: Ecchymosis - causes breaking of the capillaries. She had taken Vitamin C to help with this but it was discontinued at some point. It's now been ordered again. Here are some samples of how we write it. The one labeled IUO is how I write it. The other is how [name] wrote it. Either way is fine please let me know if you have any questions. Thanks, [Employee J]. An email dated 10/30/18 at 10:28 AM documented, Good morning [Employee J] I am currently working on the report for [Resident #24] and have a couple questions .what is [MD name]'s title? Is he/she active in [Resident #24]'s treatment? How did he/she learn about [Resident #24]'s injury? In other words, I'm trying to figure out how he ended up telling us about the ecchymosis .Any info you can share would be helpful. [Employee H]. An email dated 10/30/18 at 11:05 AM documented, Hi [Employee H], [MD name] is the Medical Director. So she's not on his direct caseload, but he oversees the care of all the pts (patients) and makes recommendations as needed. He's been here for years and is very familiar with her case. Hope that helps, [Employee J]. On 03/28/2019 at 12:45 PM, the Administrator provided all the documentation associated with the investigation which was seven pages. Included in the packet of papers: 1. Facsimile transmittal sheet dated 10/26/18 that was sent to the state agency on the day of incident 2. Facility Reported Incident Form dated 10/26/18 that was sent to state agency on the day of incident 3. A copy of the nurse's note dated 10/26/18 at 12:00 PM 4. A copy of the NP progress note dated 10/26/18 at 10:15 AM 5. A Facility Event Report dated 10/26/18 6. Handwritten notes by Employee H dated 10/26/18. 7. Typewritten report by Employee H dated 10/26/18 The Facility Event Report was a document with many boxes to select as relevant. The event date was 10/26/18. The event time was 9:50 AM. Unexplained was selected for Type of Event. Bedroom was select for Location. Bruise was selected for Type of Injury. Under the section Describe Event, it was documented, Staff reported patient had discoloration to right 3rd and 5th fingers. Fifth right digit knuckle slightly swollen and purple in color. No break in skin. Under the section Treatment/Interventions, it was documented, NP in to assess patient. New order to x-ray right hand/3rd-5th fingers discoloration to right 3-5th fingers. Ice to right hand 15 min every 4 hours x 24 hours. Nurse was notified on 10/26/18 at 9:55 AM. MD/NP notified 10/26/18 at 10:00 AM. Supervisor was notified 10/26/18 at 11:00 AM. The form was signed by the RN (registered nurse) completing the form. The copy of the handwritten notes by Employee H (investigator) was a lined paper that documented: 10/26/18 [Resident #24's last name] IUO [injury of unknown origin] No known injury/accident-nothing documented [name] - Mdirector Pt has ecchymosis - has had long time Vitamin C for symptoms. quit taking new order. On 03/28/2019 at 1:15 PM, a telephone interview with Employee H was conducted. Employee H verified that the notes listed above were her handwritten notes of the investigation. When asked about her investigation process, she stated that Resident #24 was not able to speak so she reviewed Resident #24's chart. When asked if she spoke with any of the staff or interviewed anyone in the course of her investigation, she stated, No. The typewritten report by Employee H was dated 10/26/2018. Under the section Description of Incident it was documented, Incident of Unknown Origin: Resident was found with bruising to her right hand at approximately 0950 hours in the morning of Friday, 10/26/2018. Interdisciplinary notes from 10-26-18 written by [name] RN stated there was discoloration to right 3rd and 5th fingers with 5th right digit knuckle noted to be slightly swollen and purple in color. There was no break in skin, no active bleeding, no wincing or facial grimacing when palpating the fingers. At approximately 1015 hours, FNP (family nurse practitioner) [name] assessed [Resident #24] and an x-ray of her right hand (3rd and 5th fingers) was ordered. An order for ice to the right hand every 15 minutes every 4 hours for 24 hours was also made. Continue to monitor. Under the section Facility Action Taken it was documented, Facility and Clinical Director were notified on Friday 10/26/2018 and an IUO (injury of unknown origin) investigation was initiated. [State and federal agencies] notified. Reviewed interdisciplinary notes and spoke with nursing staff and [MD name], facility medical director. As the medical director, [name] oversees the patients at [facility] and is very familiar with [Resident #24]. He stated the area appeared to be a result of ecchymosis. A condition [Resident #24] has had for quite some time and has taken vitamin C for in the past to aide (sic) with symptoms. A new order for vitamin C has been made. [Resident #24] has no documented symptoms of pain or distress from the injury. After further investigation, there are no new findings in this case. In summary, Resident #24 is completely dependent on staff for mobility and ADL care. An injury of unknown origin was identified on 10/26/18 but there is conflicting information in the clinical record documentation pertaining to the description and location of the injury (right hand versus 3rd and 5th fingers versus index finger). The practitioner ordered Vitamin C although Resident #24 had been receiving 150% of the daily recommended value of Vitamin C daily since 2010. The investigation did not include interviews with staff, potential witnesses, or practitioner to ensure Resident #24 was not a victim of abuse. The typewritten report by the investigator was dated 4 days prior to the email written by the investigator that stated, I am currently working on the report for [Resident #24] . On 03/28/2019 at approximately 3:45 PM, the Administrator and the DON were notified of findings and they offered no further documentation of information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon facility documentation review and clinical record review, the facility staff failed to review and revise a careplan for one Resident (Resident #13) in a survey in survey sample of 21 Residents. For Resident #13, the facility staff failed to review and revise the careplan to include the correct viscosity of thickened liquids and the use of a restraint to the right hand. The findings included: Resident #13, was admitted to the facility on [DATE]. Diagnoses included but were not limited to: dementia, GERD (gastro esophageal reflux disorder), glaucoma, incontinence of urine, self-injurious behavior, impaired mobility, TBI (traumatic brain injury) post MVA (motor vehicle accident), and atherosclerosis. Resident #13's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/4/19 was coded as a quarterly assessment. Resident #13 was coded as daily decision making being severely impaired. The resident was also coded as being totally dependent, requiring the assistance of two staff persons, for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Review of physician orders indicated the resident is to receive honey thickened liquids. An order written 3/5/19, read resume lunch- pureed diet via honey thickened liquids from today 3/5/19-3/11/19. Typed physician orders, signed by the provider on 3/6/19 read, lunch-pureed diet honey thickened liquids starting 3/5/19 through 3/11/19. A Physician's order written 3/13/19 read, resume diet as ordered in am (pureed) with honey thickened liquids. Physician order written 3/19/19, read, may have liquids (honey thickened) until 10am. Review of the careplan, with a team date of 1/9/19 read, (resident name) receives Nectar liquids or soda per orders and during recreational parties. An undated, handwritten entry on the careplan reads, (resident's name) diet is pureed with Nectar fluids when eating p.o (by mouth). A Physician Order dated 3/23/19 was written for a right hand mitten valid for 7 days. Review of the careplan with a team date of 1/9/19 had a line through the typewritten text of mitten to right hand. A handwritten entry, dated 2/26/19 was written on the careplan which read, trial reduction of (resident's name) rt. (right) hand mitten x 7d (days), if self injury occurs, resume rt hand mitten 2/26-3/5/19. Another handwritten entry dated 3/8/19 read, rt hand mitten d/c'd (discontinued). Review of the facility document, Careplan Clinical Procedure with a review date of 7/15/18 read, the comprehensive care plans are changed or revised by the RN to reflect change in conditions and new problems identified by the physician. The Administrator and DON were informed of the failure of staff to review and revise the careplan for Resident #13 thickened liquids and right hand mitten, on 3/28/19 at approximately 3pm. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility documentation the facility staff failed to ensure freedom from unnecessary drugs for 1 Resident (Resident #11) in a survey sample of 21 Residents. For Resident # 11 the facility staff administered Tramadol (narcotic pain medicine) 50 MG (Milligrams) twice on 3/27/19 when the order was for Tramadol 50 MG once daily at 6:30 AM. The findings included; Resident # 11 a [AGE] year old man, was admitted to the facility on [DATE] with diagnoses of but not limited to Cerebral Palsy, Ulcerative Colitis, Seizure Disorder. On 3/27/19 during clinical record review it was noted on the Physicians Order Sheet that the Resident #11 had several orders for pain medication as follows: 1. Acetaminophen Soln [Tylenol solution] 650 MG /20 ML [Milliliters] Take 20 ML via G-Tube Every 12 Hours (at 1000 and 2200) [10 AM and 10 PM] as directed. 2. Acetaminophen Soln - Every 6 hours as needed for pain or temp 100.5 or above. Max of 4000 MG/day 3. Fentanyl 25 MCG/HR [Micrograms per Hour] apply one patch every 72 hours. Remove old patch alternate sites.*External Use* 4. Tramadol HCL 50 MG -Take 1 tablet Via G-Tube at 6:30 AM Upon further review it was discovered that the Resident was given two doses of Tramadol on 3/27/19. On the Narcotic Control sheet (Nurses sign off sheet) Resident # 11 was given Tramadol 50 MG as ordered at 6:30 AM by LPN D the night shift nurse (11 PM-7:30 AM shift on 3/27/19 According to the Narcotic Control sheet on 3/27/19 the day shift nurse LPN C (Day Shift 7 AM-3:30 PM) also gave the Resident another 50 MG dose of Tramadol however no time was entered on the narcotic sheet. According to the Physician Interdisciplinary Notes the Nurse Practitioner wrote on 3/27/19 at 2:50 PM, Noted that Resident received extra dose of Tramadol this AM. Pt sleepy but awakens to stimulation / voice T-97.8 [temperature] P-104 [Pulse]-R-18 [Respirations] O2 Sat. 94% on room air [Oxygen Saturation] B/P 107/72 [Blood Pressure] Monitor vital signs q shift [every shift] with O2 Sat monitoring. On 3/28/19 at 3:30 PM, an interview was conducted with the DON who stated she was aware that the dayshift nurse had given the extra dose of Tramadol and that they did contact the physician and written a medication variance. DON also stated she would give LPN C additional in-service training on medication administration. On 3/28/19 the Administrator was made aware during the end of day conference and no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility documentation the facility staff failed to ensure 2 Residents (Residents #35, and #46) were free from unnecessary psychotropic drugs in a survey sample of 21 Residents. 1. For Resident # 35, the facility staff used Ativan PRN (as needed) for more than 14 days without a diagnosis to support its continued use. 2. For Resident # 46 the facility staff only attempted 1 gradual dose reduction since start of Thioridazine 150 MG on 11/16/17 and no GDR for the other 3 psychotropic medications. The findings include: 1. For Resident # 35, the facility staff used Ativan PRN (as needed) for more than 14 days without a diagnosis to support its continued use. Resident #35 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Schizophrenia, Involuntary Commitment, G-Tube feeding, Impaired mobility, Bilateral hand contractures, Seizure Disorder, Dialysis Dependent, and depression. On 3/25/19 at 3:00 PM a clinical record review was conducted and it was found that Resident # 35 was on several Psychotropic medications including: Lorazepam [Trade name- Ativan- an Anti-Anxiety] 2 MG every 8 hours PRN for agitation and yelling On 3/28/18 the DON was asked what the Ativan order read as indication for use. DON read from the Physicians order Lorazepam 2 mg. take 1 tablet via G-Tube every 8 hours as needed for Agitation/Yelling. When asked if agitation or yelling are diagnosis or symptoms she stated Symptoms. When asked about having the Ativan as a PRN order for more than 14 days the DON stated she was unaware that they could only get the medication PRN for 14 days. The Administrator was made aware of this issue during the end of day meeting on 3/28/19, no further information was provided. 2. For Resident # 46 the facility staff to only attempted 1 gradual dose reduction since Thioridazine (Anti-Psychotic) began on 11/16/17 and no GDR for Venlafaxine, Lorazepam, and Mirtazapine. Resident #46 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to Dysphagia, Aspiration syndrome, Hypothyroidism, Hypertension, Impaired mobility, Obstructive Sleep Apnea, Bilateral hearing impairment, major depression, with anxiety, Bipolar type 1, Pacemaker, and Seizure disorder. On 3/25/19 at 3:00 PM a clinical record review was conducted and it was found that Resident #46 was on several Psychotropic medications including: 1. Thioridazine [Trade name -Thorazine an Anti-Psychotic] 50 MG take 3 tablets [to equal 150 mg] via g-tube every 8 hours. 2. Venlafaxine [Trade name Effexor - an Anti-Depressant] 75 MG 1 tab. via g-tube in morning and evening 3. Lorazepam [Trade name- Ativan- an Anti-Anxiety] 2 MG take 1 tab. three times daily at 0700 1300 and 2000 [7am, 1PM and 8PM] 4. Lorazepam [Trade name Ativan -an Anti-Anxiety] 1 MG take 1 tab. three times daily at 0700 1300, and 2000 [7AM, 1PM, and 8PM] 5. Mirtazapine [Trade name Remeron an Anti-Depressant] 7.5 MG 1 tab. via G-Tube at Bedtime as needed for Insomnia. On 3/28/19 this surveyor requested GDR (Gradual Dose Reduction) for the psychotropic that Resident #46 was receiving. Administrator submitted a document titled Gradual Dose Reduction Guidance to Provider. The document stated: Psychotropic mediation initiated (enter date): 11/16/17 GDR Attempt: 1st Attempt List psychotropic medication in review: Thioridazine 150 MG every 8 hours. Guidance: Per CMS regulations a gradual dose reduction is recommended in the medication listed above. If a dose reduction is clinically appropriate consider reducing the 10 mg bedtime dose. Per American Psychiatric Association (APA) guidelines, a gradual reduction by 10% per month over a 6 to 24 months is preferred in order to avoid withdrawal and minimize the risk of relapse. [The document has the pharmacist Signature and date signed 11/9/18] Prescriber Response required (check box) [Box checked] Read but do not wish to implement Comments: [Doctor's name redacted] Consultation (recert.) Present medication will be continued for a while. Thanks for your suggestion. Physician Signature: [Redacted] Date: 11/13/18 On 3/28/19 the Administrator was asked if there were any further GDR's for any of the other meds or another attempt for the Olanzapine. She stated No we have looked in both charts this is the only one we have. The Administrator was made aware of this issue during the end of day meeting on 3/28/19, no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation, the facility staff failed to ensure the medication error rate was less than 5%. There were 2 medication errors (wrong time/wrong route potentials) and 25 opportunities resulting in an 8% error rate. The findings included: Resident #38, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses include but not limited to profound intellectual disability, chronic aspiration syndrome, reflux esophagitis, quadriplegia, and seizure disorder. Resident #38's most recent Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 02/25/2019 and was coded as a quarterly assessment. Resident #24 was not coded for a Brief Interview of Mental Status (BIMS). Cognitive skills for daily decision-making were coded as severely impaired. Functional status for bed mobility, transfers, eating (tube feedings), dressing, and personal hygiene were all coded as total dependence on staff. On 03/27/2019 at 9:40 AM, LPN C was observed at medication cart preparing to administer medications to Resident #38. Medications LPN C prepared to administer included but not limited to lansoprazole 30 mg (delayed-release orally disintegrating tablet) and Senna 8.6 mg tablet. LPN C opened each unit dose package and placed the whole (not crushed) lansoprazole tablet in a medicine cup and place the whole (not crushed) Senna tablet in a separate medicine cup. She placed them on a tray with the other medications to be administered, covered the tray with a cloth, and carried the tray to Resident #38's bedside. LPN C introduced herself to Resident #38 and stated, I'm going to give you your medicines now. At that time, this surveyor asked LPN C to return to the medication cart in hall. When asked about the Senna, LPN C looked at the Medication Administration Record (MAR) and stated, Oh, this shouldn't be given now. The administration time listed on the MAR was 1800. LPN C removed the Senna tablet from the tray, placed it in a plastic bag, and returned it to the medication cart drawer. LPN C then picked up the tray of medications and started to re-enter Resident #38's room. At that time, this surveyor then asked LPN C how the lansoprazole is to be given. LPN C stated, I should crush it first. LPN C returned to the medication cart, placed the lansoprazole tablet in a plastic bag, crushed the tablet, and placed the powder in a medicine cup. LPN C now had 5 medications on the tray and a cup of water. At the bedside, LPN C checked for gastric residual volume with a 60 ml syringe and then flushed with water in between each medication. LPN C reconstituted the lansoprazole with water at the bedside, removed the plunger from the syringe, attached the syringe to the gastrostomy tube, and poured the reconstituted lansoprazole into the syringe and it immediately drained into the gastrostomy tube. She poured water into the syringe to flush the medication. The current physician's orders signed and dated 03/26/2019 documented, Senna 8.6 mg tablet. Take one tablet via G-tube at 1800. Hold for diarrhea. Lansoprazole ODT (orally-disintegrating tablet) 30 mg Take 1 capsule once daily via G-tube. On 03/27/2019 at approximately 11:55 AM, Employee E, a pharmacist, was asked how lansoprazole ODT should be administered, she read the physician's order for Resident #38 and stated to give one via G-tube. When asked if it could be crushed, she stated, we don't specify whether or not to crush the med but all meds we send up can be crushed if necessary. On 03/27/2019 at approximately 12:05 PM, the DON was asked what references are utilized for professional practice standards and she stated, CMS (Centers for Medicare and Medicaid Services), CDC (Centers for Disease Control and Prevention), AMA (American Medical Association). She also provided a list of resources for nurses: [NAME] - Nursing Practice; [NAME] Gulanick, [NAME]: Nursing Care; [NAME] D'Amico, [NAME]: Health and Physical Assessment in Nursing; Mosby 2018 Drug book. The manufacturer's prescribing information publication for lansoprazole (Prevacid) delayed-release orally disintegrating tablets (ODT) under Section 2.3 entitled, Important Administration Information and sub-header Prevacid SoluTab ODT documented, Prevacid SoluTab should not be broken or cut. Prevacid SoluTab should not be chewed. Place the tablet on the tongue and allow it to disintegrate, with or without water, until the particles can be swallowed. The tablet typically disintegrates in less than 1 minute. Alternatively, for children or other patients who have difficulty swallowing tablets, Prevacid SoluTab can be delivered in two different ways oral syringe or nasogastric tube. Under the sub-header Prevacid SoluTab ODT - Nasogastric tube (? 8 French) Administration , it documented, .place a 30 mg tablet in a syringe and draw up 10 ml of water. Shake gently to allow for a quick dispersal. After the tablet has dispersed, administer the contents within 15 minutes. Refill the syringe with approximately 5 ml of water, shake gently, and flush the nasogastric tube. The manufacturer's prescribing information does not specifically address gastrostomy tube but a nasogastric tube and a gastrostomy tube both terminate in the stomach. On 03/27/2019 at approximately 5:45 PM, the DON was asked about the expectation of nurses when administering medications and she stated that the nurse should double-check the MAR after preparing the medications and before administering them to the patient. In the Seventh Edition of Lippincott Nursing Procedures under the section entitled Safe Medication Administration Practices, General it documented, To promote a culture of safety and to prevent medication errors, nurses must avoid distractions and interruptions when preparing and administering medications, and adhere to the five rights of medication administration: identify the right patient by using at least two patient-specific identifiers; select the right medication; administer the right dose; administer the medication at the right time; and administer the medication by the right route. On 03/28/2019 at approximately 5:45 PM, the Administrator and DON were notified of findings and they offered no further documentation or information.

Based on observation, staff interview, and facility documentation, the facility staff failed to label and store medications according to manufacturer's specifications in one of two facility medication rooms. Specifically, the facility staff failed to: -date a multi-dose vial of Aplisol (tuberculin PPD) after accessing the vial -date a multi-dose vial of Novolog in accordance with manufacturer's specifications -store a multi-dose vial of Novolin N according to manufacturer's specifications The findings include: On 03/26/2019 at approximately 3:15 PM, the medication room on the second floor was surveyed. LPN A and this surveyor observed multi-dose vials in the refrigerator. An open box of Aplisol had a pharmacy label that documented, Stock on it. LPN A stated the facility has an in-house pharmacy that placed the label on the box. Inside the box was a multi-dose vial of Aplisol and it did not have a plastic top on it. When asked if that vial had been opened and accessed, LPN A stated, Yes. There was not a date on the bottle or the box to indicate when it was opened. LPN A held it in her hand and stated it needed to be returned to the pharmacy because it wasn't dated therefore unknown when it was opened. An open box of Novolog had a small yellow sticker on it with the typewritten words, Do not use beyond_________(date). There was a date of 04/05/19 handwritten in the space provided. When asked about the process for dating medications, LPN A stated the Do not use beyond date is 30 days from the date it was opened. The vial of Novolog inside the box did not have a plastic cover and it was not dated. An open box of Novolin N had a small yellow sticker on it with the typewritten words, Do not use beyond_________(date). There was a date of 04/19/19 handwritten in the space provided. The multi-dose vial of Novolin N inside the box did not have a plastic cover and it was not dated. On 03/27/2019 at approximately 5:45 PM, a copy of the medication inserts for Aplisol, Novolog, and Novolin N were requested as well as the policy for medication storage and labeling. On 03/28/2019, the DON provided the medication inserts that were requested. Under the header Storage on the Aplisol medication insert, it documented, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. On the Novolog insert under the header How should I store Novolog? it documented, Opened Novolog vials should be thrown away after 28 days, even if they still have insulin left in them. On the Novolin N insert under the header How should I store Novolin N? it documented for Novolin N vials in use, Keep at room temperature below 77 degrees Fahrenheit for up to 6 weeks (42 days). Keep vials away from direct heat or light. Do not refrigerate an opened vial. On 03/28/2019, the facility staff provided a policy entitled, Medication Storage. The policy does not address the practice of dating multi-dose vials once opened. In Section R entitled, Drugs requiring refrigeration or temperature control must be maintained at proper temperature documented parameters for cold, room temperature, warm, and excessive heat. A copy of the Temperature Control Sheet for the medication room on the second floor was requested. On 03/28/2019 at 11:40 AM, an interview with the DON was conducted. When asked who determines what medications are refrigerated, the DON stated it is a combination of nursing and pharmacy and she went on to say that pharmacy shares with nursing how to store medications. On 03/28/2019 at 12:20 PM, an interview with Employee E, a pharmacist, was conducted. When asked about the process for storing multi-dose vials, Employee E stated We want to stick with manufacturer's recommendations. When shown the medication insert for Novolin N storage specifications, Employee E stated, I didn't know that Novolin N should not be refrigerated after opening. When asked about the process for dating multi-dose vials, Employee E stated that the yellow round stickers on the boxes are placed on the box by pharmacy staff and the nurses date it when they open it. A copy of pharmacy policies on medication storage and labeling was requested. On 03/28/2019 at approximately 12:25 PM, the DON presented a copy of a document entitled, March 2019 Temperature Control Sheet, 2nd Floor. Employee E and the DON verified the temperature column labeled, Room was the room temperature of the medication room and the temperature column labeled Refrigerator was the temperature of the medication refrigerator in the medication room. For 03/26/2019 (the day the Novolin N was observed in the refrigerator), the room temperature was recorded as 72.9 degrees Fahrenheit and the refrigerator temperature was recorded as 36 degrees Fahrenheit. On 03/28/2019 at 1:45 PM, Employee E provided a policy entitled, Pharmacy Services. Section K entitled Medication Dispensing does not address labeling/dating procedures/parameters for multi-dose vials. Section O entitled Drug Storage and Security does not address storage procedures/parameters for multi-dose vials. On 03/28/2019 at approximately 5:45 PM, the Administrator and DON were notified of findings and they offered no further documentation or information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility documentation the facility staff failed to ensure an accurate clinical record for 1 Resident (Resident # 3) in a survey sample of 21 Residents. For Resident #3 the facility staff failed to accurately document the intake of G-Tube feeding and flushes. The findings include: Resident #3 a [AGE] year old woman admitted to the facility on [DATE] with diagnoses of but not limited to intellectual Disability, G-Tube, and Aspiration syndrome, Cerebral Palsy with contractures of extremities, hyper salivation, incontinence, and weight loss from neglect. On 3/27/19 during clinical record review it was noted that Resident #3 had G-Tube feeding ordered and that there were a lot of blank spaces in the documentation from 1/1/19 to 3/27/19. The Tube feeding orders were as follows: Jevity 1.5 400 ML every 6 hours at 200 ML per hour over 2 hours. Flush with 300 ML of water every 6 hours. On January 2019 G-Tube Feeding Record there were empty spaces (no nurse's initials) for the following dates Check Tube Placement - Dayshift - [DATE], 16, 17, 30 also Nightshift for [DATE]th Document Residual - Dayshift - [DATE], 16, 17, and 27th Tube Feeding - 12:00 - Jan. 11, 13, 16, 17, and 30th In addition, flushes were being documented as 300 ML per shift instead of 300 ML every 6 hours On February G-Tube Feeding Record there were empty spaces (no nurse's initials) for the following dates: Check Tube Placement - Dayshift - [DATE]th and [DATE]nd and Evening shift on 19th Document Residual - Dayshift - [DATE]th and Nightshift on the 10th Tube Feeding 12:00 - [DATE]th 1800 [6PM] -[DATE]th 2400 [midnight] [DATE]th and 27th In addition, flushes were being documented as 300 ML per shift instead of 300 ML every 6 hours and missing on the 5th and 22nd on Day shift and the 22nd on Evening shift. For March 2019 G-Tube Feeding Record there were empty spaces (no nurse's initials) for the following dates. Document Residual - Dayshift - March 4th, 9th, 14th and 15th and Night shift on the 6th Tube Feeding - 12:00 -March 22nd 1800 [6 PM] - March 4th In addition, flushes were being documented as 300 ML per shift instead of 300 ML every 6 hours and not documented on March 22nd day shift. On 3/28/18 at 4:00 PM an interview was conducted with the DON who stated she was aware there was a problem and did in-servicing with the staff responsible for G-Tube documentation. The Administrator was made aware during the end of day meeting on 3/28/19 and no further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility staff failed to ensure equipment was in safe operating condition for one Resident (Resident #45) in a survey sample of 21 Residents. For Resident #45, the facility staff failed to maintain a bed in safe operating condition to prevent resident exposure to open electrical wiring. The findings included: Resident #45, was admitted to the facility on [DATE]. The resident's diagnoses included but were not limited to: profound intellectual disability, Down's Syndrome with severe congenital hear disease, pulmonic stenosis, polycythemia secondary to chronic hypoxemia, chronic hypothyroidism, osteoporosis, Hepatitis B carrier, and self injurious behavior. Resident #45's most recent MDS (Minimum Data Set) (an assessment tool) with an ARD (assessment reference date) of 12/5/18 was coded as a quarterly assessment. Resident #45 was coded as having severe cognitive impairment. The resident was also coded as requiring limited assistance of two staff members for transfers, and being totally dependent on staff for dressing, toileting and bathing. Resident #45 required supervision of one staff member for eating. On 03/28/19 at 10:29 AM, the bed controller for Resident #45's bed was observed with three areas where the wire coating was absent, and wires were exposed and accessible to the resident. CNA (certified nursing assistant) I, was in the room and came over to look. When asked if she saw anything wrong she pointed to the wires and said the wires are showing, the patient can get shocked, we are going to call someone and let them know so they can replace it. They probably just didn't notice it this morning. Employee I then unplugged bed. The Administrator and DON were informed of the facilities failure to ensure equipment is in a safe operating condition on 3/28/19 during end of day meeting at approximately 3:20pm. No further information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #13, the facility staff failed to obtain weights as ordered by the physician. Resident #13, was admitted to the facility on [DATE]. The resident's diagnosis included but were not limited to: dementia, GERD (gastro esophageal reflux disorder), glaucoma, incontinence of urine, self-injurious behavior, impaired mobility, TBI (traumatic brain injury) post MVA (motor vehicle accident), and atherosclerosis. Resident #13's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/4/19 was coded as a quarterly assessment. Resident #13 was coded as daily decision making being severely impaired. The resident was also coded as being totally dependent, requiring the assistance of two staff persons, for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. Review of physician orders signed by the nurse practitioner on 3/6/19 revealed an order that read obtain weight tonight (3-5-19) then weight 6 days weekly x 4 weeks. START 3-5-19 STOP 4-1-19. These orders were also signed on 3/6/19 by an RN that indicated she had read and checked the orders on 3/6/19. On 3/28/19 during record review, which included review of nursing notes and weight flow sheets; the weights had not been obtained 6 days weekly, as ordered. Weights were documented as having only been obtained on 3/5/19, 3/6/19, 3/14/19, 3/20/19, and 3/27/19. The facility staff failed to obtain weights on 14 occasions as ordered. During an interview with the DON (Director of Nursing) on 3/28/19 she reviewed Resident #13's clinical record and acknowledged that weights had not been obtained as ordered. The Administrator and DON were informed of the failure of staff to obtain weights as ordered on 3/28/19 at approximately 3pm. No further information was provided. Based on observations, staff interviews, clinical record reviews, and facility documentation, the facility staff failed to ensure professional practice standards for medication administration for 4 residents (Resident #38, Resident #2, Resident 11 # , Resident #13 ) in a sample size of 21. 1. For Resident #38, the facility staff failed to administer medications via gastrostomy tube according to professional practice standards. 2. For Resident # 2, the facility staff failed to document the administration of medications as ordered by the physician 3. For Resident #11 the facility staff failed to follow physicians order and administered Tramadol twice in one day when it was ordered daily at 6:30 AM. 4. For Resident #13, the facility staff failed to obtain weights as ordered by the physician The findings include: 1. For Resident #38, the facility staff failed to administer medications via gastrostomy tube according to professional practice standards. Resident #38, a [AGE] year old male, was admitted to the facility on [DATE]. Diagnoses include but not limited to profound intellectual disability, chronic aspiration syndrome, reflux esophagitis, quadriplegia, and seizure disorder. Resident #38's most recent Minimum Data Set (MDS) had an Assessment Reference Date (ARD) of 02/25/2019 and was coded as a quarterly assessment. Resident #24 was not coded for a Brief Interview of Mental Status (BIMS). Cognitive skills for daily decision-making were coded as severely impaired. Functional status for bed mobility, transfers, eating (tube feedings), dressing, and personal hygiene were all coded as total dependence on staff. On 03/27/2019 at 9:40 AM, LPN C was observed at medication cart preparing to administer medications to Resident #38. Medications LPN C prepared to administer included but not limited to lansoprazole 30 mg (delayed-release orally disintegrating tablet) and Senna 8.6 mg tablet. LPN C opened each unit dose package and placed the whole (not crushed) lansoprazole tablet in a medicine cup and place the whole (not crushed) Senna tablet in a separate medicine cup. She placed them on a tray with the other medications to be administered, covered the tray with a cloth, and carried the tray to Resident #38's bedside. LPN C introduced herself to Resident #38 and stated, I'm going to give you your medicines now. At that time, this surveyor asked LPN C to return to the medication cart in hall. When asked about the Senna, LPN C looked at the Medication Administration Record (MAR) and stated, Oh, this shouldn't be given now. The administration time listed on the MAR was 1800. LPN C removed the Senna tablet from the tray, placed it in a plastic bag, and returned it to the medication cart drawer. LPN C then picked up the tray of medications and started to re-enter Resident #38's room. At that time, this surveyor then asked LPN C how the lansoprazole is to be given. LPN C stated, I should crush it first. LPN C returned to the medication cart, placed the lansoprazole tablet in a plastic bag, crushed the tablet, and placed the powder in a medicine cup. LPN C now had 5 medications on the tray and a cup of water. At the bedside, LPN C checked for gastric residual volume with a 60 ml syringe and then flushed with water in between each medication. LPN C would draw up a medication in the 60 ml syringe with a large air bolus between the medication and the syringe plunger. LPN C would then attach the syringe to the gastrostomy tube and plunge the medication as well as the large air bolus into Resident #38's stomach. LPN C repeated that process two more times. LPN C reconstituted the lansoprazole with water at the bedside, removed the plunger from the syringe, attached the syringe to the gastrostomy tube, and poured the reconstituted lansoprazole into the syringe and it immediately drained into the gastrostomy tube. She poured water into the syringe to flush the medication and then repeated that process for the last medication. When LPN C was asked about administering medications through a gastrostomy tube, she stated, I should've put them all in by gravity. When asked if she was aware of the amount of air she injected into Resident #38's stomach, she stated she didn't know. When this surveyor told her it was approximately 150 ml of air, she stated, That's too much air. On 03/27/2019 at approximately 12:05 PM, the DON was asked what references are utilized for professional practice standards and she stated, CMS (Centers for Medicare and Medicaid Services), CDC (Centers for Disease Control and Prevention), AMA (American Medical Association). She also provided a list of resources for nurses: [NAME] - Nursing Practice; [NAME] Gulanick, [NAME]: Nursing Care; [NAME] D'Amico, [NAME]: Health and Physical Assessment in Nursing; Mosby 2018 Drug book. On 03/27/2019 at approximately 5:45 PM, the DON was asked about the expectation of nurses when administering medications through a gastrostomy tube, she stated, It shouldn't have air in it. She also stated that when air is added, that can develop more problems. In the Seventh Edition of Lippincott Nursing Procedures under the section entitled Tube Feedings and the sub-heading For gastric feeding it stated, If you're using a bulb or catheter-tip syringe, remove the bulb or plunger and attach the syringe to the pinched-off feeding tube to prevent excess air from entering the patient's stomach, causing distention.fill the syringe with formula and release the feeding tube to allow formula to flow through it. The height at which you hold the syringe will determine the flow rate. When the syringe is three-quarters empty, pour more formula into it. To prevent air from entering the tube and the patient's stomach, never allow the system to empty completely. The facility staff provided their facility policy entitled, Gastrostomy Tube Feedings. Section II Part D documented, Water for flushing the gastrostomy tube after feeding and/or medication administration. Thirty to sixty ml of water is used for flushing via gravity, unless otherwise ordered by physician. On 03/28/2019 at approximately 5:45 PM, the Administrator and DON were notified of findings and they offered no further documentation or information. 3. For Resident #11 the facility staff failed to follow physicians order and administered Tramadol twice in one day when it was ordered daily at 6:30 AM. Resident # 11 a [AGE] year old man admitted to the facility on [DATE] with diagnoses of but not limited to Cerebral Palsy, Ulcerative Colitis, Seizure Disorder. On 3/28/19 during clinical record review it was noted on the Physicians Order Sheet that the Resident #11 several orders for pain medications as follows: 1. Acetaminophen Soln [Tylenol solution] 650 MG /20 ML [Milliliters] Take 20 ML via G-Tube Every 12 Hours (at 1000 and 2200) [10 AM and 10 PM] as directed. 2. Acetaminophen Soln - Every 6 hours as needed for pain or temp 100.5 or above. Max of 4000 MG/day 3. Fentanyl [Narcotic pain medicine] 25 MCG/HR [Micrograms per Hour] apply one patch every 72 hours. Remove old patch alternate sites.*External Use* 4. Tramadol HCL [Narcotic pain medicine] 50 MG -Take 1 tablet Via G-Tube at 6:30 AM Upon further review it was discovered that the Resident was given two doses of Tramadol 50 MG on 3/27/19. The Narcotic Control sheet documented Resident # 11 being given Tramadol 50 MG as ordered at 6:30 AM by LPN E the night shift nurse (11 PM-7:30 AM shift). A second entry in the Narcotic Control sheet on 3/27/19 shows LPN C (Day Shift 7 AM-3:30 PM) also gave the Resident a 50 MG dose of Tramadol however no time of administration was entered on the narcotic sheet. According to the Physician Interdisciplinary Notes the Nurse Practitioner 3/27/19 1450 [2:50 PM] - Noted that Resident received extra dose of Tramadol this AM. Pt sleepy but awakens to stimulation / voice T-97.8 [temperature] P-104 [Pulse]-R-18 [Respirations] O2 Sat. 94% on room air [Oxygen Saturation] B/P 107/72 [Blood Pressure] Monitor vital signs q shift [every shift] with O2 Sat monitoring. According to the DON the Professional Guidance used for nursing is [NAME]. According to [NAME] the eight rights of medication administration are: 1. Right patient- Check the name on the order and the patient. Use 2 identifiers. Ask patient to identify himself/herself. When available, use technology (for example, bar-code system). 2. Right medication-Check the medication label. Check the order. 3. Right dose-Check the order. Confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well. 4. Right route- Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route. 5. Right time-Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation-Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. 7. Right reason- Confirm the rationale for the ordered medication. What is the patient's history? Why is he/she taking this medication? Revisit the reasons for long-term medication use. 8. Right response-Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant? Be sure to document your monitoring of the patient and any other nursing interventions that are applicable. Reference: Nursing2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania. On 3/28/19 at 3:30 PM an interview was conducted with the DON who stated she was aware that the dayshift nurse had given the extra dose of Tramadol and that they did contact the physician and written a medication variance. DON also stated she would give LPN C additional in-service training on medication administration. On 3/28/19 the Administrator was made aware during the end of day conference and no additional information was provided 2. For Resident # 2, the facility staff failed to document the administration of medications as ordered by the physician. Resident # 2, an [AGE] year old female, was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Profound Intellectual Disability, Dysphagia, Reactive Airway Disease, Seizure Disorder and Aspiration Syndrome. The most recent Minimum Data Set assessment was a Quarterly assessment with an assessment reference date (ARD) of 3/12/19. Resident # 2 was coded as having severe cognitive impairment. Resident # 2 was coded as requiring total assistance of one staff person for Activities of Daily Living except she required total assistance of two staff persons for bathing and transfers. Resident # 2 was coded as always incontinent of bowel and bladder. On 3/27/2019, review of the clinical record was conducted. Review of March 2019 Medication Administration Record (MAR) revealed missing documentation of administration of medications on : Albuterol 0.83% inhalers solution inhale one vial via nebulizer every 12 hours 3/9/2019 at 10:00 PM Budesonide 0.5 milligrams per 2 milliliters suspension inhale one vial via nebulizer every 12 hours 3/8/2019 at 10 AM Gabapentin 250 milligrams per 5 milliliters take 900 milligrams (18 milliliters) via G-tube (gastrostomy tube) on 3/11/2019 at 8:00 AM, 3/19/2019 at 2:00 PM Amox/Clav 250-62.5 milligrams per 5 milliliters take 10 milliliters via G-tube every 12 hours for 7 days- 3/27/19 at 12 noon Review of the February 2019 Medication Administration Record (MAR) revealed missing documentation of administration of medications on the following dates: Albuterol 0.83% inhalers solution inhale one vial via nebulizer every 12 hours 2/15/19 at 10 AM Budesonide 0.5 milligrams per 2 milliliters suspension inhale one vial via nebulizer every 12 hours 2/15/19 at 10 AM Diazepam 5 milligrams (1/2 tab) take a half tab every 12 hours via G-tube 2/15/19 at 10 AM Florastor Kids Packets mix one packet in water, juice, or non-carbonated beverage and take via G-tube twice daily 2/15/19 at 10 AM Gabapentin 250 milligrams per 5 milliliters take 900 milligrams (18 milliliters) via G-tube (gastrostomy tube) 2/15/19 at 8 AM Oxcarbazepine 300 milligrams per 5 milliliters take 300 milligrams (5 milliliters) 2/15/19 at 8 AM Pataday 0.2 % eye drops place one drop in each eye once daily for the eye 2/15/19 at 10 AM Topiramate 200 milligrams take one tablet via G-tube twice daily 2/15/19 at 8 AM, 2/23/19 at 8 PM, 2/24/19 at 8 PM Vimpat 10 milligrams per milliliters solution take 150 milligrams (15 milliliters) via G-tube twice daily 2/15/19 at 8 AM, 2/24/19 at 8 PM Senna 8.6 milligrams tablet twice a day via G tube 2/15/19 at 10 AM On 3/27/19 at approximately 12:05 PM, the Director of Nursing presented a written note with a list of resources for professional standard including [NAME] - Nursing Practice. On 3/27/2019 at 3:05 PM, an interview was conducted with the Assistant Director of Nursing who stated nurses should document medications at the time of administration. The Director of Nursing and Administrator cited [NAME] as its Nursing professional guidance used by the facility. Fundamentals of Nursing, by [NAME], stated The physician is responsible for directing medical treatment. Nurses follow physicians' orders unless they believe the orders are in error or harm clients. Guidance is given from [NAME] Solutions, Safe Medication Administration Practices, General 10/02/2015. Document all medications administered in the patient's MAR or EMAR (Electronic Medication Administration Record). If a medication wasn't administered, document the reason why, any interventions taken, practitioner notification, and the patient's response to interventions. Additional Guidance from [NAME]'s Nursing Center.com (www.nursingcenter.com) Rights of Medication Administration 1. Right patient Check the name on the order and the patient. Use 2 identifiers. Ask patient to identify himself/herself. When available, use technology (for example, bar-code system). 2. Right medication Check the medication label. Check the order. 3. Right dose Check the order. Confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well. 4. Right route Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route. 5. Right time Check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given. 6. Right documentation Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug. 7. Right reason Confirm the rationale for the ordered medication. What is the patient's history? Why is he/she taking this medication? Revisit the reasons for long-term medication use. 8. Right response Make sure that the drug led to the desired effect. If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant? Be sure to document your monitoring of the patient and any other nursing interventions that are applicable. Reference: Nursing2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania. www.nursingcenter.com Accessed online 3/29/2019. On 3/27/2019 during the end of day debriefing, the facility Administrator and Director of Nursing were informed of the findings of missing documentation of medications. The Administrator stated the Director of Nursing had identified the issue of missing documentation of medication administration in February 2019 and had done a plan of correction to address the problem. The Administrator was informed that the issue had not been resolved since there was evidence of continued missing documentation of medication administration since the problem was identified. The Director of Nursing stated she would continue to educate the nursing staff on the importance of documentation of medication administration at the time of administration. No further information was provided.

Based on observation and staff interview the facility staff failed to transport linen in a manner to prevent the spread of infection in one of two dining areas. In one of two dining areas during meal service the facility staff failed to distribute clothing protectors in a manner to prevent the spread of infection. The findings included: On 3/27/19 from 11:11am until 11:21am, during observation of meal service on the third floor, CNA F (certified nursing assistant) , CNA G, and LPN D (licensed practical nurse) were holding clothing protectors against their body, which was touching their clothing, while they were distributing the clothing protectors to residents. On 03/28/19 at 11:15 AM, during an interview with RN A, when asked how should staff transport linens, she replied staff would wash their hands, obtain linen for what they need, and carry it holding it not against their clothing or anything like that. On 3/28/19 at 2:26pm during a meeting with the Administrator and DON when asked what their expectations regarding linen transport, the DON replied, hold it in their hands, not touching their body. The Administrator and DON were made aware of staff's failure to transport linen in a manner to prevent the spread of infection during end of day meeting on 3/28/19 at 2:26pm. No further information was provided.

**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 ensure 1 resident (Resident #5) of 17 residents in the survey sample was free from a physical restraint. Resident #5 was observed wearing a seatbelt that buckled in the back of the chair. The staff was using the seat belt for fall prevention. The findings included: Resident #5, a [AGE] year old, was admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, dementia, diabetes, seizures, hypertension, chronic kidney disease and constipation. Resident #5's most recent Minimum Data Set (MDS) assessment was a quarterly assessment with an assessment reference date (ARD) of 9/29/17. She was coded with a Brief Interview of Mental Status score of 10 indicating moderate cognitive impairment. She required limited assistance of one person physical assist for bed mobility, transfers, and ambulation. She was coded to be occasionally incontinent of bowel and bladder. Her height and weight were coded as 60 inches and 162 pounds. The following note was documented in the clinical record on 4/7/17 at 9:10 a.m. resident also stated that she wanted her seat belt off so she could go to the bathroom by herself. She was reminded by the undersigned and (DON), who was also present, that she needed the seat belt for her safety since she had fallen in the bathroom before due to standing on her own without asking for staff assistance. The DON was asked to provide the date of Resident #5's last fall. The DON stated the last documented fall was 12/6/15. On 11/1/17 at 3:15 p.m., Resident #5 was observed in her room sitting in her wheel chair. Registered Nurse D (RN D) was present for the observation. Resident #5 was asked if she could take off her seat belt. She stated no because it buckled in the back. Resident #5's feet were observed to touch the ground. While Resident #5 did not appear to be sliding down in the chair, RN D stated that Resident #5 slides down in her chair. The form Consent For Use Of Restrictive Device(s) was signed by the responsible party on 8/25/16. The form documented that Resident #5 was prescribed the following restrictive devices: 1. Half Rails- Used to assist in turning and positioning the patient 2. Seat belt- Used for safety/ poor judgement The form Medical/ Protective Restraint dated May 2017 was located in the clinical record. The seat belt was listed on the form. The reason for restraint read, Poor judgement, safety. The section Periods when Devices Are Not Applied read Not applicable. Resident #5 wears the seat belt whenever she sits in the wheelchair. The most current physician order dated 10/26/17 read safety belt in chair. The following assessments of the seat belt were included in the clinical record: - 8/1/16: Protective/ Medical Device Monitoring Form read seat belt- poor judgement restraint committee recommended to continue with plan due to poor judgement. - 1/11/17: Interdisciplinary Team Care Management Conference read lap belt for positioning when up in chair. - 7/24/17: Protective/ Medical Device Monitoring Form read no reduction recommended at this time due to poor judgement. she seen in maintenance for ambulation 3 x wk for up to 250+ feet. (sic) - 9/18/17: Protective/ Medical Device Monitoring Form. The form read seat belt- poor judgement committee recommended to continue with POC (plan of care) due to poor judgement because dementia/ schizoaffective bipolar type and cognitive disorder. On 11/2/17 at 1:20 p.m., the facility staff were asked to provide the medical diagnosis or symptom that warranted the use of the restraint. The Director of Nursing (DON) and the consulting psychiatrist referenced the Psychiatric Progress note/ Quarterly Review dated 9/28/17. They referred to the diagnoses documented in the note Impression: Schizoaffective Disorder (SAD), Bipolar type; cognitive disorder NOS/ dementia NOS. The psychiatrist and DON stated that Resident #5 needed the restraint because she has poor judgement and can't self regulate due to her cognitive impairment and mental illness. The DON stated that she did not want Resident #5 to fall on her watch. The facility staff provided two nursing notes that they felt documented Resident #5's poor judgement: 6/14/17 nursing note Patient became very combative when she could not get a cola. She quickly undid her maintenance sensor, returning to her wheelchair while being verbal abusive. An staff tried to secure her in the wheelchair, she started bucking and thrashing around the wheelchair. 8/5/17 nursing note Pt (patient) removed half rail, + got out of bed. Found standing @ dresser stated she was getting clothes. Pt (patient) placed in w/c. The Administrator stated that during the observation conducted with RN D on 11/1/17, Resident #5 was noted to slide down in the chair. When asked if the facility had tried to use a wedge cushion for positioning, facility staff stated no. The DON stated that they had tried a chair alarm and Resident #5 unclipped from her shirt. When asked if they had tried a pad alarm, the DON stated that the facility did not use pad alarms. When asked if the facility had conducted a trial reduction of the seat belt use, the facility staff stated no. Earlier in the morning on 11/2/17, the facility staff had offered the example that Resident #5 did not have the seat belt on, she would stand up to try and dance. They also offered the example that Resident #5 would try to go to the bathroom alone if she didn't have the seat belt on. When asked if the resident was on a toileting program, the DON stated yes. Information about the toileting program was requested. On 11/2/17 at 12:30 p.m., the DON and Certified Nursing Assistant H (CNA H) discussed the toileting plan. The DON stated that there was no toileting plan because the resident could tell staff when she needed to use the bathroom. CNA H stated that when Resident #5 asked to use the bathroom she (CNA H) needed to release the seat belt for the resident and help her pull down the brief and pants. CNA H stated that Resident #5 did the rest of the toileting task on her own. CNA H stated that she would check in on Resident #5, help her get her pants pulled up and then lock her back in the chair. CNA H stated that once staff knew the resident was safe (buckled in wheel chair), they let her go. CNA H was asked if she thought it would help Resident #5 to be on a toileting program where staff asked her periodically if she needed to use the bathroom, CNA H stated she thought that could work. When asked if she thought the seat belt was in place for staff convenience, CNA H stated that it was easier to have it on her because it is safer. CNA H explained that Resident #5's room was purposely at the end of the hall near where the CNAs were supposed to be located. She stated that there was a stairwell door at the end of the hall that Resident #5 may try and exit if she didn't have the seat belt on. CNA H stated that in the mornings she checks with Resident #5 first to see if she wants to get up. CNA H stated that after Resident #5 is up and safe (buckled in wheelchair) the staff can go give care to other residents. On 11/2/17 at 10:00 a.m. the physical therapist (PT) discussed Resident #5's therapy. She stated that Resident #5 currently walks with an assistive device with supervision. She stated that originally the seat belt buckled in the front, but Resident #5 would unbuckle the belt. The PT stated that the placement of the belt buckle was changed to the back of the chair for Resident #5's safety because she has the potential for falls and needs redirection. The PT stated that the purpose of the belt was to try and maintain safety. Restorative nursing currently worked with Resident #5. Documentation for October 2017 was provided. The goal of therapy read Amb (ambulate) with patient using a RW (rolling walker) with stand-by to contact guard assistance x 1. Pt. (patient) to ambulate up to 200+ feet (3-5x/wk). Resident #5 completed eight days and refused nine days. The care plan for risk for fall/fracture and restraint use dated 7/12/17 was provided by the facility. The care plan problem read Independent in bed mobility and locomotion on unit in wheelchair and She requires assistance with transfers, dressing, toileting, personal hygiene and bathing. One of the interventions read Seat belt in wheel chair d/t (due to) unsafe and impulsive. On 11/2/17 at the end of day meeting, the restraint issue was reviewed with the Administrator and Director of Nursing.

Based on observation and staff interview the facility staff failed to ensure a safe environment on 2 of 2 units. The Cook/ Chill room that holds the heating and refrigeration unit for meal service was observed unlocked on both units The findings included: On 11/1/17 at 9:15 a.m., the Cook/Chill room was unlocked on the 3rd floor. A male resident in a wheel chair was observed rolling in the hallway nearby. Stored in the room was the heating and refrigeration unit with the food cart attached. In addition, hand sanitizer, sanitation wipes, plates and adaptive eating equipment were stored in the room. The Occupational Therapy (OT) Director entered the room. When asked if the door to the room was supposed to be locked, she stated yes. On 11/1/17 at 11:05 a.m., the door to the Cook/Chill room was half way open on the 2nd floor. The food cart had been removed from the heating/ cooling unit. The heating unit was hot to the touch. The temperature gauge on the unit read idle. There were no staff or residents in the area. A staff member returned to the the cook/ chill room for supplies. When asked if the door was supposed to be open, she stated no. The issue was reviewed with the Administrator and Director Nursing (DON) at the end of day meeting on 11/1/17. The Administrator stated that on the 2nd floor, staff had been injured by the door because it closed to hard and fast. The door was fixed to close more slowly.