Every finding on record at Atlas Post Acute

Based on record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#2) of four residents reviewed for accidents/hazards out of 29 sample residents. Resident #2, who was admitted on [DATE], required substantial assistance to roll from her back to her right or left side in the bed. On the afternoon of [DATE], certified nurse aide (CNA) #3 elevated Resident #2's bed and then repositioned the resident onto her side to provide incontinence care. Resident #2 rolled off the elevated bed onto the floor during care. Interviews during the survey revealed Resident #2 was communicating with staff prior to the incident, however, Resident #2's responsiveness deteriorated significantly immediately after the fall. Resident #2 said she had head pain after the fall. Resident #2 was transferred to the hospital within an hour of the fall. Resident #2 experienced cardiac arrest while en route to the hospital and expired within 10 minutes of her arrival at the hospital. Due to the facility's failure to ensure Resident #2's safety during repositioning, Resident #2 likely sustained injuries when she fell off of the elevated bed.Specifically, the facility failed to ensure Resident #2 was protected from falling during repositioning.Findings include:I. Facility policy and procedureThe Assessing Falls and Their Causes policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 4:32 p.m. It read in pertinent part, Falls are a leading cause of morbidity and mortality in nursing homes. Fear of falling may limit an individual's participation in activities. Falling may be related to underlying clinical or medical conditions, overall functional decline, medication side effects, and/or environmental risk factors. Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly.II. Resident #2A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO) diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure, cellulitis (skin infection) of the lower extremities, diabetes, cirrhosis of the liver and heart failure.The [DATE] minimum data set (MDS) assessment revealed Resident #2 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The MDS assessment identified Resident #2 required set up assistance for eating, substantial assistance from staff for repositioning in bed (rolling left to right) and was dependent on staff assistance for hygiene, bathing, dressing and transferring. B. Resident #2's witnessed fall on [DATE]The facility's incident report of Resident #2's fall from her bed was provided by the NHA on [DATE] at 2:30 p.m. The incident report documented the following:On [DATE] at 3:45 p.m. licensed practical nurse (LPN) #2 was told by a staff member that Resident #2 rolled out of bed while the staff member was changing the resident. It documented that the staff member reported the resident was on the floor and the staff member was not sure what happened. The incident report documented that a video call was made with the director of nursing (DON), who assisted with the assessment of Resident #2 while the resident was on the floor. It documented Resident #2 had a change in her level of consciousness after the fall. It documented Resident #2's oxygen saturation level (measurement of the amount of oxygen in the blood) had dropped and her blood pressure had increased. The report documented the hospice agency and emergency medical response services were notified for transfer of the resident to the hospital. The incident report documented predisposing physiological factors for the fall included edema, incontinence and weakness. C. Additional record reviewResident #2's activities of daily living (ADL) care plan, revised [DATE], revealed Resident #2 required assistance for ADL care in bathing and toileting related to impaired balance, dizziness, recent hospitalization, COPD diagnosis, diabetes, morbid obesity, rheumatoid arthritis, glaucoma and pulmonary hypertension. Interventions included bathing twice weekly, keeping Resident #2's room warm, documenting all refusals of cares, monitoring for decline in ADL function, monitoring for pain and arranging the resident's environment to facilitate ADL performance. The interventions further included having two staff members at all times when entering Resident #2's room.-However, CNA #3 provided ADL care to Resident #2 without a second staff member in the room (see interviews below).-The ADL care plan had not been revised since [DATE], despite Resident #2 experiencing decline in her ADL function and being accepted to hospice care services by [DATE].A review of Resident #2's [DATE] CPO revealed the following physician's orders:May position bed against a wall for ease of care and/or resident preference, ordered [DATE].Oxygen at 2 liters per minute (LPM) via nasal cannula continuously every day and night shift for COPD, notify physician/nurse practitioner if less than 89% (oxygen saturation), ordered [DATE].Hospice evaluation and treatment, ordered [DATE].Resident admit to hospice, diagnosis COPD, ordered [DATE].A hospice agency nursing note, dated [DATE] at 1:55 p.m., documented Resident #2 was awake and oriented to person, place and time. The note documented that Resident #2 said she was doing well. The note documented the facility nurse said Resident #2 seemed to be her old self, did not need comfort medications and was taking her scheduled medications without problems. The note documented Resident #2 was watching television in her bed at the conclusion of the visit and had no concerns or needs.A nursing progress note, dated [DATE] at 3:49 p.m., documented the nurse received a call from a nursing staff member reporting that Resident #2 had experienced a fall during ADL care. The note documented the nursing staff member had turned Resident #2 onto her side and the resident rolled out of the bed. The note documented that Resident #2 was lying on the floor on her right side, slightly tilted due to her proximity to the wall. The note documented during the assessment, Resident #2 began to exhibit signs of unresponsiveness and the emergency services (EMS) and the hospice agency were notified. It documented oxygen was applied via a non-rebreather (a device used to provide high amounts of oxygen) mask. It documented the resident was less lethargic upon the arrival of EMS to the facility. It documented Resident #2 was transferred to the hospital for further evaluation.A nursing progress note, dated [DATE] at 6:00 p.m., documented the coroner had contacted the facility at 5:10 p.m. It documented the coroner notified the facility that Resident #2 had died within 10 minutes of arrival to the hospital, after she was transferred from the facility following the fall from her bed. The note documented the coroner had requested information from Resident #2's medical record.The nursing facility to hospital transfer form was provided by the NHA on [DATE] at 2:30 pm. It documented Resident #2 was transferred to the hospital on [DATE] at 4:21 p.m. for the primary reason of a fall. It documented Resident #2 was not alert at the time of her transfer to the hospital. It documented Resident #2 was dependent on staff assistance for all ADLs. The transfer form documented Resident #2 was receiving 4 LPM oxygen by nasal cannula at the time of her transfer to the hospital.-Resident #2's oxygen requirement increased at the time of the fall, as nursing documentation revealed Resident #2 had been receiving 2 LPM of oxygen until the time of the fall on [DATE].The hospital physician's note, dated [DATE] at 4:55 p.m., documented Resident #2 arrived at the hospital unresponsive, without a pulse and was receiving artificial respirations with a bag-mask device. The physician documented EMS had told her the facility had called for assistance to transfer the resident to the hospital due to the resident's fall. The note documented Resident #2 had been able to talk upon EMS initial evaluation at the facility. The physician documented due to Resident #2's do not resuscitate (DNR) wishes, Resident #2's time of death was documented on [DATE] at 4:50 p.m. The note documented the physician thought Resident #2 had some sort of injury from the fall, which likely would have resulted in prolonged, if not futile hospitalization.III. Staff interviewsLPN #2 was interviewed on [DATE] at 10:55 a.m. LPN #2 said Resident #2 was not acting normally prior to her fall (on [DATE]). LPN #2 said the resident was acting differently that day and had asked to wear a night gown. LPN #2 said the resident never liked to wear clothes and usually wanted to wear only a brief. LPN #2 said Resident #2 was sleeping more and sometimes did not take her medications. LPN #2 said CNA #3 requested her assistance after Resident #2 fell out of the bed. LPN #2 said she went to the resident's bedside and contacted the DON through a video call to assess the resident, who was lying on the floor. LPN #2 said Resident #2's level of consciousness kept changing. LPN #2 said the resident alternated between being responsive and not, however LPN #2 said Resident #2 said, at one point, that she wanted to go to the hospital. LPN #2 said Resident #2's bed was in an elevated position when she arrived in the room, as the resident had been receiving ADL care at the time of the fall. LPN #2 said EMS was at the bedside when the resident was transferred to a gurney using a mechanical lift.The hospice agency nurse was interviewed on [DATE] at 1:19 p.m. The hospice agency nurse said the facility contacted the hospice agency when Resident #2 fell on [DATE]. The hospice agency nurse said Resident #2 was alert and communicative during the last hospice visit on [DATE]. She said Resident #2 liked to do crossword puzzles. The hospice agency nurse said Resident #2 never complained of pain or anxiety.CNA #3 was interviewed on [DATE] at 3:02 p.m. CNA #3 said she was changing Resident #2's brief when Resident #2 fell out of the bed. CNA #3 said she turned Resident #2 onto her side and then the resident said she was falling. CNA #3 said she could not reach the resident to assist, so she went to the other side of the bed, and by that time, Resident #2 was on the floor. CNA #3 said she had taken care of Resident #2 in the past and the resident had previously been able to stay on her side without rolling over. CNA #3 said the last time she took care of Resident #2, the resident's bed was against the wall so she could not roll off the bed. CNA #3 said at the time of Resident #2's fall, the bed had been moved away from the wall. CNA #3 said Resident #2 had only needed one person for transfers in the past, but probably should have had two staff members for transfers. CNA #3 said she notified LPN #2 when Resident #2 fell. CNA #3 said Resident #2 was initially talking after the fall and the resident said that her head was hurting.The DON and the regional clinical resource nurse were interviewed together on [DATE] at 6:22 p.m. The DON said she was told Resident #2 was too close to the edge of the bed and she rolled off of the bed onto the floor (on [DATE]). The DON said she was contacted and assisted LPN #2 with a nursing assessment. The DON said the nursing team decided it was best to transfer the resident to the hospital. The DON said the resident was intermittently responsive after the fall. The regional clinical resource nurse said the hospital record documented it was likely Resident #2 had injuries related to the fall.The DON was interviewed again on [DATE] at 12:12 p.m. The DON said she did not provide education to CNA #3 or nursing staff after the fall. The DON said CNA #3 did not do anything wrong when she was assisting Resident #2 with ADLs. She said CNA #3 repositioned the resident and the resident fell out of the bed during ADL care on [DATE]. The DON said CNA #3 did not need to do anything differently than what she had done.-However, according to Resident #2's ADL care plan, two staff members were to be present at all times when entering the resident's room (see record review above).

Based on observations, record review and interviews, the facility failed to ensure three (#25, #15 and #18) of seven residents were free from abuse out of 29 sample residents.Specifically, the facility failed to:-Protect Resident #18 from verbal abuse by Resident #17;-Protect Resident #15 from physical abuse by Resident #16; and,-Protect Resident #25 from physical abuse by Resident #24.Findings include:I. Facility policy and procedureThe Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised, April 2021, was provided by the nursing home administrator (NHA) on 5/12/26 at 9:00 a.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents.II. Incident of verbal abuse of Resident #18 by Resident #17 on 11/16/25A. Facility investigationThe facility's investigation was provided by the NHA on 5/12/26 at 12:42 pm. The investigation documented Resident #18 and Resident #17 were sitting at the same lunch table when Resident #17 made an inappropriate comment and said he could reach up under Resident #18's dress. The investigation documented Resident #18 became upset and tearful and reported the incident to staff. The investigation documented the facility interviewed Resident #18 and Resident #17 regarding the incident.The facility's investigation, dated 11/18/25, documented Resident #17 said he did make the comment to Resident #18 about reaching up her dress and the resident (Resident #17) said he was joking. The facility's investigation documented Resident #18 was upset and tearful when she left lunch early to report the incident to a staff member. The facility's investigation ruled out that physical abuse occurred and indicated the incident was verbal. The investigation did not identify whether or not verbal abuse was substantiated or unsubstantiated.Per an interview with the NHA during the survey, the facility did not substantiate verbal abuse (see NHA interview below).-However, verbal abuse did occur as Resident #18 was upset and tearful related to what Resident #17 said to her when she reported the incident to staff. B. Resident #18 (victim)1. Resident statusResident #18, age less than 65, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the May 2026 CPO, diagnoses included chronic obstructive pulmonary disease, cirrhosis of the liver and generalized muscle weakness.The 3/13/26 MDS assessment revealed Resident #18 was cognitively intact with a BIMS score of 15 out of 15. The resident was dependent on staff assistance for toileting hygiene and required partial/moderate assistance for upper and lower body dressing, personal hygiene and transfers.The MDS assessment indicated the resident did not have physical or verbal behavioral symptoms directed toward others.2. Resident interviewResident #18 was interviewed on 5/12/26 at 11:09 a.m. Resident #18 said there was an incident last year (2025) when she was eating in the dining room at a table with other residents. She said she had not been feeling good and was wearing a nightgown. Resident #18 said during lunch, Resident #17 told her he could reach up her dress. Resident #18 said Resident #17's statement upset her, she was tearful and left the dining room early. She said she told activities assistant (AA) #1 what Resident #17 said to her. Resident #18 said she filed a grievance and the facility staff took care of it. Resident #18 said she had bad dreams for a few nights after the incident.Resident #18 was interviewed a second time on 5/14/26 at 10:25 a.m. Resident #18 said she was upset and fearful at the time of the incident because she did not know Resident #17 well or what he might be capable of.3. Record reviewResident #18's trauma-informed care plan, dated 3/19/25, revealed a focus of trauma-informed care and documented the resident was at risk for decreased psychosocial wellbeing and emotional distress related to her personal history. The care plan goal was for her to be able to express feelings of safety and security in the environment. Interventions included approaching Resident #18 in a calm, reassuring manner, encouraging the resident to verbalize feelings and monitoring for signs and symptoms of decreased psychosocial well-being. C. Resident #17 (assailant)1. Resident statusResident #17, age [AGE], was admitted on [DATE]. According to the May 2026 CPO, diagnoses included left-sided weakness, generalized muscle weakness, impaired mobility and self-care deficit.The 3/30/26 MDS assessment revealed Resident #17 had moderate cognitive impairment with a BIMS score of 11 out of 15. He was independent for all ADLs.The MDS assessment indicated the resident did not have physical or verbal behavioral symptoms directed toward others.2. Resident interviewResident #17 was interviewed on 5/12/26 at 9:48 a.m. Resident #17 said he used to see Resident #18 in the dining room, but he did not see her anymore. Resident #17 said he remembered sitting in the dining room at the table with Resident #18 in the past. He said he made a comment one time about reaching up her dress and joking around with her.3. Record reviewA physician's progress note, dated 12/30/25, revealed there was no change in Resident #17's mental status or functional status.D. Staff interviewAA #1 was interviewed on 5/13/26 at 12 p.m. AA #1 said Resident #18 reported Resident #17 had made an inappropriate verbal comment about reaching up her dress (on 11/16/25) and Resident #18 was upset and tearful at the time. AA #1said she assisted Resident #18 with reporting the grievance.III. Incident of physical abuse of Resident #15 by Resident #16 on 12/18/25A. Facility investigationThe facility's investigation of the abuse incident involving Resident #15 and Resident #16 was provided by the NHA on 5/12/26 at 12:42 p.m. The facility's investigation documented Resident #15 was doing his therapy exercises, described as tapping his fingers on the table, when his roommate, Resident #16, became irritated and grabbed Resident #15 by the wrist and told Resident #15 to stop. The investigation documented Resident #16 was in his wheelchair and rolled over the toes of Resident #15 on his way out of the room. The investigation documented there were no witnesses to the incident in the residents' room. The investigation documented the director of nursing (DON) assessed Resident #15 and found bruising on the resident's face and wrist. The facility investigation documented Resident #16 admitted that Resident #15's tapping of his fingers on his table pushed him to grab Resident #15 to stop the tapping.The investigation indicated the facility substantiated the physical abuse.B. Resident #15 (victim)1. Resident status Resident #15, age greater than 65, was admitted to the facility on [DATE]. According to the May 2026 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), chronic pain syndrome, generalized weakness, difficulty walking, reduced mobility, anxiety and depressive disorders.The 4/14/26 MDS assessment revealed Resident #15 was cognitively intact with a BIMS score of 15 out of 15. The resident required supervision/touching assistance from staff for upper body dressing, personal hygiene and transfers. He required partial/moderate assistance from staff for lower body dressing and substantial/maximal assistance for toileting.The MDS assessment indicated the resident did not have physical or verbal behavioral symptoms directed toward others.2. Resident interviewResident #15 was interviewed on 5/11/26 at 4:15 p.m. Resident #15 said he had an incident with his previous roommate, Resident #16, last year (2025) when he tapped his fingers on the table as a therapy exercise and Resident #16 became irritated. Resident #15 said Resident #16 grabbed his wrist and hit his face and told him to stop. Resident #15 said that Resident #16 was in his wheelchair, and as he was leaving the room, he wheeled over his (Resident #15's) toes. Resident #15 said he had a bruise from the incident, but his toes were not injured.Resident #15 said he reported the incident to the nursing staff and he was assessed for injury. Resident #15 said Resident #16 was moved to a different room that day.3. Record reviewResident #15's care plan report, revised 3/19/24, revealed Resident #15 had a history of a decline in psychosocial well-being and mood state. Interventions included encouragement to openly express feelings and staff would provide emotional support as needed. A nursing progress note, dated 12/18/25 at 3:18 p.m. documented Resident #15 said his roommate had grabbed his wrist, hit his face and run over his foot.A skin assessment, dated 12/18/25, documented Resident #15 had bruising to the left wrist and right cheek.C. Resident #16 (assailant)1. Resident statusResident #16, age greater than 65, was admitted to the facility on [DATE]. According to the May 2026 CPO, diagnoses included acute and chronic kidney disease, depression, and functional decline with generalized weakness. The 3/10/26 MDS assessment revealed Resident #16 was moderately cognitively impaired with a BIMS score of nine out of 15. According to the May 2026 CPO, diagnoses included chronic and acute kidney disease, depressive disorder, functional decline with generalized weakness and reduced mobility. He required substantial/maximal staff assistance for the majority of his activities of daily living (ADL).The MDS assessment indicated the resident did not have physical or verbal behavioral symptoms directed toward others.2. Record reviewThe behavior care plan, revised 12/22/25, revealed Resident #16 had issues with self-management related to agitation, anxiety and anger. Interventions included the use of coping skills of seeking staff support, deep breathing and taking a break from situations when the resident was angry.A nursing progress note, dated 12/22/25 at 1:51 p.m., documented time was spent with Resident #16 for reviewing the resident's coping skills for managing anxiety and anger.IV. Incident of physical abuse of Resident #25 by Resident #24 on 4/22/26A. Facility investigationThe facility's investigation of the abuse incident involving Resident #25 and Resident #24 was provided by the NHA on 5/12/26 at 12:42 p.m. The facility's investigation, dated 4/22/26, documented that Resident #24 backed into Resident #25 with his wheelchair when they were both in line at the door to the outside smoking area. The investigation documented Resident #25 pushed Resident #24's wheelchair in the back and Resident #24 was startled, threw his coffee at Resident #25 and then turned around in his wheelchair and hit Resident #25 on her cheek.The investigation revealed a skin assessment was completed for both residents by registered nurse (RN) #4 and Resident #25 was noted to have a new discoloration to her right cheek. The investigation documented Resident #24 did not sustain an injury.The investigation documented Resident #25 had an xray at the facility on 4/22/26 at 2:15 p.m. The Xray revealed Resident #25 had no acute fracture or injury to her right cheek.The investigation documented the residents were separated at the time of the incident and staff monitored both residents per facility policy.The investigation revealed the NHA and RN #4 interviewed Resident #25 and Resident #24 on 4/22/26 and both residents confirmed the incident occurred.The investigation documented the facility substantiated the incident of physical abuse. B. Resident #25 (victim)1. Resident statusResident #25, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, functional decline and generalized weakness, and impaired mobility.The 3/16/26 minimum data set (MDS) assessment revealed Resident #25 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She was independent with oral hygiene and personal hygiene. She required setup/cleanup assistance for staff for lower body dressing and supervision/touching assistance from staff for toileting, bathing, upper body dressing and transfers. The MDS assessment indicated the resident did not have physical or verbal behavioral symptoms directed toward others.2. Resident interviewResident #25 was interviewed on 5/11/26 at 11:15 a.m. Resident #25 said she was trying to get out of the door to the outside smoking area (on 4/22/26) and Resident #24 was in his wheelchair in front of her and kept scooting back into her wheelchair.Resident #25 said she gave Resident #24's wheelchair a little push to stop him from backing into her. Resident #25 said Resident #24 then threw his coffee at her and turned around and hit her on the right side of the face.Resident #25 said staff separated both residents and completed assessments of both residents at the time of the incident.3. Record reviewResident #25's care plan report initiated 3/1/25, revealed she smoked without supervision.Resident #25's behavior care plan, revised 5/13/26, revealed the resident could have verbal and physical confrontation with peers when she was agitated. Interventions included separating the resident from triggering situations or other individuals as needed for safety.The nursing progress note, dated 4/22/26 at 12:10 p.m., revealed Resident #24 backed into the wheelchair of Resident #25 and then Resident #24 pushed Resident #25's wheelchair to clear the path to the door. Resident #24 turned around and threw his coffee at Resident #25 and hit her on the right cheek. The residents were separated and a head-to-toe skin assessment was completed. The progress note revealed Resident #25's skin on her check was discolored. The physician gave an order for an Xray of the resident's face, neck and right wrist.A licensed psychologist clinician note, dated 4/22/26 at 1:53 p.m., revealed the psychologist met briefly with Resident #25 who expressed feelings of anger and frustration regarding an interpersonal conflict with another resident. The social services progress note, dated 4/22/26 at 5:30 p.m., revealed Resident #25 was alert and oriented with a calm mood and was cooperative during the assessment. The resident said she was doing okay and denied ongoing distress. The social services director (SSD) reported she would reinforce separation during smoking times and continue monitoring of Resident #25 to maintain a safe environment. The social services progress note, dated 4/23/26 at 3:01 p.m., revealed Resident #25 was alert, and calm with no signs of distress noted. Resident #25 said she preferred to avoid Resident #24 during smoking times to prevent further conflict. The SSD reported she would continue to monitor the mood and behavior of Resident #25.C. Resident #24 (assailant)1. Resident statusResident #24, age less than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included diabetes, hypertension, Alzheimer's disease, and generalized weakness. The 3/16/26 DS assessment revealed Resident #24 had moderate cognitive impairment with a BIMS score of 11 out of 15. He was independent with oral hygiene. He required setup/clean up assistance from staff for personal hygiene, supervision/touching assistance for transfers and partial/moderate assistance for personal hygiene. He required substantial/maximal assistance from staff for upper and lower body dressing.The MDS assessment indicated the resident did not have physical or verbal behavioral symptoms directed toward others.2. Resident interviewResident #24 was interviewed on 5/11/26 at 3:18 p.m. Resident #24 said he remembered an incident with Resident #25 last month (April 2026). Resident #24 said Resident #25 was in back of him in the line to get out the door to the smoking area. Resident #24 said Resident #25 pushed him in the back and hit him. Resident #24 said he threw his coffee at Resident #25 and then reached over his shoulder and punched her in the face. Resident #24 said he did not have any injury from the incident. He said he was no longer in contact with Resident #25 and had no problems with her or other residents.3. Record reviewResident #24's behavior care plan, revised 5/13/26, revealed the resident sometimes was aggressive when he was uneasy. Interventions included Resident #24 would verbalize when he became uncomfortable when people were in his space.D. Staff interviewRN #4 was interviewed on 5/12/26 at 3:35 p.m. RN #4 said she did not witness the incident between Resident #25 and Resident #24 on 4/22/26, but later she observed a bruise on Resident #25's cheek.V. Additional staff interviewThe NHA was interviewed on 5/13/26 at 5:30 p.m. The NHA said Resident #18 was tearful and upset when he interviewed her about the incident with Resident #18 (on 11/16/25). The NHA said he interviewed Resident #17 about the incident and Resident #17 stated he told Resident #18 he could reach up her dress when they were sitting at the lunch table. The NHA said the facility's investigation ruled out physical abuse and did not substantiate verbal abuse.The NHA said a bruise on the arm of Resident #15 was observed from Resident #16 grabbing the forearm of Resident #15 (on 12/18/25). The NHA said an intervention after the incident included Resident #16 was moved to another room. The NHA said the facility substantiated the physical abuse.The NHA said that the smoking area was identified as a hot zone for conflict. He said Resident #25's skin assessment was completed after the incident on (4/22/26) and a red spot on her cheek was observed. He said the facility's investigation substantiated the physical abuse.

Based on observations, record review and interviews, the facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries for one (#9) of four residents out of 29 sample residents. Specifically the facility failed to ensure staff consistently provided wound care to Resident #9 in a timely manner, per physician's orders.Findings include:I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019) retrieved on 5/18/26 from https://www.internationalguideline.com/the-international-guideline, Pressure ulcer classification is as follows:Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that did not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk).Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle were not exposed. Slough may be present but did not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpableUnstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.II. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), kidney failure and peripheral vascular disease (circulation disorder). According to the 3/21/26 minimum data set (MDS) assessment, Resident #9 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The MDS assessment identified Resident #9 required moderate assistance with eating and was dependent on staff assistance for hygiene, showering, dressing and transferring.The MDS assessment documented that the resident had a stage 4 pressure injury that was present on admission.B. Record reviewA review of Resident #9's May CPO revealed the following physician's orders:Wound care: Sacro-coccyx (tailbone), extending to right buttocks, cleanse with wound cleanser, apply skin prep, cover with hydrocolloid dressing (moisture retentive bandage) every day shift every Monday, Wednesday and Friday for wound care, ordered on 3/18/26 and discontinued on 4/6/26.Wound care: Sacrococcyx extending to right buttocks, cleanse with wound cleanser, apply skin prep to periwound, cover with hydrocolloid dressing every day shift every Monday, Wednesday, Friday, Sunday for wound care, ordered on 4/22/26.-However, a review of Resident #9's April 2026 and May 2026 treatment administration records (TAR), from 4/1/26 through 5/14/26, revealed no documentation to indicate wound care was provided for the resident on 4/1/26, 4/26/26, 4/29/26, 5/4/26, 5/10/26, and 5/13/26.III. Staff interviewsThe wound care physician assistant (PA) was interviewed on 5/14/26 at 10:35 a.m. The wound care PA said Resident #9's coccyx pressure injury had completely healed and then reopened after he was hospitalized in March 2026. The wound care PA said Resident #9's wound had not worsened recently, however, he said if nursing staff were not completing wound care as ordered, it could affect wound healing.Licensed practical nurse (LPN) #1 was interviewed on 5/14/26 at 12:00 p.m. LPN #1 said there had been several days she was unable to provide wound care to Resident #9. She said on each of the days she had been unable to provide the wound care, she had asked the nurse on the next shift to complete the resident's wound care. LPN #1 said Resident #9's wound care should have been provided as ordered.The director of nursing (DON) was interviewed on 5/14/26 at 12:12 p.m. The DON said LPN #1 was the nurse on duty five of the six times that wound care was not completed for Resident #9. The DON said LPN #1 told the DON that she did not have time to perform wound care during her shift and had communicated this to the night shift nurse. The DON said there was no documentation that the night shift nurse completed Resident #9's wound care on those dates. The DON said Resident #9's wound could worsen if wound care was not provided as ordered and the resident had missed dressing changes. The DON said if the wound care was not documented in Resident #9's electronic medical record (EMR), it was not done. The DON said she began education with nursing staff regarding the importance of completing wound care as ordered and the necessary documentation.IV. Facility follow upThe DON provided a document titled Inservice: Treatment Documentation and Sign Off Compliance on 5/14/26 at 12:12 p.m. The description of the education provided included the following: Failure to sign off on treatments assigned during your shift is considered a documentation error and may lead to delays in wound care treatment, missed treatments, and potential harm to residents. Accurate documentation ensures continuity of care among staff and provides legal and clinical proof that care was completed. Staff are reminded that: All treatments must be completed as ordered. Treatments must be documented and signed off immediately after completion. Delayed or missing documentation can negatively affect resident outcomes and facility compliance. If it is not documented, it was not done.The inservice education document was signed by 10 nursing staff on 5/13/26 (during the survey).

Based on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#2) of three out of 12 sample residents.Specifically, the facility failed to notify the provider when Resident #2's pain medication was unavailable to be administered. Findings include: I. Professional reference According to PharMerica (undated) Missed Medication Administration retrieved on 2/5/26 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pharmerica.com/wp-content/uploads/2022/03/DidYouKnow_Missed-Medications.pdf Suggested steps for potential unavailable meds include: call pharmacy to order medication (faxing is also recommended for reproducible verification, but call for time sensitive medications); consult pharmacy staff to determine the appropriate delivery time (next scheduled delivery, STAT, etc); notify pharmacy of pertinent diagnoses and if any doses have already been missed; document the name of pharmacy staff you spoke to for your records, as well as keeping any fax confirmations; notify Prescriber of missed dose; and document in progress note that dose was missed and prescriber was notified (with any further instruction given by provider)II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician's orders (CPO), diagnoses included protein calorie malnutrition, contractures (tightening or shortening of tissue around a joint) to the right and left knee, chronic pain syndrome, generalized osteoarthritis and open wounds to the right and left lower leg. The 1/12/26 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff for transfers, toileting, bathing and dressing. B. Resident interview Resident #2 was interviewed on 2/4/26 at 2:03 p.m. He said he had missed his pain medication three or four separate times since he moved into the facility. He said when he missed his immediate release oxycodone, he started to feel increased pain in his legs and withdrawal symptoms that felt like he was craving the medication. He said he also takes a long acting version of the same medication so that helped dampen the effects a little bit of missing the medication. He said he was always in pain and the pain medication helped the pain but did not take it away completely. He said when the facility ran out of the pain medication, he was told they were waiting on it from the pharmacy. He said he relied heavily on the staff and if they messed up his medications, he was the one who had to suffer. C. Record review A review of the February 2026 CPOs included the following orders: -Oxycontin oral tablet extended release (ER) 12 hour abuse-deterrent 20 milligrams (mg), give one tablet by mouth two times a day for pain, ordered 4/28/25-Roxicodone oral tablet 5mg, give two tablets by mouth every four hours for chronic pain, ordered 10/14/25-Oxycodone HCl oral tablet 5mg, give two tablets by mouth every 24 hours as needed for breakthrough pain 5-10 out of 10, ordered 1/27/26-Monitor the level of pain and document 1-10. The resident's acceptable pain is 5/10. Use non-pharmacological interventions before the as needed (PRN) pain medication. Record non-pharmacological interventions in supplementary documentation. Document effectiveness. If pain continues, follow the provider's direction which may include pain medication, every day and evening shift, ordered 10/8/25. A review of the January 2026 medication administration record (MAR) documented the following: -Roxicodone was not administered a total of four out of six doses on 1/26/26 and not administered one dose on 1/31/26. These were documented as other/see nurses notes.-Resident 2's level of pain on 1/26/26 during the 7 a.m. to 7 p.m. shift was documented as 6/10. This was documented at 6:30 a.m.A review of the nursing progress notes included the following: -A nursing progress note from 1/26/26 at 3:05 a.m. documented that the Roxicodone oral tablet 5mg was on order and the nurse was unable to access the pyxis (emergency medication system). -A nursing progress note from 1/26/26 at 6:30 a.m. documented that for the Roxicodone oral tablet 5mg, there was none on hand and the night shift nurse reported it had been re-ordered. -A nursing progress note from 1/26/26 at 10:07 a.m. documented that the Roxicodone oral tablet 5mg was re-ordered and the nurse was unable to access the pyxis.-A nursing progress note from 1/26/26 at 11:26 a.m. documented to offer the resident to get up every day for one hour as tolerated and the residents preferred after lunch in the afternoon. It documented that the resident refused this due to having no pain medication. -A nursing progress note from 1/26/26 at 2:17 p.m. documented that the Roxicodone oral tablet 5mg was re-ordered and the nurse was unable to access the pyxis.-The nursing progress note from 1/31/26 at 5:56 a.m. did not document the reason the medication was not given to the resident. The pain care plan, revised 6/23/25, documented that Resident #2 was at risk for pain or discomfort due to wounds and his disease processes. Interventions included to administer medication as ordered. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/3/26 at approximately 4:32 p.m. She said she re-ordered medications once they were in the blue zone of the medication card, which was about five to seven doses left. She said she tore off the label and handed it to the provider to re-order the medication. She said the providers were at the facility on the weekdays and she was not sure what the nurses did on the weekends or overnight. She said they tried to take care of all medication ordering during the week. The nursing home administrator (NHA), director of nursing (DON), and regional clinical resource (RCR) were interviewed together on 2/4/26 at 10:45 a.m. The RCR said the process for re-ordering medications was when there was a seven day supply of the medication left in the card, ordered through the electronic medical record system or faxed to the pharmacy. She said the provider then needed to sign a new script for controlled substances and the pharmacy reached out to the providers for that. The NHA said the pharmacy can do stat (immediate) runs as needed. The DON and RCR said that if a medication was unavailable, they would expect the nurse to notify the provider to see if they could substitute it for something they had in stock or put the medication on hold and document the communication with the provider. The DON and RCR were interviewed on 2/4/26 at 11:58 a.m. The DON said the facility did not stock the oxycodone that Resident #2 had ordered in their pyxis machine. The RCR said the Roxicodone was ordered on 1/24/26 and filled and delivered to the facility on 1/26/26. She said the provider did not sign the new script until 1/26/26. LPN #4 was interviewed on 2/4/26 at 11:30 a.m. She said she took care of Resident #2. She said he was always in pain. She said he had pain in his legs because he had wounds as well as generalized pain. She said she would set a timer on her phone to make sure she got him his pain medication on time because he had so much pain. She said he refused non-pharmacological interventions for pain because he did not think they helped. She said letting him vent to her seemed to help him. Certified nurse aide (CNA) #1 was interviewed on 2/4/26 at 11:40 a.m. He said Resident #2 complained about being in pain often and he told the nurse right away. The DON and RCR were interviewed again on 2/4/26 at 3:40 p.m. The RCR said they were unsure why the dose of oxycodone was not administered on 1/31/26 and the nurse should have notified the provider and documented the reason it was not administered. The DON said there was plenty of medication in stock at that administration time.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#1) of three residents reviewed for medications errors out of four sample residents. Specifically the facility failed to:-Ensure Resident #1 was administered Midodrine (for low blood pressure) per physician's orders and parameters;-Ensure Resident #1 had a blood pressure taken prior to administration of a hypotension medication; and,-Identify and document medication errors.Findings include: I. Facility policy and procedureThe Medication Administration policy, revised April 2019, was provided by the nursing home administrator (NHA) on 10/8/25 at 11:40 a.m. It read in pertinent part, Medications are administered in a safe and timely manner, as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported and reviewed by the quality assurance performance improvement (QAPI) committee to inform process changes and or the need for additional staff training.The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.Vital signs and allergies are checked prior to administration of the medication.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and discharged [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included unspecified cirrhosis of the liver, muscle weakness, acute respiratory failure with hypoxia (low oxygen) and chronic hepatic (liver) failure.The 8/11/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He used a wheelchair and required maximal assistance with lower body dressing, putting on/off footwear, rolling left to right and sitting to lying. His overall goal was to discharge into the community.B. Record reviewReview of Resident #1's August 2025 CPO revealed the following physician's order related to hypotension (low blood pressure).Midodrine HCI (for hypotension) 5 mg (milligrams) by mouth three times a day for hypotension. Do not give if the blood pressure (BP) was above 100/60 millimeters of mercury (mmHg), ordered 8/7/25. -The physician's order required a blood pressure to be taken prior to administering the medication. A review of the August 2025 medication administration records (MAR) revealed Resident #1 was administered Midodrine 29 times during the month. Resident #1's blood pressure was not taken prior to the administration of the medication on the following days:-8/9/25 for the morning and evening dose; and,-8/10/25 for the morning dose.The Midodrine was administered 21 times when Resident #1's BP was not within the correct physician ordered parameters to give the medication or the medication was not administered when it should have been administered per the parameters. The administration discrepancies were as follows: On 8/10/25 at 12:00 p.m. Resident #1's BP was 112/62 mmHg The medication was administered but should have been held per the physician ordered parameters. On 8/11/25 at 12:00 p.m. Resident #1's BP was 106/94 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/11/25 Resident #1's evening BP was 98/54 mmHg. The medication should have been administered per the physician ordered parameters but it was not administered. On 8/13/25 at 7:00 a.m. Resident #1's BP was 165/77 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/13/25 at 12:00 p.m. Resident #1's BP was 111/60 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/13/25 Resident #1's evening BP was 102/66 mmHg. The medication was administered but should have been held per the physician ordered parameters.On 8/14/25 at 7:00 a.m. Resident #1's BP was 127/66 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/14/25 at 12:00 p.m. Resident #1's BP was 113/69 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/14/25 Resident #1's evening BP was 110/72 mmHg. The medication was administered but should have been held per the physician ordered parameters.On 8/15/25 at 7:00 a.m. Resident #1's BP was 107/66 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/15/25 at 12:00 p.m. Resident #1's BP was 115/80. The medication was administered but should have been held per the physician ordered parameters. On 8/15/25 Resident #1's evening BP was 153/80 mmHg. The medication was administered but should have been held per the physician ordered parameters.On 8/16/25 at 7:00 a.m. Resident #1's BP was 107/76 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/16/25 at 12:00 p.m. Resident #1's BP was 112/75 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/16/25 Resident #1's evening BP was 117/65 mmHg The medication was administered but should have been held per the physician ordered parameters.On 8/18/25 at 7:00 a.m. Resident #1's BP was 125/87 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/18/25 at 12:00 p.m. Resident #1's BP was 112/76 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/18/25 Resident #1's evening BP was 108/70 mmHg. The medication was administered but should have been held per the physician ordered parameters.On 8/19/25 at 7:00 a.m. Resident #1's BP was 106/72 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/19/25 at 12:00 p.m. Resident #1's BP was 104/70 mmHg. The medication was administered but should have been held per the physician ordered parameters. On 8/19/25 Resident #1's evening BP was 117/75 mmHg. The medication was administered but should have been held per the physician ordered parameters.III. Staff InterviewsLicensed practical nurse (LPN) #1 was interviewed on 10/8/25 at 2:17 p.m. LPN #1 said the resident's BP should have been measured prior to the administration of the hypotensive medication for Resident #1. She said it could not be determined if the resident required the medication or not if his BP was not measured since the nurse would be unable to determine the parameters for the medication. She said she should have given the medication on 8/11/25 when Resident #1's BP was 98/54 mmHg. She said on 8/12/25 Resident #1's BP was 105/67 mmHg and she should not have given the medication. LPN #1 said she was not sure why she confused the parameters for the administration of the medication. The director of nursing (DON) was interviewed on 10/9/25 at 12:10 p.m. The DON said if the physician's order for a medication included parameters for the medication, the parameters should be followed. She said Resident #1's BP should have been measured prior to administering his hypotensive medication. She said if the medication was given outside of the parameters, the resident could have a poor outcome. She said she would immediately provide education to the nursing staff on following parameters and ensuring a BP was measured prior to the administration of a hypertensive or hypotensive medication. The regional director of clinical services was interviewed on 12/9/25 at 12:20 p.m. The regional director of clinical services said the facility would immediately provide education to the nursing staff related to any medication with parameters in place and the importance of ensuring vital signs were measured prior to administration. She said the MAR would be changed from the greater than or lower than sign (> and <) to the words greater than or lower than. She said she would audit all residents with medication parameters to ensure the parameters were being followed appropriately.

Based on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for three (#38, #18, #23) of three residents out of 32 sample residents. Specifically, the facility failed to provide food choices according to resident preferences for Resident #38, Resident #18 and Resident #23. I. Facility policy and procedure The Resident Food Preferences policy, revised 2015, was provided by the nursing home administrator (NHA) on 10/22/24 at 4:30 p.m. It read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Nursing staff will document the resident's food and eating preferences in the care plan. II. Resident #38 A. Resident status Resident #38, age greater than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with peripheral angiopathy (blood vessel disease). According to the 9/12/24 minimum data set (MDS) assessment the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required set-up assistance with eating. The MDS assessment indicated the resident was on a therapeutic diet. B. Resident interview Resident #38 was interviewed on 10/17/24 at 9:42 a.m. The resident said he received two omelets and two sausage patties for breakfast on 10/17/24. He said he did not receive hard boiled eggs per his preference. He said there were many times he did not get hard boiled eggs with his meals and he felt like he only got them when the staff remembered. Resident #38 was interviewed on 10/21/24 at 12:30 p.m. The resident said he had two omelets and two sausage patties for breakfast on 10/21/24. He said he did not receive any hard boiled eggs. Resident #38 was interviewed on 10/22/24 at 3:56 p.m. Resident #38 said a while back when there was a different DM, he had been asked about his meal preferences and if there was anything he wanted on a regular basis. He said he told the DM he liked cottage cheese and that he wanted two hard boiled eggs with every meal. The resident said the staff did not always come the night before and ask him what he wanted to eat the next day. He said if he got something he did not like, or that was cooked poorly, he would not necessarily ask for anything else. C. Record review and observations The resident's care plan, revised 8/21/23, revealed the resident was on a therapeutic diet related to his diagnosis of diabetes. He had the potential for nutrition risk, weight fluctuations, and the potential for inconsistent meal intakes related to personal food preferences. Interventions included providing the therapeutic diet as ordered, honoring food preferences as indicated in the meal tracker application, and offering alternate choices as needed. On 8/13/24, a nutritional risk assessment revealed the goals for Resident #38 included consuming over 75% of meals, maintaining or gradually losing weight until goal weight was reached, continuing with the current diet order, monitor meal intakes, weights, and labs, and honor food preferences as able. The October 2024 CPO revealed the resident was on a consistent carbohydrate (diabetic) diet, with regular textured foods, thin liquid consistency, and double protein/entree portions with all meals related to weight loss, ordered on 3/24/24. Resident #38's meal tickets from 10/17/24 and 10/21/24 revealed the following: Double protein/entree portions with all meals. Per resident's request, no dessert on tray for lunch/dinner; he will season his own food. He does not like oregano or cilantro. He wanted two boiled eggs with each meal. On 10/17/24 at 12:40 p.m. Resident #38 was served his lunch in his room. He received two hamburger patties, onions and two cups of coffee. -The resident did not receive hard boiled eggs with his meal. On 10/21/24 at 12:30 p.m., Resident #38 was served his lunch in his room. He received two cups of coffee, a cup of milk, a side of cottage cheese and two hamburger patties. -The resident did not receive hard boiled eggs with his meal. D. Staff interviews The dietary manager (DM) was interviewed on 10/21/24 at 3:14 p.m. The DM said the resident's food preferences were obtained within 48 hours of their admission to the facility and yearly after that unless something changed. The DM said she used a dietary interview sheet to obtain the residents'likes, dislikes and preferences. The DM said if the resident's preference or situation changed, she filled out a communication sheet for staff and entered it into the computer system so it printed out on the resident's meal ticket. The registered dietitian (RD) and speech therapist (ST) were interviewed together on 10/22/24 at 2:18 p.m. The RD said Resident #38's original preference sheet, dated 3/7/24, did not indicate a preference for hard boiled eggs with meals. She said the resident likely requested the two hard boiled eggs from the DM by going directly to the kitchen. The ST said the certified nurse aides (CNA) that worked on night shift verified preferences with residents. She said unless a resident said otherwise, they would get those preferences the next day with their meals. She said if a resident did not want their usual preference, the CNAs crossed the preference off their ticket. The ST and the RD said if hard boiled eggs were on Resident #38's meal ticket as his preference, he should have gotten them. The ST said if Resident #38 did not get his eggs, then staff probably did not read the meal ticket. The ST said it was possible that they did not give him the eggs because of what else he had for his meal, like an omelet, but that should have been clarified with the resident first. She said Resident #38 was vocal about making his needs known and he knew he could request eggs if he did not get them. The RD and the ST said the diet orders and preferences on meal tickets should be followed, otherwise residents could choke on a texture they could not handle and the RD could not obtain accurate calorie counts. The ST and the RD said they had educated the kitchen staff on preparing meal trays, verifying orders and preferences with residents and double-checking that resident meals were correct. The ST and the RD said they also audited resident diet orders and preferences every two weeks. CNA #1 was interviewed on 10/22/24 at 3:23 p.m. CNA #1 said menus came out overnight and CNAs asked residents what meals they wanted for the next day. She said the CNAs also double checked to make sure the resident's preferences were up-to-date. She said if the resident did not want what was on the regular menu they could choose from the bistro menu, and the CNAs wrote that on the resident's meal ticket. CNA #1 said when she passed trays at mealtime, she checked the ticket and tray for accuracy, and if something was missing she went to the kitchen to get the missing item. She said the residents knew they could ask for specific items, especially if they were missing from their order. She said the CNAs offered to get requested items for residents. CNA #1 said if food or drink preferences were listed on the ticket, then the resident should be getting those items. She said if a resident specified they wanted hard boiled eggs at every meal and that was written on the ticket, she said she assumed the resident should get them at every meal even at breakfast, unless when asked, the resident said they did not want them at breakfast. CNA #2 was interviewed on 10/22/24 3:42 p.m. CNA #2 said she thought food preferences were obtained upon admission and then added to the meal tickets. She said when trays were passed in the morning, CNAs could ask preferences then and go get different items if the resident requested. She said Resident #38 liked two cups of cottage cheese with his meals, hard boiled eggs and no dessert. She said with breakfast, he still wanted the hard boiled eggs even if he had omelets for his main meal. She said the CNAs noticed if the resident was missing something and they would go get the missing item for him. 48112 III. Resident #18 A. Resident status Resident #31, age 72 , was admitted on [DATE] and readmitted on [DATE]. According to the October 2024 CPO, diagnoses included peripheral vascular disease (blood vessels narrow and reduce blood flow), bipolar disorder (a mental illness that causes extreme mood swings) and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). The 8/21/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment revealed the resident was on a mechanically altered diet and a therapeutic diet. B. Resident interview Resident #18 was interviewed on 10/16/24 at 11:17 a.m. She said she liked small meals and her meat chopped up because she did not have all her teeth. She said she was not always served small meals. C. Observations On 10/21/24 at 11:30 a.m., cook (CK) #1 prepared Resident #18's lunch meal. CK #1 served Resident #31 a regular portion of ground chicken with sauce, a regular portion of chopped buttered egg noodles with gravy and a regular portion of chopped squash medley. Resident #18's meal ticket indicated she preferred a small portion for lunch. D. Record review The nutrition care plan, revised 8/13/24, revealed the resident received small portion lunches per preference. Interventions included honoring the resident;s food preferences as noted on the tray card system. The 8/20/24 nutritional assessment revealed the resident's likes and dislikes section documented to refer to the resident's meal ticket. IV. Resident #23 A. Resident status Resident #23, age 73, was admitted on [DATE] and readmitted on [DATE]. According to the October 2024 CPO, diagnoses included peripheral vascular disease, cerebral infarction (disrupted blood flow to the brain), malignant neoplasm of the colon (colon cancer), anoxic brain injury (brain deprived of oxygen), psychotic disturbance, mood disturbance, anxiety and severe protein-calorie malnutrition (the body does not get enough foot, protein, and calories). The 9/26/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of nine out of 15 The MDS assessment revealed the resident was on a mechanically altered diet and a therapeutic diet. B. Resident representative interview Resident #23's representative was interviewed on 10/17/24 at 8:51 a.m. She said the facility called her to see if the resident could take an antidepressant medication because the medication helped increase appetite. She said she asked the facility to offer food he liked to eat to help with his food intake. The representative said Resident #23 liked pancakes, biscuits and gravy and apples. The representative said the resident had an apple fritter recently and an unknown staff member said they would see if he could have more apples in his diet. C. Record review The nutrition care plan, revised 9/10/24, revealed the resident received double portions for all meals. The 9/9/24 nutritional interview revealed the resident liked applesauce as a snack. -The nutritional interview did not document the resident's likes and did not indicate the resident was to receive double portions for all meals. The 10/1/24 interdisciplinary team progress note revealed the resident enjoyed biscuits and gravy and would provide double portions when available. The 10/22/24 interdisciplinary team weight progress note revealed the resident received white gravy at breakfast per his request. The facility provided a grievance form and investigation document for Resident #23. The 9/20/24 grievance form revealed the resident asked for more pureed eggs. The kitchen staff said there were no pureed eggs available. The investigation revealed dietary staff were educated on 9/20/24. The investigation revealed if the dietary staff ran out of a serving, they should prepare more on the spot to meet the resident's request. V. Staff interviews The DM was interviewed on 10/21/24 at 3:13 p.m. The DM said she was responsible for obtaining the resident's food preferences. She said she reviewed the food preferences at admission, annually and as needed. She said she documented the preferences on the dietary interview form. She said dietary staff knew a resident's food likes and dislikes based on the resident's meal ticket. The DM said Resident #18 preferred small portions at lunch. She said she did not know Resident #18 received a regular portion of the lunch meal on 10/21/24. She said she would work with the staff to ensure resident's received their food preferences. The DM said Resident #23 liked white gravy, hamburgers and biscuits with gravy. The DM said the meal ticket should indicate to serve double portions of biscuits of gravy. The RD and the ST were interviewed on 10/22/24 at 2:17 p.m. The RD said the DM was responsible for obtaining the resident's food preferences. The RD said the food preferences interview was completed at admission, annually and as needed. The ST said the resident's food preferences were also changed if the resident had weight changes or if their diet order changed based on their therapy sessions. The RD said a resident's routine likes were placed on the meal ticket. The ST said the DM, the RD and the ST had access to the resident's meal tickets. The RD and the ST said Resident #18 preferred small portions at lunch. The RD and the ST did not know Resident #18 received a regular portion of the lunch meal on 10/21/24. The NHA was interviewed on 10/22/24 at 11:11 a.m. The NHA said a dining committee meeting was started about four to five months ago because there was a high number of food grievances. The NHA said the residents who filed a grievance about food were invited to the dining committee. The NHA said another intervention included the manager on duty did a test tray once a day for quality assurance. The NHA said she was not aware Resident #18 was not served a small portion on 10/21/24 and Resident #23 was not served a double portion on 10/21/24 per their preferences. VI. Facility follow up The NHA provided an inservice agenda and sign in sheet on 10/22/24 (during the survey). The nursing and dietary staff were trained on 10/22/24. The training included for the staff to read the resident's meal ticket before giving the meal to the resident. The training said the staff should ensure the resident received the correct diet order, fluids, portion sizes, quantity and supplement. The NHA provided a meal ticket for Resident #23. It revealed the double portion preference was removed. -However, the resident's preference for double portions when biscuits and gravy was on the menu was missing from the meal ticket.

Based on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on two of two medication carts. Specifically, the facility failed to: -Ensure insulin (medication for diabetes) pen injection devices were labeled appropriately with open dates; and, -Ensure inhaler medications were labeled appropriately with open dates. Findings include: I. Professional references According to the Lantus glargine insulin package insert, retrieved 5/6/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, When in use can be kept at room temperature for up to 28 days. According to the Humalog package insert, retrieved on 5/6/24 from https://uspl.lilly.com/humalog/humalog.html#ug, Do not use Humalog past the expiration date printed on the label or 28 days after the first usage. According to the Fluticasone inhaler manufacturer's guidelines, retrieved on 5/6/24 from https://www.advair.com/, Store Fluticasone inhaler in the unopened foil pouch and only open when ready for use. Safely throw away Fluticasone in the trash one month after it is opened or when the counter reads zero, whichever comes first. II. Facility policy and procedures The Storage of Medication policy, revised November 2020, was provided by the nursing home administrator (NHA) on 4/29/24 at 4:50 p.m. It revealed in pertinent part, The facility stores all drugs and biologics in a safe, secure and orderly manner. The nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Medications are stored separately from food and are labeled accordingly. III. Observations and staff interviews On 4/29/24 at 9:55 a.m., the 400 hall medication cart was observed with licensed practical nurse (LPN) #1. The following items were found: -One Fluticasone inhaler that did not have an open date. The medication's box indicated the medication needed to be disposed of one month after opening; and, -One Humalog insulin pen with no open date. LPN #1 was interviewed on 4/29/24 at 10:00 a.m. LPN #1 said insulin medications should be dated when opened to determine when it needed to be discarded LPN #1 said the medication's box indicated to discard the Fluticasone inhaler one month after opening. LPN #1 said the inhaler was not dated and unsure when it was opened. The 500 hall medication cart was reviewed on 4/29/24 at 10:05 a.m. with LPN #2. The following items were found: -One Humalog insulin pen that was dated with a date of opened 2/22/24; and, -One Lantus insulin pen with a date of opened 3/19/24. -The Humalog insulin pen should have been disposed of on 3/21/24 and the Lantus insulin pen should have been disposed of on 4/16/24. LPN #2 was interviewed on 4/29/24 at 10:10 a.m. LPN #2 said Humalog and Lantus insulin pens were good for 28 days after they were opened. LPN #2 said after 28 days, it was possible the medication would be dangerous to administer to a resident. He said open dates were important to know, as some medications were only good for a specific number of days. The director of nursing (DON) was interviewed on 4/30/24 at 2:10 p.m. The DON said medications such as insulin and inhalers should be labeled with the resident's name and the date it was opened. The DON said some medications were only good for a certain number of days after they were opened. She said the effects of the medication could decrease if it was administered after the date it should have been disposed of. The DON said she would provide education for the nursing staff right away.

Based upon observations, interviews and record review, the facility failed to ensure one (#32) of three residents reviewed for assistance with activities of daily living (ADL) received fingernail care out of the 31 sample residents. Specifically, the facility failed to ensure Resident #32's fingernails were trimmed and clean. Findings include: I. Facility policy and procedure The Fingernails/Toenail policy, revised February 2018, was provided by the nursing home administrator (NHA) on 4/30/24 at 1:56 p.m. It revealed in pertinent part, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent residents from accidentally scratching and injuring their skin. II. Resident #32 A. Resident status Resident #32, age greater than 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, muscle weakness, and anoxic brain damage (brain injury related to lack of oxygen). The 2/6/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. He required one person physical assistance with transfers.He required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene. B. Observations On 4/24/24 at 10:21 a.m., Resident #32 was lying in bed. Resident #32's fingernails were visibly soiled. The resident's fingernails were dirty with a dark substance underneath several nails. The resident's fingernails were untrimmed and approximately one inch long. On 4/25/24 at 1:50 p.m. the resident was sitting in his wheelchair in the 600 hall dining room watching television. The resident's fingernails were untrimmed, visibly soiled and had a dark substance under several nails. On 4/29/24 at 3:15 p.m. Resident #32 was observed in his bed in his room. His fingernails were untrimmed and were one inch long. There continued to be dark debris underneath his fingernails. On 4/30/24 at 11:14 a.m. the resident was observed with trimmed but dirty fingernails (dark debris) underneath several nails. -CNA #1 trimmed Resident #32's fingernails on 4/29/24 but did not clean the dark debris from underneath the nails. C. Record review The comprehensive care plan, revised 1/30/24, revealed the resident was at risk for skin breakdown related to anoxic brain damage, generalized weakness, decreased mobility and self inflicted scratches to arms. The interventions included encouraging the resident to allow his fingernails to be trimmed and cleaned. The 2/4/24 progress note documented the resident received fingernail care because his fingernails were long and dirty with dark debris underneath his nails. The resident tolerated it with no behaviors. -However, a review of the resident's electronic medical record (EMR) on 4/30/24, did not reveal documentation to indicate the resident had received further nail care since 2/4/24. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/29/24 at 1:25 p.m. CNA #1 said Resident #32 required assistance with his activities of daily living (ADL), including trimming his fingernails. She said the resident's fingernails were long and had a dark substance underneath them. CNA #1 said dirty and long fingernails could cause injuries such as skin tears CNA #1 said she would assist the resident with fingernail care. Licensed practical nurse (LPN) #2 was interviewed on 4/29/24 at 1:40 p.m. LPN #2 said Resident #32 was dependent on staff and required total assistance with his ADLs. LPN #2 said the CNAs were responsible for providing nail care for every resident during showers and as needed. He said Resident #32's nails were dirty and long. LPN #2 said the resident was at risk of skin breakdown and self-inflicted scratches with his long fingernails. He said the resident's fingernails should be kept trimmed and cleaned. LPN #2 said dirty fingernails could collect bacteria that could lead to the resident getting sick. The director of nursing (DON) was interviewed on 4/30/24 at 2:15 p.m. The DON said the nursing staff was responsible for ensuring residents were assisted with fingernail care. The DON said long and dirty fingernails could lead to illness and injuries, such as skin tears. The DON said she would provide education to the nursing staff and ensure staff completed weekly checks of the resident's nails to ensure their nails were kept clean and trimmed.

Based on observations, record review and interviews, the facility failed to ensure one (#27) of five residents reviewed for unnecessary medications out of 31 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure a resident with a continuous glucose monitor was monitored effectively to include frequency of the glucose monitor changes, training staff on the continuous glucose monitor, and care planning the use of a continuous glucose monitor. Findings include: I. Professional reference According to the Freestyle Libre 2 continuous glucose monitor manufacturer's guidelines, retrieved on 5/1/24 from https://www.freestyle.[NAME]/us-en/safety-information.html, What should you know about wearing a Sensor: -The Sensor can be worn for up to 14 days. -Some individuals may be sensitive to the adhesive that keeps the Sensor attached to the skin. If you notice significant skin irritation around or under your Sensor, remove the Sensor and stop using the System. Contact your healthcare professional before continuing to use the System. -Intense exercise may cause your Sensor to loosen due to sweat or movement of the Sensor. Remove and replace your Sensor if it starts to loosen and follow the instructions to select an appropriate application site. -The System uses all available glucose data to give you readings so you should scan your Sensor at least once every 8 hours for the most accurate performance. Scanning less frequently may result in decreased performance. -Do not reuse Sensors. The Sensor and Sensor Applicator are designed for single use. Reuse may result in no glucose readings and infection. Not suitable for re-sterilization. Further exposure to irradiation may cause inaccurate results. -If a Sensor breaks inside your body, call your healthcare professional. According to the Freestyle Libre 2 continuous glucose monitor manufacturer's guidelines, retrieved on 5/1/24 from https://www.freestyleprovider.[NAME]/us-en/monitoring-freestyle-libre.html. Easy to monitor: FreeStyle Libre 2: Minute-to-minute glucose readings stream directly to your patients' smartphones. II. Resident #27 A. Resident status Resident #27, age 68, was admitted on [DATE]. According to the April 2024 computerized physician's order (CPO), diagnoses included Type I diabetes mellitus, muscle weakness and chronic pain. The 3/1/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interview Resident #27 was interviewed on 4/24/24 at 9:50 a.m. Resident #27 said he had a continuous glucose monitor. He said he would report his blood glucose levels to the nurse three times a day when he received the blood glucose levels on his smartphone. C. Record review The care plan, initiated 12/7/23 and revised 4/26/24, identified Resident #27 had a diagnosis of diabetes. Interventions included obtaining blood glucose checks as ordered and reporting to the physician if the blood glucose was outside of set parameters. -The diabetic care plan did not address the use of a continuous glucose monitor. The April 2024 CPO documented the following physician's orders: Monitor the blood sugar via cgm (continuous glucose monitor) to the upper arm before meals every day (QD). Ordered 3/20/24. Okay to use Freestyle Libre 2 cgm (continuous glucose monitor). Ordered 3/7/24. -The April 2024 CPO did not identify the frequency of cgm (continuous glucose monitor) changes or identify that the resident was to report blood glucose levels to the nurse that he received on his smartphone. -The facility was unable to provide documentation to indicate the staff had been trained on how to use Resident #27's Freestyle Libre 2 cgm (continuous glucose monitor). II. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 4/29/24 at 10:40 a.m. LPN #2 said she had not received any training on the continuous glucose monitor. She said she thought the continuous glucose monitor would be changed every eight days. She said there was not an order that identified the day the continuous glucose monitor needed to be changed. She said Resident #27 reported his blood sugars to the nurse on duty. The director of nursing (DON) was interviewed on 4/29/24 at 4:10 p.m. The DON said Resident #27 reported his blood sugars to the nurse. She said he would get the readings on his phone. She said he changed his monitor by himself and kept his own supplies. She said the facility should have kept track of the frequency for when the continuous glucose monitor needed to be changed. She said the continuous glucose monitor was good for 14 days and she would provide education to the staff. She said the facility had just completed an assessment that identified he was able to change his monitor on his own. She said the assessment should have been done sooner. She said there should have been a care plan to identify the use of a continuous glucose monitor. She said the facility would revise the care plan and train the staff on the Freestyle Libre 2 continuous glucose monitor.

Based on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for one (#20) of three residents reviewed for respiratory care out of 31 sample residents. Specifically, the facility failed to ensure Resident #20 received oxygen therapy in accordance with the physician's order. Findings include: I. Facility policy and procedure The Oxygen Administration policy, revised October 2010, was provided by the nursing home administrator (NHA) on 4/29/24 at 1:59 p.m. It revealed in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician' s order for this procedure. Review the physician' s orders or facility protocol for oxygen administration. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. II. Resident #20 A. Resident status Resident #20, age greater than 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, anxiety disorder, malignant neoplasm of an unspecified part of the left lung (lung cancer), chronic obstructive pulmonary disease (airflow blockage) and type two diabetes (abnormal glucose levels). The 2/13/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She required two person physical assistance for transfers and one person physical assistance with bed mobility, dressing, eating, toileting and personal hygiene. The MDS assessment indicated the resident used oxygen therapy. B. Observations On 4/24/24 at 9:20 a.m., Resident #20 was lying in bed with oxygen in place via nasal cannula. The oxygen concentrator was set at 4 liters per minute (LPM) via nasal cannula. On 4/25/24 at 10:50 a.m. the resident was lying in bed. There were two unidentified staff members in her room assisting her to reposition in bed. The oxygen concentrator was set at 4 LPM of oxygen via nasal cannula. On 4/29/24 at 2:15 p.m. the resident was receiving oxygen at 4 LPM via nasal cannula. On 4/30/24 at 9:14 a.m. the resident was receiving oxygen at 4 LPM via nasal cannula. C. Record review The respiratory care plan, revised 10/10/24, documented the resident required oxygen therapy related to ineffective gas exchange. The interventions included applying oxygen via nasal cannula at 3 LPM continuously and administering medications as ordered by the physician. The April 2024 CPO documented a physician's order for oxygen to be set 3 LPM via nasal cannula continuously to keep the resident's oxygen saturation at or above 90%, ordered on 12/28/24. A review of the April 2024 medication administration record (MAR) from 4/1/24 to 4/30/24 documented the licensed nursing staff documented the resident received 3 LPM of oxygen via nasal cannula. -However, observations on 4/24/24, 4/25/24, 4/29/24 and 4/30/24 revealed the resident was receiving 4 LPM. III. Interviews Certified nurse aide (CNA) #1 was interviewed on 4/29/24 at 1:20 p.m. CNA #1 said the nurses communicated the oxygen rates for each resident to the CNAs. She said the CNAs did not adjust the oxygen settings. She said the licensed nurses set the liter flow on the resident' s oxygen concentrator. CNA #1 said Resident #20's concentrator was set at 4 LPM of oxygen per nasal cannula. Licensed practical nurse (LPN) #2 was interviewed on 4/29/24 at 1:35 p.m. LPN #2 said Resident #20 was receiving 4 LPM of supplemental oxygen. LPN #2 said Resident #20 should have been receiving 3 LPM of oxygen according to the physician' s order. LPN #2 said the physician orders needed to be followed as written to ensure residents received the correct treatments and medications. LPN #2 said the physician should have been contacted to obtain a new order if there was a need to increase the resident's oxygen from 3 LPM to 4 LPM. The director of nursing (DON) was interviewed on 4/30/24 at 2:00 p.m. The DON said a physician's order was required for any medication and treatments. She said in an emergent situation, oxygen could be administered or increased, but a physician's order should be obtained within 24 hours of the change. The DON said it was the responsibility of the licensed nurses to ensure residents were on the correct liter flow of oxygen at the beginning of their shift. The DON said not following the physician' s order could result in medical complications such as shortness of breath, cell damage to the brain. She said she would provide education to the floor nurses to prevent future errors.

Based on observations, record review and interviews the facility failed to ensure one (#14) of one residents reviewed for activities of daily living were provided with services or treatments to prevent the reduction in range of motion out of 39 sample residents. Specifically, the facility failed to ensure Resident #14 was provided with preventative measures to help minimize the development of and the worsening of contractures. Resident #14 had a contracture to his left hand and no preventative measures were implemented. When Resident #14 was assessed during the survey on 10/31/23, his left hand finger contractures worsened and he developed a contracture to his right hand. Findings include: I. Facility policy and procedures The Activities of Daily Living (ADL) Supporting policy, revised in March 2018, was provided by the nursing home administrator (NHA) on 10/30/23 at 8:29 p.m. The policy revealed residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who were unable to carry out ADLs independently. The Resident Mobility and Range of Motion policy, revised July 2017, was provided by the regional director of clinical services (RDCS) on 11/7/23 at 12: 17 p.m. The policy revealed that residents would not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion would receive treatment and services to increase and/or prevent a further decrease in ROM. Residents with limited mobility would receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility was unavoidable. -As part of the resident's comprehensive assessment, the nurse would identify the resident's current range of motion of his or her joints, limitations in movement or mobility, opportunities for improvement, and previous treatment or services for mobility. -As part of the comprehensive assessment, the nurse would also identify conditions that placed the resident at risk for complications related to ROM and mobility. This included muscle wasting/atrophy, contractures and/or other complications that could cause or contribute to immobility, impaired ROM or injury from falls (postural hypotension, urinary incontinence). -During the resident's assessment, the nurse would identify the underlying factors that might have contributed to a range of motion or mobility problems. These include immobilization (bedfast, chair or wheelchair usage), neurological conditions (cerebral palsy, cerebral-vascular accident), conditions in which movement might lead to pain and/or conditions that limit or immobilize movement of limbs or digits (splints). -The resident's care plan would be developed by the interdisciplinary team based on the comprehensive assessment, and would be revised as needed. The care plan would include specific interventions, exercises and therapies to maintain, prevent avoidable decline in and/or improve mobility/range of motion. Interventions might include therapies, the provision of necessary equipment/exercises, based on professional standards of practice that were consistent with state laws and practice acts. -The care plan would include the type, frequency, duration of interventions, as well as measurable goals and objectives. The resident and representative would be included in determining these goals and objectives. Documentation of the resident's progress toward the goals and objectives would include attempts to address any changes or decline in the resident's condition or needs. The Functional Impairment - Clinical Protocol, revised in March 2018, was provided by the RDCS on 11/6/23 at 12:17 p.m. The policy revealed, upon admission to the facility, whenever a significant change of condition occurred, and periodically during a resident's stay, the physician and staff would assess the resident's function along with their physical condition. As part of the physical examination, the physician would include items that related to function as well as the potential to benefit from rehabilitative services; for example, proprioception, sensation, muscle tone, range of motion, gait, balance, joint swelling/abnormalities, strength, edema, and cognition. The staff and physician would identify individuals with the potential for significant improvement in function or significant decline in function, including the ability to perform ADLs. -As appropriate, the physician would identify and evaluate medical conditions and medications that impacted a resident's function (for example, muscle weakness or pain due to adverse medication effects, persistence of complications from recent hospitalization , and sedation or confusion due to fluid/electrolyte imbalance). The physician and staff would review and analyze the preceding information to evaluate the influence of medical factors on function and vice-versa, to help guide subsequent treatment and care planning. The physician would identify and document the impact of medical conditions on function and identify a resident's potential to benefit from rehabilitative services, such as physical and occupational therapy. The staff and physician would collaborate to identify a rehabilitative or restorative care plan to help improve function, quality of life, meet a resident's goals/needs and attain other desired outcomes such as discharge to the community. Based on a review of available information (including results of the evaluation), the physician would determine if a resident met the criteria for skilled therapy services. The physician and staff would address risk factors related to exercise or activity, and consider any relevant precautions. The physician would order any therapy services based on the above considerations. The physician would pay attention to the relevance and effectiveness of such interventions. The physician would not just sign off therapy orders perfunctorily. -The staff would monitor and document the resident's function (for example, evidence of reduced ADL dependency, improved ambulation, improved balance and gait) and would discuss this with the physician periodically in conjunction with a discussion of medical interventions and plans of care. The physician would identify the subsequent relevance of therapy services, based on reviewing the resident's progress relative to his/her care goals (functional stabilization or improvement), the status of conditions and the current treatment regimen that have been identified as affecting his/her function. II. Resident interview and observations The resident was observed on 10/30/23 at 10:54 a.m., seated in a motorized wheelchair in his room. He had bilateral wrist/hand/finger contractures. He did not have any bilateral splints in place. He said he wanted splints for both of his wrists/hands/fingers. He said he had been asking staff for bilateral splints for over a year and they told him that they would see about getting him some. The resident was observed on 10/30/23 at 12:12 p.m. seated in a motorized wheelchair in the dining room. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. A staff member was assisting the resident with his meal. The resident was observed on 10/31/23 at 8:45 a.m. seated in a motorized wheelchair by a nurse medication cart. The resident was being administered medication by the nurse. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident was observed on 11/1/23 at 7:31 a.m., seated in a motorized wheelchair in the dining room. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident was observed on 11/1/23 at 1:43 p.m., seated in a motorized wheelchair in the common television area near hall 500-600. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident was observed on 11/2/23 at 12:49 p.m., seated in a motorized wheelchair in the common television area near hall 500-600. He had contractures on both of his wrists/hands/fingers. He did not have a splint in place for either wrist/hand/fingers. The resident demonstrated he was unable to open his fingers on either hand. III. Resident #14 A. Resident status Resident #14, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included quadriplegia, spinal stenosis in the cervical region, anxiety, schizoaffective disorder, chronic obstructive pulmonary disease, history of transient ischemic attack, muscle weakness, abnormal posture, reduced mobility, history of musculoskeletal system and connective tissue disorders. The 7/25/23 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. According to the assessment, the resident did not exhibit behaviors or refuse care. The resident required extensive staff assistance with two plus persons to physical assist for bed mobility, dressing toileting and personal hygiene. The resident was totally dependent on staff and required physical assistance from two or more persons for transfers. The resident had functional limitations in ranges of motion with impairment on both sides that included his upper extremity (shoulder, elbow, wrist, hand). The resident did not receive any therapy services during the seven-day review period. B. Record review A care plan for dependence with ADL care related to quadriplegia, and chronic pain, cognitive loss was initiated on 3/16/21 and revised on 10/27/23. The plan also revealed the resident exhibited or was at risk for alterations in functional mobility related to quadriplegia, osteoarthritis, degenerative disc disease, history of a fall with spinal cord injury at the cervical levels of 4-7, cervical stenosis of the spine, history of lumbar surgery, history of an open reduction and internal fixation right hip. The relevant interventions were the resident required one to two staff persons for assistance with ADL. Staff were to monitor the resident for shortness of breath, fatigue and/or a change of condition and adjust the ADL task accordingly. Staff were to also encourage the resident to pace himself during an ADL task. Staff were to provide cueing for safety and sequencing to maximize the resident's current level of function. The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. A care plan for restorative nursing program related to bed mobility/transfers was initiated on 9/14/22 and revised on 8/21/23. The relative interventions were to encourage the resident to utilize the bed bar for repositioning on his wide bariatric bed. The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. A care plan for being at risk for decreased ability to perform ADLs related to recent hospitalization , weakness, decreased mobility, diabetes mellitus, and dizziness was initiated on 5/12/21 and revised on 6/6/23. Relevant interventions were for staff to monitor for decline in ADL function. Staff were to refer to rehabilitation therapy if a decline in ADL was noted. Staff were to monitor for complications of immobility (pressure ulcers, muscular atrophy, contractures, incontinence, urinary/respiratory infections). The plan did not reveal the resident had bilateral contractures of his wrist/hands/fingers. The occupational therapy (OT) initial evaluation dated 10/27/2020 noted range of motion for the musculoskeletal right upper extremity (elbow/forearm) was impaired. The left upper extremity hand had impaired range of motion. The musculoskeletal strength for the right upper extremity and the left upper extremity were impaired. -The passive range of motion for the left index finger metacarpophalangeal joint was 70 degrees and for the proximal interphalangeal joint was 75 degrees. -The passive range of motion for the left middle finger metacarpophalangeal joint was 70 degrees and for the proximal interphalangeal joint was 75 degrees. -The active range of motion for the left ring finger metacarpophalangeal joint flexion was 0 (zero) degrees and for the proximal interphalangeal joint flexion was 0 (zero) degrees. -The passive range of motion for the left right finger metacarpophalangeal joint was 75 degrees and for the proximal interphalangeal joint flexion was 75 degrees. -The passive range of motion for the left little finger metacarpophalangeal joint flexion was 70 degrees and for the proximal interphalangeal joint flexion was 75 degrees. -The short term goals were for the resident to tolerate use of a left wrist splint for one hour without sign of skin breakdown or complaint of pain in the left thumb with a target date of 11/16/2020. The long term goals were for the resident to wear a left splint for eight hours without skin breakdown or complaint of pain with a target date of 11/25/2020. -There were no short or long term goals for the resident's right wrist/hand/fingers. The occupational therapy (OT) evaluation dated 12/17/22 revealed the right upper extremity was not tested due to mixed tone; non-functional upper extremity loss of motor control that was chronic in nature. The range of motion of the upper extremity was not tested due to clinical reasons of other tone; non-functional upper extremity that was chronic in nature. The left upper extremity range of motion was not tested related to clinical reasons of mixed tone; non-functional upper extremity. The tone was abnormal; upper extremity muscle tone was spastic, hypertonic, and/or hypertonic flaccid. -There was no recommendation for the use of splints. The occupational therapy (OT) evaluation on 1/26/23 revealed the right upper extremity wrist strength was impaired (no measurements were taken). The left upper extremity was impaired (no measurements were taken). The range of motion of the right upper extremity revealed wrist and hand impairment. -There was no recommendation for the use of splints. The Rehabilitation Screening form dated 10/27/23 (completed during the survey) revealed contractures present and a need for splints. The left wrist and right wrist demonstrated moderately and reflected approximately 50% of full ROM. The left and right fingers were severe and reflected 25% or less of full ROM. Occupational Therapy Evaluation and Plan of Treatment start date of 10/31/23 (completed during the survey) revealed the left wrist had no displays of contractions during active or passive range of motion. The left proximal interphalangeal joints had resting contractures at 90 degrees and passive range of motion to 145 degrees. The right wrist had no displays on contractures. The right wrist active range of motion was limited and would benefit from a resting hand splint. The right interphalangeal joints had resting contractures at 145 degrees, passive range of motion at 170 degrees and would benefit from a resting hand splint. One new goal revealed that the resident would present with a functional wear schedule wearing bilateral hand splints with no redness, or areas of concerns for 15 minutes to preserve joint mobility (target 11/13/23). -The OT assessment dated [DATE] (approximately three years later from 10/27/2020) revealed the resident had contractures of both the left and right interphalangeal joints. This assessment's new goal was for bilateral splints for these areas. This assessment revealed the resident now needed a splint for both hands. -The resident's left hand finger contractures worsened at the hand/knuckle joint based on the decline over three years. -The resident did not have any known contractures to his right hand at baseline and based on the current measurement developed a decline in range of motion. IV. Staff interviews The director of rehabilitation (DOR), registered nurse consultant (RNC) and the quality improvement specialist consultant (QISC) were interviewed on 11/2/23 at 12:02 p.m. They said the resident only had contracture measurements on 10/27/2020 and during the survey on 10/31/23. They said the OT initial evaluation on 10/27/2020 revealed the resident's range of motion for the musculoskeletal right upper extremity (elbow/forearm) was impaired. The left upper extremity hand had impaired range of motion. The musculoskeletal strength for the right upper extremity and the left upper extremity were impaired. The evaluation revealed left hand passive/active range of motion measurements of the resident's fingers and there were no measurements for the resident's right hand. The evaluation had short term goals, that the resident would tolerate use of a left wrist splint for one hour without sign of skin breakdown or complaint of pain in the left thumb with a target date of 11/16/2020. The long term goals were the resident would wear a left splint for eight hours without skin breakdown or complaint of pain with a target date of 11/25/2020. There were no short or long term goals for the resident's right wrist/hand/fingers. They said the evaluation only mentioned the resident's left hand, with a recommendation for the use of a splint for the left hand and did not mention the right hand. They said the documentation on the Rehabilitation Screening form dated 10/27/23 revealed the resident had contractures and there was a need for splints. This screening occurred during the survey process. They said the documentation on the Occupational Therapy Evaluation and Plan of Treatment start date of 10/31/23 revealed a new goal for the resident was to provide bilateral hand splints with no redness or areas of concern for 15 minutes to preserve joint mobility (target 11/13/23). This screening occurred during the survey process. They said the resident did not have any current services for his bilateral hand contractures nor was he on a restorative program for his hand contractures. They acknowledged there was no specific care plan for the resident's bilateral hand contractures.

Based on observations, record review and interviews, the facility failed to provide effective pain management program for two (#53 and #4) of three residents reviewed for pain management out of 39 sample residents. Resident #53 had pain control during a wound dressing change on 10/31/23 at 4:15 p.m. The resident experienced severe pain during the dressing change. The resident was administered a pain medication at 3:40 p.m., although the resident told the nurse that she was in pain, the dressing change continued. The resident was not offered any other type of pain intervention. In addition, the facility failed to for Resident #4: -Have a pain parameters for as needed (PRN) pain medications; and, -Thoroughly assess the resident's pain. Findings include: I. Facility policy The Pain -Clinical Protocol policy, updated October 2022, was received on 11/2/23 at 1:00 p.m. from the nursing home administrator. The policy read in pertinent part, The staff and physician will identify the characteristics of pain such as location, intensity, frequency pattern and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example wound care. II. Resident #53 A. Resident status Resident #53, age 84, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO)diagnosis included bilateral venous stasis ulcers in lower extremities. The 9/21/23 minimum data set (MDS) assessment documented the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The he resident as having two venous and arterial ulcers. The resident had an open lesion and received non sterile dressings. The pain section documented that the resident received PRN (as needed) pain medication. Resident #53 did not receive non-medication interventions for pain. B. Resident interview and observation Resident #53 was interviewed on 10/31/23 at 9:45 a.m. The resident said she had two wounds on both of her lower legs. She said the dressings were changed daily. The resident was observed to have both of her legs wrapped in Curlex wrap with the date of 10/30/23 written on the dressing. C. Wound care observations and resident interview Wound care treatment was observed for Resident #53 on 11/1/23 at 4:15 p.m. The wound care was completed by registered nurse (RN) #1, registered nurse (RN) #3. The quality improvement specialist consultant (QISC) was in the room for a short while. RN #3 was the wound nurse. Certified nurse aide (CNA) #5 was in the room to assist with resident care. The overbed table was used to hold the wound care supplies. RN #1 began to remove the old dressing, spraying the area where the dressing was being pulled away to expose the skin. The dressing was not pre soaked or saturated. As a result when RN #1 pulled off the dressing, Resident #53 verbalized her pain as RN #1 was pulling off the dressing. The resident said, you are debriding the wound. It hurts. Stop! RN #1 did not stop and continued, she responded by saying this was how it was performed and she had performed rounds with the wound physician. She said this as she sprayed the bandage. The resident continued to state the pain she felt as RN #1 continued with the above actions. The QISC intervened and asked if the resident had been given any pain medications before the procedure began. The resident stated that she had not received any pain medications. The QISC asked for a check of the medication administration record (MAR) to see if the resident had received any pain medications prior to the procedure. The QISC returned to the room and said the MAR showed the resident had received Oxycodone 5mg by mouth at 3:40 p.m. The resident was notified and no further medications were administered. The QISC left the resident's room. The resident continued to complain of the pain as RN #1 removed the bandage. RN #1 responded by saying; I know. I know. The resident responded by saying, you have no idea what another person's pain is! After the dressing was removed from each lower extremity, the outer layer of the resident's skin (epidermis) was absent and exposed the second layer of skin (dermis) on the back of the resident's lower leg. The dressing was removed and as the wound cleaner was sprayed on the open wounds, she would say each time it was sprayed that her skin stung, as it was sprayed on the open wounds. Resident #53 was interviewed on 11/2/23 at 8:20 a.m. The resident expressed that during the dressing change on 11/1/23 she sustained a lot of pain and she felt her stated feelings were disregarded, as she expressed the amount of pain she was in, although RN #1 continued with the dressing change. D. Record review The care plan last updated on 9/27/23 identified the resident was at risk for skin breakdown related to decreased activity, diabetes, peripheral vascular disease. The care plan showed the resident had actual wounds to her bilateral lower extremities. Pertinent approaches were to observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered. Complete a weekly skin check by licensed nurse weekly. According to the medication administration orders (MAR) for November 2023 the resident was receiving following medications for pain: Acetaminophen 325 milligram (mg), two tablets every eight hours as needed for mild pain. The order was started on 9/23/22. The order directed to notify the physician if more than three doses in 48 hours. Do not exceed 3 grams a day. Oxycodone HCI oral tablet 5 mg, give one tablet by mouth every six hours as needed for pain 6-10 (with 10 being the worst on the scale). The most recent wound assessment completed on 10/27/23 by the wound care physician (WCP) revealed the resident had two wounds on her bilateral lower extremities. The November 2023 treatment administration record (TAR) showed the physician order was as follows: Left lower leg wash with wound cleaner and pat dry with a 4 X 4 gauze. Apply xeroform to open areas. Cover with ABD (absorbent dressing) and kerlix (to cover wounds) every day and as needed every day shift for wound care. The order was started on 10/21/23 E. Interview The director of nurses (DON) and the QISC were interviewed on 11/2/23 at 1:40 p.m. The QISC said the resident had bilateral venous stasis wounds on her lower extremities. She said the wound physician was involved and saw her weekly. The DON said the dressing changes were to be completed one time a day and as needed. The DON said the resident's legs were to be washed with wound cleanser and the order was to pat it dry with gauze. The DON said after hearing how the dressing was removed (see above) she said the orders would have to be clarified with the physician, as it did not direct how to remove the dressing. The QISC said she had left the room to verify the medication which was administered. She said once they saw the resident had received pain medication and it was not effective for the dressing change, then they should have stopped the dressing changes until the physician could have been called for additional pain medications. The QISC was interviewed a second time on 11/2/23 at approximately 5:30 p.m. The QISC said they spoke with the resident and she verified that the resident had excessive pain with the dressing change on 11/2/23. 47350 III. Resident #4 A. Resident status Resident #4, age 94, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO) the diagnoses included chronic obstructive pulmonary disease (COPD), right femoral fracture and opioid dependence. The 8/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was dependent with toileting, transfers, personal hygiene and required set up assistance only with eating. It indicated the resident was on a scheduled pain medication program, received PRN medications and did received pharmacological interventions for pain management. B. Record review The pain management care plan, initiated on 9/12/19 revised on 4/16/21, indicated the resident had pain related to chronic pain with narcotic dependence history. Interventions included pain medications per physician order, assist with repositioning for comfort, document complaints and non verbal signs of pain, encourage resident to communicate pain, implement relaxation and distraction techniques, observe for potential side effects of medication, therapy to screen as necessary, utilize pain scale as indicated. -A review of Resident #4's comprehensive care plan did not reveal a person centered approach with identification of location, type or intensity of pain the resident experienced. It did not include personalized non-pharmacological interventions to address the resident's pain. It did not identify a baseline assessment of pain or person centered pain management goals. The October 2023 medication administration record (MAR) documented the resident was prescribed the following medications: -Acetaminophen 650 milligrams (mg) at bedtime for pain, ordered 6/9/21. -Methadone 5 mg at bedtime for pain, ordered 6/12/22. -Methadone 2.5 mg once a day for pain, ordered 7/1/22. -Acetaminophen 650 mg every 6 hours as needed for mild pain, ordered 3/31/23. -Hydromorphone 2 mg every two hours as needed for pain, ordered 9/18/23. -A comprehensive review of the October 2023 MAR failed to document location, intensity and type of resident's pain being treated for Acetaminophen, Methadone and Hydromorphone. -The physician orders did not include specific pain scale parameters for the PRN Acetaminophen and Hydromorphone. -The documentation did not include a pain assessment prior to or after the administration of pain medications. C. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 11/2/23 at 11:40 a.m. She said pain assessment should be done prior and after any administration of a pain medication. She said residents that were on multiple pain medications, had been determining which pain medications they wanted to take and parameters were not always ordered for pain medications. The DON was interviewed on 11/2/23 at 1:23 p.m. She said pain medication assessment evaluations should be done on admission and quarterly and when there was a change in the resident's condition. She said there should be physician ordered parameters for all pain medications. She said that pain assessments should be done before and after pain medications administration and documented on the MAR. She said that it had been identified that pain assessment evaluations and pain assessment documentation on the MAR were not being done and were an issue. 20287

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for three out of three units at the facility. Specifically, the facility failed to: -Ensure residents' personal toiletry items were labeled appropriately; -Ensure residents were provided with an opportunity to participate in hand hygiene before meals; -Ensure a wound cleanser was placed in an appropriate place; and, -Ensure the staff had knowledge to ensure blood glucose meters were cleaned properly; Findings include: I. Failure to ensure resident toiletry items were marked in shared rooms A. Observations 11/1/23 at 1:30 p.m. -room [ROOM NUMBER] a shared room, had an unmarked comb at the sink. -room [ROOM NUMBER] a shared room, had an unmarked and unbagged urinal in the bathroom. -The 500 hall shower room had a used unmarked deodorant. -room [ROOM NUMBER] a shared room, had blue container with no name, which had lipstick and other toiletry items at the sink which was unmarked. Also a bar of soap was sitting directly on the sink. II. Failed to ensure residents were provided with an opportunity to participate in hand hygiene before meals A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 11/10/23 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by the CDC, inactivate SARS-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. B. Facility policy The Handwashing/Hand Hygiene policy, dated August 2019, was reviewed by the regional director clinical services (RDCS) on 11/2/23 at 5:53 p.m. The policy read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections. All personal shall be trained and regularly in services on the importance of hand hygiene in preventing the transmission of health care -associated infections. All personal shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections together personnel, residents and visitors. C. Observations On 10/31/23 at approximately 12:00 p.m. the residents in the main dining room were not offered hand hygiene prior to their meal being served. On 11/1/23 at 11:42 a.m. certified nurse aide (CNA )#2 was observed to pass hand hygiene towelettes to residents in the dining room. The CNA was observed to help clean residents hands, collecting used towelettes and passing out new towelettes to the residents in the dining room. However, she did not perform hand hygiene for herself between each task. On 11/1/23 at 1:43 p.m., licensed practical nurse (LPN) #2 was observed to take the vital signs of a resident. She wore gloves while she took the vitals. After completing the vitals, she wore the gloves to hallway, and pushed the vital sign machine down the hall. She then picked up the disinfectant wipe container with her gloved hands, and then cleaned the machine. She failed to perform hand hygiene after leaving the resident room. On 11/1/23 at 501 p.m., the room trays arrived on the 300 unit. At 5:08 p.m., an unidentified certified nurse aide (CNA) passed a room tray to room [ROOM NUMBER]. No handwashing was offered to the resident. The staffing coordinator (SC) was observed to pass several trays to residents on the 300 unit. room [ROOM NUMBER], #315 and room [ROOM NUMBER]. Residents were not offered hand hygiene. On 11/1/23 at 5:31 p.m., the room trays arrived on the 500 unit. At 5:38 p.m., LPN #4 was observed to pass a room tray to the resident in room [ROOM NUMBER]. However, hand hygiene was not offered. D. Staff interview The newly appointed infection preventionist (WN) and the regional nurse consultant (RNC) were interviewed on 11/2/23 at 2:30 p.m. The RNC said the staff were to wash or use hand sanitizer in before and after each task. The RNC said the staff had been trained and educated on hand hygiene. She said the staff were to offer handwashing to residents prior to their meal served. III. Exterior trash dumpster A. Observation On 11/2/23 at 4:30 p.m., with the food service manager present, the dumpster was observed to have approximately 20 dirty used gloves scattered around the ground of the dumpster. Two gloves which were directly in front of the dumpster had light brown substance all over the gloves. B. Staff interview The food service manager was interviewed on 11/2/23 at 4:30 p.m. The food service manager said the dumpster was cleaned by himself and the maintenance director. He said every piece of trash including gloves needed to make it into the dumpster. IV. Failure to ensure wound cleanser was placed in an appropriate place A. Observation On 11/1/23 at 4:45 p.m., registered nurse (RN) #1 was observed to complete wound dressing changes on Resident #53. RN #1 used the wound cleanser and then hung the bottle by the sprayer on the lip of the trash can. RN #1 said she had no other place to put the wound cleanser bottle. B. Staff interview The director of nurses (DON) and the quality improvement specialist consultant (QISC) were interviewed on 11/2/23 at 1:40 p.m. The QISC said the wound cleanser bottle should not be placed on the trash can, as it was not a clean area. 47350 V. Standard precautions for resident glucometers A. Professional reference Institute for Safe Medical Practices. (July 2021). Infection transmission risk with shared glucometers, fingerstick devices, and insulin pens. https://www.ismp.org/resources/infection-transmission-risk-shared-glucometers-fingerstick-devices-and-insulin-pens retrieved on 11/7/23. Whenever possible, blood glucometers should not be shared. If they must be shared, each device should be cleaned and disinfected after every use, per the manufacturer's instructions. B. Manufacturer guidelines Evencare G3 meter manufacturer cleaning and disinfecting procedure guidelines, provided by the nursing home administrator (NHA) on 11/1/23 at 1:50 p.m, included the following guidelines, The Evencare G3 meter should be cleaned and disinfected between each patient. CaviWipes germicidal wipes manufacturer guidelines (2023), https://www.metrex.com/en-us/caviwipes1v retrieved on 11/7/23, included the following guidelines, One minute contact time for virucidal, bactericidal (including tuberculosis) activity. Clorox Healthcare Bleach germicidal wipes manufacturer guidelines (2023), https://www.cloroxpro.com/products/clorox-healthcare/bleach-germicidal-disinfectants/?upc=044600303581, retrieved on 11/7/23, included the following guidelines, Kills human immunodeficiency virus (HIV) in 30 seconds, hepatitis C virus (HCV) in one minute, three minutes for all pathogens listed on label. B. Observations On 11/1/23 at 7:15 a.m. licensed practical nurse (LPN) #1 took out from the medication cart a glucometer not labeled for a resident to check Resident #12's morning glucose. He then returned the glucometer to the medication cart, disposed of Resident #12 test strip from the glucometer that contained blood and wiped down the glucometer with a Cavi wipe with a disinfectant time of one minute. He did not keep the glucometer wet for the designated one minute disinfectant time. C. Staff interviews LPN #1 was interviewed on 11/1/23 at 7:20 a.m. He said each medication cart had a shared glucometer and residents did not have their own designated glucometers. He said the product they were supposed to use were Cavi wipes and that the glucometers needed to stay wet for three minutes to clean glucometers between each resident. LPN #3 was interviewed on 11/1/23 at 8:05 a.m. She said residents did not have individually designated glucometers. She said there was one glucometer on each medication cart to use between residents. She said they cleaned the glucometers with the Sani Cloth germicidal wipes and the disinfectant time was three to five minutes. She said they also had bleach wipes and there was a three minute disinfectant time. Registered nurse #1 was interviewed on 11/2/23 at 8:45 a.m. She said that Cavi wipes were used for glucometers after each use. They need to be wiped, wrapped and left wet for two minutes. She said they also use bleach wipes and glucometers needed to stay wet for two minutes. The DON was interviewed on 11/2/23 at 9:12 a.m. She said the facility had one glucometer for each medication cart and they were to be cleaned after every use. She said they had different products they were using including the Cavi wipes and the bleach wipes. She said she did not know what the disinfectant time was for each of these products but said that the manufacturer's recommendations for each of these products should be followed when disinfecting the glucometers after every use. She said using multiple products for the use of cleaning glucometers was confusing for staff in ensuring that the proper manufacturer guidelines for disinfection were followed.

Based on observations, record review and staff interviews the facility failed to provide services for three (#4, #12 and #36) of four reviewed out of 39 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #4, Resident #12 and Resident #36's vital signs were monitored prior to the administration of a blood pressure medication. Findings include: I. Professional reference Khashayar.F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine.https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 11/8/23. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. Kizior, R. J, [NAME], K. J. (2023). Losarten. [NAME] Nursing Drug Handbook. Elsevier, p. 720. Obtain blood pressure, heart rate immediately before each dose, in addition to regular monitoring. II. Observations and record review On 11/1/23 at 7:15 a.m. licensed practical nurse (LPN) #1 was observed dispensing and administering Coreg (a beta blocker blood pressure medication) 6.25 mg to Resident #12. At 7:11 a.m. LPN #1 did not check for resident vital signs on the medical record, including the resident's blood pressure and pulse, prior to administration. The November 2023 computerized physician order (CPO) documented a physician order of Carvedilol (Coreg) 6.25 milligrams (mg) twice a day for hypertension. -The CPO did not document any vital sign parameters for when to hold the medication or to notify the physician of irregular vital sign results. At 7:30 a.m. LPN #1 was observed and dispensing Losartan 25 mg 0.5 tablet and Metoprolol 25 mg to Resident #36. LPN #1 did not check the medical record for the resident's vital signs including blood pressure and pulse prior to the administration. The November 2023 CPO documented a physician order of Metoprolol extended release (ER)25 mg by mouth twice a day for chronic heart failure and Losartan 25 mg 0.5 tablet once a day for chronic heart failure. -The CPO documented to monitor blood pressure every shift and call the physician if the systolic blood pressure was greater than 150. At 8:05 a.m. LPN #3 was observed dispensing and administering Metoprolol 75 mg (gave three 25 mg tablets). LPN #3 did not check the medical record for the resident's vital signs including blood pressure and pulse prior to the administration. The November 2023 CPO documented a physician order of Metoprolol ER 25 mg tablets give 75 mg once a day for hypertension. -The CPO did not document any vital sign parameters for when to hold the medication or to notify the physician of irregular vital sign results. III. Staff interviews Registered nurse (RN) #1 was interviewed on 11/2/23 at 8:45 a.m. She said that prior to the administration of any blood pressure medication, blood pressure and pulse should be assessed. She said this was done to keep from dropping the blood pressure and pulse too low after administering the medication. The director of nursing (DON) was interviewed on 11/2/23 at 9:17 a.m. She said that any resident on a blood pressure medication should have a blood pressure assessed prior to the administration of any blood pressure medication. She said this was done to ensure the blood pressure and pulse were not too low prior to the administration of the medication. She said the vital signs should be documented on the resident's medical record and attached to the blood pressure order.

Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for three licensed practical nurses (LPNs) and and one registered nurses (RNs). Specifically, the facility failed to: -Complete competencies for LPN #1, #3 and #2; and, -Complete competencies for RN #5 Cross-reference F760 failure to identify skill training and competencies for staff education in mathematics calculations for liquid medications. I. Observation On 11/1/23 at 7:35 a.m. licensed practical nurse (LPN) #1 checked Resident #36 ' s oral morphine order on the medication administration record which read Morphine 20 milligrams (mg)/5 milliliters (ml) give 0.25 ml. LPN #1 obtained the oral morphine from the medication administration cart which read 100 mg/5 ml. He then pulled up 0.25 ml of the 100mg/5ml concentration and administered it to Resident #36. II. Competencies The competency files for LPN #1, LPN #2, LPN #3 and RN #5 were reviewed. Competencies for mathematical calculations for liquid medications was not provided. III. Interview The quality improvement specialist consultant (QISC) was interviewed on 11/1/23 at approximately 3:00 p.m. The QISC said they did not have competencies on mathematical calculations for liquid medications. She said they were providing training. IV. Facility follow-up The facility provided documentation on 11/1/23 that the nurses were provided on the spot medication administration for liquid narcotics and ensuring math was correct.

Based on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for five (#64, #34, #26, #21 and #52) of eight residents reviewed for immunizations out of 39 sample residents. Specifically, the facility failed to: -Offer Resident #64 and #21 the pneumococcal vaccine upon admission; -Offer additional doses of the pneumococcal vaccine to Resident #26 and #34; and, -Offer Resident #52 the pneumococcal vaccine after signing a consent to receive. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States, 2023, retrieved on 11/5/23, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: Routine vaccination - pneumococcal -For those ages 19 or older with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance) followed by PPSV23 (pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23)or one (1) dose PCV20 (pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20). (see notes) -For those over the age of 65 who meet age requirement and lack documentation of vaccination, or lack evidence of past infection was: One (1) dose PCV15 followed by PPSV23 or one (1) dose PCV20. Special situations: Age 19-[AGE] years with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown: One (1) dose PCV15 or one (1) dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. -Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus (HIV), Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies. -Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF (cerebral spinal fluid) leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies. II. Facility policy The Pneumococcal Vaccine policy, revised March 2022, was provided by the nursing home administrator (NHA) on 10/30/23. It read in pertinent part, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, wil be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. III. Resident #64 A. Resident status Resident #64, age 62, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO) diagnoses included, type II diabetes, history of transient ischemia attack and cerebral infarction (stroke) without residual deficits. The 8/22/23 minimum data set assessment (MDS) revealed Resident #64 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. -The MDS documented, that the resident was not up to date on the pneumococcal vaccination, due to not being offered. B. Record review A review of Resident #64's electronic medical record (EMR) revealed the immunization tracking sheet showed the resident had not received the pneumococcal vaccination. -The EMR showed a blank consent as it was not signed and did not show any decision. IV. Resident #34 A. Resident status Resident #34, age 87, was admitted on [DATE]. According to the November 2023 CPO the diagnoses included COPD. The 8/3/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. -The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination. B. Record review A review of Resident #34's EMR revealed the immunization tracking sheet showed the resident received pneumovax dose one on 7/28/14 and the Pneumococcal Polysaccharide vaccination (PPV23) on the same date of 7/28/14. -There was no evidence that the resident had been offered the pneumococcal vaccine any other date. V. Resident #26 A. Resident status Resident #26, age 88, was admitted on [DATE]. According to the November 2023 CPO diagnoses included chronic hypoxic respiratory failure, chronic heart failure (CHF), atrial fibrillation and type II diabetes. The 9/14/23 MDS assessment revealed the resident had minimal cognitively impairment with a brief interview for mental status score of 13 out of 15. -The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination. -The annual 6/22/23 MDS coded the resident as not being up to date on the pneumonia vaccination because it was not offered. B. Record review A review of Resident #26's EMR revealed the immunization tracking sheet showed the resident received the Prevnar 13 on 12/23/14. -There was no evidence that the resident had been offered the pneumococcal vaccine any other date. VI. Resident #21 A. Resident status Resident #21, age 90, was admitted on [DATE]. According to the 7/8/23 MDS assessment diagnoses included coronary artery disease and chronic obstructive pulmonary disease. The 7/8/23 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of seven out of 15. -The MDS documented the resident was not up to date on the pneumococcal vaccination, due to not being offered. B. Record review A review of Resident #21's EMR revealed the immunization tracking sheet showed the resident had not received the pneumococcal vaccination. -There was no evidence that the resident had been offered the pneumococcal vaccine any other date. VII. Resident #52 A. Resident status Resident #52, age 72, was admitted on [DATE]. According to the November 2023 CPO diagnoses included hypertension and pulmonary embolism. The 9/24/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. -The MDS assessment inaccurately documented the resident was up to date on the pneumonia vaccination. B. Record review A review of Resident #52's EMR revealed the immunization tracking sheet showed the consent required for the Prevnar 13 pneumonia vaccination. A pneumococcal vaccination consent form signed on 3/9/22 (the year was incorrect on the form, as the resident was admitted on [DATE]) showed the resident gave consent to receive the Prevnar 13 vaccination. However, the resident had not received it. VIII. Interview The regional nurse consultant (RNC) and the new infection preventionist (RN #3) were interviewed on 11/2/23 at 2:30 p.m. The RNC said the facility offered residents pneumonia vaccinations. She said at admission the resident's vaccination record was obtained. She said the Colorado Immunization Information System (CIIS) was utilized. She said the admitting nurse would then offer and provide education to the resident on the importance of being vaccinated against pneumonia.

Based on record review and interviews, the facility failed to submit a preadmission screening and resident review (PASRR) level I for one (#23) of four residents reviewed for PASRR out of 39 sample residents. Specifically, the facility failed to submit a PASRR level I for Resident #23 who was admitted with a known major mental illness. Findings include: I. Facility policy and procedure The PASRR policy and procedure, with no review date, was received by the nursing home administration (NHA) on 11/1/23 at 1:50 p.m. It read in pertinent part: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions. II. Resident status Resident #23, age 75, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included major depressive disorder and anxiety. The 9/11/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. She required supervision of one staff member with transferring, dressing, toilet use and personal hygiene. The PASSRR was not coded on the assessment. The 6/13/23 MDS assessment coded the resident had not been evaluated by level II PASRR. III. Record review The October 2023 medication administration record (MAR) revealed Resident #23 had orders for Trazadone (antidepressant) for a diagnosis of insomnia, venlafaxine (antidepressant) for diagnosis of depression, seroquel (antipsychotic) for behavior management and ativan (antianxiety) for diagnosis of terminal agitation. The psychotropic medication use care plan, with a last review date of 9/21/23, revealed Resident #23 was at risk for complications related to the use of seroquel, trazodone, ativan and venlafaxine. It indicated she would use the smallest, most effective dose, without side effects for 90 days. Interventions included completing behavior monitoring, monitoring for changes in mental status and functional levels, monitoring for continued need of medication as related to mood and behaviors and monitoring for side effects and consulting physician or pharmacist as needed. -The facility failed to have a PASRR on file for Resident #23 IV. Staff interviews The nursing home administrator (NHA) was interviewed on 11/1/23 at 1:20 p.m. She said the facility had recognized a lack of follow through with PASRR not being submitted timely and were in the process of conducting a facility audit. She said the goal of the audit was to ensure resident needs were being identified timely. The social services director (SSD) was interviewed on 11/1/23 at 3:00 p.m. She said every resident admitting to a long term care facility must have a PASRR level I completed. She said a PASRR was required by the facility to ensure care needs could be met for any resident identified as having a major mental illness. She said she could not find documentation or any record of a PASRR level I being completed for Resident #23. She said a PASRR level I would be completed and submitted to the overseeing State Agency for Resident #23.

Based on record review and staff interviews, the facility failed to inform residents of the facility's bed hold policy for one (#85) of three residents reviewed for discharge/transfer out of 39 sample residents. Specifically, the facility failed to ensure Resident #85 or their responsible party were informed in writing of the facility's bed hold policy prior to being discharged or transferred from the facility. Findings include: I. Facility policy and procedure The Bed Holds and Returns policy, dated October 2022, was provided by the director of nurses (DON) on 11/2/23. The policy read in pertinent part, All residents/representatives are provided written information regarding the facility and state bed-hold policies which address holding or reserving a resident's bed during periods of absence (hospitalization s). Residents, regardless of payer source, are provided written notice at least twice: a. Notice 1: well in advance or any transfer (admission packet); and b. Notice 2: at the time of transfer (or if the transfer was an emergency, within 24 hours). II. Resident #85 A. Resident status Resident #85, under age 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2023 computerized physician orders (CPO) diagnoses included cerebral palsy, legal blindness, reduced mobility, major depressive disorder, personality disorder, complete paraplegia and history of diseases of the musculoskeletal system and connective tissue. The 10/4/23 minimum data set (MDS) assessment documented the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive two person assistance with bed mobility, transfers, dressing, toileting, extensive one person assistance with personal hygiene and set up assistance for eating. B. Resident representative interview The resident's responsible party was interviewed on 11/2/23 at 1:00 p.m. The resident's responsible party said the resident was discharged to the hospital for pain. She said she nor her daughter received written notice about a bed hold notice upon transfer, which was described the bed hold policy. B. Record review The 10/13/23 progress note documented the resident was discharged to the hospital. The paramedics transported the resident to the hospital. -The medical record failed to show a written bed hold policy was provided for the discharge to the hospital on 10/13/23. C. Interview The director of nurses (DON) was interviewed on 11/3/23 at 11:00 a.m. The DON said the bed hold policy was to be provided in writing to the resident/responsible party upon discharge. The DON reviewed the medical record and was unable to locate any documentation that the bed hold policy was provided in writing to the resident/responsible party.

Based on observations, record review and staff interviews the facility failed to ensure the right to self administer medications appropriately in one (#34) out of 39 sample residents. Specifically, the facility failed to -Ensure Resident #34 had an evaluation and a physician's order for Resident #34 to self administer eye drops and nasal spray at the bedside; and, -Ensure Resident #34 had a physician's order to self administer inhalers at the bedside Findings include: I. Facility policy and procedure The Self Administration of Medications policy and procedure, reviewed February 2021, was provided by the NHA on 11/2/23 at 1:00 p.m. It read in pertinent part, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT ) assesses each resident's cognitive and physical abilities to determine whether self administering medication is safe and clinically appropriate for the resident. Self administered medications are stored in a safe and secure place, which is not accessible by other residents. Any medications found at the bedside that are not authorized for self administration are turned over to the nurse in charge for return to the family or responsible party. II. Resident #34 A. Resident status Resident #34, age 87, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO) the diagnoses included COPD. The 8/3/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She was independent with eating, toileting, transfers and required set up only for personal hygiene. B. Observations On 10/30/23 at 2:45 p.m. Resident #34 had combivent inhaler, advair inhalers, fluticasone nasal spray and eye drops on her bedside table. C. Record review The medication self administration care plan, initiated 5/3/18, revealed the resident chooses to self administer medications and keep Aspercreme with lidocaine at bedside in a locked drawer. Interventions included obtaining a physician's order to store the medication at the bedside and obtaining a complete physician's order for the resident to self administer the specific medication. -A comprehensive review of the care plan failed to reveal care planned interventions for the self administration of Combivent and Advair inhalers, fluticasone nasal spray or eye drops. The November 2023 CPO did not reveal documentation of a physician's order for self administration of Combivent inhaler, Advair inhaler, fluticasone nasal spray or eye drops. The Self Administration of Medications evaluation, dated 6/22/23, revealed Resident #34 could self administer inhaled and nebulized medications and keep by the bedside. -The self administration of medication evaluation indicated that nasal or eye medications could not be self administered. A physician order was obtained on 11/1/23, during survey, that Resident #34 could self administer inhalers and keep them at the bedside. III. Staff interviews LPN #3 was interviewed on 11/1/23 at 10:00 a.m. She said residents who self administer medications need a physician order and should be documented on the medical administration record (MAR) . She was not aware that a self evaluation needed to be done prior to allowing a resident to self administer or keep medications at the bedside. The DON was interviewed on 11/1/23 at 10:25 a.m. She said a self administration evaluation was completed and medications that could be self administered identified. She said there needs to be a physician order for which medications could be self administered. She said these medications needed to be locked up at the resident's bedside to keep medications from getting in the hands of other residents. She said that Resident #34 had been self administering her inhaler medications but was not allowed to self administer the nasal spray or eye drops. She said the nasal spray and eye drops should be administered by a nurse and locked back into the medication administration cart.

Based on record review and interviews the facility failed to coordinate assessments with the preadmission screening and resident review (PASRR) program for two (#16 and #32) of nine residents reviewed for PASRR out of 39 sample residents. Specifically, the facility failed to: -Ensure a PASRR level II evaluation was available in the medical record of Resident #16 with a known major mental illness; and, -Ensure a PASRR level II evaluation was completed for Resident #32 after the resident was identified as having a known major mental illness. Findings include: I. Facility policy and procedure The PASRR policy and procedure, with no review date, was received by the nursing home administration (NHA) on 11/1/23 at 1:50 p.m. It read in pertinent part: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. A record of the pre-screening shall be maintained in the resident's medical record. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. II. Resident #16 A. Resident status Resident #16, age 83, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included depression and bipolar disorder. The 8/11/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required supervised assistance with transferring, dressing, toilet use and personal hygiene. The PASRR was not coded on the assessment. The 2/26/23 MDS assessment coded the resident had not been evaluated by a level II PASRR. B. Record review The 3/9/2020 post admission PASRR/status change revealed Resident #16 was being reviewed for a change in a psychiatric medication, no serious symptoms were reported by facility and a level II PASRR was already in place at the facility. The mood and symptoms care plan, with a review date of 9/21/23, revealed Resident #16 was at risk for distressing and fluctuating mood symptoms related to depression and bipolar disorder, symptoms included angry outbursts. It indicated the resident would verbalize thoughts and feelings that contribute to depression and the resident would engage in counseling or supportive relationships. Interventions included attempting non pharmacological interventions such as music, art, pet visits, empowering activities such as a volunteer job or engaging in resident council and encouraging the resident to participate in weekly counseling sessions. -The facility failed to produce a PASRR level II evaluation for Resident #16, nor was there a care plan pertaining to any evaluation recommending interventions from an evaluation. -The facility failed to produce any documentation of counseling sessions for Resident #16. III. Resident #32 A. Resident status Resident #32, age 69, was admitted on [DATE]. According to the October 2023 CPO, the diagnoses included anxiety and schizophrenia. The 9/11/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He was independent with transferring, toilet use and personal hygiene. The PASRR was not coded on the assessment. The 3/8/23 MDS coded the resident had been evaluated by a level II PASRR and determined to have a serious mental illness. B. Record review The 7/6/23 PASRR level I revealed Resident #32 would require a level II evaluation regarding known or suspected major mental illness and the facility would be contacted by a PASRR employee regarding scheduling the level II evaluation. The mood and behavior care plan, with a review date of 9/21/23, revealed Resident #32 was at risk of presenting with distressing or fluctuating mood and behaviors related to a diagnosis of schizophrenia, he would become hyper-fixated for short periods of time and facility was monitoring episodes and behaviors of increased rapid pacing and rapid speech. It indicated the resident would demonstrate an improved mood state as evidence by displaying a happier demeanor. Interventions indicated Resident #32 enjoyed listening to music, walking around, socializing with various staff members, being provided supportive visits by social services as needed and watching television in his room. IV. Staff interview The social services director (SSD) was interviewed on 11/1/23 at 10:30 a.m. She said every resident admitting to a long term care facility must have a PASRR completed. She said a PASRR was required by a facility to ensure care needs could be met for any resident identified as having a major mental illness. She said it was the responsibility of the hospital or referring facility to make the PASRR referral or the responsibility of the facility to make the PASRR referral if a resident admitted from their home in the community. She said she had only been working in the building since August 2023 and would attempt to locate PASRR level II evaluations for Resident #16 and #32. The nursing home administrator (NHA) was interviewed on 11/1/23 at 1:20 p.m. She said the facility had recognized a lack of follow through with PASRR not being submitted timely and were in the process of conducting a facility audit. She said the goal of the audit was to ensure resident needs were being identified timely. The SSD provided PASRR update on 11/1/23 at 2:38 p.m. regarding Resident's #16 and #32. She was unable to receive the PASRR level II evaluation for Resident #16 as the national provider identifier (NPI- numerical identifier that identifies an individual provider or a healthcare entity) had changed. She said a PASRR level II evaluation was never completed for Resident #32 because the previous social worker had not followed through on scheduling.

Based on observations, interviews and record review, the facility failed to ensure residents had the right to a dignified existence out of 42 sample residents. The facility failed to ensure residents experienced a dignified living experience by ensuring residents were treated with respect and dignity. Residents of the facility expressed being yelled and chastised by staff and retaliation by the facility. A resident stated he was tired of feeling like we are nobody, he served his country for freedom and he can't die with dignity; he wanted to be treated like a human being, not a child. Furthermore, the facility failed to treat Resident #83 with respect and dignity. Findings include: I. Residents being treated with respect and dignity (cross-reference F565 resident group response) A. Resident group interview The resident group interview was conducted on 4/20/23 at 11:00 a.m., with 12 alert and oriented residents. The resident in the council meeting said the following: The residents said that dignity and respect had always been a thing around here as residents were always being yelled at and chastised by the staff. One resident said I am tired of the retaliation. When you blow the whistle they retaliate. One of the residents said I am tired of feeling like we are nobody, we are grown adults. The resident then said it makes me wonder why I served my country for freedom and we can't die with dignity. I want to be treated like a human being, not like a child. B. Administrative interview The director of nursing (DON) was interviewed on 4/20/23 at 5:00 p.m. The DON said the staff treat the residents with respect and dignity. She said when she received a complaint, she would ensure it was investigated to rule out abuse. She said at times the complaint could be customer service oriented, then the staff would be educated on customer service. She said customer service was taught at orientation and it included respect and dignity. Staff were trained to listen to residents and to ensure the resident was cared for in a dignified manner. She said residents had the right to complain and not to be fearful of retaliation. II. Resident #83 A. Resident status Resident # 83, age 81, was admitted to the facility on [DATE]. The April 2023 computerized physicians orders (CPO) indicated that the resident had a diagnosis of chronic obstructive pulmonary disease, insomnia, anxiety disorder, hallucinations, type 2 diabetes and chronic kidney disease. The 3/22/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. Resident #83 required supervision with eating, support was provided with showers, however the resident refused each time. The resident required the use of a manual wheelchair. The resident was independent with toilet use, dressing, and bed mobility. B. Observation On 4/19/23 at approximately 1:45 p.m. loud arguing between Resident #83 and the receptionist could be heard. Resident #83 was at the front receptionist desk. The resident was telling the receptionist that she had not done something that he had requested. He was talking loud, using foul language and his tone of voice was argumentative. The receptionist was observed to engage the resident with her tone of voice, was also argumentative and she continued to reply back to the resident in a disrespectful manner. She did not talk to the resident in a manner which provided dignity. C. Resident interview Resident # 83 was interviewed on 4/18/23 at approximately 2:00 p.m. The resident said he did not like how the facility staff spoke to him. He said he had to deal with a lot of issues in his life, but the way he was spoken to by facility staff made him upset. He said the staff would not believe him when he asked for assistance and the request was always matched with an argument from the staff. He said he knew he did not communicate his needs in a pleasant manner. The resident was interviewed a second time on 4/19/23 at approximately 2:45 p.m. The resident said that he felt like his right to be treated with dignity was taken from him. He said that he did not think the receptionist should talk to him the way she did. D. Record review The care plan, revised 1/27/23, included that arguing with Resident # 83 made his situation worse which made him feel like he had been scolded in front of the other residents. The social services (SS) advised the staff for the resident to be spoken to in a calm manner which diffuses a situation. E. Staff interviews The DON was interviewed on 4/19/23 at 2:08 p.m. She said Resident #83 had been asking the staff all day about the refrigerator in his room to be repaired. She said Resident #83 told her he felt like he had been disrespected by the staff. Resident #83 spoke of an incident in which he spoke to the receptionist about his refrigerator. He said she told him that it was not her job to look at his refrigerator and that he should go talk to the maintenance department about his problem. Certified nurse aide (CNA) #9 was interviewed on 4/19/23 at 4:00 p.m. The CNA confirmed she observed the interaction between the receptionist and Resident #83. She said that although Resident #83 could be difficult, the receptionist should have walked away when he was using foul language rather than using the disrespectful tone. 48114

Based on observations, interviews and record review, the facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living (ADLs) for two (#8 and #11) out of three reviewed for ADLs out of 42 sample residents. Resident #8 admitted to the facility for long term care with diagnoses of cerebral palsy (disorders that affect a person's ability to move and maintain balance and posture), legal blindness, paraplegia (paralysis of the lower body), reduced mobility, lack of coordination, major and depressive disorder.The resident required extensive two person assistance with most ADLs. The resident had used an electric wheelchair for independence and mobility since she was four years old. The facility failed to repair the resident's electric wheelchair which prevented her from getting out of bed, attending activities and the ability to socialize with staff and other residents (cross-reference F679 for activites). The resident stated due to not being able to use her electric wheelchair, it has been death to me and said they (the facility) took my legs away. I can't leave my room. She said the facility did not feel like her home anymore. Per staff interviews, the resident was not herself and upset since she was unable to get out of her room due to not having her electric wheelchair. In addition, the facility failed to ensure strategies were in place to effectively communicate with Resident #11, who spoke a language other than English and assess Resident #11's wheelchair and ambulation to maintain his mobility. Findings include: I. Resident #8 A. Resident status Resident #8, under age 65, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the April 2023 computerized physician orders (CPO) diagnoses included cerebral palsy, legal blindness, reduced mobility, lack of coordination, major depressive disorder, personality disorder, generalized anxiety disorder, stiffness of joints, muscle weakness, contractures of left elbow, right elbow, left wrist, and right wrist, complete paraplegia and history of diseases of the musculoskeletal system and connective tissue. The 3/29/23 minimum data set (MDS) assessment documented the resident had a minor cognitive deficit with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required extensive two person assistance with bed mobility, transfers, dressing, toileting, extensive one person assistance with personal hygiene and set up assistance for eating. The resident used an electric wheelchair. B. Resident interview and observation The resident was interviewed on 4/17/23 at 4:47 p.m. The resident said her personalized electric wheelchair was broken. The tray that was used for her to do activities was broken. She said a certified nurse aide (CNA) broke the tray by letting it slam to the floor rather than letting it go slowly. She said her electric wheel chair which she used for mobility would not turn on. The resident said the wheelchair had been broken for approximately five weeks. She said she had written a letter to administration to inform them the wheelchair was broken and it still had not been fixed. The resident said she had been using an electric wheelchair since the age of four years old. She said she could not use a manual chair. The resident was interviewed a second time on 4/18/23 at 2:58 p.m. The resident said the electric wheelchair had been working on her birthday and three days later it stopped working. The resident said she had been sitting in the wheelchair in the room and attempted to turn it on to move into position to get into bed and it would not turn on and it had not worked since. She said a few days after it had stopped working she had asked a CNA to check the chair to see if it would work and it would not. She said that neither staff or administration had informed her about either a new chair or fixing the current one. She said she started using an electric wheelchair at age four and that was all she had ever known, she said using a manual wheelchair would be like death to me. She said she would have to depend on everyone to move her in the chair. She felt the facility had dehumanized her by not fixing the wheelchair, they took my legs away. I can't leave my room. During the interview at 3:08 p.m. the resident called a family member. The family member said the facility staff have not been nice at all and she felt she had to stay away and could not visit the resident. She said the facility informed her they would have to pay out of pocket to get the wheelchair fixed or a new one and the facility had not offered any assistance, they are not helping at all. She said the resident had been praying to die and the resident had been suffering mental anguish because the wheelchair was not working. As a result of the wheel chair not working, the resident has had to stay in bed, otherwise, she was always up and about. The resident said she felt the facility was not a home anymore. The resident was interviewed a third time on 4/19/23 at 10:16 a.m. She said that her family member had the wheelchair company and had been informed there had been appointments scheduled to come inspect the wheelchair to see what would be needed to fix it and that the appointments had been canceled by the facility. She had been informed that she was qualified for new parts that would fix the chair. She said this information makes her feel like they kept her in bed on purpose when they did not need to. During the survey from 4/17/23 to 4/24/23 the resident did not leave her bed. C. Record review Care plan The care plan for daily routine, revised on 10/24/22, documented the resident indicated it was important that she had the opportunity to engage in daily routines that are meaningful to her. Interventions include it was important for her to be able to choose her bedtime, watching tv (television), and to engage in her favorite activities. The care plan for psychosocial distress, revised on 10/24/23, documented the resident exhibited psychosocial distress with her own well-being. Interventions include: monitor mood state or behavioral symptoms impacting social relationships, encourage resident participation in activity preferences, encourage the resident to notify and seek out staff support as indicated for support and intervention. The care plan for distressed mood, revised on 2/7/22, documented the resident is at risk for distressed/fluctuating mood symptoms related to sadness/depression. The resident may exhibit depressed mood through mood swings, self-isolation, less talkative increased tearfulness, increased sleep, decreased appetite, and repeatedly going over thoughts. Interventions include: monitor for signs/symptoms of worsening sadness/depression, social services to provide support as needed. Progress notes An encounter with the physician note dated 2/3/23, documented a persistence of depression and the tray and wheelchair being broken again, stuck in the reclined position, thus being confined to her bed and not happy. She said that her mood sucks, often has low energy and is getting worse. The resident said she has severe anxiety and a main source of was due to isolation. She said she tries to stay busy by hanging out with other residents. She said she was unable to do art because the tray for the wheelchair was broken and would take six months to replace, she had tried to do some art but was unsuccessful. A social services note dated 2/10/23 documented a phone call with a wheelchair company regarding the expense to fix the electric wheelchair. A social services note dated 2/22/23 documented social services communication with the insurance company regarding lack of funds to repair the electric wheelchair. Nursing note dated 3/3/23 documented the resident had been up in her electric wheelchair and participating in activities that day. -The wheelchair was running due to the maintenance director wrapping the joystick (see director of nursing interview), however the wheelchair was still not functioning properly. A social services note dated 3/31/23 documented a phone call with a care coordinator regarding the expense to fix the broken electric wheelchair. Interdisciplinary team (IDT) note dated 4/5/23 documented the resident's electric wheelchair was not working and therapy had been working with the wheelchair company for maintenance and the resident potentially needs a new wheelchair. A nursing note dated 4/10/23 documented the residents refusal to use a manual wheelchair because they were ill fitting, caused pain, and she would be unable to move herself, requiring another person to move her. A general note dated 4/11/23 documented the electric wheelchair was broken and then reported the resident being frustrated with the chair being broken and she was unwilling to use a manual wheelchair due to being uncomfortable and the resident was in bed during the visit. D. Wheelchair company interview and documentation The director of the wheelchair company was interviewed over the phone on 4/24/23 at 1:14 p.m. He said he was the director for the area. He remembered speaking to the family member. He said once a wheelchair was paid for by Medicaid it stayed covered by them. He said he had informed the family member that appointments had been scheduled visits but did not know why they had been canceled. The director delivered documentation for 10/19/22 that revealed, an order for repairs was created but canceled later the same day. The facility manager called and wanted to process an order for a new chair, the repair order was canceled and forwarded to another department. On 10/19/22 the rehabilitation department of the wheelchair company received a call from the facility to start an order for a new chair, they were informed that Medicaid did not pay for a new wheelchair in a skilled nursing facility, the order was canceled on 10/31/22. No further contact had been established since 10/31/22. -The facility did not contact the wheelchair company to establish a repair order again. E. Staff interviews Registered nurse (RN) #1 was interviewed on 4/19/23 at 10:44 a.m. She said the resident would rather have the electric wheelchair than any other one, she would not be able to use a manual wheelchair, someone would have to move her. The RN said the resident would visit a lot and go eat in the dining room, she said now she could not do those things. RN #2 was interviewed on 4/19/23 at 10:44 a.m. The RN said the resident used to be all over the place in the electric wheelchair since she loved to get out. The activities director (AD) was interviewed on 4/19/23 at 12:40 p.m. The AD said the resident liked to get out and do activities. She said the resident and another resident enjoyed having a book club and that she was very social and enjoyed visiting people in the building. The AD said the resident liked being in her room sitting in the chair listening to music, watching tv and playing solitary type games on the tv. The AD said the resident was upset about the wheelchair being broken. The DON was interviewed on 4/19/23 at 2:00 p.m. The DON said the tray and the wheelchair were broken and have been for a few months. The DON said the resident could fill out a grievance form if something was broken. The DON said the previous maintenance director had wrapped the joy stick, the controller of the wheelchair, to keep it working. The DON said the therapy department would be the contact for the wheelchair company not the social services department. She said they have attempted to have it fixed but did not explain how. 48114 II. Resident #11 A. Resident status Resident #11, age 89, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease and other intervertebral disc degeneration, lumbar region. The 2/20/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of zero out of 15. He required extensive assistance with dressing, toilet use, and personal hygiene. He used a wheelchair and walker for mobility. Hospice care was coded. No therapy or restorative nursing minutes were coded. B. Resident observations On 4/17/23 at 12:10 p.m. Resident #11 sitting in an oversized wheelchair in the dining room. C. Resident interview and representative interview On 4/19/23 at 1:36 p.m. Resident #11 was interviewed and he shook his head up and down when asked how he was doing. Resident #11 had difficulty understanding what was asked due to a language barrier. Resident #11's daughter was interviewed by phone on 4/20/23 at 5:03 p.m. She said her father spoke little English. She said the facility had a language line for him and staff should be using it to communicate with him. She said that she asked for physical therapy (PT) for her father and the facility told her that when they ask him to participate in PT he always says no. She said she had been told they could not force him to do PT. She said to the facility if they could encourage him to go and they told her no. The daughter said that Resident #11's wheelchair was issued from the facility. She said he had a walker in his room and should be using it. She he had a regular cane and the facility took the cane away from him. She said that her father was prone to falling and needed assistance. D. Record review The care plan, dated 4/17/23, documented that Resident #11 had communication challenges secondary to speaking a foreign language. Interventions documented: to provide Resident #11 with a translator to aid in communications. The care plan, revised on 4/22/21, indicated Resident #11 had impaired communication as evidenced by language barrier. His primary language is Cantonese. Interventions documented: interpreter as needed. Refer to Speech Therapy for screening as appropriate. Encourage the resident/patient to speak slowly. Encourage and validate meaning or nonverbal communication. Break tasks down into smaller steps. Allow sufficient time for the resident/patient to process and respond. Give one direction at a time or ask one question at a time and repeat directions. The care plan, revised on 10/4/22, indicated Resident #11 required assistance for ADL in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to limited mobility, dementia, frailty. Interventions documented: provide resident supervision set up assistance with ADLs, may need one person assist at times especially with toileting and grooming. He walks with a walker. Monitor for decline in ADL function. Refer to rehabilitation therapy if decline in ADLs is noted. Provide cueing for safety and sequencing to maximize current level of function. Arrange resident/patient environment as much as possible to facilitate ADL performance as indicated. Provide resident set-up supervision assist for bed mobility. E. Interviews Certified nurse aide #2 (CNA) was interviewed on 4/23/23 at 9:30 p.m. CNA #2 said he had never used the language line to communicate with Resident #11. Licensed practical nurse #3 (LPN) was interviewed on 4/23/23 at 9:35 p.m. LPN #3 said that Resident #11 did not understand much and he was not very verbal. LPN #3 said that no staff had used the language line and was not sure if they had a language line. LPN #3 was not able to find where the language line information was kept. The social service director (SSD) was interviewed on 4/24/23 at 11:40 a.m. The SSD said she contacted the family first and asked what the resident was able to understand. She said the language line had been downloaded onto tablets. She said the chaplain was going to get someone to interpret, but had not happened. The SSD said Resident #11 would point at things to get his point across. She said she had a picture book for him and he stated, I talk and did not like the pictures. She said he was the first resident the facility have had communication issues with. She said she was not sure how much he understood or what the staff were asking. She said he was more verbal with things he liked. The SSD was unable to pull up the language line on her tablet. The social service assistant (SSA) was interviewed on 4/24/23 at 12:00 p.m. He said the language line software was easy to use and was able to pull up the information. The SSA said all staff had access to either video chat or phone chat in the preferred language needed. He said staff had not been trained on how to use the language line. Licensed practical nurse (LPN) #1 was interviewed on 4/24/23 at 12:09 p.m. LPN #1 said she had never used the tablet to communicate with Resident #11. LPN #1 pulled a tablet out from behind the nurses station and was able to log in. LPN #1 said she would ask yes or no questions with Resident #11. Certified nurse aide (CNA) #4 was interviewed on 4/24/23 at 12:25 p.m. CNA #4 said that she used simple words in order to communicate with Resident #11. CNA #4 said she had never had a full conversation with Resident #11. The director of rehabilitation (DOR) was interviewed on 4/24/23 at 7:00 p.m. She said Resident #11's wheelchair was 20 inches and was too big for him. She said she would send additional information about Resident #11's wheelchair. -However, no documentation was provided before exit on 4/24/23.

Based on observations, record review and interviews, the facility failed to ensure two (#11 and #2) of four out of 24 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Resident #11 was admitted to the facility for long term care on 9/24/22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Following a hospital stay due to [CONDITION(S)] from 4/21/22 to 5/19/22, the resident was readmitted to the facility with a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon the resident's readmission to the facility on [DATE], the facility failed to obtain a readmission weight and an annual height to estimate the resident's normal body weight as part of the nutritional monitoring for the resident. The facility failed to accurately calculate Resident #11's bolus enteral feeding (means of providing nutritional formula directly through g-tute) which led to the facility providing 560 calories less per day than the recommended amount based on the resident's estimated nutritional needs. Due to the facility's failure to adequately monitor the resident's nutritional status and to ensure Resident #11's nutrition and hydration needs were met, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] .) in 11 days, which was 9.8%. Additionally, the facility failed to adequately monitor Resident #2's nutritional status by ensuring weight discrepancies were clarified and nutritional interventions were put into place and re-evaluated to prevent a significant weight loss. Based on observations, during the survey process, the facility failed to ensure Resident #2 received the nutritional interventions put in place by the registered dietitian (RD), such as double portions and set up assistance with his meals. The facility failed to re-weigh the resident as requested by the RD timely (from 5/13/22 to 5/25/22 when the resident was sent to the hospital for a change of condition) to determine if the resident had sustained actual weight loss and determine if additional interventions should be put into place. Findings include: I. Facility policy and procedure The Weight policy and procedure was provided by the RD on 6/1/22 at 11:15 a.m. It revealed, in pertinent part, Residents are weighed upon admission, weekly x4 weeks, then monthly unless their treatment plans dictate differently. Weights are obtained on all residents by the 7th of the month. This facilitates the weight monitoring process by the dietician. Any resident with a 3-pound change +/- (weight gain or weight loss) will have a re-weight to verify weight change. Unit manager/designee brings the names and records of residents with weight loss to the interdisciplinary team meeting weekly. Weekly weights will be implemented on residents experiencing weight changes of three or more pounds in a week. These residents will remain on weekly weights until the weight is stabilized. The Enteral Management policy and procedure was provided by the RD on 6/1/22 at 11:28 a.m. It revealed, in pertinent part, Gastrostomy tube (G-tube): A tube that is placed directly into the stomach through an abdominal wall incision for administration of foods, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube. An assessment of the patient;s nutritional status which may include usual food and fluid intake, pertinent laboratory values, appetite, and usual weight and weight changes. The Fluid Balance policy and procedure was provided by the RD on 6/1/22 at 11:28 p.m. It revealed, in pertinent part, The Center will provide the patients/residents (hereafter 'patient') with sufficient amounts of fluids based on individual needs. Patient's hydration status will be determined through routine nursing evaluation. II. Resident #11 A. Resident status Resident #11, younger than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/15/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. He required limited assistance of two people for bed mobility, personal hygiene and extensive assistance of two people for transfers, dressing, and toileting. It documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 5/19/22 nutrition progress note the resident was readmitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated the resident would remain NPO and had a PEG tube placed for enteral feedings. B. Observations On 5/26/22 at 10:40 a.m.licensed practical nurse (LPN) #2 entered Resident #11's room with one carton (237ml) of [MEDICATION(S)] 1.5 (enteral nutrition formula) and the supplies to provide Resident #11 with an enteral bolus feeding. LPN #2 asked the resident if he was hungry. Resident #11 responded yes. LPN #1 said Resident #11 always reported he was hungry when she administered his enteral feedings. LPN #1 checked the residual of the PEG tube and then administered 30 ml (milliliters) of water through the PEG tube. She began pouring the enteral formula through the PEG tube until all 237 ml were administered. She then flushed the tube with 30ml of water. -However, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/1/22 at 9:56 a.m. LPN #4 and certified nurse aide (CNA) #1 weighed Resident #11 with a mechanical lift. The resident's weight read 182.3 lbs and was confirmed by LPN #4 and CNA #1. -While LPN #4 and CNA #1 were positioning Resident #11 to be weighed in the mechanical lift, the resident requested water four times. Resident #11 said he was very thirsty. LPN #4 did not address the resident was thirsty by communicating to the physician for additional water flush or mouth swabs for comfort. Resident #11 was observed with white build up in the cracks of his lips, on his tongue and corner of his mouth. C. Record review 1. Hospital admission from 4/21/22 to 5/19/22 A review of the hospital medical record on 5/31/22 at 9:00 a.m. documented: Resident #11 was admitted to the hospital on 4/21/22 with severe [CONDITION(S)]. The resident required intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their airway). Resident #11 was extubated on 5/7/22, which was 17 days after he was admitted to the hospital. On 5/17/22 a PEG tube was placed to begin enteral feedings as the resident was unable to swallow safely. The physician ordered for the resident not to consume anything by mouth (NPO). The physician attempted to place a feeding tube through the resident's nose several times throughout the resident's hospital stay, however the resident continued to pull the tube out. The hospital RD recommended the resident receive Pivot 1.5 formula at 55 ml per hour to meet his estimated nutritional needs. On 5/19/22, the hospital RD documented that the resident weighed 202 lbs (91.8 kilograms). She estimated the resident needed 1836 to 2295 calories or 25 to 30 calories per kilogram (kg) and one ml of fluid per calorie or per physician order. Resident #11 was readmitted to the facility on [DATE] with the following nutritional recommendations: Pivot 1.5 at 15 ml per hour for 24 hours., then increase 10 ml per hour every eight hours until the goal rate of 55 ml per hour is reached with 30 ml water flushes every four hours. Add a multivitamin with minerals once per day. On 5/24/22 Resident #11 was sent to the emergency department and returned the same day as his PEG tube was leaking. The hospital was unable to replace the PEG tube as it had not had time to heal since it had been placed. The hospital physician ordered the tube to be wrapped with tape to prevent leaking until it could be replaced in a couple weeks. 2. Nutritional care plans The nutritional care plan, initiated on 5/20/22 and revised on 5/24/22, revealed the resident was at nutritional risk related to NPO status and the resident was to receive 100% of his nutrition needs via his PEG tube. It documented the resident was receiving 255 ml [MEDICATION(S)] 1.5 from bolus feeds four times per day until the correct tubing was delivered to the facility. Upon arrival of the tubing the resident would be placed on a continuous enteral feeding via PEG tube of [MEDICATION(S)] 1.5 at 55 ml/ hour. The interventions included monitoring the resident's adherence to the NPO diet, monitoring of the resident's electrolytes, monitoring the resident's tolerance of current tube feed orders, providing a multivitamin via the PEG tube as ordered by the physician, and weighing the resident as ordered by the physician. The enteral nutrition care plan, initiated on 5/25/22, revealed the resident had an enteral feeding tube to meet his nutritional needs related to dysphagia (swallowing difficulty). The interventions included providing aspiration precautions, checking the placement of the tube daily prior to providing feedings, monitoring labs as ordered by the physician, and monitoring the resident's skin around the enteral tube. 3. Resident #11's weights Resident #11's weights were documented in the resident's medical record as follows: -On 4/12/22, the resident weighed 197.8 lbs. obtained with a chair scale at the facility. -On 4/21/22, the resident weighed 217 lbs. The resident's weight was obtained at the hospital. -On 5/10/22, the resident weighed 208 lbs. The resident's weight was obtained at the hospital. -On 5/19/22, the hospital RD documented that the resident's weight was 202 lbs. It did not indicate the date in which the weight was obtained. -On 6/1/22, during the survey process, the resident weighed 182.3 lbs obtained with a mechanical lift. -The resident had a 7.8% (15.5 lbs) weight loss, which was considered significant, from 4/12/22 to 6/1/22 in two months. The resident had a 9.8% (19.7 lbs) in 11 days from 5/19/22 to 6/1/22. -The facility failed to obtain an admission weight when the resident was readmitted from the hospital on 5/19/22, his weight was not obtained until 6/1/22 (during the survey), which was 14 days later. The resident was not consistently weighed, nor reweighed for concerns/monitoring when the resident returned from the hospital as indicated by nurse practitioner interview (see below). 4. Nutritional assessments/progress notes The 5/19/22 nutrition progress note documented Resident #11 was readmitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It indicated the resident would remain NPO and had a PEG tube placed for enteral feedings. The continuous tube feeding hospital physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital RD was agreeable to change the formula from Pivot 1.5 to [MEDICATION(S)] 1.5, however the rate should remain at 55 ml per hour for 24 hours with the addition of Proheal three times per day to ensure the resident received adequate protein. It documented the resident was at risk for refeeding syndrome (a potentially fatal syndrome that is caused by a fluid and electrolyte shift that can occur in individuals with limited to no nutrition consumed over several days) as he had not received nutrition for 11 days while he was admitted to the hospital, which required the resident's electrolytes being monitored closely. It indicated the resident's estimated nutritional needs were based on the hospital obtained weight of 202 lbs or 91.8 kg. The residents estimated daily calorie needs were documented as 1836 to 2295 calories (20-25 calories per kg), 92 to 138 grams of protein (1-1.5 grams per kg), and 1836 to 2295 ml fluid per day (1 ml fluid per calorie per day). The recommended tube feed order was [MEDICATION(S)] 1.5 at a rate of 55 ml per hour for 24 hours with 30 ml Proheal three times per day and 60-90 ml water flush every four hours. This order provided 2277 calories and 128 grams protein, which meets 100% of the resident's esteemed nutrition needs. It documented the kangaroo pump (used to administer enteral feedings continuously) was not functioning properly upon the residents' readmission to the facility.The facility was unable to obtain a new pump until the following day. A temporary tube feeding order was put into place until the new pump arrived, which read Pivot 1.5 60 ml bolus (a dose of formula given all at once) every four hours with 15 ml water flushes before and after each bolus. Upon arrival of the new pump, the original order of [MEDICATION(S)] 1.5 at 55ml per hour for 24 hours with 30ml water flushes every four hours would apply. The 5/24/22 nursing progress note documented the registered nurse (RN) notified the resident's physician that there was not an order in place for the resident to receive continuous enteral nutrition. The on-call physician was notified the facility did not have [MEDICATION(S)] 1.5, but did have [MEDICATION(S)] 1.2. The on-call physician requested the day provider to address the issue, since there was a change in calories when switching formulas. The 5/24/22 nutritional assessment documented the resident was susceptible to weight loss after being NPO for 11 days and a weight had still not been obtained since the resident's readmission to the facility. The recommended tube feed order was [MEDICATION(S)] 1.5 at 55 ml per hour for 24 hours a day with 30 ml Proheal three times per day and 30 ml water flushes every four hours. This provided 2280 calories per day, 84 grams protein per day, and 1320 total volume of formula plus 180 ml of fluid from flushes for a total volume of 1500 ml per day. -However, [MEDICATION(S)] 1.5 only contains 76% free water to be included towards total fluid needs per day. The resident was receiving 1003 ml free water from the formula. The 5/24/22 nutritional assessment continued to document the temporary order of 255 ml [MEDICATION(S)] 1.5 bolus four times a day with 30 ml water flushes every four hours was put into place as the facility did not have the correct tubing. The estimated nutrition needs were based on the RD assessment from the hospital, which documented the resident needed 1836 to 2295 calories per day, 92 to138 grams protein per day, and 1836 ml fluid per day (one ml per calorie per day). The 5/24/22 nutritional assessment continued to document the continuous enteral feed order of [MEDICATION(S)] 1.5 at 55 ml per hour or the 255 ml [MEDICATION(S)] 1.5 bolus four times per day in conjunction with 30 ml proheal three times a day met 100% of the resident's estimated calorie/protein needs. -However, the RD note completed on 5/24/22 (see below) documented the bolus feedings only met 94% of the resident caloric needs. The bolus feedings provided 560 calories less than the continuous feedings. In addition, the resident was at risk for refeeding syndrome and was supposed to have his formula administered slowly until he met the goal rate, however he was changed to 255 ml bolus, which he was provided with all 255 ml at one time instead of slow infusion until he met his goal rate. The 5/24/22 nutritional assessment continued to document the RD recommended to increase the water flushes from 30 ml every four hours to 60 ml every four hours and monitor the resident's tolerance to promote adequate hydration status. The interventions included providing enteral nutrition as ordered, increasing water flushes to 60 ml every four hours to promote adequate hydration status, providing 30 ml Proheal three times per day, providing a multivitamin daily as ordered, monitoring weights as ordered, monitoring the resident's tolerance of tube feedings, monitoring the resident's electrolytes for refeeding syndrome, and monitoring the resident's hydration status. The 5/24/22 nutritional assessment continued to document the nutrition plan of care goals included maintaining the resident's current body weight, maintaining the resident's hydration status, and ensuring the resident did not exhibit signs or symptoms of dehydration. The 5/24/22 nutrition progress note documented the kangaroo pump was delivered to the facility, but the facility did not have the correct tubing for the pump. The physician ordered the resident to receive 255 ml of [MEDICATION(S)] 1.5 four times per day, 30 ml water flush before and after the feedings and continue the scheduled proheal three times a day. This new order provided 1720 calories, 105 grams protein, 1140 ml fluids. The RD recommended increasing the water flushes to 60 ml every four hours, which met 94% of the residents estimated calorie needs and 100% of his estimated protein needs. The RD indicated she would reevaluate once the continuous feed was initiated. The 5/24/22 nutrition progress note documented the resident was transported to the hospital due to a leak in the resident's PEG tube. The RD indicated she would reassess the resident upon readmission to the facility. The 5/25/22 nutrition progress note documented the PEG tube leak was repaired in the hospital and the resident would continue to receive 255 ml of [MEDICATION(S)] 1.5 four times per day as ordered by the physician until the Kangaroo pump tubing was delivered to the facility. -The facility did not provide the Kangroo pump and tubing from when the resident readmitted from the hospital on 5/19/22 with a new PEG tube until at least being identified during the survey on 6/1/22 (see nutrition note below), which was 13 days. The 6/1/22 nutrition progress note (during the survey) documented Resident #11 had triggered for a significant weight loss of 7.8% in 90 days. With the residents recent weight loss, the resident's estimated nutrition needs were recalculated and the RD recommended a new enteral feeding regimen. The nursing staff had reported to the RD that the resident was tolerating the continuous tube feeding well at the rate of 55 ml per hour for 24 hours with 30 ml warm water flushes every four hours. The resident and nursing staff reported no gastrointestinal distress, but indicated the resident had dry mouth, in which fluid flushes were recommended to be increased to support adequate hydration status for the resident. It indicated the resident's estimated nutrition needs based on a weight of 182.3 (83 kg), 2485 to 2900 calories per day (30 to 35 calories per kg of current body weight to promote weight maintenance and weight restoration with recent weight loss), 83 to 124 grams protein per day (1-1.5 grams protein per kg), and 2075 to 2490 ml fluid per day (25 to 30 ml fluid per kg). The new tube feed recommendation of [MEDICATION(S)] 1.5 at 65 ml per hour for 24 hours with warm water flushes of 120 ml every three hours in conjunction with 30 ml proheal two times per day provided the resident with 2540 calories per day, 130 grams protein per day, and 2147 ml fluid per day. This recommendation met 100% of the resident's estimated nutrition, protein, and fluid needs. The RD recommended the resident to be weighed weekly. D. Staff interviews The RD was interviewed on 6/1/22 at 10:22 a.m. She said the nursing staff were responsible to obtain admission and readmission weights immediately when the resident arrived at the facility. She said residents were weighed upon admission and then weekly for four weeks. She said if the resident's weight remained stable, the resident was placed on monthly weights. She said if a resident had weight changes, the resident would be weighed weekly until the resident's weight was stable. The RD said the nursing staff were responsible for obtaining heights upon admission and annually. She said this contributed to the nutritional monitoring for residents. The RD said she was responsible for requesting re-weighs when she anticipated an inaccurate weight. She said she notified the restorative nursing aides to obtain a new weight. She said re-weighs should be conducted within 24 hours of the recommendation unless it was requested over the weekend She said she typically used the Mifflin St. Jeor formula to calculate estimated nutrition needs when completing nutritional assessments. The RD said Resident #11 was in the hospital for several weeks with severe [CONDITION(S)]. She said he did not get nutrition for 11 days while in the hospital and was at risk for refeeding syndrome. She said since the facility had not obtained a readmission weight when he returned to the facility. She said she used the hospital weight that was obtained the day he was readmitted to the facility, which was 202 lbs (91.8 kg). She said Resident #11 needed 20 to 25 calories per kg body weight, which the original tube feed recommendation met with 2280 calories per day or 24.8 calories per kg. She said the facility was unable to get the correct tubing for the kangaroo pump and the physician ordered the resident to have bolus feedings until the correct tubing was received. She said the new order was 255 ml [MEDICATION(S)] 1.5 four times per day through the bolus feeding with 30 ml of Proheal three times per day. She said this provided 1830 calories or 19.9 calories per kg. -However, 19.9 calories per kg of weight was under the recommendation of 20 to 25 calories for kg that was initially recommended by the facility RD. In addition, the resident was at risk for refeeding syndrome and was supposed to have his formula administered slowly until he met the goal rate, however he was changed to 255 ml bolus, which he was provided with all 255 ml at one time for four times a day. She confirmed since the nursing staff was observed providing on 237 ml [MEDICATION(S)] 1.5 four times a day with 30 ml proheal three times a day, this provided 1830 calories or 18.76 calories per kg, which was only 94% of the residents estimated nutritional needs. She said since the resident was not meeting his estimated nutrition needs he could have lost weight. The RD said when the physician changed the enteral feeding orders, she should have made a recommendation to increase the feedings as it could have led to weight loss and muscle wasting. The RD said she used the hospital RD's recommendation for fluid needs, which was 15 ml fluid per kg. -However, per the hospital records the hospital RD recommended one ml fluid per one calorie or 1836 ml to 2295 ml fluid per day. He was receiving 900 ml fluid per day, which was a deficit of 936 ml of fluid per day. She confirmed she recommended increasing the resident's water flushes to 60 ml every four hours on 5/24/22 and it had still not been implemented. She said she would email the nursing management to update the orders in the electronic medical record when she had recommendations for enteral feedings. She confirmed, based on Resident #11 receiving 237 ml [MEDICATION(S)] 1.5 four times a day and 30 ml water flushes every six hours, the resident was receiving 900 ml of fluid per day, which was significantly lower than the residents estimated fluid needs. She said reporting thirst or white build-up in the cracks of the lips and mouth were signs of dehydration. She said since the resident was not meeting his estimated fluid needs the resident could become dehydrated. She said with the weight obtained on 6/1/22, of 182.3 lbs, Resident #11 was considered to have sustained a significant weight loss. She said the decrease of calories could have contributed to the resident's significant weight loss. The nurse practitioner (NP) was interviewed on 6/1/22 at 1:00 p.m. She said the facility should have obtained a readmission weight for Resident #11 upon his return to the facility. She said the resident's weight was used to monitor if the resident was meeting their estimated nutritional needs. She said she had ordered the facility to obtain a weight, but it had not been completed. She said the weight that was obtained on 6/1/22 by the facility of 182.3 lbs revealed a significant weight loss. She said she relied on the RD to accurately calculate and ensure the estimated nutritional needs were met for all residents on enteral feeding. The director of nursing (DON) was interviewed on 6/1/22 at 1:28 p.m. She said admission and readmission weights should be completed as soon as the resident arrived at the facility. She said the RD should have requested a new weight when she completed a readmission assessment for Resident #11. She said a calorie deficit greater than 500 calories per day was concerning and could lead to weight loss. III. Resident #2 A. Resident status Resident #2, age 77, was admitted on [DATE] and discharged on [DATE] (during the survey) to the hospital. According to the May 2022 CPO, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/24/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He required extensive assistance of two people for bed mobility, transfers, dressing and toileting. He required extensive assistance of one person for personal hygiene and set-up assistance for eating. It documented the resident had not had a significant weight loss during the assessment period and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] B. Observations During a continuous observation on 5/25/22 beginning at 11:01 a.m. and ended at 3:50 p.m. the following was observed: At 11:22 a.m. two unidentified certified nurse aides (CNA) entered Resident #2's room after donning personal protective equipment (PPE) as Resident #2 was on isolation precautions related to a recent positive COVID-19 test. At 11:32 a.m. the two unidentified CNAs exited Resident #2's room with a soiled brief. They closed the door to the resident's room upon exiting. At 1:01 p.m. CNA #3 entered Resident #2's room dressed in PPE with the resident's lunch tray. He exited the room at 1:02 p.m. and closed the resident's door. A 3:45 p.m. facility staff had still not entered the resident's room since delivering his lunch tray. The lunch tray remained covered and untouched. -The resident was not provided any encouragement or eating assistance. He did not receive double portions as indicated on his meal tickets and care plan. C. Record review The nutritional care plan, initiated on 9/22/2020 and revised on 3/23/22, documented the resident was at nutritional risk related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Diff), hypertension, dementia, depression, diabetes mellitus type two (DM2), gout, and absence of a digestive tract. It indicated the resident had increased energy needs related to an unstageable pressure wound to the left foot. The interventions included encouraging fluids, providing proheal protein supplement, honoring food preferences, providing double portions, weighing the resident, monitoring changes in nutritional statues (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and reporting to the dietitian, offering alternative food choices if less than 50% of a meal was consumed, and monitoring the resident's intake at all meals. Resident #2's weights from November 2021 to May 2022 were documented as follows: -On 11/2/21, the resident weighed 181 lbs. -On 12/5/21, the resident weighed 183.7 lbs. -On 1/8/22, the resident weighed 185.6 lbs. -On 2/8/22, the resident weighed 184.1 lbs. -On 3/9/22, the resident weighed 181.4 lbs. -On 4/4/22, the resident weighed 177.2 lbs. -On 5/11/22, the resident weighed 167.9 lbs. -The resident had a 5.2% weight loss (20.7 lbs), which was considered significant from 4/4/22 to 5/11/22, and a 8.8% weight loss (21.4 lbs), which was considered significant from 2/8/22 to 5/11/22. The 3/23/22 nutritional assessment documented the resident was on a consistent carbohydrate diet with large portions. He received 30 ml Proheal three times a day to promote wound healing related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . for six months. It indicated the resident averaged a meal intake of 86% over that past week, which was consistent from previous assessments. The resident reported he was happy with the food and had no additional preferences. The interventions included providing a diet as ordered by the physician, providing double portions, and providing 30 ml Proheal three times per day to promote skin healing. The care plan goals included maintaining the resident's current weight and skin integrity improvement. The 5/13/22 nutrition note documented the resident had sustained a weight loss and the RD requested a re-weigh. The 5/17/22 nutrition note documented the resident had triggered for a significant weight loss of 5.2% in 30 days and 8.8% in 90 days. A re-weigh was requested by the RD. The resident reported he had noticed gradual weight loss despite good meal intakes. The RD obtained new dietary preferences from the resident and updated them in the meal system. The resident agreed to add a frozen nutrition treat twice per day with lunch and dinner. In addition, the RD recommended weekly weights and noted the resident may benefit from liberalizing a consistent carbohydrate diet to a regular diet to increase the resident's caloric intake. -According to the resident's medical record, the facility had not obtained a re-weigh as requested by the RD. Thirteen days after the reweigh was requested by the RD, the resident was sent to the hospital on 5/25/22 for a change of condition as he became unresponsive. The 5/24/22 nutrition progress note documented the resident requested to have the frozen nutrition treated with lunch and dinner discontinued and to trial a different supplement. The resident agreed to trial fortified pudding with lunch and dinner. The resident's weekly weight had still not been obtained. D. Staff interviews The RD was interviewed on 6/1/22 at 10:22 a.m. She said she requested Resident #2 be reweighed on 5/17/22 and had not received the re-weigh as of 5/25/22 when the resident was sent to the hospital. She said the facility staff should obtain the re-weigh sooner than 13 days after it was requested. She said when Resident #2 triggered for significant weight loss, she visited with the resident and he was only agreable to having supplements added at lunch and dinner. The RD said since the resident was on double portions, he should have been served a double entree, a starch, and a vegetable at meals. The RD said the CNAs were responsible for documenting the amount each resident consumed in the electronic medical record (EMR). She said there were several meals that did not have the amount consumed documented. The RD said Resident #2 had a significant weight loss, which could have potentially been prevented if an intervention was put into place earlier. The DON was interviewed on 6/1/22 at 1:28 p.m. She said the staff should have obtained Resident #2's re-weigh within 24 hours of the RD making the request.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring and worsening for three (#12, #6, and #2) of five out of 24 sample residents. Specifically, the facility failed to ensure Resident #12's pressure injury to the coccyx/sacrum did not worsen. Resident #12, who was at high risk for developing pressure injuries, was admitted to the facility with a healing stage 2 pressure injury to the sacrum/coccyx. The facility failed to encourage the resident to reposition and follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure treatments were provided as ordered by the physician and develop a person-centered care plan for the resident's pressure injury to the sacrum/coccyx. Resident #12 was admitted to the facility with a stage 2 pressure injury to her sacrum. The facility's failure contributed to the worsening of Resident #12's pressure injury worsening from a healing stage 2 to her sacrum/coccyx to an unstageable wound on 3/23/22. The resident was sent to the hospital on 4/20/22 due the fever and possible sacral wound infection. When the resident return from the hospital on 4/25/22, the sacral/coccyx wound was debrided and classified as a stage 4. Additionally, the facility failed to: -Ensure treatments were provided as ordered by the physician for Resident #6's pressure injury to the sacrum; and, -Ensure Resident #2 was repositioned timely. Findings include: I. Facility policy and procedure The Skin Integrity Management policy and procedure, revised June 2021, was provided by the nursing home administrator (NHA) on 6/1/22 at 11:39 a.m. It revealed, in pertinent part, The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. Identify the patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. Perform skin inspection on admission/readmission and weekly. Document on the treatment administration record (TAR) or in Point Click Care (PCC). Perform wound observations and measurements and complete a skin integrity report upon initial identification of altered skin integrity, weekly, and with anticipated decline of the wound. Perform daily monitoring of the wounds or dressings for presence of complications or declines and document. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated. Implement pressure ulcer prevention for identified risk factors. Determine the need for support surface for bed and chair. Determine the need for heel protectors and heel lift devices and utilize per manufacturer's guidelines. Implement skin/wound care guidelines as applicable. Implement special wound care treatments/techniques, as indicated and ordered. Document daily monitoring of ulcer site, with or without dressing. For wounds that do not require a daily dressing change, monitor: the status of the dressing, status of the tissue surrounding the dressing and adequate control of wound pain. For wounds that require a daily dressing change or wounds without a dressing, monitor for signs of decline in wound status. If unanticipated decline in wound, surrounding tissue, or new or increased wound, and complete the skin integrity report and notify the physician. II. Resident #12 A. Resident status Resident #12, age less than 65, was admitted on [DATE]. According to the May 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/28/22 minimum data set (MDS) assessment, the resident had minimal cognitive impairment with a score of 14 out of 15 on the brief interview for mental status (BIMS). The resident required total assistance with activities of daily living. The MDS coded the resident as having an unhealed stage 4 pressure ulcer. She was at risk for pressure ulcers. The MDS coded the resident as not having any behaviors or refusal of care. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note further documented this was discussed with licensed practical nurse (LPN) #1. B. Observations On 5/23/22, during a continuous observation which started at 10:30 a.m. and ended at 12:30 p.m. Resident #12 was sitting in her wheelchair, outside in the supervised smoking area. -At 11:45 a.m. the resident's position remained unchanged. -At 12:15 p.m. the resident's position remained unchanged. The facility staff did not encourage the resident to lie down in bed to offload the pressure to the resident's sacrum/coccyx. On 5/26/22, during a continuous observation which started at 9:41 a.m. and ended at 12:30 p.m., Resident #12 was not offered or encouraged to lie down after smoking and after 30 minutes of sitting up in the wheelchair. -At 9:41 a.m. Resident #12 was observed being assisted out of bed by two unidentified staff members. -At 10:18 a.m. certified nurse aide (CNA #2) assisted the resident out of her room with the wheelchair to the dining room, waiting for her smoking break. -At 10:50 a.m. CNA #2 was assisted back into the dining room from the supervised smoking area. CNA #2 remained in the dining room, however did not provide education to Resident #12 about lying down in bed after her smoke break. -At 10:54 a.m. CNA #2 wheeled the resident back to her room and poured her a soda. She did not offer to lay the resident down in bed or reposition the resident. -At 11:08 a.m. LPN #1 entered the resident's room to answer a question for her roommate. While in the room, he made a joke to the resident and then exited the room. He did not offer to lay the resident down or provide education to the resident on repositioning. -At 11:25 a.m. CNA #2 asked her if she wanted another drink of the soda. She provided her a drink, but did not ask the resident to lie down or provide education about lying down. -At 11:45 a.m. the resident remained in the same position, with no offer to offload, reposition or lie down. -12:10 p.m. the resident remained in the room sitting in her wheelchair. The resident had not been offered to lie down for the past two hours. On 5/31/22 at 9:30 a.m. the coccyx/sacral wound was observed with the resident's primary care physician (PCP) and the wound physician. The wound to the coccyx/sacrum was observed to have beefy red tissue at the bottom with well defined edges. The wound physician said the wound was smaller than the previous week when he had observed the wound. The wound physician replaced the wound vac treatment (a machine used to treat wounds) and said the wound was healing. He reinforced education with the resident to only remain up in the wheelchair for 30 minutes at a time and the important of offloading the coccyx/sacrum. C. Resident interview Resident #12 was interviewed on 5/25/22 at 6:25 p.m. The resident said that she did have a pressure ulcer injury on her coccyx. She said she had recently returned from the hospital. She said that she was unable to move on her own and that a hoyer mechanical lift was utilized to move her from the chair to the bed. She said that she stayed in her chair for the day, and that she was not always offered to go to lie down. She said she liked to go out to smoke. She said the pressure ulcer injury would hurt at times when she had been sitting on the wound for too long. D. Worsening of the coccyx/sacral pressure injury The 2/9/22 admission assessment documented the resident was admitted to the facility with a stage 2 pressure injury to the sacrum measuring 2 cm (centimeters) x 2 cm x 0.1 cm. The 2/23/22 admission Braden scale for predicting pressure injuries revealed the resident was at a high risk for developing pressure sores. The assessment revealed the resident had no sensory perception impairment, her skin was constantly moist, she was bedfast, was completely immobile, had adequate nutrition, and had a problem for friction or shear which indicated she required moderate to maximum assistance in moving. The 3/12/22 wound report documented the pressure injury on the sacrum was a stage 2 with 15% slough. The wound tracker dated 3/23/22 report documented the coccyx pressure injury was unstageable and had worsened with 10% granulation, 30% slough and 60% eschar. The drainage was moderate seropurulent drainage. The wound tracker dated 3/29/22 report documented the coccyx pressure injury was unstageable with 40% granulation, 20% slough, and 40% eschar. The wound was noted as better from previous week. The 4/5/22 wound tracker documented the coccyx wound as unstageable with 30% granulation, 30% slough and 20% eschar with moderate serous drainage. The wound was noted to show improvement. The wound tracker dated 4/12/22 documented the coccyx wound as unstageable with 100% eschar. The wound was documented as worsened. The drainage was moderate and malodorous (smelling very unpleasant). The wound tracker dated 4/19/22 documented the coccyx wound had worsened and it was 50% granulation, 30% slough, and 20% eschar. The drainage was significant seropurulent and malodorous. On 4/20/22, Resident #12 was sent to the hospital for a possible infection due to the resident having a fever and a foul smelling sacral pressure injury. The 4/21/22 history and physical from the hospital showed the resident was admitted for a sacral decubitus ulcer. The note further documented the decubitus ulcer with necrotic tissue noted, malodorous. CT of the abdomen and pelvis showed the midline sacral decubitus ulcer is deepening with new posterior cortical erosion of the first coccygeal segment and displaced fracture of second coccygeal segment for which early [CONDITION(S)] could not be excluded. Continue [MEDICATION(S)] and [MEDICATION(S)]. Irrigation and debridement of sacral pressure ulcer. Resident #12 returned to the facility on [DATE] from the hospital. The resident returned with a wound vacuum. The wound was debrided. The 4/26/22 wound tracker documented that the stage 4 pressure ulcer injury was 100% granulation with moderate serous drainage. The wound was showing improvement. Continued with the wound vacuum. The 5/2/22 PCP progress note documented that the wound physician had concerns about the stage 4 pressure injury on the sacrum. It did not include the measurements of the wound. The wound had an odor. The physician had told the resident to turn every two hours, however, the resident said that staff did not offer it. The care plan, last updated on 4/25/22, revealed the resident had actual skin breakdown to the sacrum. Interventions included: -Pressure redistribution surface to bed as per guideline -Utilize positioning devices as appropriate to prevent pressure over bony prominences; and, -Provide wound treatment as ordered. -The care plan failed to address that the wound physician was following the resident, and that the resident was to be up in the wheelchair for only 30 minutes three times a day. E. Resident refusals of care Although the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes were reviewed from 2/9/22 to 5/6/22 and failed to show the resident was encouraged and educated on the importance of relieving the pressure on her coccyx. The April 2022 and the May 2022 behavior log did not show that the resident had any behaviors and refusals. The care plan last updated on 5/17/22 identified the resident was resistive to care, specifically insisting on being in her mobile wheelchair for extended amounts of time and refused to be repositioned in her bed to decrease the amount of time on high pressure areas. Pertinent approaches were to explain care, and to continue to provide education to Resident #12 about the health risks of remaining on high pressure areas for extended amounts of time. F. Failure to ensure physician ordered treatment was completed The March 2022 treatment administration record (TAR) showed the resident was to have a dressing changed daily on the sacrum but it was not completed on 3/19/22 and 3/27/22. The April 2022 TAR showed the resident was to have a dressing change daily on the sacrum but it was not completed on 4/6/22, 4/7/22 and 4/20/22. -The resident's medical record failed to show any evidence of the reason for the missed dressing changes. G. Interviews CNA #5 was interviewed on 5/25/22 at 6:32 p.m. The CNA said the resident required a hoyer mechanical lift for all transfers. He said she was cooperative and did not refuse care. He said that she had a call light that she could request to lie down. He said that she would let him know when she was ready for bed, otherwise she stayed in her chair and watched television with her roommate. Licensed practical nurse (LPN) #1 was interviewed on 5/26/22 at 12:15 p.m. The LPN said Resident #12 had an unstageable pressure injury on her coccyx/sacrum which had worsened. He said she had returned recently from the hospital as she had an infection in the wound. She returned with a wound vacuum. He said that the wound physician followed the resident. He said the dressing was changed every 72 hours, however, he did not change the dressing. He said he assessed the dressing to ensure there were no leaks from the wound vacuum. He said the assistant director of nurses, the wound nurse or the wound physician was responsible to change the dressing every 72 hours or as needed. The LPN said the physician had placed an order that the resident was to only be up in the wheelchair for 30 minutes at a time. He said that in the beginning he would encourage the resident of the importance of lying down, however, she would refuse to lie down. He said that in the beginning he had kept encouraging the resident to lie down, however he had given up on consistently telling her the importance of lying down, as she always refused. He said that was why the wound worsened. He said that she was afraid of missing her smoking opportunities. The assistant director of nurses (ADON) was interviewed on 5/2/22 at 2:00 p.m. The ADON said she was familiar with the resident's sacral pressure injury. She confirmed the documentation referred to the sacral pressure injury as also the coccyx pressure ulcer. She said that the wound became large enough that it was over both the sacral and coccyx area. The ADON said the resident was admitted to the facility with a stage 2 pressure injury to the sacrum. She said that the resident was not followed by the wound physician for the stage 2. She said the nursing management were not aware the resident was non-compliant with turning and repositioning before the pressure injury worsened to unstageable. She said the resident was unable to move independently and required total assistance. She said the resident refused to lie down, as she did not want to miss her smoking breaks. She said the resident was to be repositioned in bed every two hours, and that she was to be up for only 30 minutes up to three times a day for smoking breaks. She said the resident needed to be offered and encouraged to lie down after 30 minutes. If the resident refused, then it should be documented and the resident should be provided education on the importance of relieving the pressure on her sacrum/coccyx. The ADON said the wound had shown improvement for the past two weeks. She reviewed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She said if the TAR had holes, then the treatment was not completed. The charge nurse was responsible to notify the nursing administration that the dressing was not changed, so a plan could be made. The wound physician was interviewed on 5/26/22 at 2:15 p.m. The wound physician said he had been following the resident for the pressure injury since 4/2/22. He said the wound was unstageable because the depth of the pressure injury could not be seen. He said that the wound was debrided as 80% of the wound was necrotic and 20% slough. He said on 4/19/22 it started to smell and she went to the hospital. The hospital debrided it and it was now a stage 4. He said when she came back from the hospital the wound was debrided again. He said since the debridement of the sacral pressure injury and the wound vacuum, it was beginning to heal. He said that she did need to relieve the pressure by lying down. He was aware that she was not compliant, however the staff needed to provide education to the resident. LPN #1 was interviewed a second time on 5/26/22 at 2:57 p.m. LPN #1 confirmed he did not change the dressing on the resident's sacrum pressure injury. He said when he had signed off on the May 2022 treatment administration record (TAR) it was signing off that the wound physician or the ADON had changed the dressing. III. Failure to ensure treatments were administered as ordered by the physician A. Resident status Resident #6, age 73, was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 CPO, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/29/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. She required extensive assistance of two people with bed mobility, transfers, dressing and toileting and extensive assistance of one person with personal hygiene. It indicated the resident had a stage 4 pressure injury. B. Record review The skin integrity care plan, initiated on 2/15/22 and revised on 4/25/22, documented the resident was at risk for skin breakdown due to poor mobilization. It indicated the resident had an actual skin breakdown of a stage 4 pressure injury to the sacrum. The interventions included turning and repositioning the resident every two hours, encouraging the resident to consume all fluids of choice during meals, observing the resident's skin condition with care, pressure redistribution to the bed and chair and providing wound treatments as ordered by the physician. The 5/24/22 wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The measurements were documented as 6 cm (centimeters) length x 6.5 cm width x 6.5 cm width x 1 cm depth. It indicated the wound had a moderate amount of serous drainage with a wound bed with 100% granulation. It indicated the wound was improving. The March 2022 treatment administration record (TAR) documented the following: To sacrum: cleanse with wound cleanser, pat dry with 4x4 gauze. Paint the periwound with [MEDICATION(S)] solution. Apply a nickel thick layer of santyl to the wound base. Apply [MEDICATION(S)] to the wound base, lightly fill the wound to remove all dead space, including in undermining with calcium alginate. Cover with a foam dressing every day shift for wound care-ordered 2/28/22 and discontinued on 3/21/22. -According to the March 2022 TAR, there were blanks on the treatment record to indicate the wound treatment had not been provided as ordered by the physician from 3/1/22 to 3/7/22 and 3/18/22. To sacrum: cleanse with wound cleanser, pat dry with 4x4 gauze, paint periwound with [MEDICATION(S)] solution and allow to dry. Paint the macerated periwound skin with skin prep and allow to dry. Apply silver alginate to the wound base and fill all dead space including undermining and cover with a foam bandage every day shift for wound care-ordered 3/21/22 and discontinued on 4/25/22. -According to the March 2022 TAR, there were blanks on the treatment record to indicate the wound treatment had not been provided as ordered by the physician on 3/23/22, 3/24/22 and 3/28/22. The April 2022 TAR documented the following: To sacrum: cleanse with wound cleanser. Pat dry with 4 x 4 gauze. Paint periwound with [MEDICATION(S)] solution and allow to dry. Paint macerated periwound skin with skin prep and allow to dry. Apply silver alginate to the wound base and fill all dead space including undermining. Cover with foam bandage every day shift for wound care-ordered 3/21/22 and discontinued on 4/25/22. -According to the April 2022 TAR, there were blanks on the treatment record to indicate the wound treatment had not been provided as ordered by the physician on 4/5/22, 4/6/22, 4/8/22 and 4/11/22-4/25/22. The May 2022 TAR documented the following: To coccyx-Cleanse with [MEDICATION(S)] wound cleanser, pat dry with 4 x 4 gauze. Apply [MEDICATION(S)] 10% solution to periwound and allow to dry. Lightly fill wound space with silver alginate. Cover with dry dressing. May secure with tape every day shift for wound care-ordered 4/29/22 and discontinued 5/18/22. -According to the May 2022 TAR, there were blanks on the treatment record to indicate the wound treatment had not been provided as ordered by the physician on 5/8/22 and 5/12/22. C. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 6/1/22 at 1:25 p.m. She said all treatment orders should be administered according to the physician orders. She said when a treatment order was provided, the nurse should sign off on the TAR to indicate it was completed. She said if a resident refused the treatment, after attempting another time, the nurse should select the code that indicated refusal and sign off on the TAR. LPN #3 said Resident #6 had a stage 4 pressure injury to the coccyx/sacrum. She confirmed there were multiple blank spots on the TAR for Resident #6's treatment to the sacrum and coccyx. She said it appeared as though the treatments were not provided according to the physician orders. The director of nursing (DON) was interviewed on 6/1/22 at 1:27 p.m. She said treatments should be administered according to physician orders. She said each treatment should be signed off on the TAR once the treatment had been administered. She said if a resident refused a treatment, there was a specific code the nurse should choose to indicate the refusal along with the nurse's initials. She said a blank on the TAR could mean missed documentation, omission or a missed treatment. IV. Failure to reposition timely A. Resident status Resident #2, age 77, was admitted on [DATE] and discharged on [DATE]. According to the May 2022 CPO, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/24/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He required extensive assistance of two people for bed mobility, transfers, dressing, toileting; extensive assistance of one person for personal hygiene and set-up assistance for eating. It documented he had one facility acquired stage 4 pressure wound. B. Observations During a continuous observation on 5/25/22 beginning at 11:00 a.m. and ending at 3:45 p.m., Resident #2 was lying in bed in a supine position. -At 11:16 a.m. an unidentified CNA placed an isolation cart and signs on Resident #2's door. The CNA said the resident had tested positive for COVID-19 and shut the resident's door. -At 11:22 a.m. two unidentified CNAs entered Resident #2's room and provided incontinence care. Upon exiting the room Resident #2 remained in a supine position. -At 1:01 p.m. CNA #3 delivered Resident #2's lunch tray. Upon exiting the room Resident #2 was observed lying in a supine position. CNA #3 did not reposition the resident. -At 3:45 p.m. staff had not entered the resident's room since 1:01 p.m. On 5/25/22 at 5:15 p.m., Resident #2 was sent to the hospital due to a change of condition, therefore no further observations were able to be conducted during the survey process. C. Record review The skin care plan, initiated on 3/29/22 and revised on 4/18/22, revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He was at risk for skin breakdown related to weakness, decreased mobility, dementia, and incontinence. The interventions revealed, in pertinent part, to provide wound treatment as ordered, to off load/float heels while in bed, and complete weekly wound assessments. The 5/24/22 wound physician note documented that the resident had a stage 4 pressure injury to the left distal foot that measured 1 cm length x 1 cm width x.3 cm depth. The current treatment was to cleanse with wound cleanser and paint [MEDICATION(S)] once a day and as needed. The May 2022 CPO revealed the following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Wound left distal foot and toe without nail - paint peri wound and wound base with [MEDICATION(S)] 10% solution. Leave open to air. Okay to wear sock-ordered on 5/4/22; and, Encourage (to get) out of bed once a day every shift-ordered on 8/21/21. -A review of the May 2022 TAR revealed the resident did not receive two (5/7/22 and 5/18/22) out of 22 treatments. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 6/1/22 at 1:15 p.m. She said Resident #2 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said Resident #2 frequently refused to get out of bed, but the staff should encourage him to reposition every few hours. She said Resident #2 did not typically refuse to be repositioned when offered. The director of nursing (DON) was interviewed on 6/1/22 at 1:28 p.m. She said Resident #2 should have been offered or encouraged to be repositioned every two hours.

Based on record review, observations and interviews, the facility failed to ensure one (#1) of three residents were free of significant medication errors out of 24 sample residents. Specifically, the facility failed to ensure Resident #1 was not administered another resident's medications which caused a decline in his medical condition which required hospitalization . The facility further failed to ensure interventions identified as part of the performance improvement plan were put into place to prevent any additional significant medication errors. Resident #1 received 300 milligrams (mg) [MEDICATION(S)] (a medication for blood pressure), 10 milliequivalents (meq) potassium (mineral supplement) and 12.5 mg [MEDICATION(S)] (a medication used for [CONDITION(S)]) that were not prescribed to him on 2/5/22. He experienced a significant change of condition, became unresponsive and was sent to the emergency room . Upon discovering the significant medication error, the facility implemented a quality assurance performance improvement (QAPI) plan to prevent further medication errors within the facility. However, during the survey process, it was determined the facility failed to ensure the interventions identified in the QAPI were implemented to prevent further significant medication errors. Findings include: I. Professional reference According to Fundamentals of Nursing, by Potter, Perry, Stockert, Hall & Ostendorf, 9th Edition (copyright 2017), page 624-627. A medication error can cause or lead to inappropriate medication use or patient harm. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/or failing to administer a medication. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation Medication errors often occur because a patient gets a drug intended for another patient. Therefore an important step in safe medication administration is being sure that you give the right medication to the right patient. It is difficult to remember every patient's name and face. Before administering a medication, use at least two patient identifiers. II. Resident #1 A. Resident status Resident #1, age 83, was admitted on [DATE]. According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/24/22 nursing progress note documented the resident had mild cognitive impairment and he required staff assistance with all activities of daily living (ADLs). B. Record review The 2/5/22 nursing progress note documented at 8:25 a.m. registered nurse (RN) #1 entered the resident's room to notify him of a medication error. Upon entering the room RN #1 noticed the resident was drooling and his feet were hanging over the side of the bed. RN #1 attempted to wake the resident, but the resident was not responding to questions. RN #1 repositioned the resident in the bed. -At 8:55 a.m. RN #1 called poison control. A list of the medications the resident received were provided to poison control from the RN. Poison control recommended the resident be sent to the hospital. The 2/5/22 situation, background, appearance, review, and notification (SBAR) form documented the resident had a change of condition related to a medication error. He had an altered level of consciousness by being drowsy and difficult to arouse. The resident's functional status remained stable, however the resident had respiratory changes. The physician was notified of the change of condition. The 2/5/22 hospital transfer form documented the resident's blood pressure was 96/54, a heart rate of 77, respiration rate of 17, temperature of 98.9, and oxygen saturation of 92%. It indicated the resident's representative was notified of the resident's transfer to the hospital. The investigation report following the significant medication error on 2/5/22 was provided by the director of nursing (DON) on 5/6/22 at 11:00 a.m. The 2/5/22 event summary report documented Resident #1 received three medications that were not prescribed to him including: 300 mg [MEDICATION(S)] (a medication for blood pressure), 10 milliequivalents (meq) potassium (mineral supplement) and 12.5 mg [MEDICATION(S)] (a medication used for [CONDITION(S)]). The root cause of the significant medication error was related to the licensed nurse not using a patient identifier when administering the resident's medication. The resident decompensated quickly after the medication error and required emergent medical care. The licensed nurse was provided education regarding the five rights of medication administration. It documented ongoing education for licensed nurses regarding medication administration was provided. The 2/7/22 QAPI meeting summary documented an audit was completed for photos of residents in their charts and nametags on all residents' rooms to prevent further significant medication errors. -However, during the survey process, observations showed four residents did not have name tags outside of their rooms as an identifiers, as was indicated on the facilities QAPI plan. On the 500 hallway, four rooms had the residents documented in the wrong room in their electronic medical record. The resident who was physically in the A side of the room was listed in the medical charting system as residing on the B side of the room. The name tags on the outside of the rooms were also incorrect in identifying which resident resided in each bed. The facility failed to ensure the interventions set forth in the QAPI plan were in place and audited for accuracy to prevent any further significant medication errors. III. Staff interviews The DON was interviewed on 6/1/22 at 1:28 p.m. She said licensed practical nurse (LPN) #5 had a significant medication error on 2/5/22 while administering medications. She said LPN #5 started working at the facility on that day and was being trained by RN #1. The DON said LPN #5 caught her mistake and reported it to RN #1. RN #1 then assessed Resident #1, who had already begun to decompensate. The DON said RN #1 contacted the provider who ordered for nursing to monitor the resident for any further changes. She said RN #1 also contacted poison control who recommended sending the resident to the hospital for further medical care. She said a competency assessment had been conducted for LPN #5 on 2/5/22 following the medication error. She said on the spot training was provided alongside a medication administration audit for all licensed nurses in the facility. She said this was considered the audits the facility put into place through the QAPI program following the significant medication error. She said following the medication error on 2/5/22, the admissions coordinator conducted an audit to ensure all residents had a name tag outside of their room and a picture in their chart as a resident identifier. She said the licensed nurses should use identifiers to ensure medications were being administered to the correct resident. She said the admissions coordinator was responsible for continuing to ensure all residents had name tags for their room and pictures in their medical chart, but she recently left the facility. She said no other staff member had taken over that area to ensure the name tags, pictures and medical records were accurate. The DON said she had conducted an audit during the survey process and noted residents on the 500 hallway to be in the wrong rooms. She said several residents were physically residing in the A side of the room, but the electronic medical records and the nametags outside of the resident's room indicated they were in the B side of the room. She said she found several residents throughout the facility that did not have name tags on their door. She said this could lead to further medication errors. She said she updated the resident rooms in the electronic medical records and the nametags.

Based on observations, interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for two (#3 and #19) out of five reviewed for skin conditions out of 24 sample residents. Specifically, the facility failed to ensure Resident #3 received the care and services to treat existing venous stasis ulcers, prevent the development of additional wounds and the worsening of existing wounds. Resident #3 was admitted to the facility for respite care for seven days. He was admitted to the facility with four venous stasis wounds to his bilateral lower extremities. The 9/8/21 admission nursing assessment completed did not document the resident had any existing wounds. A skin assessment was not completed during his stay at the facility. Resident #3 received home health services on 9/7/21, the day prior to his admission to the facility. The home health wound notes documented four existing wounds, which were evaluated and being actively treated. Resident #3 discharged from the facility on 9/15/21 and received home health services on 9/16/21. According to the home health wound documentation on 9/16/21, three wounds had worsened and Resident #3 had acquired five additional wounds during his respite stay at the facility. The facility failed to evaluate and implement treatments for the wounds, which led to the wounds worsening and the development of five additional wounds (being facility acquired) during his seven day stay. Additionally, the facility failed to document, obtain treatment orders and treat an identified skin tear for Resident #19. Findings include: I. Facility policy and procedure The Skin Integrity Management policy and procedure, last revised on 6/1/21, provided by the nursing home administrator (NHA) on 2/10/22 at 9:00 a.m. revealed, in pertinent part, The implementation of an individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Practice standards include: review pre-admission information to plan for patient's needs prior to admission, complete comprehensive evaluation of the patient upon admission/readmission to the Center, perform daily monitoring of wounds or dressings for presence of complications or declines and document, prior to discharge, provide the patient/family/health care decision maker with instruction regarding specific wound care treatment and document on the 'discharge instructions' section of the discharge transition plan, document daily monitoring of ulcer site, with or without dressing. II. Failure to identify Resident #3's wounds and provide the necessary treatment and services A. Resident #3 1. Resident status Resident #3, age 77, was admitted on [DATE] and discharged on [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/15/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance of two people for bed mobility, transfers, toileting and extensive assistance of one person for dressing and personal hygiene. It indicated the resident did not have any wounds upon admission. 2. Resident representative interview Resident #3's spouse was interviewed on 2/7/22 at 10:48 a.m. She said she was the primary caretaker for Resident #3 and she admitted him to the facility for a seven day respite stay. She said Resident #3 had been receiving home health services for wound management prior to his admission to the facility. She said when the resident discharged from the facility following his respite stay, his wounds had worsened. She said the facility did not provide treatments to his wounds. She said the home health nurse had put on a dressing to his second left toe prior to admission to the facility. She said the dressing had the home health nurse's initials and date. She said the same dressing was on his toe when she brought him home on the day of his discharge from the facility. She said when she had taken the resident home, she noticed he had developed several new wounds. She said she did not receive any information from the facility upon discharge regarding any new wounds. 3. Resident #3's skin condition prior to admission to the facility According to the 9/7/21 home health wound notes, provided to the facility prior to Resident #3's admission by the home health agency, Resident #3 had four venous stasis ulcers. It indicated the resident was being seen on a regular basis for wound care. The notes documented the following: -Wound #1 to the left calf was scabbed over, measured .7 length (L) x .7 width (W) x .1 depth (D) centimeters (cm), dry and intact, with serous drainage; -Wound #2 to the right shin measured 1.1L x 1.1W x <.1D cm, was beefy red in color, intact, and had a small amount of serous drainage; -Wound #3 to the second left toe measured .7L x 1.0W x .7D cm, intact, with no drainage; and, -Wound #4 to the left third toe was healing, pink, and intact. 4. Resident #3 skin condition, as documented by the facility, upon the resident's admission The 9/8/21 nursing admission assessment did not document any skin concerns for Resident #3, however, according to the home health documentation the resident had a venous stasis ulcer to the left calf, right shin, second left toe, and third left toe. The 9/8/21, 9/9/21, 9/10/21, 9/11/21, 9/12/21, 9/13/21, 9/14/21 and 9/15/21 daily nursing assessments indicated Resident #3 did not have any skin conditions or concerns. The 9/8/21 and 9/9/21 nursing progress notes documented Resident #3's skin was warm and dry. -The facility failed to identify any existing skin concerns from admission, the worsening and the development of new skin concerns. A review of the resident's electronic medical record on 2/8/22 at 9:00 a.m revealed the resident did not have treatment orders or a plan of care implemented that addressed the care for the four venous ulcers while he was admitted to the facility, despite the home health history and physical that documented the four wounds prior to admission. The 9/14/21 discharge plan documentation from the facility documented the resident had weeping areas to his lower extremities and needed to see a wound doctor for treatment. No other assessments or information was documented to indicate the areas were addressed, monitored and treated during the respite stay. 5. Resident #3's skin condition immediately following his discharge from the facility on 9/15/21 The 9/16/21 home health wound notes documented Resident #3 continued with the four venous stasis ulcers he had prior to admission and developed five additional wounds during his stay at the facility. Resident #3 was seen by the home health nurse on 9/16/21 the day after discharging from the facility. The wound notes documented the following: -Wound #1 to the left calf was scabbed over and slightly red. Wound #1 did not worsen during Resident #3's stay at the facility. -Wound #2 to the right shin was not healing, measured 4.7L, 7.3W, and .1D cm, beefy red in color, had large amounts of foul odor serosanguineous drainage, had irregular edges with yellow slough, and was tender to the touch (symptoms of infection). Prior to the resident's admission to the facility, the measurements of the wound were documented as 1.1L x 1.1W x <.1D cm, The wound was beefy red in color, intact, and had a small amount of serous drainage. The wound had worsened during the resident's stay at the facility. -Wound #3 to the second left toe was no longer healing, measured .5L x .9W, x .1D cm, had white slough present, was red and macerated, small amounts of yellow foul smelling drainage, and jagged edges (symptoms of an infection). The home health nurse had treated the wound prior to admission and placed a dressing with her initials and date on the wound. Upon discharge the dressing was still present on the resident's toe, with the home health nurse's initials and date. The wound worsened during the resident's stay at the facility. -Wound #4 to the left third toe was healing and beefy red prior to the resident's admission to the facility. The wound had a blister and was tender to touch following the resident's stay at the facility. The wound notes documented the following wounds were newly developed during Resident #3's respite stay at the facility: -Wound #5 was documented as an unknown wound type to the left fourth toe acquired during the resident's admission at the facility. The wound measured .1L x .1W x.1D cm, dry, red, scabbed, with yellow slough surrounding the wound (symptoms of infection). -Wound #6 was documented as an unknown wound type to the right shin below wound #2 and was acquired during the resident's admission at the facility. It was indicated as not healing, measured 2.0L, 1.9W, and .1D cm, was beefy red in color, tender to touch, had jagged edges and had moderate amounts of serosanguineous drainage (symptoms of infection). -Wound #7 was documented as an unknown type of wound to the right shin below wound #6 and was acquired during the resident's admission at the facility. It was indicated as not healing, measured 2.0L x 1.5W X .1D cm, was beefy red in color, dry, macerated, and had moderate amounts of serosanguineous drainage (symptoms of infection). -Wound #8 was documented as an unknown type of wound to the right shin and to the right of wound #6 and #7 and was acquired during admission. It was not healing, measured 1.0L x 1.3W x .1D cm, beefy red in color, macerated, and had moderate amounts of serosanguineous drainage (symptoms of infection). -Wound #9 was documented as an unknown wound type to the left second toe and was acquired during the resident's admission to the facility. It measured .6L x .9W x.1D cm and had a small amount of serous drainage. Resident #3 admitted to the facility with four venous stasis ulcers. During his stay, three of the four wounds worsened by increasing in size or developing signs and symptoms of infection. He acquired five additional wounds during his stay at the facility. According to the documentation provided by the home health company on 2/8/22 at 4:01 p.m. the home health nurse contacted the facility to provide information regarding the care the resident received while at the facility. The nursing note revealed the resident informed the home health nurse the facility never looked at or treated the wounds on his lower extremities. The facility was notified by the home health nurse that a dressing which covered the wound to the second left toe was left on for the resident's entire stay and was removed by the home health nurse when the resident returned home from the facility. The home health nurse reported to the NHA that the resident had four wounds upon his admission to the facility, which were not treated and three of which had worsened. The home health history and physical, which was provided to the facility upon admission, documented the resident had existing wounds. The facility failed to complete a skin assessment upon the resident's admission to the facility and throughout Resident #3's stay. The facility failed to ensure the resident's existing wounds were treated and monitored. This resulted in wounds worsening during the resident's stay at the facility. 4. Staff interviews The director of nursing (DON) and NHA were interviewed on 2/9/21 at 12:30 p.m. The DON said skin assessments should be completed upon admission, weekly and as needed for all residents. She said the facility called skin assessments, skin checks. The DON said skin checks should be completed by a licensed nurse, the resident's entire body surface should be visualized by the nurse, and should encompass the entire body from head to toe to identify skin concerns. She said if a new wound or skin concern was found during a skin check, the nurse should notify the physician and obtain treatment orders. She said newly identified wounds should be referred to the wound physician, who rounded at the facility weekly. The DON said all wounds should have treatment orders and should be included on the resident's plan of care. The NHA said the resident was admitted prior to her starting at the facility. The DON said she was on vacation during Resident #3's respite stay, but an interim NHA completed the investigation. The DON reviewed the investigation, which concluded the resident did not have wounds. She confirmed she did not interview the nurses or complete the investigation. She confirmed she had not laid eyes on the resident's skin to have first hand knowledge of the resident's skin. The DON said upon discharge the nurse attempted to set up a wound consult as Resident #3 had weeping wounds. She said she was not sure how the investigation concluded the resident did not have any wounds, when the discharge documentation included a request for wound care due to the resident's weeping wounds. The DON confirmed the facility did not identify the resident's existing wounds, monitor the wounds or provide treatments for the existing and newly acquired wounds during the resident's respite stay at the facility. III. Failure to obtain treatment orders for Resident #19 A. Resident status Resident #19, age 89, was admitted on [DATE]. According to the February 2022 CPO, the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/31/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required supervision with setup assistance for bed mobility, transfers, dressing, eating, toileting, personal hygiene and bathing. B. Record review The anticoagulation medication use care plan, revised on 7/25/21, revealed the resident was at risk for injury or complications due to the resident's use of anticoagulation medication therapy. The interventions included a comprehensive skin assessment that would be conducted weekly and to observe the resident for bleeding. The skin integrity care plan, revised on 10/27/21, revealed the resident was at risk for skin breakdown due to weakness and debility, dementia, incontinence, and history of [CONDITION(S)]. The interventions included to provide treatments to skin tears according to physician orders, observe for signs of infection until healed and report changes and the use of arm protectors as ordered by the physician. It indicated the resident had wounds on his coccyx and left forearm. The 2/6/22 skin check documented that no skin injury or wound was identified. -However, according to the observations starting on 2/1/22, the resident had multiple dark red dried spots of blood on his shirt. C. Resident observations and interview On 2/1/22 at 3:20 p.m., Resident #19 was observed wearing a blue denim button down shirt with multiple dark red dried spots of blood on the left sleeve of the resident's shirt. On 2/3/22 at 10:22 a.m. Resident #19 was observed wearing the same blue denim button down shirt. The spots of dried blood were still observed on the left sleeve of the resident's shirt. On 2/7/22 at 12:26 p.m. Resident #19 was observed wearing the same blue denim button down shirt with the spots of dried blood still present on the left sleeve. On 2/7/22 at 1:57 p.m. Resident #19 said he had a sore on his arm. He said he was not sure how or what date it happened. He pulled up the left sleeve of his blue denim button down shirt and a skin tear was observed to the left forearm, approximately 1 cm (centimeter) by 1 cm covered with dark red dried blood. On 2/8/22 at 8:50 a.m. Resident #19 was observed wearing a different shirt, which was observed to be clean. -Resident #19 was able to pick out his own clothes, but the staff were to put them out for him. He was observed above with the same shirt on, on four different days over the course of six days. D. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 2/8/22 at 9:25 a.m. She said Resident #19 dressed himself. She said the staff set out clothes for him every day. CNA #6 said the resident had a skin tear on the left forearm. She said she would report it to the nurse. Licensed practical nurse (LPN) #2 was interviewed on 2/8/22 at 9:29 a.m. She said Resident #19 had a shower that morning with CNA #5. She said she had not received a report that Resident #19 had a skin tear on the left forearm. LPN #2 said she would observe the skin tear, start the change of condition assessment, notify the resident's family and physician, and provide treatment to the skin tear. CNA #5 was interviewed on 2/8/22 at 2:05 p.m. CNA #5 said she assisted Resident #19 with his shower that morning. She said she did not see a skin tear on his left forearm. She said she had helped the resident shower and dress. CNA #5 said any change of condition should immediately be reported to the nurse. Registered nurse (RN) #1 was interviewed on 2/9/22 at 11:22 a.m. RN #1 said skin assessments were completed as assigned on the user-defined assessment (UDA) list (in the resident's electronic medical record), which was usually upon admission, weekly and as needed. RN #1 said she preferred completing the assessment when the resident was in the shower or personal hygiene was being performed by the CNA so she would be able to see the resident's entire body and have help to reposition the resident. RN #1 said the resident should be visualized from top to bottom including the head, back, chest, arms, bottom and all the folds, legs, ankles, heels, toes and in-between the toes. She said she remembered completing the skin assessment for Resident #19 on 2/6/22. RN #1 verified she documented that there were no injuries or wounds found at that time. RN #1 said she remembered seeing the blood on the resident's shirt. She said she remembered seeing the skin tear on the resident's left forearm. She said she forgot to document it on the skin assessment. She said she should have completed the change of condition assessment, documented the skin tear, notified the resident's family and physician and obtained treatment orders to provide care for the resident's wound. She confirmed after she saw the resident's skin tear she did not provide a treatment. The director of nursing (DON) and NHA were interviewed on 2/9/22 at 12:30 p.m. The DON said skin assessments were completed upon admission, weekly and as needed by a licensed nurse. She said the nurse should look for and document any new skin concerns for the resident. The DON said that if there were any new issues, the resident would be assigned to wound care if needed. She said that any new wound or skin concern should be reported to the resident's representative/family and the physician and obtain treatment orders. The DON said she would provide education to the nursing staff to complete skin checks timely and thoroughly. She said she would perform a skin sweep throughout the entire facility.

Based on record review and interviews, the facility failed to ensure one (#2) out of 24 sample residents were kept free from neglect. The facility failed to ensure Resident #2 was not neglected by staff by providing the care and services the resident required to maintain the highest practicable well-being. This is evidenced by the following statements. Specifically, the facility failed to ensure Resident #2 received the care and services required to prevent an avoidable pressure injury from developing and worsening. On 8/6/21, the resident's representative reported she had informed a male nurse that Resident #2's right ear had been bleeding six weeks prior. The resident's medical record did not reveal documentation that the resident had been assessed when the injury was reported to the nurse and all prior skin checks documented no skin injury. According to the hospital documentation on 8/3/21, Resident #2's right ear wound was classified as a deep wound that had continuous pressure causing a pressure injury which led to a defect in his right ear with signs and symptoms of an infection. After the resident returned from the hospital on 8/3/21, the facility failed to provide the treatment and services consistent with accepted standards of practice by failing to provide the physician ordered treatment on seven occasions. Findings include: I. Facility policy and procedure The Abuse policy and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 2/10/22 at 10:30 a.m. It revealed, in pertinent part, (The facility) prohibits abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all patients. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restrain not required to treat the patient's medical symptoms. Neglect is defined as the failure of the (facility), its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. II. Resident #2 A. Resident status Resident #2, age 78, was admitted on [DATE], readmitted on [DATE] and discharged on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/22/21 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score of 12 out of 15. He required supervision with set up assistance with bed mobility, transfers, dressing, eating, toileting and personal hygiene. It indicated the resident did not reject care during the assessment period. It indicated the resident was at risk for pressure injuries. B. Record review The skin integrity care plan, initiated on 6/25/19, documented the resident had a risk for skin breakdown related to dry skin, [CONDITION(S)], discolored fingers and hands from smoking, weakness, impaired cognition and incontinence. The interventions included: observe skin for signs and symptoms of skin breakdown, evidenced by: redness, cracking, blistering, decreased sensation and skin that does not blanch easily; observe the resident's skin condition daily with activities of daily living (ADL) care and report abnormalities; and conduct a weekly skin assessment by the licensed nurse. The ADL care plan, initiated on 6/26/19, documented the resident was at risk for decreased ability to perform ADLs related to impaired cognition, behaviors and weakness. The resident required supervision and set up assistance for most ADLs. The resident required limited assistance from one staff member with personal hygiene, grooming and bathing. The risk for contracting and spreading COVID-19 care plan, initiated on 10/19/2020, documented that the resident refused to wear his mask at times in the common areas and did not practice social distancing. The resident would become verbally angry and not follow re-direction given by staff members. It indicated the resident frequently refused to change the face mask when it was soiled. The interventions included to provide the resident with education related to COVID-19, state and federal recommendations for long-term care facilities; social services to work one on one with the resident and his family to encourage mask wearing, social distancing and frequent hand hygiene when in common areas; staff to remind the resident of COVID-19 precautions, mask wearing, social distancing, isolation precautions and hand washing every shift when in common areas; and staff to report when the resident did not adhere to social distancing and handwashing to the social services department and the unit manager. C. Failure to prevent an avoidable pressure injury from developing and worsening The 6/17/21, 6/24/21, 7/1/21, 7/8/21, 7/22/21 and 7/29/21 skin check assessments documented a skin check was performed with no skin injury or wounds. The 8/3/21 nursing progress note documented the resident had sustained a wound on his right ear. The strap of the facial mask was cutting into the cartilage of the resident's right ear. The physician was notified and indicated he would be at the facility the following day to assess the wound. He ordered that a wound consult be completed for the resident. The 8/3/21 change of condition assessment revealed the resident had a deep wound into the cartilage of the resident's right ear. It had a three plus cap refill (a measure of the time it takes for a distal capillary bed to regain color after pressure has been applied to cause blanching), was not bleeding, but was oozing scant serous fluid (signs of infection). The recommendation included for the resident to be evaluated at the hospital. The unit manager assessed the wound and determined the wound needed to be stitched and the resident should be sent to the hospital. The physician and power of attorney (POA) were notified and the resident was transported to the hospital. The 8/5/21 nursing progress note documented that the resident's representative had come to the facility that morning. She had several concerns regarding the wound to the resident's right ear. She said she was not informed the resident had been sent to the emergency room for the wound to be evaluated. She said a month and a half ago, she had noticed the resident's ear was bleeding and told the male nurse. She entered the resident's room and found multiple facial masks with ear loops. The nurse apologized, removed the facial masks and provided the resident with a face shield. The nurse said she would notify the NHA of the resident's representative concerns. -The facility failed to identify the wound caused by the facial mask and consistently documented no skin concerns on the weekly skin assessments, put a treatment in place prior to the wound worsening from the mask digging into the resident's ear, into the cartilage and resulting in oozing serous fluid. The facility failed to assess and document the wound to the resident's right ear when it was reported by the resident representative six weeks prior to the documentation of 8/3/21. D. Hospital documentation The 8/3/21 emergency room physician notes documented Resident #2 was sent to the emergency department because of a sore to the resident's right ear. The resident said he received one shower per week, and asked staff for assistance in the shower, however staff would tell him, no you can do it by yourself. He said the staff would leave him alone in the shower room. The resident said he wore his mask all of the time. It documented the resident had a deep laceration to the right ear from a facial mask being left on for an unknown amount of time. The laceration was 2 cm (centimeters) in length, completely open and detached approximately 0.5 cm back from his scalp on the helix (outer rim), starting at the top of the helix to the right ear, going down into his antihelix Crura (part of the visible ear; curved prominence of cartilage parallel with and in front of the helix). There was an additional open sore on the bottom with purulent drainage (white, yellow or brown fluid slightly thick in texture made up of white blood cells trying to fight an infection). The detachment was approximately 0.25 cm in width. The wound was cleaned and irrigated with 100 ml (milliliters) of sterile saline. A large amount of dead skin was removed from behind his ears and inside his cymba and scaphoid fossa of the resident's bilateral ears. The resident was given an initial dose of antibiotics and sent back to the facility with a prescription to continue the antibiotics for seven days. The resident was provided information for an ENT (ear nose and throat physician) for outpatient follow-up. It documented, When looking at the patient's wound and discussing with the patient his care at the facility seems to be a case of neglect. I had asked the paramedic to call the facility inquiring about his ear. She states that she called the facility and spoke with the nurse at the facility who states that he was sent to the emergency department today because the patient's sister was visiting and noticed there was something wrong with his ear. The nurse then informed her that the patient refuses to bathe quite frequently. When discussing this with the patient, he states he asks for assistance with bathing and is refused assistance, and is left alone in the shower to bathe on his own. I do believe this is neglect. The attending physician documented the wound had continuous pressure causing a pressure injury which led to a defect in his right ear with signs and symptoms of an infection. It indicated the nurse practitioner contacted adult protective services for this chronic injury which appeared to be neglect. E. Failure to provide treatments as ordered by the physician The August 2021 CPO revealed the following physician orders: -Clean wound with wound cleaner with a 4x4 gauze. Apply Aquaphor to the area daily and as needed every day. Discontinue when resolved-ordered 8/3/21, discontinued 8/6/21. -Right ear wound: clean with wound cleaner, pat dry, leave open to air. One time a day for right ear wound-ordered 8/6/21 and discontinued 8/8/21. -Right ear wound: clean with wound cleaner, pat dry, leave open to air every day shift-ordered 8/8/21. The August 2021 treatment administration record (TAR) revealed the treatment to the wound to the resident's right ear was not documented as provided (left blank) on five occasions: 8/10/21, 8/18/21, 8/19/21, 8/20/21 and 8/24/21. The September 2021 TAR revealed the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . F. Facility investigation The 8/6/21 facility investigation revealed the facility reported an allegation of neglect. It indicated the resident's family accused the facility of neglect due to the development of the wound to the resident's right ear. The resident was sent to the hospital for an evaluation. It documented the resident had skin checks completed with no concerns identified until 8/3/21 and had refused skin checks in the past. -However, the resident's medical record did not reflect documentation that indicated the resident had refused any skin checks prior to the identification of the wound to the resident's right ear. -The investigation did not include interviews with any staff members regarding the statement made by the resident's representative who informed the nurse a month and a half prior that the resident's ear was bleeding or an attempt to identify the staff member. -The investigation did not include a conclusion or summary of the investigation completed by the facility. III. Staff interviews Registered nurse (RN) #1 was interviewed on 2/9/22 at 11:22 a.m. RN #1 said skin assessments were performed when they show up on the user-defined assessment (UDA) list (in the resident's electronic medical record). She said she preferred completing the assessment when the resident was in the shower or personal hygiene was being performed by the certified nurse aide (CNA) so that she would be able to see the resident's entire body and have help to reposition the resident. RN #1 said the resident should be checked from top to bottom including the head, ears, back, chest, arms, bottom and all the folds, legs, ankles, heels, toes and in-between the toes. The NHA and the director of nursing were interviewed on 2/9/22 at 12:27 p.m. The DON said skin assessments should be completed upon admission by the nurse, weekly and as needed. She said the weekly skin assessments were known as skin checks. She said skin checks were scheduled in the resident's electronic medical record and would show up on the nurses to do for that particular day. The DON said the nurse should put actual eyes on the resident and look at the resident's entire body surface. She said the nurse should document the status of any existing and new skin concerns on the skin check. She said all new skin concerns should be reported to the physician, the resident and/or family, treatment orders obtained and put into place with associated monitoring and updates to the resident's care plan. The NHA said she was not working at the facility during the time Resident #2 sustained a wound to his right ear. The DON said she was working at the facility, however she was out of town during that time. The DON said the former NHA was the lead on the investigation. She said she opened up the investigation, during the survey process, and it only included the documentation submitted through the state portal. She said she was unable to find documentation of the rest of the investigation. She said it appeared as though the former NHA did not try and determine who the male staff member was or complete staff interviews. She said Resident #2 had frequent behaviors and refusals. She said she found out Resident #2 had been sleeping in his facial mask. She said she saw the nursing progress note which indicated the resident's representative had reported an ear injury six weeks prior. She said that was not included in the facility investigation. She said the facility did not put any interventions into place following this incident. She said she was unable to find a conclusion to the investigation. She said the documentation from the hospital indicated the wound had been present for a while and had sustained constant pressure. She said the wound should have been documented on the skin checks prior to 8/3/21. She said she would be providing the nursing staff education on how to complete a skin check and ensure the nurses were looking at all the skin surfaces of the resident. She said because she was not there at the time, she did not know if the skin checks were completed correctly, but it appeared as though they were not accurate.

Based on observations, interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and likelihood of transmission of Covid-19 and the cross-contamination of wounds. Record review revealed the facility had one staff member who was positive for Covid-19 as of 6/25/21 and one resident who was positive for Covid-19 as of 7/1/21. The facility's failures in implementation of its infection control program created an immediate jeopardy situation with the likelihood of serious harm if not corrected immediately, due to the potential for transmission of the highly infectious Covid-19 virus to all residents residing in the facility. Observations and interviews from 6/28/21-7/8/21 revealed the following systemic failures in the facility's implementation of its infection control program to prevent the transmission of Covid-19: Staff failed to properly wear personal protective equipment (PPE) throughout the facility, including when caring for residents in quarantine rooms; staff failed to encourage or assist residents to wear masks correctly when out of their rooms; staff failed to ensure visitors and vendors were screened and educated on the proper donning and doffing of PPE; and staff failed to ensure clear and consistent signage on doors of residents identified as requiring precautions. Observations and interviews further revealed that staff failed to ensure the same pair of scissors would not be used on multiple residents during wound care. Findings include: I. Facility status - Covid-19 positive staff and residents The facility Covid-19 line listing documented one staff member was positive for Covid-19 on 6/25/21 and one resident was positive for Covid-19 on 7/1/21. The facility had 14 residents residing on the 100 and 200 halls in quarantine as they were new admissions. All the rooms on hallway 200 were quarantined. The residents in rooms [ROOM NUMBERS] were the only unvaccinated residents residing on the 200 hall. Some of the rooms on hallway 100 were quarantined but not all. II. Immediate Jeopardy A. Findings of Immediate Jeopardy Multiple observations and interviews throughout the days of the survey (6/28/21 to 7/8/21) revealed staff lacked knowledge of appropriate PPE usage in the facility when caring for residents in quarantine as well as when caring for residents not in quarantine when there was a known Covid-19 infection in the facility. Staff wore their masks below their nose and/or chin. Residents, too, wore their masks below their noses or down by their chins when out of their rooms and staff did not encourage or assist the residents to wear their masks correctly. Visitors and vendors entered the facility without the receptionist (RECT) screening and educating them on proper donning and doffing of PPE. Further, quarantine rooms on the 100 halls had inconsistent signage on the doors regarding infection control measures. Finally, the same pair of scissors were used for multiple residents during wound care. These failures created the likelihood for serious harm to all facility residents due to potential transmission of infections and the highly contagious Covid-19 virus and the cross-contamination of residents' wounds B. Facility notice of immediate jeopardy On 7/7/21 at 12:00 p.m. the Center Executive Director (nursing home administrator/NHA) was notified the failures above in infection control created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm due to Covid-19 and cross-contamination of wounds. C. Facility plan to remove immediate jeopardy On 7/8/21 at 9:00 a.m. the NHA provided a plan to remove the immediate jeopardy. The plan read: Corrective Action: ·On July 7, 2021, Center Nurse Executive, Unit Managers, and/or designee initiated education with staff on Infection Control and PPE practices to include specific PPE (type and fit) to be donned and doffed for residents on transmission based precautions. All staff will be re-educated before the next scheduled shift before July 9, 2021. Employees with scheduled time off, on leave of absence (FMLA), vacation, or as needed (PRN) staff will be re-educated prior to returning to duty. Ongoing staff education will be implemented with new onset of transmission based precautions to ensure staff adhere to PPE practices. ·The Infection Preventionist and/or designee will validate PPE practices are followed daily by rounding each shift to verify staff and visitors are donning and doffing PPE appropriately. The findings will be tracked by utilizing an audit tool to monitor compliance. The Infection Preventionist and/or designee will review the results of the audit in the monthly quality assurance and performance improvement (QAPI) meeting to ensure compliance is achieved and sustained. Subsequent plans of correction will be implemented if compliance is not sustained to include remedial education, progressive disciplinary action if needed, and increased frequency of audits. ·If non-compliance is identified during rounds, the Center Executive Director, Center Nurse Executive, and/or Infection Preventionist will be notified and on the spot education will be provided on adherence to Infection Control practices. ·Center Nurse Executive and/or designee verified clear and consistent signage was in place on doors of residents under transmission based precautions on July 6, 2021. ·The Admission Director, Center Nurse Executive, Center Executive Director and/or designee will review new admission placement based on vaccination status and place clear and consistent signage on doors of residents on transmission based precautions. The correct signage will be tracked and verified by the Infection Preventionist and/or designee. ·On July 6, 2021, the Business Office Manager re-educated screeners and validated competencies for screening vendors, staff, and visitors upon entering the facility. Education to be completed by July 7, 2021, prior to screeners working their next scheduled shift. On July 7, 2021, the Infection Preventionist and/or designee completed a Screener Competency checklist with the Business Office Manager to validate compliance. ·The Business Office Manager and/or designee will audit the screening process three times a week on each shift to ensure compliance is achieved and sustained. The Center Executive Director and/or designee will review the screening tool three times a week to ensure visitor education is provided and documented on the screening log. The Designated Screener will educate visitors and vendors on the Core Principles of Covid-19 Infection Prevention upon entry. Visitors and vendors will be provided with written instructions/education on the Core Principles of COVID-19 Infection Prevention after verbal education is completed. The Infection Preventionist and/or designee will validate PPE practices are followed daily by rounding each shift to verify visitors are donning and doffing PPE appropriately. The findings will be tracked by utilizing an audit tool to monitor compliance. ·The Designated Screener and/or designee will report non-compliance to the Center Executive Director, Center Nurse Executive, and/or Infection Preventionist. On the spot education will be provided to staff who are non-compliant with adherence to Infection Control practices. ·Wound physician was educated on June 30, 2021 on Infection Prevention and Control practices by ProHealth Director of Clinical Services. The Wound Champion and/or designee will round with the wound physician weekly to verify the Physician is using the correct instruments to prevent the spread of infection. If non-compliance is identified during wound care related to infection control practices it will be reported to Center Nurse Executive and/or designee. Re-education will be completed by Center Nurse Executive and/or designee. ·The Wound Champion and/or designee will ensure individual supplies to include scissors are provided to each resident requiring wound care if applicable. The Wound Champion, Unit Managers and/or designee will audit wound care three times a week to ensure infection control is maintained and individual supplies are utilized. ·On July 7, 2021, Center Executive Director and Center Nurse Executive will conduct a root cause analysis on Infection Control and submit findings to the Quality Assurance Performance Improvement Committee. The Quality Assurance Performance Improvement committee will review findings and make recommendations to promote changes and compliance of Infection Control practices. The Quality Assurance Performance Improvement committee will review and analyze findings from audits and observations monthly and develop additional measures on an ongoing basis to sustain compliance. ·Center Executive Director or designee will report findings of audits and observations in the monthly Quality Assurance Performance Improvement meeting for three months to ensure compliance is achieved and sustained. Subsequent plans of correction will be implemented as needed. The Quality Assurance Performance Improvement Committee consists of: The Center Executive Director, Center Nurse Executive, Medical Director, and three other key personnel. ·Unit Managers and/or designee completed a facility wide audit on July 6, 2021 to identify resident vaccination status to include fully/partially/or unvaccinated status. The Center Executive Director, Center Nurse Executive, Infection Preventionist and/or designee will maintain an active and continually updated list of resident vaccination status. The vaccination status will be stored in a binder at the Nursing Station to protect the private information of each resident. ·Resident vaccination status has been established and is readily accessible by referring to the spreadsheet created with a list of residents listed by unit and vaccination status (fully/partially/ or unvaccinated). This spreadsheet will be updated by Infection Preventionist/designee daily during the morning meeting and re-distributed to nursing stations. ·Newly admitted residents who are not fully vaccinated or those who may have had exposure to COVID-19 will be quarantined in their rooms with the doors closed for 14 days. Residents who attempt to leave their room will be redirected to their rooms. ·Residents will adhere to face coverings while out of their room in the lobby/common area and in the proximity of others. Residents observed without face coverings will be promptly provided with a mask, assisted with application of mask if necessary, and redirected to their room. Staff will communicate refusals to the Infection Preventionist, Center Nurse Executive, and Center Executive Director. The plan of care will be reviewed and revised for residents who are non-compliant on quarantine/isolation and will include increased supervision up to one on one supervision if necessary. On July 7, 2021, the Center Executive Director and Center Nurse Executive designated an Infection Preventionist to monitor and assist with sustaining compliance. C. Removal of immediate jeopardy On 7/8/21 at 9:32 a.m. the NHA and the director of nursing (DON) were notified that the immediate jeopardy situation was lifted based on the facility's implementation of the above plan. However, deficient practice remained at F level, the potential for more than minimal harm that is widespread. III. Systemic failure to implement an effective infection prevention and control program to prevent the spread of Covid-19. A. Facility policies 1. The Covid-19 policy and procedure, dated 3/27/2020, revised 6/7/21, provided by the NHA on 7/8/21 at 4:00 p.m. read in pertinent part: -In addition to Standard Precautions, Contact and Airborne Precautions will be implemented for patients suspected or confirmed to have COVID-19 based on the Centers for Disease Prevention & Control (CDC) guidance, to prevent the development and transmission of COVID-19. -For the purposes of this policy, Airborne Precautions is defined as wearing an N95/approved KN95 respirator upon entry into the patient's room, in addition to the recommended personal protective equipment (PPE), keeping the door to the patient's room closed. -Implement universal use of face masks/respirators and eye protection while in the Center. -For patients with an undiagnosed respiratory infection, staff follow Standard/Contact/ Droplet Precautions (i.e., facemask, gloves, isolation gown) with eye protection when caring for a patient unless the suspected diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Newly admitted and/or readmitted patients will be cohorted. -Patients on Transmission-Based Precautions are restricted to their room except for medically necessary purposes. -If a patient has to leave his/her room, he/she must wear a facemask or cloth face covering throughout the duration of their time outside of the room or center. 2. On 7/7/21 at 3:00 p.m. the DON provided a copy of staff expectations when caring for residents in the (quarantined) admission unit. It read in part: Expectations of staff caring for residents on the admission unit is to provide residents on isolation (quarantined) with patient specific precautions to include: -Hand hygiene BEFORE and AFTER contact with patient, environment, and removal of PPE -N95 mask, gown, face shield upon entering room; Change gown after each patient contact -Keep room door closed, remind and redirect resident about closing door; Patient to wear a mask when out of room and maintain social distancing. B. Professional references According to Center for Disease Control (CDC) guidance, Responding to Coronavirus (COVID-19) in Nursing Homes Considerations for the Public Health Response to COVID-19 in Nursing Homes, updated 4/30/2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, accessed 7/17/21: -Even as nursing homes resume normal practices and begin relaxing restrictions, nursing homes must sustain core infection control (IPC) practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and HCP (heathcare personnel) in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death . -In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. -All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. According to the Centers for Disease Control and Preventions (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 Pandemic, Implement Universal Source Control Measures updated 11/4/2020, retrieved online at www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, on 7/12/21, revealed in pertinent part, -Facemasks should cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Residents should wear their own cloth mask when out of their rooms or when others are around. HCP should wear a facemask at all times while they are in the healthcare facility, including in break rooms and other spaces where they might encounter co-workers. Hand hygiene should be performed immediately before and after any contact with their face mask. According to t]he Centers for Disease Control and Prevention (CDC) Using PPE, last updated 4/3/2020, retrieved on 7/12/21 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html, included the following recommendations for how to put on (don) PPE gear: - Identify and gather the proper PPE to don. -Perform hand hygiene using hand sanitizer. -Put on an isolation gown. Tie all of the ties on the gown. Assistance may be needed by another healthcare personnel. -Put on NIOSH-approved N95 filtering face-piece respirator or higher (use a facemask if a respirator is not available). Do not wear a respirator/face mask under your chin or store in a scrubs pocket between patients. Respirator straps should be placed on the crown of head (top strap) and base of neck (bottom strap). Facemask ties should be secured on the crown of head (top tie) and base of neck (bottom tie). If the mask has loops, hook them appropriately around your ears. -Put on a face shield or goggles. -Perform hand hygiene before putting on gloves. Gloves should cover the cuff (wrist) of the gown. -Healthcare personnel may now enter the patient room. C. Observations and interviews revealed the facility failed to ensure infection control measures were implemented to prevent the spread of Covid-19. As set forth above, the facility Covid-19 line listing documented one staff member positive for Covid-19 on 6/25/21 and one resident positive for Covid-19 on 7/1/21. The facility had 14 residents residing in the 100 and 200 hallways in quarantine as they were new admissions. The residents in rooms [ROOM NUMBERS] were the only unvaccinated residents residing in the 200 hall. Contrary to facility policy and CDC guidance, staff failed to properly wear personal protective equipment (PPE) throughout the facility, including when caring for residents in quarantine rooms; staff failed to encourage or assist residents to wear masks correctly when out of their rooms; staff failed to ensure visitors and vendors were screened and educated on the proper donning and doffing of PPE; and staff failed to ensure clear and consistent signage on doors of residents identified as requiring precautions. 1. 7/1/21 -At 8:00 a.m. during medication pass on the 400 hall, licensed practical nurse (LPN) #1 was observed with both elastic straps of her N95 mask around her neck and a gap under her chin where the mask was not touching her face. -At 8:15 a.m. an unidentified certified nurse aide (CNA) was seen delivering a breakfast tray to quarantine room [ROOM NUMBER], where an unvaccinated, newly admitted resident resided. She was wearing a N95 mask and a pair of goggles. She did not don a gown or gloves when she entered the room. She exited the room wearing the same goggles and mask. -At 8:20 a.m. two unidentified CNAs were seen entering quarantine room [ROOM NUMBER], where an unvaccinated, newly admitted resident resided. They both wore N95 masks. One CNA wore goggles, however, the other CNA did not, and neither CNA donned a gown or gloves before entering the room. The CNAs exited the room wearing the same masks. After exiting the room, one of the CNAs obtained a pair of goggles for the CNA who did not have them. LPN #1 was interviewed on 7/1/21 at 8:30 a.m. She said the CNAs did not have to don full PPE to enter quarantine rooms [ROOM NUMBERS] if they were delivering meal trays. She said the CNAs were only to don full PPE if they were providing care. 2. 7/6/21 a. Front entrance - receptionist/screener and entry to 100 and 200 hallways -At 9:05 a.m. the front desk receptionist (RECT #2) stated all staff and visitors, regardless of the unit they were visiting or working on, were required to wear eye protection and a N95 mask due to facility guidance related to the new positive Covid-19 cases. A gown was required if entering a quarantine room or the 200 hallway. The sign posted at the screening area upon entry through the facility front door read, Do you have your mask and eye protection? However, a poster was observed posted on the wall outside the social service office to identify the status of the required personal protective equipment (PPE) on 7/6/21. It stated the requirement was for a mask only. -At 9:15 a.m. a female visitor was observed standing at the nurses' station located about 20-30 feet from the front entrance to the facility. She wore a disposable gown and a N95 mask. She did not have on eye protection or gloves. She was standing near several staff members and other staff walked past without commenting. None of the staff commented on the presence of the female visitor until RECT #2 approached the visitor and asked her to return to the 200 (quarantine) hallway where she was visiting someone. The 200 hallway double doors were observed closed and an isolation precaution sign was posted on the outside of the door which read, contact plus airborne precautions. Instructions included to wear a N95/approved KN95 Respirator, gown, face shield, and gloves upon entering the room. Change gown after each patient contact; keep room door closed. Patient must remain in room unless medically necessary to leave. Patient must wear a face mask when out of room and maintain social distancing. Perform all procedures/tests in patient room, if able. The visitor approached by RECT #2 returned to the 200 hallway. She stood in the 200 hallway and removed her disposable gown, disposing of it in a nearby trash can. She then returned to the nurses' station in the front entrance with her N95 mask on. She was not observed washing or sanitizing her hands. -At 9:17 a.m. the wound registered nurse (WRN) was interviewed at the nurses' station in the front entrance and just outside the entry to the 100 and 200 hallways. She said visitors are informed that once they enter the 200 hallway where the residents are under quarantine, they, as well as staff, should have on disposable gowns, N95 masks, eye protection, and gloves should be available to don before entering the residents' rooms. She said the visitors should stay in the room they are visiting and use the call light if they need assistance. The visitors should not be wearing the disposable gowns off the unit. She said all individuals coming into the 200 hallway must have a N95 mask on and eye protection. She said that she had not seen many staff members stopped by the screener to put eye protection on and she was not wearing eye protection during the interview at the front entrance nurses' station. -At 9:22 a.m. the front entrance RECT #2 said that when visitors come in, she provides them a verbal education on how to don the gown, N95, and eye protection before they go to the 200 hallway to visit someone. She said she does not document the PPE donning and doffing education, but she gives them the verbal guidance upon admission. She said the visitors should not be exiting the quarantine hallway with their disposable gowns still on. -At 10:12 a.m. a housekeeper (HSK) was observed exiting the 200 quarantine hallway. She was wearing a N95 mask, but no eye protection. She said she was supposed to wear a N95 mask on the 200 hallway, and eye protection but said it was hard to wear the eye protection while cleaning the unit and exiting the hallway. She said she was not aware of any new education on infection control measures or PPE changes since the facility's identification of Covid-19 in the facility. -At 10:13 a.m. a nurse was observed at the nurses' station at the front entrance just outside the 100 and 200 hallways. She was not wearing eye protection. -At 10:14 a.m. a male staff member was observed entering the front door without being screened and only wearing a N95 mask. RECT #2 did not stop the staff member. -At 10:15 a.m. the DON was observed at the nurses' station located in the front entrance to the facility and just outside the 100 hallway and the 200 quarantine hallway. She was not wearing eye protection. -At 10:50 a.m. the NHA was observed entering the front entrance to the facility wearing only a N95 mask and no eye protection. The screener did not stop the NHA. -At 11:15 a.m. and until 11:25 a.m., the front entrance was observed. A male visitor was at the front entrance screening desk. He was holding a yellow disposable gown, a N95 mask and eye protection. He was informed by the screener to put the N95 mask on and to put the eye protection and gown on before visiting a resident residing on the quarantined 200 hallway. However, he was observed going through the front lobby holding his gown and eye protection and entering the 200 hallway; once there, he put on his disposable gown and eye protection. He did not have gloves. Several staff were observed at the front entrance nurses' station, but they did not stop or correct the visitor before he entered the 200 hallway without appropriate PPE. A second visitor was observed receiving the same instruction as above from the front RECT #2. He was observed entering the 200 hallway wearing his N95 mask, but not eye protection. A plastic lidded bin was observed at the front entrance screening area. The bin was labeled gowns. Yellow disposable gowns and gown strings were observed hanging outside the lid. RECT #1 said that visitors should place their disposable gown in a provided trash bag, and doff it into the gown bin upon exit from the facility. -At 11:35 a.m., CNA #11 was interviewed while the 100 hallway resident door postings were observed. She said that the residents on the 100 hallway had different PPE postings on their doors. She said some residents required only a mask, some only eye protection, and some required different degrees of gowns, gloves, and masks (see below). She said it was confusing, so she just relied on what was posted on the door. She did not know why some had full PPE and some only had part of this requirement. The CNA did not have eye protection on and the second secured rubber band for her N95 mask lay across the front of her mask and not behind her head. Observations of the 100 hallway during the tour (7/6/21 from 4:04 p.m. to 4:11 p.m.) revealed inconsistent signage on room doors in the 100 hallway, some with instructions that varied from facility policy. Specifically: -room [ROOM NUMBER] - no signage on the door -room [ROOM NUMBER] - signage indicated N95 mask, gloves, gown, and contact plus airborne precaution -room [ROOM NUMBER] -signage indicated eye protection only -room [ROOM NUMBER] - signage indicated surgical mask only -room [ROOM NUMBER] - signage indicated eye protection only -room [ROOM NUMBER] - signage indicated N95 mask and included a donning and doffing poster -room [ROOM NUMBER] - signage indicated eye protection sign and contact plus airborne precaution -room [ROOM NUMBER] - signage indicated contact plus airborne precaution LPN #1 was interviewed on 7/6/21 at 11:44 a.m. She said she wore eye protection because it made her feel safer. She said that even though it was posted as a requirement for entrance to the facility, only a few staff members complied. She could not recall the last education staff was provided regarding PPE use. RECT #2 said she completed a verbal education with visitors, but could not identify or locate any documentation that showed visitors had been educated. She said she is the one that supplies PPE to the visitors prior to their entry into the facility. -At 1:00 p.m. a vendor was seen delivering boxed items to the facility. He was allowed entry through the front door without being screened, and was not asked to wear a mask or eye protection as he unloaded the boxes in the front lobby where residents were present. -At 2:30 p.m. a water delivery vendor arrived to deliver large water bottles. He knocked on the conference room door and was not wearing a mask or eye protection. He said he was not screened when he entered the facility and he had not been screened since the mask mandate was lifted in April, 2021. He said he delivered water to many facilities and businesses in the region. 3. 7/7/21 -At 5:59 p.m. registered nurse (RN #8) entered the facility and spoke loudly to the receptionist (RECT #1). She was overheard refusing to follow the updated PPE guidelines the facility established to remove the immediate jeopardy (see above). She, instead, insisted on going to the nurses' station 20-30 feet from the front entrance and putting on her PPE there. At 6:05 p.m. RECT #1 was interviewed. He said he had been educated on how to properly screen all staff, visitors, and vendors upon their entry into the facility. He said RN #8 had refused to follow the screening process, and he was told to let her go and report the situation. He said he did not know what else to do to handle non-compliant staff members. At 6:15 p.m. the DON and NHA said they had been immediately informed of the actions of RN #8 and had reprimanded her. They both said that they would not want any non-compliant individuals to enter the facility. They stated there would be additional education done right away so that all screeners were educated on the screening process and how to address non-compliant staff and visitors. b. 300, 400, 500, and 600 hallways Many staff were seen throughout the facility not wearing eye protection and not wearing their N95 masks correctly, as evidenced by one elastic strap only or both straps around their necks or one strap loose in front of the mask or tucked inside the front of the mask. -At 8:00 a.m. during medication pass on the 400 hall, LPN #5 was not wearing eye protection while passing medications. -At 10:34 a.m. at the nurses' station on the 300/400 hall, the activity assistant (AA) seated at the desk had both straps of her N95 around her neck, exposing her chin and nose. She and another staff member were not wearing eye protection. There was an ice chest on a cart in the hall across from the nurses' station desk. An unidentified resident was observed using the ice scoop to place ice in two Styrofoam cups. She touched the inside of the scoop container with her bare hand. Her mask was below her nose. Six residents were seen in the 300/400 hallways with their masks below their noses or down by their chins and staff did not encourage them to apply them correctly. -At 10:47 a.m. unit manager (UM) #1 was seen with the top strap of her N95 laying on the front of her mask and she was not wearing eye protection. She said she did not have goggles on because they did not fit over her glasses; she had not considered wearing a face shield in place of goggles. She said staff's last education regarding PPE was a couple weeks ago. She said all staff, including housekeeping, should be wearing eye protection since they now had a Covid positive resident in the facility. -At 10:55 a.m. on the 500/600 hall, an unidentified nurse was seen standing at a medication cart with the top strap of her N95 mask tucked behind the front of the mask. RN #3 was observed with both straps of her N95 mask around her neck and the mask down on her nose. -At 11:00 a.m. CNA #1 said the CNAs had PPE education about a month ago that included what to wear in isolation (quarantine) rooms and in the facility when the facility was in or out of outbreak status. (Covid-19 positive resident/staff in the facility.) D. Administration interviews 1. The DON confirmed staff's failure to implement infection control measures required by facility policy and CDC guidance. On 7/6/21 at 11:40 a.m. the DON was interviewed. She said she and the NHA had their infection control preventionist (ICP) certificates but the facility had not had a designated ICP since 7/1/21. She said education was provided to all staff a couple weeks ago during an all staff zoom meeting. She said it covered the correct PPE to wear when in outbreak status and when not. They covered the new virus variant, testing, frequency, and vaccinated/unvaccinated staff. She said on a unit with a Covid-19 positive resident, staff remain on that hall and, when entering the Covid-19 positive room, they were to wear full PPE (N95 mask, goggles or face shield, and a gown and gloves). If they wore goggles, they were to discard the N95 when exiting the room, and then apply a new one. If they wore a face shield, staff did not need to change the N95. She said both straps of the N95 masks were to be placed correctly, one above the head and the other lower around the neck. She said she had n[TRUNCATED]

Based on observation, record review, and staff and resident interviews, the facility failed to provide adequate supervision to prevent accidents/hazard with one (#2) resident who smoked in her room and one (#14) at risk for burns, which had a potential to affect 71 residents residing at the time of survey due to the risk of fire in the facility. The facility failed to prevent Resident #2 from smoking in her room with oxygen. Resident #2, who was on two liters of oxygen continuously, smoked in her room. Resident #2 continued to smoke in her room with oxygen and other flammable materials like bedding and curtains without regard to education provided by the facility or the smoking contract she had in place between her and the facility. Resident #2 smoking in her room caused concern for the safety of herself, other residents and staff in the facility which created an immediate jeopardy situation given the likelihood of serious harm if immediate action was not taken due to the risk of fire occurring in the facility. In addition, the facility failed to prevent Resident #14, who required assistance from staff for activities of daily living, from getting first [MEDICAL CONDITION] an electric blanket from his right hip to ankle. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy The facility failed to prevent Resident #2 from smoking in her room with oxygen. Resident #2 was on two liters of oxygen continuously per physician orders. Resident #2 smoking in her room placed her, other residents and staff at risk of harm due to potential of fires and burns. The facility failed to act upon the behavior smoking contract, dated 9/3/2020, once the resident violated the facility safety practices with smoking. The contract included designated smoking areas, safe smoking practices such as not smoking around oxygen, and with willful disregard of safety to others, termination of smoking privileges would occur, or the facility would initiate the discharge process. Interviews with staff revealed they were aware of the resident smoking in the room, however did not take steps to intervene. The staff stated they were fearful of injury due to potential of fire but they did not feel empowered by administration to intervene (for example confiscating the resident's smoking paraphernalia) beyond education and reminders. B. Imposition of immediate jeopardy Immediate jeopardy template provided to the facility on [DATE] at 10:15 a.m. with verbal notification to the nursing home administrator (NHA). Resident #2's behaviors and failures in the facility's response created a situation of immediate jeopardy. C. Facility response to immediate jeopardy On 1/14/21 at 12:09 p.m., the following abatement plan was submitted by the NHA to remove the immediate jeopardy situation. The abatement plan read: Corrective Action: 1:1 (one on one) placed with resident to prevent smoking in residents' rooms for her safety and the safety of other residents started on 1/14/21, to be ongoing. Discontinuation of 1:1 to be determined with provider evaluation and/or when resident discharges from the facility. Education related to safe smoking, smoking policy and education specific to this resident started on 1/14/21 to staff regarding responsibility of the 1:1 staff for all staff on all shifts including over the weekend to be completed by 1/17/21. Education included 1:1 to monitor for smell of smoke from residents room, notify management if smell of smoke is identified, 1:1 will knock and enter room upon smell of smoke to verify safety. 1:1 to offer resident assistance to go outside to smoke as she desires Social Services (department) to review with resident smoking cessation options. Provide ongoing education to resident about the safety risks of smoking in room. D. Removal of the immediate jeopardy On 1/14/21 at 1:33 p.m. the NHA was notified that the immediate jeopardy had been removed based on staff interview and review of the facility's abatement plan. However, deficient practice remained at F level (widespread with the potential for more than minimal harm) based on Resident #2's prevalence for smoking in her room in close proximity to oxygen, which resulted in an increased fire and burn risk to her, other residents and staff. II. Smoking population and smoking policy A. Smoking population The NHA provided the following information via email on 1/28/21 at 10:19 a.m. It read in pertinent part, There are 27 residents who smoke, 17 are independent smokers and 10 are supervised. Of the 27 residents who smoke, 9 use oxygen and 18 do not use oxygen. Of the 9 residents who use oxygen, 4 are independent smokers, and 5 are supervised smokers. Resident #2 is listed as a supervised smoker who uses oxygen. B. Professional reference on the hazards of smoking with oxygen The National Fire Protection Association, Medical Oxygen Safety 2016, retrieved on 1/27/21 at 1:50 p.m. from: https://www.nfpa.org/~/media/files/public-education/resources/safety-tip-sheets/oxygensafety.pdf?la=en documented in pertinent part, Portable medical oxygen in the home has grown over the past decade. Medical oxygen adds a higher percentage of oxygen to the air a patient uses to breathe. Fire needs oxygen to burn. If a fire should start in an oxygen-[MEDICATION NAME] area, the material burning will burn more quickly. The American [MEDICATION NAME] Society website, Patient Education: Oxygen therapy, (updated July 2020), retrieved on 1/27/21 at 1:57 p.m. from: http://www.[MEDICATION NAME].org/patients/patient-resources/resources/oxygen-therapy.pdf documented in pertinent part, You should never smoke while using oxygen. Your nose, hair, and clothing can catch fire very quickly and cause life-threatening burns. Keep oxygen at least 6 feet (2 meters) away from any open flame. C. Facility smoking policy The Smoking policy, revised 11/20/18, was provided by the NHA on 1/19/21 at 4:11 p.m. via email. It read in pertinent part, For centers that allow smoking, it will be permitted in designated areas only. Patients will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, will be supervised. Supervised smoking is defined as 'The observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations.' For centers that allow smoking, oxygen use is prohibited in smoking areas. If there is a 'willful' disregard for safety to others or the center is jeopardized by a patient's disregard for the smoking policy, termination of smoking privileges or initiation of a discharge plan may occur. III. Failure to supervise Resident #2 to prevent unsafe smoking in her room within close proximity to oxygen. A. Resident status Resident #2, under the age of 60, was admitted on [DATE] with readmission on 12/20/2020. According to the January 2021 computerized physician orders (CPO), the [DIAGNOSES REDACTED]. The 1/6/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance from staff with bathing, bed mobility, transfers, dressing and locomotion. The resident experienced depression including little interest or pleasure in doing things; feeling down, depressed or hopeless; and felt tired or had little energy. She exhibited verbal behavioral symptoms directed towards others on a daily basis. She rejected care four to six days during the seven-day review period. B. Observations and interviews On 1/13/21 at 8:36 p.m. cigarette smoke was coming from Resident #2's room. The resident did not give permission to enter when her door was knocked on. A staff member, who asked to remain anonymous, was notified and said he/she was aware the resident smoked in her room frequently. The staff member shrugged and said the intervention was to educate her about how unsafe it was for her to smoke in her room. The staff member said that she was fearful of fire hazard since the resident smoked in the room with her oxygen tanks nearby. The staff member said usually the resident remembered to turn off the machine before smoking. The staff member said her hands were tied because management did not stop the smoking. The staff member said she had not witnessed the resident smoking but would talk to her later. The staff member went to the other end of the hallway and assisted another resident. At 8:40 p.m., the director of nursing (DON) was notified of the smell of cigarette smoke and she said she was aware the resident smoked in her room. She asked if the smoking was witnessed and she was notified about the inaction of the staff member (see above). She said she would provide education to the resident about how unsafe it was to smoke in her room and remind staff to check on the resident when there was the smell of smoke. She said she felt her hands were tied because the resident would not relinquish her smoking paraphernalia and she did not want to violate the resident's rights by confiscating the items. She said she understood the fear her staff verbalized regarding fire and burn hazards, since the resident smoked at bedside in close proximity to oxygen. She said she had the same concerns about the fire and burn hazards. Resident #2 was interviewed 1/14/2021 at 11:48 a.m. She said she smoked in her room because she could only smoke in a section which was very far from her room. There was a large oxygen concentrator and portable oxygen unit in the resident's room. She said she had only been allowed to smoke four times per day and said she was not supervised when she smoked (according to the facility, she required supervision, see smoking population section). She said to line up to smoke was very inconvenient and prior she could only be outside in the smoking area for 10 minutes. She said this should not be a prison. She said they just opened up again (after COVID-19 outbreak) and now she could go out when she wants and she could stay out. She said she understood the dangers of smoking with oxygen but she had never smoked with oxygen on. She said she made sure the staff turned it off to protect herself. She said she called a certified nurse aide and had them turn off the oxygen before she smoked in her room. C. Record review Review of care plan revealed under focus section Resident #2 may smoke with supervision per smoking assessment related to smoking her room as seen by staff. She refused nicotine patch and gum. Initiated on 10/27/2020 and revised on 12/20/2020 The goal was for Resident #2 to smoke safely for 90 days per smoking assessment with revision on 11/11/2020. Interventions documented were: -Offered resident alternatives to smoking such as nicotine patch and gum. Date initiated 12/20/2020, no revisions. -Educated on the facility's smoking policy. Revision 11/11/2020. -Inform of and reinforce smoking restriction. Date initiated 11/04/2020, no revisions. -Inform and remind of location of smoking areas and times. Revision on 11/11/2020. -Reassess ability to smoke with supervision with any change in condition. Revision 11/11/2020. -Supervise with smoking in accordance with assessed needs. Revised 11/11/2020. -Ensure that appropriate cigarette disposal receptacles are available in smoking areas. Date initiated 11/04/2020, no revisions. -Monitor compliance to smoking policy. Revision 11/11/2020. Resident #2's comprehensive care plan documented is alert and is able to make her needs known. She chooses to take care of her belongings. She will do independent activities such as visiting with other residents, smoking, watching TV (television) in her room and relaxing. Smoking assessment noted in the progress notes on 11/18/2020 at 10:50 a.m. read that the Interdisciplinary team (IDT) review of smoking. Assessment and care plan reviewed. Remains independent smoker. Has behavior contract for history of unsafe smoking practices. The 11/18/2020 progress note read A smoking evaluation was completed today. However, no new interventions were put into place for unsafe smoking practices. The assessment concluded that the resident was deemed to be safe smoking independently, however the care plan read that the resident required supervision when smoking, see care plan. The smoking assessment that resident is an independent smoker is in disagreement with the care plan stating she requires supervision. The 12/20/2020 at 1:26 p.m. nurse progress note read the resident was seen by floor staff smoking a cigarette in her room. Staff educated to resident smoking was prohibited in the facility as it posed a threat of safety to those in the facility, including the resident, due to oxygen in her room which was flammable. The resident refused to give staff oxygen concentrator and refused to put out her cigarette. The floor nurse offered her nicotine gum and/or patch to which the resident refused as well. The nurse offered to take resident out to smoke at the facility's smoking times to which resident refused as well. The medical doctor (MD) was notified and aware of situation. The 1/1/21 at 2:12 a.m. nurse progress note read the resident continued to smoke in her room with oxygen concentrator in there. When staff prompted her to go outside with the rest of the independent smokers, the resident told staff I will smoke in my room and I don't give a (expletive) if you don't like it. Get the (expletive) out of my room. The 1/2/21 at 7:33 p.m. nurse progress note read the resident smoking a cigarette. The resident was informed she could go outside to smoke. She said I'll just smoke in my room. There was an oxygen concentrator in the room. The 1/6/21 at 3:50 a.m. nurse progress note read that the resident continued to smoke in her room with oxygen concentrator The resident felt there was no need to hide it when staff walked in. The nurse reminded the resident of the dangers of smoking and the rules of the facility. The 1/7/21 at 10:17 p.m. nurse progress note read the resident was smoking a cigarette while the nurse was in the resident's room administering medication. Nurse reminded that smoking in room was not allowed. The 1/9/21 at 8:18 p.m. nurse progress note read the resident continued to smoke in her room. Certified nursing aides (CNAs) discovered resident smoking at start of their shift and the nurse walked in with medication and the resident was sitting in bed smoking. The 1/11/21at 5:24 a.m. nurse progress note read the resident again was in her room smoking cigarette. The 1/12/21at 2:24 a.m. nurse progress note read the resident smoking in room. Her oxygen concentrator was off, yet the nasal cannula in place. The 1/12/21 at 12:51 p.m. nurse progress note read the nurse entered the resident's room which had remnants of smoke. D. Additional interviews Licensed practical nurse (LPN) #2 was interviewed 1/12/2021 at 4:32 p.m. LPN #2 said Resident #2 smoked in her room. When she did smoke in the room, the staff tried to educate her on risk to herself and others. The staff let the DON and MD know. She was blatant with her actions and did not care and refused to hand over her cigarettes. The staff offered different stimulation, patches, gum, and activities. When staff let her know, she provided education to the resident. She did wear oxygen most of the time, but had refused at times. She said the resident had never smoked in front of her nor had she caught her in the act. The resident had a right to smoke so we tried to do what we could. IV. Failed to provide supervision to Resident #14 while using a heating blanket which resulted in first [MEDICAL CONDITION] the right thigh extending to the ankle. A. Facility policy and procedure The Application of Heat policy, revised 11/1/19, was provided by the NHA on 1/19/21 at 5:57 p.m. It read in pertinent part: Heating pads may be used; however, proper use is essential to avoid thermal injuries. Manufacturer's instructions must be followed closely to prevent injuries and death related to the use of heating pads. Most injuries [MEDICAL CONDITION] prolonged use or inappropriate temperature setting. Prolonged use on one area of the body can cause a severe burn, even when the heating pad is at a low temperature setting. Use of heating pads requires the following safeguards: 1. Heating pads brought from home must be inspected by maintenance. 2. Use of heating pad must be care planned for safety and include area of the body for which the heating pad is to be used, length of use, and setting. 3. Patients may not sleep with a heating pad that is turned on. Requested from NHA any policy or procedure on heating blankets, first request was 1/19/2021 at 3:35 p.m. via email , second request 1/27/21 at 10:27 a.m. via email. Although NHA responded on 1/28/21 at 10:27 a.m. and said she was looking for a different policy still. -No specific heating blanket policy has been provided. B. Resident status Resident #14, below the age of 60, was admitted on [DATE]. According to the January 2021 computerized physician orders (CPO), the [DIAGNOSES REDACTED]. The 11/23/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance from staff with all activities of daily living (ADL) including dependent with eating, oral hygiene, toileting hygiene, shower/bathing, dressing, rolling, and transfers. C. Resident interview and observation Resident #14 was interviewed 1/19/21 at 10:16 a.m. The resident was supine in bed. The resident asked CNA #3 to reposition his body and head to a better position. CNA #3 repositioned the resident in bed with extensive assistance since he was unable to himself. Resident #14 said that his burn was better and like a sunburn. He said he did not have the electric blanket anymore. He said he had had it at the facility for three years. He said on 1/6/21 he had a COVID-19 vaccination and got sleepy and cold, and fell asleep with the electric blanket on. When he woke up he had the burn, he said the blanket just felt warm to him, he said he did not feel it burning him. D. Record review No physician orders, assessments, or care plan found in record review for use of a heating blanket or pad with Resident #14. The 10/17/2019 physician note read that Resident #14 Had recent fever to 104 degrees (fell asleep with heating blanket on) and chills. The 1/12/21 at 11:12 a.m. nurse progress note read that On the morning of 1-11-21, this Nurse received report from night shift regarding resident using a electrical heating blanket. Staff noted blanket when nights shift took his temp and it was high. The blanket was removed and Resident was educated by Nightshift Nurse. When day shift CNA entered room on this day, it was noted that Resident was continuing to use blanket. CNA reported to this Nurse. This Nurse re educated Resident on danger of heating blanket, and blanket was removed. Resident refused to remove blanket, but did agree to leave it turned off. The 1/12/21 at 11:18 a.m. nurse progress note read that It was reported to this nurse by night shift that resident had red blotches on his leg, When this nurse assessed resident it was noted that residents right leg had red blotched areas from thigh to ankle, areas were very warm to touch, with +1 [MEDICAL CONDITION] (fluid retention). Resident did have heated blanket on but it was turned off when nurse entered room. MD notified. Resident re educated again on safety issues of blanket. Resident told this nurse that redness was not from blanket, that he would have felt it if it was getting to hot. Resident was educated on his DX (diagnosis) and MS and was told that he would probably not feel the heat. Resident did agree to allow nurse to completely remove blanket from the bed. Will continue to monitor. The 1/12/21 at 2:00 p.m. the nurse practitioner note read that Staff called regarding residents use of electric heating blanket. Resident assessed: Integumentary (skin): Entire right leg hot to touch, erythemic (redness), dry, and skin intact. Circulation: trace [MEDICAL CONDITION], dorsal pedis pulses +2. Ordered further monitoring of leg q2 (every two) hours for 3 days, blanket removed at this time, apply aloe vera to area for 3 days, and notify NP with any site changes including peal, blister, swell, or become more erythemic. Likely 1st degree burn to skin, explained to resident and staff we will wait to see leg reaction/resolution for further treatment orders. The 1/16/21 signed at 10:33 a.m. physician note read that Resident #14 First degree burn right leg after using heating pad. E. Facility investigation Reviewed facility investigation report on 1/19/21 at 8:53 a.m. There was no investigation completed, the folder contained printed copies of electronic medical records such as the resident's facesheet and progress notes. There was a staff training heating blankets/pads were not allowed. When investigation requested again, NHA provided on 1/25/21 at 1:50 pm via email a risk management summary report. It read that the date and time of the event was 1/12/21 at 7:00 a.m. The event was labeled abuse alleged, neglect, mistreatment. Event location was the resident's room and the injury was a burn. Report preparer was primary nurse (LPN #5) and DON. Circumstances of the event were described as follows: Morning rounds observed redness to the right leg, areas were blotchy, starting at thigh and down to ankle. Areas were warm to touch, vital signs were within normal limits. Resident was alert, denied pain. Found electric blanket on resident, blanket as not turned on asked resident if blanket could be removed. Nurse practitioner (NP) notified. NP came to the facility to assess resident. NP determined this is a superficial first degree burn; injury due to resident declining to allow staff to appropriately remove blanket from his bed. New orders received. Wound physician to round with RN (registered nurse) 1/12/21. Resident continues to deny to staff and NP that areas are not from the blanket, that he insists that it is from recent covid shot. NP educated resident on covid shot, reactions, as well as on safety and disease process with [MEDICAL CONDITION] (MS). Resident stated to NP that he would have felt the blanket getting too hot. Resident re-educated on use of blanket, disease process of MS for ability to feel such sensations as well as inability to regulate own body temperature accurately due to MS disease process. Resident is A&O x3 (alert and oriented to date, place and time) able to make needs known and is independent in most decisions. NP states that when speaking with resident, it came up that the resident has had an issue with a heating blanket in the past, states that he got blanket as a gift. Abuse investigation: Interventions added immediately after allegation of abuse: removal of electric blanket with resident's permission. Staff education initiated. Summary of interview with resident: Resident received blanket as a gift and wished to utilize. Summary of interview with staff: Staff identified burn and acted accordingly. Conclusion is that the event was: Abuse non-substantiated. Summarize all findings to support abuse non-substantiated: Resident did not accuse anyone of neglect or abuse. Resident did sustain injury due to his choice of using blanket. Root cause conclusion: Resident desire to use electric blanket. Corrective actions: removal of blanket and education. Preventive maintenance schedule: no, if no, reason not performed: resident's property, facility unaware of usage. F. Staff interviews CNA #1 was interviewed on 1/19/21 at 10:05 a.m. She said heating pads and blankets were not allowed in the facility for use by residents. CNA #2 was interviewed on 1/19/21 at 10:09 a.m. She said there were no heating pads or blankets on the unit but there had been previously. LPN #1 was interviewed on 1/19/21 at 10:11 a.m. She said heating pads and blankets were not allowed due to safety of the resident and none of the residents had one. She said she was not aware that Resident #14 was using a heating blanket at night since she worked the day shift. The NHA was interviewed on 1/19/21 at 10:40 a.m. She said heating pads/blankets were not allowed She stated Resident #14 got items delivered from online and that was how he obtained the heating blanket. She stated she did not know how long he had it or when he got the heated blanket. She said she recently educated the facility staff that heating pads/blankets were not allowed. LPN #4 was interviewed on 1/19/21 at 2:50 p.m. She said she worked day shift and was told on nurse report (at change of shift from night shift to day) the heating blanket had been on Resident #14 and he had a burn. She reported applying aloe vera, as ordered, to the burned area. She stated that the resident understood he cannot use the heated blanket She said the CNA staff had been putting the heating blanket on the resident, at night mainly, and when day shift took care of the resident the heated blanket was not used.

Based on interviews and record review, the facility failed to ensure one (#2) of three out of 19 sample residents was kept free from verbal abuse, mental abuse, and neglect. Resident interview and record review revealed the resident was having an anxiety attack on [DATE] upon return from [MEDICAL TREATMENT] treatment. She asked licensed practical nurse (LPN) #3 for anti-anxiety medication, and LPN #3 did not administer the medication for more than an hour. The resident began to scream and yell as the anxiety attack progressed. Registered nurse (RN) #4 observed the resident's distress, did not intervene, and was verbally abusive to the resident. Resident #2 stated LPN #3 delayed medication administration causing the resident increased anxiety and vulnerability. LPN #3 and RN #4 were intimidating the resident, standing with arms crossed, failing to leave her room when asked, saying that they did not want her in their unit and said it did not matter how nurses treated patients and delayed her medication. The facility did not conduct an abuse investigation when Resident #2 reported when two staff members had intimated the resident, with the two staff members still working with the resident after she had reported the abuse allegations. The facility did not conduct an abuse investigation that included interviewing other residents working with the two staff members. The resident brought it to the facility's attention on [DATE] when she asked about the status of her grievance she filed regarding LPN #3 and RN #4 with the facility on [DATE] when the alleged perpetrators were suspended during the investigation. These failures contributed to the resident feeling as she stated, humiliated, embarrassed, vulnerable and intimidated. Cross-reference: -F609 failure to report an allegation of abuse timely to the State Agency; -F610 failure to investigate timely, prevent and correct alleged violations; and, -F742 failure to provide treatment/services for mental/psychosocial concerns. Findings include: I. Facility policy and procedure The Abuse Prohibition policy, revised [DATE], was provided by the nursing home administrator (NHA) via email on [DATE] at 11:38 a.m. It read in pertinent part, The centers prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents. Under the Elder Justice Act (EJA), employees are designated as mandated reporters and are obligated to immediately report any suspicion of a crime against a resident. The center will implement an abuse prohibition program through the following: training of employees; identification of possible incidents or allegations which need investigation; investigation of incidents and allegations; and reporting of incidents, investigations, and center response to the results of their investigations. A. Resident #2 1. Resident status Resident #2, under the age of 60, was admitted on [DATE] with readmission on [DATE]. According to the [DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance from staff with bathing, bed mobility, transfers, dressing and locomotion. The resident experienced depression including little interest or pleasure in doing things; feeling down, depressed or hopeless; and felt tired or had little energy. She exhibited verbal behavioral symptoms directed towards others on a daily basis. She rejected care four to six days during the seven-day review period. 2. Resident interview and observations The resident was observed on [DATE] at 1:48 pm. She had just returned from [MEDICAL TREATMENT], and was crying and moaning in her room. The resident was overheard saying to the certified nurse aide (CNA) that she wanted to go to bed and asked the CNA to assist her in getting out of her wheelchair. The resident said that the backs of her legs were sore from being in the chair since early in the morning. Two CNAs used the mechanical lift to transfer the resident to her bed. The resident was softly crying and moaning and said she did not feel well, then requested a lunch tray. The resident was interviewed on [DATE] at 1:54 p.m. She said that something happened a week ago and no one was doing anything about it. She said on [DATE] she returned from [MEDICAL TREATMENT] and needed to go to the bathroom, she was having a panic attack, and they needed to use the mechanical lift lift so she had to wait for assistance from staff. She said the CNA staff came to help, and they went to tell LPN #3 that she needed her anti-anxiety pill. She said she would not be able to transfer until medication was taken because of her anxiety level. She said LPN #3 went outside to smoke and left her for a long time. She said the CNA kept telling LPN #3 that she needed her pill but the nurse would not bring it. She said the CNA checked back in on her and asked if she had gotten her medication yet and she said no. Resident #2 said it took ,[DATE] minutes for LPN #3 to come to her room and she asked LPN #3 why did it take so long. The LPN did not say anything and left her room. She said LPN #3 returned 15 minutes later with registered nurse (RN) #4. The resident said that both nurses said to her, We can do what we want to and no one ever died of an anxiety attack. She said this caused her more anxiety so she screamed at them to get out of her room. The nurses stood in front of the doorway with their arms crossed and did not leave her room when asked. She said this made her feel intimidated and very vulnerable, like the nurses could treat her however they wanted. The resident said her neighbor and friend Resident #19 was a witness and heard her screaming at the nurses so he came to help. She said RN #4 was shutting the door on him and he pushed it open with his foot so he could see his friend. Resident #19 then went and got the social service assistant (SSA). (See Resident #19 and SSA witness statements below.) Resident #2 said that since the survey was initiated, the director of nursing (DON) was doing an investigation but she never came to interview her immediately after the situation occurred. She said she had to go find the DON after the incident because she never followed up with her about what would be done with the staff and how they treated her. She said the DON told her that the nursing staff needed to be educated. The resident said she told the DON that she wanted the staff suspended for a few days. She said she had waited for over one hour to get an anti-anxiety pill and the CNA staff had said LPN #3 had not been too busy to administer it. She said LPN #3 remained her nurse after the incident and was still her primary nurse. However, the resident did not express fear from LPN #3 and RN #4. Resident #19, who was Resident #2's friend and neighbor, was interviewed on [DATE] at 4:54 p.m. He said he got social services when he heard Resident #2 crying and upset because she wanted her medication. He said Resident #2 was waiting for her medication and LPN #3 knew it. He said the nurses were not listening to her because she was upset. He said he went and got the SSA. He said RN #4 worked another floor but she came down to assist LPN #3. He said LPN #3 agitated Resident #2 because instead of administering Resident #2's medication, she went out to take a smoke break. He said that RN #4 told Resident #2 that it did not matter where the nurses went and what they did, it was none of Resident #2's business. He said when he came to the aid of his neighbor, Resident #2, he had to put his foot in the door because RN #4 tried to close the door and not allow him in to see whether his friend was ok or not. He said the SSA did help calm things down and the SSA helped Resident #2 file a grievance. He said as far as he knew no one had come to him for an interview or to investigate the grievance. Resident #2 was interviewed a second time on [DATE] at 11:48 a.m. She said the incident that occured on [DATE] made her feel very vulnerable, like the nurses could talk to her and treat her anyway they wanted. She said the DON told her that she was going to provide education to the two nurses but she did not trust that the DON would follow through and help her. She said fortunately her neighbor went and got help from the SSA. Resident #2 said that she had just gotten out of the hospital and was in the facility for rehabilitation, but felt that she was getting weaker. She said she used to be able to stand up, and the reason she came to the facility was to get stronger. She said she was so weak they must now use the mechanical lift. She said she was exhausted coming back from [MEDICAL TREATMENT] and was having a melt down and needed to go to the bathroom and needed an anti-anxiety pill. She said she had to wait over an hour for the pill which increased her humiliation and embarrassment because of the way the nurses were treating her. Resident #2 said the nurse went to go smoke after the medication request and that increased her frustration. She said she filed a grievance with the SSA on the day of the incident. 3. Record review a. Abuse investigation The nursing home administrator (NHA) provided a folder that contained electronic health records for the resident, however, did not contain the investigation. The NHA provided the investigation on [DATE] at 1:50 p.m.via email. The investigation contained the following content: The [DATE] SSA witness statement read, On [DATE] (Resident #19) came to the social service (SS) office and asked to speak with the director of social services (DSS). The writer explained to the resident that the DSS was out of the office and asked if I could help him. (Resident #19) stated that (Resident #2) had concerns with nurse (LPN #3) and asked if this writer could go talk with (Resident #2). Upon arrival at the resident's room, (Resident #2) was overheard yelling at nurse (RN #4 and LPN #3). This writer overhead (RN #4) say, ' it does not matter ' and (Resident #2) responded ' it does matter how nurses treat residents! ' As (Resident #19) and this writer approached (Resident #2) room, the nurses closed the door, (Resident #19) kept the door from closing with his foot (nurses did not appear to see this writer at the door). (Resident #2) continued to use profanity and yell at the nurses asking them to leave her room. This writer asked if she could enter the room, (Resident #2) said yes and began telling this writer her concerns with the nurses. (Resident #2) explained that she had an anxiety attack and asked CNAs to call the nurse to bring her anxiety medication. (Resident #2) said that CNAs told nurse (LPN #3) multiple times (Resident #2) needed her anxiety medication, the nurse took an hour to provide the resident with her medication. Per (Resident #2) and staff nurse, (LPN #3) went outside to smoke and take the unsupervised smokers outside prior to giving (Resident #2) her requested medication. (Resident #2) asked the nurses to leave her room several times, both nurses remained in the room, with their arms crossed. This writer requested the nurses leave this writer alone with the resident, the nurses did step out of the room at that time. (LPN #3) was heard telling nurse (RN #4) that she did not want (Resident #2 and Resident #19) in her hall, which both residents also overhead and responded, ' (expletive) you! ' (Resident #2) expressed that she wanted to make a grievance against (LPN #3 and RN#4). This writer spoke with (Resident #2), who reports (LPN #3) told her that it doesn ' t matter how staff treats residents. (Resident #2) also reported being upset with (LPN #3) for taking an hour to provide her anxiety medication, responding to the resident, ' No one died because they needed to wait for their anxiety meds. ' (Resident #2) specifically said she wanted to make a grievance on both nurses. (Signed by the SSA [DATE]) The [DATE] training that was provided to RN #4 by the DON read, We need to be aware of the perception of others. Customer service is a huge part of our processes as healthcare professionals. Even in the instance of a resident having an increase in behaviors towards others and if they need the second person as a witness (or if a resident is care planned for two persons for all cares), the resident still has the right to choose to have someone in their room or not. We need to remember to respect resident wishes. The [DATE] training that was provided to LPN #3 by the DON read, Please ensure that medications are prioritized for adequate response time with patient care. If there is not an emergency elsewhere, pain medication should be prioritized. The undated document that was not labeled or signed read, Witness of the person who witnessed the occurrence: (Resident #19) Perpetrator-(RN #4); Synopsis of incident requiring report to be made: (Resident #2) is alleging verbal abuse by (RN #4). (Resident #2) alleges that she and (RN #4) were involved in a verbal altercation regarding her medication and care; reports that (RN #4) was verbally abusive and told her she is allowed to speak to her and treat her any way that she wants and would not leave her room when asked to by (Resident #2). The nursing home administrator (NHA) provided on [DATE] at 1:50 p.m. via email a risk management summary (RMS) report. In summary it read that the date and time of the event was [DATE] at 3:00 p.m. however the state agency was not notified until [DATE] at 1:45 p.m. The circumstances of the event were described as the resident stated the communication from the nurse was perceived as abusive and that she was mad that she did not get her medications as requested for a long time. Witnesses were listed as CNA #2, CNA #5, SSA, and RN #4; however LPN #3 (primary nurse at time of medication request), and Resident #19 (neighbor) were not mentioned. When the report asked if other residents were involved it said no, however Resident #19 was a witness and went to the SSA to request help. It stated an unidentified nurse was suspended, however LPN #3 continued as primary caregiver the week of and week after the event per progress notes, staff schedule, and observations. Alleged perpetrator interviews only documented that RN #4 was interviewed. There was no record of LPN #3 being interviewed. The event was not entered into the RMS within 24 hours. The summary said the abuse was unsubstantiated, the nurse did not make a verbal threat, and the nurse was unprofessional. The LPN #3 was educated on prioritizing medications and resident's immediate needs. The root cause/conclusion documented: Poor customer service delivery from (RN #4) and (LPN #3). Conflicting statements from resident/staff. The NHA's investigative summary and conclusions did not support the resident interviews and witness statements. b. Staff interviews LPN #3 was interviewed on [DATE] at 2:26 p.m. (She had been observed working as Resident #2's primary nurse all day on [DATE] from 6:00 a.m. to 6:00 p.m., and again worked with the resident on [DATE].) She said she had been working at the facility since [DATE]. She said it had been really fast paced and lots of things were happening at once, but eventually everything got done and she got done what she could. She said she was the floor nurse who did medication pass, treatments, took physician orders [REDACTED].#2 was she wanted pain and anxiety medication. She said she was on the phone with the doctor and could not leave, and had a personal phone call that took 45 minutes. She said she was getting the medication ready and that she did not blame Resident #2 for being upset. The social services director (SSD) was interviewed on [DATE] at 12:41 p.m. She said the resident grievance process was that residents came to social services and got a form. Staff could take a grievance verbally and write it up if needed. After writing the grievance form, social services gave it to the appropriate department so that it could be followed up on. The SSD said in the case of Resident #2, the grievance was nursing related so it was given to the director of nursing (DON) and NHA. She said they followed-up with grievances in the morning meetings. She said they had 72 hours to resolve grievances, unless it was an abuse allegation, then it would start immediately. If it was an abuse allegation it went to the NHA, who was the abuse coordinator. Certified nurse aide (CNA) #2 was interviewed on [DATE] at 1:04 p.m. She said she saw Resident #2 return from [MEDICAL TREATMENT] last week ([DATE]). She said the resident was typically uncomfortable and agitated when she returned from [MEDICAL TREATMENT]. She said she asked what the resident needed and she said she needed her anti-anxiety medication. She let LPN #3 know. CNA #2 said Resident #2 was upset with how long it took, at least 40 minutes to one hour and 15 minutes to get the anti-anxiety medication. CNA #2 said that LPN #3 went out to take a smoke break after the medication request. CNA #2 said she talked to Resident #2 to calm her down and did what she could. CNA #2 kept Resident #2 informed and told the resident she had requested the medication from LPN #3. She said they were unable to take Resident #2 to the bathroom prior to the medication because they could not get the mechanical lift sling under Resident #2 because she was too agitated. But after the medication the resident was calm and they assisted her to the bathroom. She said the DON was notified after the incident. CNA #5 was interviewed on [DATE] at 1:18 p.m. She said she worked when Resident #2 had an anxiety attack (on [DATE]). She went into the resident's room and answered the call light a few times when waiting for the medication for the resident. She said Resident #2 had asked for her anti-anxiety medication, she could hear her crying, screaming, and cursing. She said LPN #3 took at least 45 minutes to get her medication. She said LPN #3 was working with a doctor. She said Resident #2 finally calmed down after about 45 minutes to one hour after receiving her medication. CNA with medication aide authority was interviewed on [DATE] at 4:53 p.m. She said she worked on [DATE] when Resident #2 had an anxiety attack. She said she was in the same hall but on the other end. She said LPN #3 was giving medications for the hall Resident #2 was on. She said Resident #2 was upset because she wanted her medication and she heard the resident yelling and crying. She did not say she offered the resident any assistance. The DON was interviewed on [DATE] at 12:07 p.m. She said the nursing home administrator (NHA) was the abuse and neglect coordinator. She said she assisted with the investigations and so did the social service department. She said for the incident with Resident #2, it was directed to the NHA. She said she was involved in the interviewing process of the investigation. The NHA was interviewed on [DATE] at 10:40 a.m. She said the facility did not have a committee that reviewed the abuse allegations, however every department was involved in the investigation process of an abuse allegation. She said the investigation process included talking to the resident making the complaint, and other residents and staff and documenting the review. The NHA was unable to provide a completed abuse investigation, as requested. She was likewise unable to explain why the abuse allegation was unsubstantiated. The NHA was unable to explain why Resident #2's behavior was under scrutiny when LPN #3 and RN #4's treatment of [REDACTED]. The NHA was not able to explain why the facility's initial investigation documented there were no witnesses, although other staff and another resident witnessed the event. The NHA said she had had training on the abuse investigation process, but she was unable to provide documentation of any training provided for her staff on the correct process for investigating allegations of abuse since the [DATE] incident. The NHA acknowledged the grievance and abuse investigation process for Resident #2 was not followed properly. The NHA stated that Resident #2 was upset with not receiving her medication timely, however the grievance was not handed off to her until the week after the incident. The NHA said when it occurred on [DATE] it was not an abuse or neglect incident, however no one investigated to determine if it was or not. RN #4 was interviewed on [DATE] at 2:45 p.m. She said concerning incident on [DATE] with Resident #2, that she was working the nurse practice educator position that day. She said she had walked to the unit to do an education on [DATE]. She said she remembered hearing Resident #2 yelling and CNA staff walking in her room. She said LPN #3 was there and said Resident #2 was yelling because she wanted her anti-anxiety medication. She said LPN #3 had just finished working with a physician and then another provider had interrupted LPN #3. RN #4 said she went in to tell Resident #2 that her nurse was coming soon with the medication. She said that was when Resident #2 yelled and said get out of her room. She said she went back to LPN #3, who was pulling medication from the cart and wanted RN #4 to go with her to give the medication. She said they went back to Resident #2 and handed medication cup, and Resident #2 had asked why there were two pills. LPN #3 said one was for pain and one was for anti-anxiety. Resident #2 said she did not ask for a pain pill and threw the cup of water toward LPN #3. RN #4 told Resident #2 that it was not appropriate to throw water. Resident #2 was yelling and said to leave her room. RN #4 said at that point Resident #2 was mad her medications were late, she was not sure how late. RN #4 asked Resident #2 if she wanted more water to take her pills and Resident #2 said she would take her pills whenever she wanted. She said Resident #2 said she would have taken pills if they had come earlier. She said Resident #2 was complaining about what LPN #3 was doing and why it took so long and RN #4 said she (LPN #3) did not have to let you know what she was doing on her own time. RN #4 said the social worker (SSA) came and asked to be alone with the resident. RN #4 let SSA know about the medication cup and to let LPN #3 or herself know if Resident #2 took it. RN #4 said she reported the incident immediately, via text, to the DON and the NHA, and they advised her to document it in the chart. RN #4 said she wrote a progress note. RN #4 said since the incident Resident #2 has not been her regular patient, although she did work with her occasionally after the incident. The NHA was interviewed on [DATE] at 4:52 p.m. She acknowledged that Resident #2 was not protected from the alleged perpetrator during the investigation. She acknowledged the grievance/abuse process was not followed properly and immediate steps to protect Resident #2 were not implemented. She said the alleged perpetrators were suspended during the investigation but it did not happen when the allegation was made on [DATE], until it was brought to the facility's attention on [DATE] when Resident #2 asked about the status of her grievance. She said they started the grievance/abuse investigation process with doing education but they needed to go back and finish that education on abuse. The NHA said she did have documentation of the incident in the facility risk management system and that she would send those reports. The NHA confirmed on [DATE] at 1:48 p.m. via email that LPN #3 was no longer working with Resident #2. Also, RN #4 had limited interactions with Resident #2 since she worked as a nurse educator. The facility failed to ensure Resident #2 was free from verbal abuse, mental abuse, and neglect.

Based on record review and interviews, the facility failed to provide treatment and care services in accordance with professional standards of practice for two residents (#1 and #2) of three residents reviewed for change of condition out of 19 sampled residents. Specifically, the facility failed to recognize a change in Resident #1's cognitive condition and coordinate the resident's care among the facility, the resident's representatives, the physicians, and occupational and physical therapists. The lack of coordinated care resulted in abnormal laboratory results, some in critical ranges, to not be completed as ordered or ensure appropriate clinical intervention when needed. The abnormal laboratory results for diabetic management of Resident #1, with a known history of type 2 diabetes, showed abnormal results, however failed to include communication between the facility and the managed care clinic to ensure timeliness of care and services. Resident #1 was hosptalized on [DATE] with a [DIAGNOSES REDACTED]. The facility failed to consistently track and monitor a facility acquired pressure ulcer to the right buttock. Ultimately the right buttocks wound was identified at the hospital on [DATE] as an unstageable pressure ulcer. Additionally, the facility failed to notify the physician of blood glucose levels outside of normal parameters for Resident #2. Findings include: I. Resident #1 A. Resident status Resident #1, age 96, was admitted on [DATE] and discharged on [DATE] to the hospital. According to the September 2020 computerized physician orders [REDACTED]. The 8/11/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. She required supervision and staff setup assistance with bed mobility, transfers, locomotion on/off unit, dressing, eating, toileting, and personal hygiene. The 9/14/2020 discharge MDS assessment revealed the resident was not identified to have one or more unhealed pressure ulcers/injuries. However, record review revealed the resident had an abrasion that was being treated prior to the hospitalization , see below. B. Family interview Resident #1's family member was interviewed on 1/12/21 at 9:09 a.m. She said that prior to COVID-19 restrictions, she and other family members would visit Resident #1 regularly. She said since visitations were not allowed in September 2020, she would speak with Resident #1 on the phone every day. She said all of a sudden, Resident #1 stopped answering her phone and she was concerned that something was going on with her health. She said that she tried calling the facility but it was difficult to get a hold of staff on the phone. She said she had to call the managing clinic team and ask them to send Resident #1 to the hospital for a more thorough examination. She said she was told at the hospital that Resident #1 was found to be dehydrated and had sores on her buttocks. II. Failure to recognize abnormal laboratory results showing a severe decline in Resident #1's condition The facility failed to ensure they had a complete medical record that included physician progress notes [REDACTED]. A. Record review 1. Care plans The diabetic care plan, initiated on 9/12/2019 and revised on 10/3/2019 revealed the resident had a [DIAGNOSES REDACTED]. It contained the following interventions: -Administer hypoglycemic medications as ordered; -Assess skin integrity daily with care and report abnormalities; -Monitor for signs and symptoms of [MEDICAL CONDITION]/[DIAGNOSES REDACTED] and report abnormal findings to the physician; and, -Monitor for signs and symptoms of infection and report as indicated. The care plan created 9/12/2020 identified the resident to be at risk for injury or complications related to the use of anticoagulation therapy. It contained the following interventions: -Anticoagulation to be given as ordered; -Labs as ordered; and, -Observe for active bleeding, for example hematuria (blood in urine), bruising, blood in stool, nose bleeds, or bleeding gums. 2. CPO Review of the September 2020 CPO revealed Resident #1 was not taking any diabetic medication. The 9/12/19 to 9/14/2020 physician order [REDACTED]. -Order start date: 5/4/2020; Eliquis, give 5 milligrams (mg) by mouth once a day for [MEDICAL CONDITION]. There was no evidence that the anticoagulant was considered in the treatment of [REDACTED]. 3. Complete blood count and Comprehensive metabolic panel (CMP) The 7/14/2020 at 8:15 p.m. complete blood count (CBC) lab results were: -Red blood cell count (RBC) was 2.50 millions per cubic millimeter (m/mm3). The reference range listed in the lab report was 3.40-4.90 m/mm3. A low RBC can indicate an internal bleed or kidney disease. -Hemoglobin (HGB) was 8.20 grams per deciliter (G/DL). The reference range listed in the lab report was 11.00-15.00 G/DL. Low HGB levels are an indicator of [MEDICAL CONDITION]. -Hematocrit (HCT) was 24.5 percent. The reference range listed in the lab report was 34.0-44.5 percent. Low HCT percentages indicate an insufficient supply of red blood cells. The 7/14/2020 at 8:15 p.m. CMP lab results were: -Sodium was 130 millimoles per liter (MMOL/L). The reference range listed in the lab report was 135.0-145.0 MMOL/L. Low sodium levels can cause fatigue, confusion, and indicate kidney failure. -[MEDICATION NAME] was 2.8 grams per deciliter (G/DL). The reference range listed in the lab report was 3.5-5.0 G/DL. Low [MEDICATION NAME] levels can indicate kidney or liver disease, malnutrition, or infection. -Blood urea nitrogen (BUN) was 20 milligrams per deciliter (MG/DL). The reference range listed in the lab report was 7-25 MG/DL. High BUN levels can indicate kidney disease or injury is present. -Creatinine was 0.7 MG/DL. The reference range listed in the lab report was 0.4-1.5 MG/DL. High creatinine levels can indicate impaired kidney function or disease. No documentation was found or provided from the facility or managed care team to indicate these labs had corresponding physician orders [REDACTED]. The 9/14/2020 at 8:50 a.m. CBC lab results were: -Red blood cell count (RBC) was 3.20 millions per cubic millimeter (m/mm3). The reference range listed in the lab report was 3.40-4.90 m/mm3. A low RBC can indicate an internal bleed or kidney disease. This reflected a slight improvement since 7/14/2020 lab results, however remained abnormal level without corresponding evidence of communication about the resident's health status between the facility and managed care clinic. -Hemoglobin (HGB) was 10.20 grams per deciliter (G/DL). The reference range listed in the lab report was 11.00-15.00 G/DL. Low HGB levels are an indicator of [MEDICAL CONDITION]. This reflected a slight improvement since 7/14/2020 lab results, however remained abnormal level without corresponding evidence of communication about the resident's health status between the facility and managed care clinic. -Hematocrit (HCT) was 30.9 percent. The reference range listed in the lab report was 34.0-44.5 percent. Low HCT percentages indicate an insufficient supply of red blood cells. This reflected a slight improvement since 7/14/2020 lab results, however remained at an abnormal level without corresponding evidence of communication about the resident's health status between the facility and managed care clinic. The 9/14/2020 at 9:03 a.m. CMP lab results were: -Sodium was 130.0 millimoles per liter (MMOL/L). The reference range listed in the lab report was 135.0-145.0 MMOL/L. Low sodium levels can cause fatigue, confusion, and indicate kidney failure. This result showed the level did not improve; it remained the same since 7/14/2020 lab results, however remained abnormal level without corresponding evidence of communication about the resident's health status between the facility and managed care clinic. -Blood urea nitrogen (BUN) was 67 milligrams per deciliter (MG/DL). The reference range listed in the lab report was 7-25 MG/DL. High BUN levels can indicate kidney disease or injury is present. This result showed the level to be remarkably high and was not identified as abnormal on the 7/14/2020 labs. -Creatinine was 3.7 MG/DL. The reference range listed in the lab report was 0.4-1.5 MG/DL. High creatinine levels can indicate impaired kidney function or disease. This result showed the level to be remarkably high and was not identified as abnormal on the 7/14/2020 labs. -[MEDICATION NAME] was 3.1 grams per deciliter (G/DL). The reference range listed in the lab report was 3.5-5.0 G/DL. Low [MEDICATION NAME] levels can indicate kidney or liver disease, malnutrition, or infection. This result showed a slight improvement since 7/14/2020 lab results, however remained abnormal level without corresponding evidence of communication about the resident's health status between the facility and managed care clinic. -Glomerular filtration rate (GFR) was 12.06. The reference range listed in the lab report was greater than 59.00. The GFR measures kidney function. A low GFR indicates the kidneys are not working efficiently. This result showed the level to be remarkably low and was not identified as abnormal on the 7/14/2020 labs. 4. Progress notes The 9/9/2020 managed clinic physician note revealed Resident #1's family member contacted the physician with the following concerns: -Resident #1 was sleeping all the time (for which the facility had no documentation of the resident's change with sleepiness), -Resident #1 was not answering the phone, -Resident #1's hearing had gotten worse, and -There had been no follow-up on blood found in Resident #1's stool. The note revealed the following instructions: the clinic would follow-up with the resident to verify the hearing aides were fitting and working properly, repeat the fecal immunochemistry test, comprehensive metabolic panel, and complete blood count test immediately, and increase [MEDICATION NAME] (medication for treating [MEDICAL CONDITION]). However, the laboratory tests mentioned above in the physician note, comprehensive metabolic panel and complete blood count test were not collected until 9/13/2020 at 5:48 a.m. The 9/13/2020 at 3:25 p.m. progress note revealed a nurse spoke with Resident #1's family member at approximately 3:25 p.m. and informed her that Resident #1 was requesting to be seen by her physician. The family member informed the nurse that she would like to speak with the physician as well. The nurse indicated that she would tell the physician to contact the family member. The 9/13/2020 at 4:08 p.m. progress note revealed that Resident #1's nurse practitioner from the managed care team had spoken with Resident #1's family member and that someone from the managed care team would see the resident and assess her. The facility did not have the documentation that Resident #1 was seen by the nurse practitioner or a physician on 9/13/2020, however laboratory tests were done, see results below. The facility failed to ensure coordination of care between the managed clinic and the facility's care team. The 9/14/2020 progress note revealed that the physician from the managed care clinic alerted the facility that Resident #1 had unstable labs which indicated possible kidney damage and the resident needed to be sent to the hospital. The resident was sent to the hospital at 10:45 a.m. 5. Nutritional assessment The 8/10/2020 nutritional assessment revealed Resident #1 had partial dentures to her bottom jaw, but did not wear them, she had chewing difficulty, she consumed 83% of meals, per skin check no skin issues (abrasion to right buttock). In Summary there was no significant weight changes, she remained on fortified foods, and supplements consuming 79% of her supplement. 6. Activities of daily living (ADL) flow record According to the September 2020 ADL flow record there was missing documentation. It documented as follows: -Breakfast Resident #1 consumed 100% of her meal on 9/4/2020 and 9/7/2020 and 10% of her meal on 9/13/2020. She consumed 480 milliliters (ml) of fluid on 9/4/2020, 240 ml on 9/7/2020 and 100 ml on 9/13/2020. -Lunch Resident #1 consumed 100% meal on 9/4/2020, 75% on 9/6/2020, 100% on 9/7/2020 and refused on 9/13/2020. She consumed 480 ml of fluid on 9/4/2020, 280 ml on 9/6/2020, 240 ml on 9/7/2020 and 120 ml on 9/13/2020. -Dinner Resident #1 consumed 50% of her meal on 9/2/2020, 50% on 9/3/2020, 100% on 9/5/2020, 75% on 9/6/2020, 100% on 9/7/2020, 100% on 9/12/2020, and 100 % on 9/13/2020. She consumed 140 ml of fluid 9/2/2020 and 9/3/2020, no fluid on 9/5/2020 and 9/6/2020, 140 ml on 9/7/2020, 240 ml on 9/12/2020, 140 ml on 9/13/2020. The record did not document any meal intake or fluids on 9/1, 9/8, 9/9, 9/10, or 9/11/2020. There were 25 missed opportunities to document food/fluid intake for 9/1/2020 to 9/14/2020. Additionally the record documented Resident #1 consumed food and fluids on 9/14, 9/15, and 9/16/2020 after the resident was discharged to the hospital the morning of 9/14/2020. 6. Fecal immunochemical test (FIT) Professional reference The Medline Plus, Fecal immunochemical test (FIT), (last updated on 1/5/21), retrieved on 1/28/21, from: https://medlineplus.gov/ency/patientinstructions/ 4.htm It read in pertinent parts, This test is performed to detect blood in the stool that you cannot see. Most (FIT) tests have the following steps: -Flush the toilet before having a bowel movement. -Put the used toilet paper in the waste bag provided. Do not put it into the toilet bowl. -Use the brush from the kit to brush the surface of the stool and then dip the brush into the toilet water. -Touch the brush on the space indicated on the test card. -Add the brush to the waste bag and throw it away. -Send the sample to the lab for testing. -Your doctor may ask you to test more than one stool sample before sending it in. Progress notes The 7/24/2020 progress note at 4:43 p.m. revealed the managed care's physician's office faxed an order to the facility for a fecal immunochemistry test (FIT) (a laboratory test for blood in stool). The note revealed a facility nurse attempted to call the physician's office three times with no success to clarify the orders. The 7/24/2020 progress note at 4:53 p.m. revealed a facility nurse spoke with the on call physician from the managed care team who would see if an on call nurse could bring the supplies needed for the FIT test to the facility. The 7/27/2020 progress note at 11:40 a.m. revealed a facility nurse spoke with a nurse from the managed care team to discuss the FIT procedure for Resident #1. The managed care team nurse stated someone from the managed care team would bring the supplies and once the stool had been collected would process the sample. The 7/28/2020 progress note at 9:38 a.m. revealed a facility nurse notified the managed care physician's office that a stool specimen was collected and the managed care team could pick up and process the sample. No documentation found in the resident's medical records or provided by the facility, indicated if the sample was picked up, processed, or the results. The 8/7/2020 progress note at 3:03 p.m. revealed a facility nurse notified the managed care physician's office that a stool specimen was collected and the managed care team could pick up and process the sample. The note did not indicate if this was a second specimen or the first specimen to be processed. No documentation found in the resident's medical records or provided by the facility, indicated if the sample was picked up, processed, or the results. B. Staff interview The clinic service manager from the managed care team was interviewed on 1/19/21 at 4:00 p.m. She said when the physician spoke with the nursing staff at the facility regarding Resident #1's transfer to the hospital on [DATE], the nurse stated the resident was fine but the family was voicing concerns and wanted the resident to be sent to the hospital. She said labs were collected 9/13/2020 at 5:48 a.m. and results were obtained on 9/14/2020 labs at 8:50 a.m. She said the labs showed low sodium levels, blood urea nitrogen (BUN) was high, creatinine was high, albumen was low, and kidney functioning was off. She said the resident's hematocrit and hemoglobin were low and red blood count was off. She said these lab results indicated the need for hospitalization . The clinic service manager from the managed care team provided the following information via email on 1/26/21 at 11:26 a.m. She indicated that when a resident was in a nursing facility, the facility would draw the labs. She indicated if the resident was at the clinic being seen by a provider, the staff may obtain labs in the clinic since the resident was already present. She indicated that anytime a resident was seen by a provider, labs were completed, or procedures were completed, all notes would be faxed to the facility nurses station. She indicated the process was for the provider to input a note with or without orders, send a task to the clinic staff to send the note to the facility, the clinic staff then faxed the note to the facility nurses station. The clinic staff who handled the task would then call the nurses station to confirm receipt of the physician note and answer any questions. She indicated that the managed care team attended resident care conferences if they were notified by the facility of a care conference occurring. She said the managed care team previously attended care conferences in person but had been most recently attended via telephone due to COVID-19 restrictions. The director of nursing (DON) was interviewed on 1/20/21 at 11:54 a.m. She said since she entered the role of DON, she had attempted to establish better communication with the managed care team. She said she had a contact at the managed care team who she would reach out to if she could not get a hold of them. She said communication with the managed care team had been an ongoing battle since they did not document in the facility medical records system. She said she also did not always receive resident records when they were requested. She said the facility relationship with the managing care team needed to be addressed and improved. She acknowledged the licensed staff in the facility should have followed up with any lab orders received from the provider and should have been documented in the clinical record. C. Diabetic monitoring 1. Professional reference The Center for Disease Control and Prevention (CDC), All About Your A1C, (last reviewed 8/21/18), retrieved on 1/26/21 from: https://www.cdc.gov/diabetes/managing/managing-blood-sugar/a1c.html#:~:text=The%20A1C%20test%E2%80%94also%20known,care%20team%20manage%20your%20diabetes. It read in pertinent part, the hemoglobin A1c test is a simple blood test that measures your average blood sugar levels over the past 3 months. It's (It is) one of the commonly used tests to diagnose prediabetes and diabetes, and is also the main test to help you and your health care team manage your diabetes. A normal A1C level is below 5.7%, a level of 5.7% to 6.4% indicates prediabetes, and a level of 6.5% or more indicates diabetes. Within the 5.7% to 6.4% prediabetes range, the higher your A1C, the greater your risk is for developing type 2 diabetes. MedlinePlus, Carbon [MEDICATION NAME] (CO2) in Blood, (last reviewed 7/30/2020), retrieved on 1/27/21 from: https://medlineplus.gov/lab-tests/carbon-[MEDICATION NAME]-co2-in-blood/#:~:text=Too%20little%20CO2%20in%20the,%2C%20weight%20loss%2C%20and%20dehydration. It read in pertinent part, Too little CO2 in the blood may indicate: ketoacidosis, a complication of type one and type two diabetes; acidosis, a condition in which you have too much acid in your blood; kidney disorders. 2. Record review Review of the September 2020 CPO revealed Resident #1 was not taking any diabetic medication (see above in CPO, interview below). The 4/24/2020 managed clinic physician note revealed Resident #1 was scheduled to have her hemoglobin A1c test on 4/26/2020. The 4/24/2020 at 12:03 p.m. facility progress note revealed the facility received orders for a hemoglobin A1c lab draw on 4/26/2020. However, there was no corresponding evidence that the laboratory test was conducted on 4/24/2020. The 7/14/2020 Hemoglobin A1c lab results reported on 7/17/2020 were: -Hemoglobin A1c level was 7.8 percent, however remained abnormal level without corresponding evidence of communication about the resident's health status between the facility and managed care clinic. -Glucose level was 357 milligrams per deciliter (mg/dL) documented in the 7/14/2020 CMP (see above). The standard range for glucose levels listed on the lab report was 75-110 mg/dL. However, the abnormal level was without corresponding evidence of communication about the resident's health status between the facility and managed care clinic. The 9/8/2020 basic metabolic panel (BMP) lab report result was; glucose level of 380 mg/dL, which remained abnormal level without corresponding evidence of communication about the resident's health status between the facility and managed care clinic. The 9/8/2020 progress note at 1:05 a.m. revealed the facility notified the physician at the managed clinic regarding critically low lab results which showed a critical low carbon [MEDICATION NAME] (CO2) level of 14 millimoles per liter (MMOL/L). The reference range was 22-30 MMOL/L. The facility notified the physician at the managed clinic and received no new orders. The 9/14/2020 lab results were a critical low CO2 level of 11 MMOL/L. This level worsened from 9/9/2020. There was no corresponding evidence that the facility notified the physician of the critical level or if the managed care physician received the abnormal lab results and determined to not act and failed to communicate to the facility resident care needs. The 9/14/2020 comprehensive metabolic panel (CMP) lab report results for glucose level was 262 mg/dL. The 9/14/2020 progress note revealed that the physician from the managed care clinic alerted the facility that Resident #1 had unstable labs which indicated possible kidney damage and the resident needed to be sent to the hospital. The resident was sent to the hospital at 10:45 a.m. The 9/14/2020 at 11:20 a.m. hospital summarization of the encounter lab result and note read the hemoglobin A1c result was 13.4 percent. The physician at the hospital documented, Discussed with son that (the) patient was most likely severely dehydrated which caused her confusion along with having a skin fungal infection which is being treated. Her A1c 12.4, son states she was a diabetic but has not been on any medications for 3 to 4 years because her diabetes resolved. He is not sure why that was never realized sooner while she was at the nursing home. Discussed the need for glucose management and starting insulin here. Pt (patient) will need to continue DM (diabetes mellitus) management on discharge. D. Staff interviews The director of nursing (DON) was interviewed on 1/14/21 at 11:53 a.m. She said it was up to the physician to determine how a resident's diabetes would be monitored. She said Resident #1's managed care physician did not have the facility check her blood sugars. She said Resident #1's managed care physician performed their own labs and those labs were not done at the facility so she did not always receive the results. She said there were communication issues between the facility and the managed care team as at times they might not have communicated lab results with the facility so the facility may not have had the same information. She said the facility notified the managed care team of the resident's critical CO2 levels on 9/9/2020 but without new physician orders [REDACTED]. She said if nursing staff had noticed changes in the mentation or routine care needs of a resident, then they would report these changes to the nurse and it would be monitored and discussed in the morning report. If the change seemed significant, the nurses would initiate a change in condition form and call the doctor; however this is contrary to the managed care physician note of the family's concern reported on 9/9/2020 (see above). The clinic service manager from the managed care team was interviewed on 1/19/21 at 4:00 p.m. She said the physicians that provided the resident's care no longer worked at the clinic but she felt she could speak on behalf of the care she received at the clinic. She said a physician performed a physical examination of Resident #1 in February 2019 and noticed that the resident's prescription for [MEDICATION NAME] (insulin) had not been filled since October of 2018. She said that due to Resident #1's hemoglobin A1c result of 6.8 percent on 2/27/19 and due to the resident's age, the physician did not prescribe diabetes therapy at that time. She could not speak on the later abnormal laboratory results. She acknowledged the 4/24/2020 Hemoglobin A1c was missed and should have been followed up on. III. Failure to consistently track and monitor Resident #1's pressure injury A. Record review 1. Care plan The care plan, initiated 9/12/19 and revised on 1/21/2020 identified the resident as being at risk for skin breakdown related to the following concerns: [DIAGNOSES REDACTED] (inflammation of skinfolds caused by skin-on-skin friction); anticoagulant therapy; prone to bruising; advanced age; limited mobility; and an actual fungal infection in the pannus (area of excess skin and fat in the abdomen region) and groin. The pertinent interventions included the following: -Provide preventative skin care for example lotions, barriers, creams, as ordered; -Apply barrier cream with each cleansing; -Observe skin condition daily with activities of daily living (ADL) care and report abnormalities. -Observe skin for signs/symptoms of skin breakdown for example redness, cracking, blistering, decrease in sensation, and skin that does not blanche easily; -Provide wound treatment as ordered; and, -Weekly skin assessment by a licensed nurse. 2. Resident #1's assessments of pressure injuries The 1/5/2020 change in condition note and facility skin assessment revealed a new skin wound was identified. It was identified as an abrasion to the right buttocks due to moisture associated skin damage. It was measured as two circular areas approximately 1.25 centimeters (cm) each. It indicated the change was reported to the primary care physician at the managed care clinic and new orders were obtained. However, there was no further documentation regarding the tracking, measurement, or the condition of the abrasion to include the response of the treatment for [REDACTED]. The physician orders [REDACTED]. The 1/5/2020 Braden scale for predicting pressure sore risk assessment identified the resident was at mild risk with a score of 16, (15-18 indicated mild risk). It revealed the following risk factors: -Occasionally moist, skin was occasionally moist. -She spent the majority of each shift in bed or chair. -Slightly limited in mobility. -Nutrition was probably inadequate. She rarely ate a complete meal and generally only ate half of any food offered. -Problems with friction and skin shear. She required moderate to maximum assistance in moving. Complete lifting without sliding against sheets was impossible. She frequently slid down in her bed or chair, requiring frequent repositioning with maximum assistance. The skin integrity care plan, updated 1/5/2020, included the following pertinent interventions after the wound identification: -Apply zinc base cream with dimethicone cream twice daily until resolved; -Encourage the resident to consume all fluids of choice during meals; -Observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered; -Obtain skilled physical and occupational therapy evaluations to improve functional mobility; -Weekly wound assessment to include measurements and description of wound status; and, -Wound related pain management interventions as indicated. The newly identified skin risks including friction and moisture from incontinence on the 1/5/2020 Braden Scale document, see above, were not included as interventions on the care plan. The 2/2/2020 facility skin assessment revealed the right buttock abrasions were delicate but healed. Although this note reflected the wound healed, the note below from the physician documented it was not completely healed. The 2/5/2020 physician progress notes [REDACTED]. The 2/9/2020 facility skin assessment revealed the resident had no identified skin injuries or wounds. This note indicated the abrasion was healed or not visible to identify on the assessment. The note below indicated that the abrasion was healed but being monitored. The 2/16/2020 facility skin assessment revealed the right buttock abrasions were delicate but healed. This note indicated the abrasion was healed but being monitored. No documentation found in the resident's medical records or provided by the facility to show interventions were put in place to prevent the abrasion from recurring. The 3/8/2020 and 3/15/2020 facility skin assessments revealed the resident had an abrasion to the right buttock and it was identified as being a previously noted skin injury/wound recorded. The previous documentation reflected the abrasion was healed, this note indicated that the abrasion reopened. The 3/29/2020 facility skin assessment revealed the resident had no identified skin injuries or wounds. The prior assessment indicated the abrasion reopened and this assessment reflected the abrasion was not present. The 4/5/2020, 4/12/2020, 4/19/2020, 4/26/2020, 5/3/2020, 5/10/2020, facility skin assessments revealed the buttocks (plural was indicated however, the documentation failed to indicate location of multiple areas of concern) were red and treatment was in progress. The assessment showed the buttocks were red but did not give location of redness or description of the surrounding tissue in the area. The prior assessment identified no abrasion was present and this note indicated there was a change to the skin condition but did not indicate if the redness was related to the abrasion. The 5/17/2020, 5/24/2020, and 5/31/2020 facility skin assessments revealed the resident had no identified skin injuries or wounds. These notes (TRUNCATED)

Based on observations, record review, and interviews, the facility failed to provide appropriate mental health treatment and services to attain the highest practicable mental and psychosocial well-being for one (#2) out of three sample residents. The facility failed meet the resident's mental and psychosocial needs. The facility failed to implement therapeutic behavioral interventions to prevent/decrease staff-to-resident altercations with Resident #2. The facility failed to implement and document on the care plan new behavior interventions after behavioral episodes for Resident #2. Resident interview and record review revealed the resident was having an anxiety attack on [DATE] upon return from [MEDICAL TREATMENT] treatment. She asked licensed practical nurse (LPN) #3 for anti-anxiety medication, and LPN #3 did not administer the medication for more than an hour. The resident began to scream and yell as the anxiety attack progressed. Registered nurse (RN) #4 observed the resident's distress, did not intervene, and was verbally abusive to the resident. These failures contributed to the resident feeling as she stated, humiliated, embarrassed, vulnerable and intimidated. Cross-reference F600, free from abuse and neglect; Cross-reference F609, reporting of alleged violations; and, Cross-reference F610, investigate/prevent/correct alleged violation. Findings include: I. Facility policy and procedures The Grievance/Concern policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:08 a.m. via email. It read in pertinent part, The resident has the right to voice grievances to the Center without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding their Center stay. All residents may voice grievances/concerns and recommendations for changes. Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any resident. Social Services personnel will serve as patient advocates in the grievance/concern process. The Center Executive Director (CED) will serve as the Grievance Officer who is responsible for overseeing the grievance process. Purpose is to assure prompt receipt and resolution of patient grievance/concern. Immediate action will be taken to prevent further potential violations of any resident right while the alleged violation is being investigated. For reports of abuse, follow the state-specific abuse policy for management of the incident and documentation requirements. II. Resident #2 A. Resident status Resident #2, under the age of 60, was admitted on [DATE] with readmission on [DATE]. According to the [DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance from staff with bathing, bed mobility, transfers, dressing and locomotion. The resident experienced depression including little interest or pleasure in doing things; feeling down, depressed or hopeless; and felt tired or had little energy. She exhibited verbal behavioral symptoms directed towards others on a daily basis. She rejected care four to six days during the seven-day review period. B. Resident interview and observation. Resident #2 was observed and interviewed on [DATE] at 1:48 p.m. She said she had just returned from [MEDICAL TREATMENT], and she was observed crying and moaning in her room. The resident told the CNA in her room that she wanted to go to bed and asked the CNA to assist her in getting out of her wheelchair. The resident said that the backs of her legs were sore from being in the chair since early in the morning. The CNAs used the mechanical lift to transfer the resident to her bed. The resident was softly crying and moaning and said she did not feel well then requested a lunch tray. Resident #2 said that something happened a week ago and no one was doing anything about it. She said on [DATE] she returned from [MEDICAL TREATMENT] and needed to go to the bathroom, she was having a panic attack, and they needed to use the mechanical lift lift so she had to wait for assistance from staff. She said the CNA staff came to help, and they went to tell LPN #3 that she needed her anti-anxiety pill. She said she would not be able to transfer until medication was taken because of her anxiety level. She said LPN #3 went outside to smoke and left her for a long time. She said the CNA kept telling LPN #3 that she needed her pill but the nurse would not bring it. She said the CNA checked back in on her and asked if she had gotten her medication yet and she said no. Resident #2 said it took ,[DATE] minutes for LPN #3 to come to her room and she asked LPN #3 why did it take so long. The LPN did not say anything and left her room. She said LPN #3 returned 15 minutes later with RN #4. The resident said that both nurses said to her, We can do what we want to and no one ever died of an anxiety attack. She said this caused her more anxiety so she screamed at them to get out of her room. She said the nurses stood in front of the doorway with their arms crossed and did not leave her room when asked. She said this made her feel intimidated and very vulnerable, like the nurses could treat her however they wanted. The resident said her neighbor Resident #19 was a witness and heard her screaming at the nurses so he came to help. She said RN #4 was shutting the door on him and he pushed it open with his foot so he could see his friend. He then went and got the social service assistant (SSA). He said the SSA heard the problem, (see SSA witness statement, cross-reference F600 abuse). Resident #2 said that since the survey the director of nursing (DON) was doing an investigation but she never came to interview her immediately after the situation occurred. She said she had to go find the DON because she never followed up with her about what would be done with the staff and how they treated her. She said the DON told her that the nursing staff needed to be educated. She said she waited for over one hour to get an anti-anxiety pill and the CNA staff had said LPN #3 had not been too busy. She said LPN #3 remained her nurse after the incident and currently. However, the resident did not express fear from LPN #3 and RN #4. Resident #19, Resident #2's friend and neighbor, was interviewed on [DATE] at 4:54 pm. He said he got social services when he heard Resident #2 crying and upset because she wanted her medication. He said Resident #2 was waiting for her medication and LPN #3 knew it. He said the nurses were not listening to her because she was upset. He said he went and got the SSA. He said RN #4 worked another floor but she came down to assist LPN #3. He said LPN #3 agitated Resident #2 because she went out to take a smoke. He said that RN #4 told Resident #2 that it did not matter where the nurses went and what they did, it was none of Resident #2's business. He said when he came to the aid of his neighbor, Resident #2, he had to put his foot in the door because RN #4 tried to close the door and not allow him in to see whether his friend was ok or not. He said the SSA did help calm things down and the SSA helped Resident #2 file a grievance. He said as far as he knew no one had come to him for an interview or to investigate the grievance. Resident #2 was interviewed again on [DATE] at 11:48 a.m. She said the incident that occured on [DATE] made her feel very vulnerable, like the nurses could talk to her and treat her anyway they wanted. She said the DON told her that she was going to provide education to the two nurses but she did not trust that the DON would follow through and help her. She said fortunately her neighbor went and got help from the SSA. Resident #2 said that she had just gotten out of the hospital and has not had therapy for months and was getting weaker. She said she used to be able to stand up, and the reason she came to the facility was to get stronger. She said she was so weak they must now use the mechanical lift. She said she was exhausted coming back from [MEDICAL TREATMENT] and was having a melt down and needed to go to the bathroom and needed an anti-anxiety pill. She said she had to wait over an hour for the pill which increased her humiliation and embarrassment because of the way the nurses were treating her. Resident #2 said the nurse went to go smoke after the medication request and that increased her frustration. She said LPN #3 was standing around doing nothing last week, because the aides told her. She said she filed a grievance with the SSA on the day of the incident. Resident #2 was interviewed again on [DATE] at 11:48 a.m. at [DATE]. She said the incident that occured on [DATE] made her feel very vulnerable, like the nurses could talk to her and treat her anyway they wanted. Resident #2 explained that she had just gotten out of the hospital and has not had therapy for months and was getting weaker. She said she used to be able to stand up, and the reason she came to the facility was to get stronger. She reports she was exhausted coming back from [MEDICAL TREATMENT] and was having a melt down and needed to go to the bathroom and needed an anti-anxiety pill. She had to wait over an hour for the pill and that increased her humiliation and embarrassment. Resident #2 said the nurse went to go smoke after the medication request and that increased her anxiety. She said she LPN #3 was standing around doing nothing last week, because the aides told her. She said she filed a grievance with social service assistant (SSA) on the day of the incident. LPN #3 came in during the interview to check Resident #2 oxygen saturation levels. Observed that the alleged perpetrator LPN #3 was Resident #2 primary nurse on that day. C. Record review The [DATE] revised care plan documented that Resident #2 was at risk for exhibiting verbal behaviors, and verbal outbursts related to: poor impulse control, psychiatric disorder, major [MEDICAL CONDITION], generalized anxiety disorder, and [MEDICAL CONDITION] disorder. It read in pertinent part resident was provided education regarding the need to come to staff when these occurrence happen so they can be addressed before they escalate. She verbalizes understanding. The interventions read in pertinent part, assess the resident for symptoms of pain; encourage resident to seek staff/caregiver support when feeling frustrated; evaluate the nature and circumstances (i.e. triggers) of resident verbal behavior; gently guide the resident from the environment while speaking in a calm, reassuring voice; allow time for expression of feeling, provide empathy, encouragement, and reassurance; encourage resident to seek staff support for distressed mood; Listen to resident and try to calm. However, interviews revealed the facility nurse staff failed to implement the stated care plan interventions during the incident on [DATE]. D. Staff interviews LPN #3 was interviewed on [DATE] at 2:26 p.m. She said it had been really fast paced and lots of things were happening at once, but eventually everything got done and she got done what she could. She said she was the floor nurse who did medication pass, treatments, took orders and did charting. She said the situation on [DATE] with Resident #2 was that she wanted pain and anxiety medication. She said she was on the phone with the doctor and could not leave, and had a personal phone call that took 45 minutes. She said she was getting the medication ready and that she did not blame Resident #2 for being upset. The social services director (SSD) was interviewed on [DATE] at 12:41 p.m. She said the resident completed a grievance report. She said Resident #2's grievance was nursing related so it was given to the DON and NHA. She said they followed up with grievances in morning meetings. She said they had 72 hours to resolve grievances. She acknowledged the grievance process was not followed in a timely manner. Certified nurse aide (CNA) #2 was interviewed on [DATE] at 1:04 p.m. She said she saw Resident #2 return from [MEDICAL TREATMENT] last week on [DATE]. She said the resident was typically uncomfortable and agitated when she returned from [MEDICAL TREATMENT]. CNA #2 said Resident #2 said she needed her anti-anxiety medication. CNA #2 let LPN #3 know. CNA #2 said Resident #2 was upset with how long it took, at least 40 minutes to one hour and 15 minutes, to get her medication. CNA #2 said LPN #3 went out to take a smoke break after the medication request. She said she talked to Resident #2 to calm her down and did what she could. She said she kept Resident #2 informed and told her they went to LPN #3. She said they were unable to take Resident #2 to the bathroom prior to the medication because they could not get the mechanical lift sling under Resident #2 because she was too agitated. But after her anti-anxiety medication, Resident #2 was calm and they assisted her to the bathroom. CNA #2 said the DON was notified after the incident. CNA #5 was interviewed on [DATE] at 1:18 p.m. She said she was there when Resident #2 had an anxiety attack on [DATE]. She went in the room and answered the call light a few times when waiting for the medication for the resident. She said Resident #2 had asked for her anti-anxiety medication, she could hear her crying, screaming, and cursing. CNA #5 said LPN #3 took at least 45 minutes to get the resident's medication. She said LPN #3 was working with a doctor. She said Resident #2 finally calmed down after about 45 minutes to one hour, after receiving her medication. CNA with medication aide authority was interviewed on 1//,[DATE] at 4:53 p.m. She said she was working on [DATE] when Resident #2 had an anxiety attack. She said she was in the same hall but on the other end. She said LPN #3 was giving medications for the hall Resident #2 was on. She said Resident #2 was upset because she wanted her medication and she heard her yelling and crying. RN #4 was interviewed on [DATE] at 2:45 p.m. She said concerning the incident on [DATE] with Resident #2, that she was working as the nurse practice educator (NPE) position. She said she had walked to the unit to do an education. She said she remembered hearing Resident #2 yelling and CNA staff walking in her room. She said LPN #3 was there and said Resident #2 was yelling because she wanted her anti-anxiety medication. She said LPN #3 had just finished working with the physician and then another provider had found LPN #3 to talk to her. RN #4 said she went in to tell Resident #2 that her nurse was coming soon with the medication. She said that was when Resident #2 yelled and said get out of her room. She said she went back to LPN #3 who was pulling medication from the cart and wanted RN #4 to go with her to give the medication. She said they went back to Resident #2 and handed medication cup, and Resident #2 had asked why there were two pills. LPN #3 said one was for pain and one was for anti-anxiety. Resident #2 said did not ask for a pain pill and threw the cup of water toward LPN #3. RN #4 told Resident #2 that it was not appropriate to throw water. Resident #2 was yelling and said to leave her room. RN #4 said at that point Resident #2 was mad that medications were late, she was not sure how late. RN #4 asked Resident #2 if she wanted more water to take her pills and Resident #2 said she would take her pills whenever she wanted. She said Resident #2 said she would have taken pills if it would have come earlier. She said Resident #2 was complaining about what LPN #3 was doing and why it took so long and RN #4 said she did not have to let you know what she was doing on her own time. RN #4 said the social worker (SSA) came and asked to be alone with the resident. RN #4 let SSA know about the medication cup and to let LPN #3 or herself know if Resident # 2 took it. RN #4 said she reported the incident immediately, via text, to the DON and the NHA, and they advised her to document it in the chart. RN #4 said she wrote a progress note. RN #4 said since the incident Resident #2 has not been her regular patient, although she did work with her occasionally after the incident. The NHA was interviewed on [DATE] at 10:40 a.m. The NHA acknowledged that the grievance process for Resident #2 was not followed properly. The NHA stated that Resident #2 was upset with not receiving her medication timely, however the grievance was not handed off to her until the week after the incident. The facility failed to meet the resident's psychosocial needs, causing her distress.

Based on observations, record review and interviews; the facility failed to ensure residents' right to be free from abuse for two (#7 and #5) of two residents investigated for abuse out of 20 sample residents. Resident #7 was not protected from sexual abuse and Resident #5 was not protected from verbal abuse. The facility failed to ensure the safety of residents in the facility. A grievance was filled out on 1/3/2020 for Resident #7 regarding Resident #11 wandering into her room at night. Throughout the grievance investigation, there were delayed interviews up to 10 days after the grievance was initiated. Several interviews confirmed Resident #11 wandered into other resident rooms and had been found in other residents' beds. A stop sign was considered an intervention by the facility. An incident was reported on 1/16/2020 when Resident #11 was found in Resident #7's bed. According to Resident #7 along with additional interviews; Resident #11 had touched her inappropriately resulting in Resident #7 being fearful of Resident #11. The facility failed to ensure Resident #11 was sitting away from Resident #7 in the dining room resulting in Resident #7 feeling fearful and always looking over her shoulder. The facility failures caused Resident #7 to suffer sexual abuse; and feel unsafe, miserable, worried, fearful and [MEDICAL CONDITION] of Resident #11. The facility further failed to provide adequate interventions to ensure Resident #5 was not subjected to verbal abuse from Resident #18, that resulted in mental anguish, depressed mood, tearfulness, and self-isolation. The facility failed to protect Resident #5 from the ongoing verbal abuse that was witnessed by staff and other residents. Even though the incidents were known to occur, they were not documented, reported to the facility's abuse coordinator, investigated, or reported to the State survey agency. These failures resulted in psychosocial harm to Resident #5. Findings include: Cross-reference to F609 reporting of alleged violations, F610 investigating abuse allegations, and F744 dementia care and services. I. Facility policy and procedure The Abuse Prohibition policy revised (MONTH) 2019, provided by the registered nurse lead (RNL) on 1/29/2020 at 11:22 a m. revealed in part, The center will implement an abuse prohibition program through the following .prevention of occurences; identification of possible incidents or allegations which need investigation; protection of residents during investigation .verbal abuse is any use of oral, written, ot gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability .sexual abuse is a non-consensual contact of any type with a resident. It includes but is not limited to sexual harrassment, sexual coercion or sexual assault .Policy: to ensure that center staff are doing all that is within their control to prevent occurrenes of abuse, mistreatment, neglect . II. Failure to protect Resident #7 from sexual abuse by Resident #11 [NAME] Resident #7 and Resident #11 status 1. Resident #7 status Resident #7, age 95, was admitted on [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. The 1/14/2020 minimum data set (MDS) assessment revealed the resident had moderate cognitive deficit with a brief interview for mental status (BIMS) score of 11 out of 15. For mood, the resident had little interest or pleasure in doing things (frequency: 2-6 days); feeling down, depressed, or hopeless (frequency: 2-6 days); feeling tired or having little energy (frequency 2-6 days); poor appetite or overeating (frequency: never or 1 day); feeling bad about yourself (frequency: 2-6 days); trouble concentrating on things (frequency: 2-6 days) . No behaviors marked. The resident was coded as an extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene with one person physical assistance. The resident was coded as total dependence for locomotion on and off the unit. 2. Resident #11 status Resident #11, age 93, was admitted on [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 12/23/19 MDS assessment revealed the resident had severe cognitive deficit with a BIMS score of zero out of 15. No symptoms of mood were documented. The resident was documented as having rejection of care (daily); and wandering (daily). For wandering: the resident was not coded for placing resident at significant risk of getting to a dangerous place and not coded for significantly intruding on the privacy or activities of others. For functional status, the resident was coded as supervision with walking in room/in corridor, eating and bed mobility. The resident was limited assistance with dressing, toilet use and personal hygiene. B. Interviews Family for Resident #7 was interviewed on 1/27/2020 at 3:33 p.m. She said there were concerns with Resident #11 since he moved to the unit walking stick. She said Resident #11 was found in Resident #7's bed on a Thursday night. She said the resident was sleeping and she had awoken when the staff came to get Resident #11 out of her bed. She said she thought it happened about 9:00 p.m. She said Resident #7 was afraid of Resident #11 and she was still afraid of him. She said Resident #7 was always looking behind her. She said she was always looking to see where Resident #11 was while she was eating in the dining room. She said Resident #7 was worried that he would get away from the one-on-one sitter. She said she did not think they had put up the stop sign for Resident #7's room until the instance where the resident was found in her bed. She said the stop sign was stopped when the one-on-one sitter started with Resident #11. She said the stop sign became a constant reminder for Resident #7. She said she had declined a room change because she liked her roommate and was comfortable with the room. She said Resident #11 had to remain on the unit (walking stick) because of his cognition. She said Resident #7 declined the sexual assault test at the hospital because it was too much for her. She said Resident #11 did touch her but she was told there were no marks on them. Resident #7 was interviewed on 1/28/2020 at 9:14 a.m. She said Resident #11 sat there near her in the dining room. She said she did not know his name. She said he was in her bed that one time. She said earlier, he had walked into her room and looked around. She said sometime after that, he got into bed with her. She said that Resident #11 touched her all over including her breasts and private areas. She said she did not know he was in her bed at first. She said she was not awake at first. She said it made her feel miserable. She said the staff had come into the room to get him out of her bed. When asked if she was fearful, she said oh yeah. She said she was still a little afraid. She said the staff swore they would keep him out of her room. She said he sat next to her in the dining room and it does bother me because they seat him right next to me. She said they were supposed to keep him away from her. She said she did not feel completely safe. She said she could sleep okay but she was still not eating well. C. Observations, record review and interviews Review of the care plan, revised 1/27/2020 and created on 1/27/2020, revealed in part, (Resident) exhibits psychosocial distress with own well-being and /or social relationships related to: male resident coming into her room and laying on her bed the evening of 1/16/2020. Resident was offered a room change. Resident declined. Interventions included: Offer counseling; evaluate the need for psych/behavioral health consult. Facilitate resident/patient contact with support system .Assist resident/patient to process feelings and find positive outcomes. Incident 1/3/2020: Review of the grievance/concern form, dated 1/3/2020, revealed the following: -Individual presenting concern: resident representative, relationship - daughter; -Describe concern: Resident's daughter reports that resident told her there was a man walking around in her room. She attempted to wake up her roommate, and she was unable to wake her. Resident reported her call light was not within each for her to call staff for assistance. Resident also reported to her daughter they do this all the time. -Staff member: social work executive (SWE). -Was grievance resolved: Yes- Spoke with resident's daughter, agreed to a stop sign being placed on resident's door frame to prevent other residents from entering. Education with staff being completed regarding all call lights within reach. This was signed by the RNL. -Fourteen staff members were interviewed- Have you seen any males go into Resident #7's room? Five of the staff members said Yes. Four of the staff members said Resident #11 was seen going into her room. These interviews were completed on 1/6/2020 and 1/7/2020. -Twenty-four staff members were interviewed- Have you seen Resident #11 go into other resident's beds? Nine staff members said Yes. Staff members identified Resident #11 had been found in five other resident's beds. This included Resident #16. These interviews were completed on 1/13/2020. (10 days after the grievance was filed) -Five residents were interviewed- Was anyone in your room last night. The residents said No. These residents were interviewed on 1/13/2020 and the interview question only pertained to one night. (10 days after the grievance was filed) -Statement by the nursing home administrator (NHA), signed 1/14/2020, revealed Reported on 1/12 that Resident #11 has gone into other residents' rooms. Staff and resident interviews identify that he is going into other resident rooms. No resident has voiced concern of fear and denies anyone touching them. Resident is being monitored and redirected from other resident rooms. A sign has been placed outside his room so that he may identify his room. The SWE was interviewed on 1/28/2020 at 12:29 p.m. She said she would sometimes help the residents fill out the grievances. She said the forms were also available for the residents to fill out on their own. She said she never received the above grievance. She said it was not brought to her attention and it should have been. The progress notes were reviewed and did not contain any notes related to this grievance. Review of the social services assessment and documentation, dated 1/14/2020 and signed 1/27/2020, revealed the following; -Cognitive patterns: the resident is understood with the ability to express ideas and wants; the resident understands verbal content. Resident appeared to understand questions asked of her and was able to answer questions independently. -Mood: Resident incident with another resident .Resident is fearful of other male residents coming into her room. Incident 1/16/2020: Review of the incident report, dated 1/16/2020, revealed the following: -Occurrence date: 1/16/2020; time: 1840 (6:40 p.m.) -Report first received date: 1/17/2020 1642 (4:42 p.m.) -On 1/16/2020 at 1840, staff redirected a male resident that was wrapped in a blanket, fully clothed with shoes on sleeping at the bottom of a female resident's bed. Female resident was asleep under her own blankets when male resident was redirected from her room. -On 1/17/2020 at 1410, the resident's daughter reported that the resident had told another daughter there was a man in her room that tried to sexually assault her and she had to fight him off. Resident's daughter reported that she was going to take her mother to (outside program) to be assessed and if need be to the emergency room (ER) for examination. At the time of this report, facility does not have the results of the examination. -Both residents have had head to toe skin assessment to assess for signs of injury. Male resident had a mark on his foot from his shoe. Female resident did not report the above allegation to any staff. Roommate of the female resident was interviewed by SWE and she reports neither hearing or seeing any disturbance. -Male resident has been provided a 1:1, police department notified. Message left for the local ombudsman. Notification to adult protection service (APS). -In addition to the above occurrence, there were four staff statements obtained by the facility, during the investigation. Review of the event summary report, dated 1/16/2020, revealed the following: -Resident #11 -Date/time of event: 1/16/2020 6:35 p.m. -Physician notified- No -Representative notified- No -Resident was found sleeping at the foot of another resident's bed with his clothes on. He was removed by a certified nurse aide (CNA). He has been found in several other rooms this shift. -Witness: CNA #6 -Recent Diagnosis: [REDACTED]. -Recent history of: intrusion of personal space, wanders the facility in and out of room. Root cause: Patient is confused and he wanders in and out of the residents' rooms. -Corrective action: 1:1. Review of the event summary report, dated 1/16/2020, revealed the following: -Resident #7 -Date/time of event: 1/16/2020 6:25 p.m. -Event location: Resident room -Physician notified- No -Representative notified- Yes. -Male resident from room .was found sleeping on the foot or Resident #7 bed. He was immediately removed by CNA at this time. He was completely dressed with his shoes on and he was wrapped in a separate blanket then Resident #7. CNA said Resident #7 woke up and she was very upset and she was requesting to call her daughter. CNA brought her to the nurses station wearing her gown, socks and a lap blanket .the phone to Resident #7 and she said, that man has been in my bed 2x now . There was no evidence of a struggle. -Corrective actions: Patient was placed at 1:1. The SWE was interviewed on 1/28/2020 at 12:29 p.m. She said she was not aware of the above incident until the day after in which she received a call from the outside program. She said she was told Resident #11 was found at the foot of the bed, fully clothed and the CNA redirected him back to his room. She said she interviewed Resident #7 and she was upset with Resident #11 being in her bed. She said Resident #7 was scared he would do it again. She was fearful. When she asked the resident where he was, she had indicated he was lying next to her when she woke, not the end of the bed. She said they started one-on-one with Resident #11 and they were seeking placement at another facility for Resident #11. Review of the progress notes revealed the following: -1/16/2020 20:35 (8:35 p.m.)- Male patient was found to be lying at the foot of residents bed. He was removed by staff. Resident #7 became very upset, her daughter .and administrator was notified. Resident has a stop gate on her doorway. Review of the ED physician documentation, dated 1/17/2020, revealed the following: - .Presents for evaluation with concern for possible sexual assault. She states that she awoke this morning and noted another man at her .lying in her bed. She presents now for sexual assault nurse examiner evaluation Review of the ED documentation, dated 1/17/2020, revealed the following: -When asked what brought her in, she said .he comes in the night and bothers me or whatever. -When asked when it happened, she said He comes in the night. Last night, all the nights. It's happened more than once. -When asked what happened, she said I was asleep in my bed and the nurses caught him and got him. -When asked if he touched her, she said Yes. -When asked if she could say where, she said Not really, I was asleep. -When asked if anything hurt, she said No. - .discussed options for patient including evidence collection, however patient declined. Review of the SWE statement, dated 1/18/2020, revealed (Writer) interviewed Resident #7 regarding the incident that took place on 1/16/2020 with Resident #11. Resident #7 was asked if she could recall the incident, she states I noticed he kept coming in, it was bad. She states she did not know that he was in her room until she woke and saw him laying here and gestured next to her in bed. She recalled going to see someone and states, they checked me all out, so far I'm okay. Resident #7 also states I'm afraid he is going to find his way in here again, get in my bed or try and rape me. Resident #7 was advised that Resident #11 was on one-to-one with staff present with him at all times. She states, he could distract them and come in. She was advised to utilize her call light should she see him coming to her room. Resident #7 reiterates that she is fearful Resident #11 could come in her room again. Review of the progress notes revealed the following: -1/24/2020 10:50- During resident's assessment today, resident was offered counseling services related to recent incident with another resident. Resident stated that 'I saw a psychiatrist from Denver, and when asked if she would like to see a counselor, she stated he was a counselor and declined offer of counseling, again stating I already seen one. Resident #7 was observed in her room, in her bed on 1/27/2020 at 3:13 p.m. There was no stop sign on her door. The NHA stated Resident #11 was on one-on-one observation. At 3:55 p.m., the resident was in her bed sleeping. The resident's roommate was interviewed at 3:59 p.m. and she said she did not want to go to dinner. She was afraid someone was going to come into her room. She said a female resident was standing at the doorway, one time. She said the female resident was putting on her coat and it scared her. She said she had not seen any male residents enter the room. The registered nurse (RN) was interviewed on 1/27/2020 at 4:08 p.m. She said Resident #11 had a sitter. She said he went to bed around 9-9:30 p.m. She said he had a sitter related to an accusation. She said before the resident had a sitter, he would pace the halls and and he laid down anywhere. Resident #7 was observed on 1/27/2020 at 9:07 p.m. She was lying in her bed, half dressed. Her lower body was bare, aside from her brief. She had the call light in her hand. Resident #11's room was located down the same hall and there was a chair located outside the resident's room. The sitter was not in the chair. The sitter went into the room a few minutes later. An outside program staff member was interviewed on 1/28/2020 at 8:30 a.m. She said Resident #7 continued to feel fearful. She said the facility had Resident #11 on a one-on-one sitter, but the resident had been observed wandering in the common areas and dining area without a sitter. She said the facility told her it was good enough that staff were around when he wandered. She said the resident felt better this day and Resident #7 wanted to put everything behind her. She said she was concerned about the resident's long term success at this current facility. Resident #7 was observed on 1/28/2020 at 8:32a.m. eating breakfast in the dining room.She was at a dining table located on the far left side of the room. Her back was facing the walkway. Resident #11 was observed at a table directly behind her, diagonally. Resident #7 was in a wheelchair and feeding herself oatmeal. At 8:59 a.m., Resident #7 was finished with breakfast and was getting wheeled out by staff. The observed staff parked her right next to Resident #11 for a few seconds. Resident #11 was observed to have looked directly at Resident #7. She was then further wheeled out of the dining room. The SWE was interviewed on 1/28/2020 at 2:10 p.m. She said she did not realize Resident #11 was sitting so close to Resident #7 in the dining room. She said she thought they had discussed it before. She said the residents did not have assigned seating. She said it was understandable that Resident #7 was uncomfortable with the arrangement. CNA #5 was interviewed on 1/28/2020 at 9:20 a.m. She said Resident #11 had been wandering into resident rooms since he moved to walking stick hallway. She said she was aware of him going into three resident rooms. Resident #17 was interviewed on 1/28/2020 at 9:30 a.m. He said Resident #11 wandered into his room every once in a while. He said this resident had used his bathroom and had taken his shirt. CNA #6 was interviewed on 1/28/2020 at 12:43 p.m. She said she was doing rounds and found Resident #11 at the foot of Resident #7's bed. She said he was asleep and that whenever he was tired he would crawl into bed and go to sleep. Resident #16 was interviewed on 1/28/2020 at 1:12 p.m. She said Resident #11 had come into her room. She said he would wander to her room in the middle of the night. She said it would take a while to get him out. She said he liked to touch things in her room, but did not get into her bed. She said this had happened about two weeks prior. A resident group meeting was held on 1/28/2020 at 11:21 a.m. with four (#12, #13, #14 and #15) residents the facility deemed interviewable. Resident #14 said Resident #11 had tried to crawl into bed with her four times, when she first arrived at the facility (around the beginning of (MONTH) 2020). She said she used the call light and had to bang on the wall. She said it took about 15 minutes for the staff to help her. She said every time she fell asleep, she heard someone come into her room. She said he would never say anything, but he would shuffle in. She said she told him to leave and the resident would tell her he just wanted to go to bed. She would say Not with me. She said Resident #11 had gotten the covers completely off of her and sat down. She said he tried to get into bed with her, under the covers. She said it was better since the resident started one-on-one supervision. She said it took a week of complaining before they did anything to fix things. Resident #14's statement provided by the SWE on 1/28/2020 at 2:10 p.m. revealed, Resident #14 states that on the first night she was in the facility, Resident #11 came into her room four different times trying to get into bed with her and attempting to take her covers. Resident #14 states that this occurred every night for the first week that she was here. Resident #14 stated that one of the last times that it occurred, I was on the call light forever and was banging on the wall and hurt my wrist. Resident #14 is wearing wrist braces today for the first time since she was admitted and when asked about them, states I have carpal tunnel and wear them when they hurt. Resident #14 stated that each time the resident had to be escorted out of the room by staff and that CNAs (2 CNAs and one nurse named) were aware as they were the ones escorting him out. Each time telling her We're sorry, we'll get him out of here and we'll take care of it. Resident #14 states that this behavior typically occurs in the wee hours after midnight. She states that she is not fearful of him, I don't think that he could do anything. The NHA, director of nurses (DON) and the RNL were interviewed on 1/29/2020 at 9:04 a.m. They said Resident #11 had moved to the hall around (MONTH) 31st. She said the original intervention was placement of the stop sign on Resident #7's door. The RNL said that intervention was in place the whole time. When asked about keeping the other residents safe after the first grievance, they said they always offered stop signs. They said they did not go to the individual rooms, to offer the residents anything in addition. They said the allegation from Resident #14 was new to them. They said this resident never voiced her concerns. That is disconcerting. The DON said she had talked to Resident #7 after the occurrence and she said she was worried that he was going to get back into her room. They said the stop sign did not come down until Resident #11 was on one-on-one observation. They acknowledged it was the perception of the resident. They said the dining room placement was brought to their attention the day before from the SWE. They said that SWE said Resident #7 looked around to see if he was there. III. Failure to protect Resident #5 from verbal abuse by Resident #18 [NAME] Resident status 1. Resident #5 Resident #5, age under 60, admitted on [DATE] and readmitted [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. The 1/9/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was positive for mood symptoms of feeling down and depressed and was negative for behavior symptoms. She was dependent on one to two staff members for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. She had impairment of both upper and lower extremities and used a wheelchair for mobility. She was frequently incontinent of bowel. 2. Resident #18 Resident #18, age 77,was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2020 CPO [DIAGNOSES REDACTED]. The 1/13/2020 MDS assessment she was cognitively intact with a BIMS score of 15 out of 15. She was negative for [MEDICAL CONDITION] and behavior symptoms and positive for mood symptoms. She was independent in all areas of activities of daily living (ADLs). She received antipsychotic medications on a routine basis. B. Resident #5 interview and observations Resident #5 was interviewed on 1/27/2020 at 1:30 p.m. She said she had issues with one resident who was verbally abusive to her. She said Resident #18 made verbally abusive comments to her and other residents. She said, the abuse had been going on for several months and it was still happening. She said several months ago Resident #18 made fun of her feet because of the way they look, so now I make sure I have socks on whenever I go out of my room. She said it would happen mostly in the dining room at meal time in front of the other residents and it embarrassed her terribly. She said Resident #18s comments brought her to tears several times. She said she would often not go to the dining room for meals so I don't have to deal with her. She felt Resident #18s comments were derogatory, belittling, uncalled for, and abusive in nature. She said when Resident #18 would make demeaning comments, staff would tell her to knock it off and she would laugh and say she was not doing anything. She said she was told that Resident #18 had a disability and could not help it. She said she was told not to say anything to Resident #18. She said, last summer, the nursing home administrator (NHA) at the time, told her to ignore her. Resident #5 said she did not wear dentures during meals and Resident #18 would say you have food going down your face and you look ugly. She said a couple nights ago she was in the hall in her wheelchair and was having a stomach cramp and Resident #18 said, what are you doing, pooping your pants? She said multiple staff members and other residents have witnessed the ongoing abuse. Observations in the main dining room, during the breakfast meals on 1/28-1/29/2020 and lunch meals on 1/27/2020-1/29/2020, Resident #5 was not seated at her table for the meals. C. Record review 1. Resident #5 Review of the care plan, initiated 5/16/13 and revised 6/18/19 revealed Resident #5 had the potential to exhibit behaviors of sadness/decline in mood as evidenced by sad facial expression, being extra quiet, feelings easily hurt, maybe crying. Interventions included to arrange counseling as needed and to encourage verbalization of feelings during one to one visits as needed. The care plan, initiated 1/13/16 and revised 9/10/19 revealed Resident #5 exhibited mood symptoms as evidenced by tearfulness and self isolation. She had expressed frustration/distress with another resident making fun of her feet telling her that she needs to wear socks because her feet are ugly. Resident #5 said she preferred to wear socks to avoid further confrontation with that resident. Intervention included escorting the room for less stimuli. The care plan initiated 4/16/18 and revised 8/8/19 revealed Resident #5 was at risk for distressed mood symptoms related to sadness/depression. She may exhibit depressed mood through self-isolation, less talkative, and increased tearfulness. Interventions included monitoring for signs/symptoms of worsening sadness/depression and worsening anxiety/fear. The care plan initiated 8/8/19 and revised 8/14/19 revealed Resident #5 exhibited psychosocial distress with own well-being and or social relationships related to frequent conflicts with another resident. Review of the psychiatrist progress notes documented the following: -11/11/19 Another resident is making staff cry with her comments. -11/21/19 Resident #5s problems include depression, anxiety, tears, and giving power to others who are abusive. -12/5/19 Resident #5 feels she gives too much and puts her heart out there and it gets stomped on. -12/19/19 Resident #5 has issues with standing up to others. -12/24/19 Resident #5 has issues with self esteem. 2. Resident #18 Review of Resident #18s care plan initiated 11/18/15 and revised 7/14/19 revealed the resident exhibits distressed mood symptoms as evidenced by threatening others with an intervention to redirect by engaging in alternate activity. The care plan initiated 7/14/19 and revised 1/27/2020 revealed the resident has the potential to demonstrate verbal behaviors related to [MEDICAL CONDITION] and depression. Resident #18 has recently been witnessed and/or reported to be making derogatory and/or negative comments towards other residents about their weight, the way they look, dress, and behave, making other residents feel uncomfortable. Resident #18 continues to make derogatory and hurtful statements to other residents. Interventions added on 1/27/2020 included Resident #18 to be redirected by staff when making rude and hurtful comments to other residents. Staff education provided related to redirection to resident when hurtful and rude comments are directed at other residents. The care plan initiated 9/5/19 and revised 11/6/19 revealed Resident #18 was seen by the psychiatrist due to recent insulting/hurtful statements to other residents. Intervention included sharing appropriate thinking and setting limits if resident attempts to respond impulsively to altered thinking. Review of the psychiatrist progress note dated 11/29/19 read: Her baseline mental status is that of being very psychotic. Several weeks ago she was insulting other residents. Review of the nursing progress note dated 1/13/2020 at 8:00 a.m., documented by the LPN read: Mental status alert and oriented to person, place, and time. D. Other resident interviews Resident #14 was interviewed on 1/27/2020 at 11:40 a.m. She said Resident #18 was verbally abusive to other residents. She said she witnessed many abusive comments from Resident #18 directed at Resident #5 in the dining room and during activities. Resident #18 would make fun of other residents' physical disabilities. She would make fun of Resident #5s feet and caused Resident #5 to make sure her feet were covered with socks when she was in the dining room. She acknowledged the comments were especially upsetting to Resident #5. Resident #19 was interviewed on 1/27/2020 1:50 p.m. She said she had witnessed verbal abuse from Resident #18 to Resident #5 many times. She said no one should have to listen to or be subjected to the way Resident #18 was allow

Based on interviews and record review, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (#5) of two residents reviewed for investigations of abuse out of 20 sample residents. Specifically, the facility failed to investigate incidents of alleged verbal abuse from Resident #18, that resulted in mental anguish, depressed mood, tearfulness, and self-isolation for Resident #5. Although staff knew of these incidents, they were not investigated or reported to the State survey agency in a timely manner. The facility's failures to report and investigate contributed to Resident #18's continuing verbal abuse toward Resident #5, who reported feeling demeaned, belittled, abused, brought to tears, and avoided going to the dining room for meals. Findings include: I. Facility policy and procedure The Abuse Prohibition policy and procedure, dated 6/1/96 and revised 7/1/19, provided by the assistant director of nursing (ADON) on 1/29/2020 at 11:30 a.m., read in pertinent part: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Abuse also includes instances of abuse of all patients, irrespective of any mental or physical condition, cause of physical harm, pain, or mental anguish. It includes verbal abuse. Willful, in this definition of abuse, means the individual must have acted deliberately. Verbal abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability. If the suspected abuse is resident to resident an investigation will be completed. The facility is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. II. Resident status, interview, observation and record review [NAME] Resident #5 Resident #5, age under 60, admitted on [DATE] and readmitted [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. The 1/9/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was positive for mood symptoms of feeling down and depressed and was negative for behavior symptoms. She was dependent on one to two staff members for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. She had impairment of both upper and lower extremities and used a wheelchair for mobility. She was frequently incontinent of bowel. Resident #5 was interviewed on 1/27/2020 at 1:30 p.m. She said she had issues with one resident who was verbally abusive to her. She said resident #18 was verbally abusive to her and other residents. She said the abuse had been going on for several months and it was still happening. She said it would happen mostly in the dining room at meal time. She said staff and other residents witnessed the comments on many occasions and certified nurse aide (CNA) #1 witnessed the comments on more than one occasion. She said Resident #18 made these comments in front of other residents and it embarrassed her terribly and brought her to tears several times. She said she would often not go to the dining room for meals so I don't have to deal with her. She felt Resident #18's comments were derogatory, belittling, uncalled for, and abusive in nature. She said when Resident #18 would make demeaning comments, staff would tell her to knock it off and she would laugh and say she was not doing anything. Resident #5 said she was told that Resident #18 had a disability and could not help it. She said she was told not to say anything to her. She said, last summer, the nursing home administrator (NHA) at that time told her to ignore her. Resident #5 said she did not wear dentures and while she was eating in the dining room, Resident #18 would say you have food going down your face and you look ugly. She said a couple nights ago she was going down the hall in her wheelchair and was having a stomach cramp and Resident #18 said, What are you doing, pooping your pants? She said the licensed practical nurse (LPN) witnessed the comment and she was unsure of what she did about it. Observations in the main dining room, during the breakfast meals on 1/28-1/29/2020 and lunch meals on 1/27/2020-1/29/2020, Resident #5 was not seated at her table for the meals. Review of the care plan, initiated 5/16/13 and revised 6/18/19 revealed Resident #5 had the potential to exhibit behaviors of sadness/decline in mood as evidenced by sad facial expression, being extra quiet, feelings easily hurt, maybe crying. Interventions included to arrange counseling as needed and to encourage verbalization of feelings during one to one visits as needed. The care plan, initiated 1/13/16 and revised 9/10/19, revealed Resident #5 exhibited mood symptoms as evidenced by tearfulness and self isolation. She had expressed frustration/distress with another resident making fun of her feet telling her that she needs to wear socks because her feet are ugly. Resident #5 said she preferred to wear socks to avoid further confrontation with that resident. Interventions included escorting the resident to her room for less stimuli. The care plan, initiated 4/16/18 and revised 8/8/19, revealed Resident #5 was at risk for distressed mood symptoms related to sadness/depression. She may exhibit depressed mood through self-isolation, less talkative, and increased tearfulness. Interventions included monitoring for signs/symptoms of worsening sadness/depression and worsening anxiety/fear. The care plan, initiated 8/8/19 and revised 8/14/19, revealed Resident #5 exhibited psychosocial distress with her own well-being and or social relationships related to frequent conflicts with another resident. Review of the psychiatrist progress notes documented the following: -11/11/19 Another resident is making staff cry with her comments. -11/21/19 Resident #5's problems include depression, anxiety, tears, and giving power to others who are abusive. -12/5/19 Resident #5 feels she gives too much and puts her heart out there and it gets stomped on. -12/19/19 Resident #5 has issues with standing up to others. -12/24/19 Resident #5 has issues with self esteem. A social service progress note of 7/15/19 at 3:22 p.m. read in part: Resident #5 was in the social services office today to talk about her feelings regarding recent issues with another resident. There was no further documentation from social services regarding the above mentioned issue. Review of nursing progress notes from 7/19 through 1/29/2020 revealed no documentation of incidents of verbal abuse to Resident #5, although staff and other residents acknowledged it was happening. B. Resident #18 Resident #18, age 77,was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2020 CPO, [DIAGNOSES REDACTED]. The 1/13/2020 MDS assessment revealed she was cognitively intact with a BIMS score of 15 out of 15. She was negative for [MEDICAL CONDITION] and behavior symptoms and positive for mood symptoms. She was independent in all areas of activities of daily living (ADLs). She received antipsychotic medications on a routine basis. Review of Resident #18's care plan, initiated 11/18/15 and revised 7/14/19, revealed the resident exhibits distressed mood symptoms as evidenced by threatening others with an intervention to redirect by engaging in alternate activity. The care plan, initiated 7/14/19 and revised 1/27/2020, revealed the resident has the potential to demonstrate verbal behaviors related to [MEDICAL CONDITION] and depression. Resident #18 has recently been witnessed and/or reported to be making derogatory and/or negative comments towards other residents about their weight, the way they look, dress, and behave, making other residents feel uncomfortable. Resident #18 continues to make derogatory and hurtful statements to other residents. Interventions added on 1/27/2020 included Resident #18 to be redirected by staff when making rude and hurtful comments to other residents. Staff education provided related to redirection to resident when hurtful and rude comments are directed at other residents. The care plan, initiated 9/5/19 and revised 11/6/19, revealed Resident #18 was seen by the psychiatrist due to recent insulting/hurtful statements to other residents. Intervention included sharing appropriate thinking and setting limits if the resident attempts to respond impulsively to altered thinking. Review of the psychiatrist progress note dated 11/29/19 read: Her baseline mental status is that of being very psychotic. Several weeks ago she was insulting other residents. Review of the nursing progress note dated 1/13/2020 at 8:00 a.m., documented by the LPN read: Mental status alert and oriented to person, place, and time. III. Resident interviews Resident #14 was interviewed on 1/27/2020 at 11:40 a.m. She said Resident #18 was verbally abusive to other residents. She said she witnessed many abusive comments from Resident #18 directed at Resident #5 in the dining room and during activities. Resident #18 would make fun of other residents' physical disabilities. She would make fun Resident #5's feet and caused Resident #5 to make sure her feet were covered with socks when she was in the dining room. She acknowledged the comments were especially upsetting to Resident #5. Resident #19 was interviewed on 1/27/2020 1:50 p.m. She said she had witnessed verbal abuse from Resident #18 to Resident #5 many times. She said no one should have to listen to or be subjected to the way Resident #18 was allowed to talk to people. She said, We are just in the dining room to enjoy our meals but are subjected to nasty comments. She said it bothered and upset her and she felt bad for Resident #5 for having to put up with the demeaning comments directed at her. Resident #20 was interviewed on 1/27/2020 at 3:40 p.m. He said he had witnessed, on many occasions, Resident #18's verbal abuse to Resident #5. He said he knew it upset Resident #5 because the comments would make her cry. IV. Staff interviews The nursing home administrator (NHA) was interviewed on 1/27/2020 at 3:16 p.m. She said abuse of any kind would not be tolerated. It is the responsibility of the staff, as mandatory reporters, to notify the appropriate individuals of any witnessed abuse or any allegation of abuse. She said she is the abuse coordinator for the facility and was not aware of the verbal abuse from Resident #18 to Resident #5, therefore it was not investigated The LPN was interviewed on 1/27/2020 at 3:45 p.m. She said she did not witness the incident a couple nights ago between Residents #5 and #18. She said Resident #5 told her after the fact and said she had told a supervisor about it. She said she did not document anything about the incident. She said if the resident had initially reported it to her then she would have made documentation of the incident. She was unaware of any other instances of alleged abuse between the two residents. The social work executive (SWE) was interviewed on 1/28/2020 at 1:00 p.m. She said as far back as (MONTH) 2019, it was known that Resident #18 had made fun of Resident #5s feet and it was brought to her attention at that time. She said Resident #18s comments were very upsetting to Resident #5. She said she felt it was verbal abuse. She said she was told by the prior director of nursing (DON) to tell Resident #18 to be nice and making demeaning or derogatory remarks was not appropriate. She said she reported it to the previous NHA at that time. She said she was unaware if the incident was investigated. She said if she or any staff member witnessed abuse or an allegation of abuse is brought to their attention they should immediately notify the NHA who was the abuse coordinator so an investigation could be started. CNA #1 was interviewed on 1/28/2020 at 2:09 p.m. He said he had known about the verbal abuse for several weeks and a lot of the staff was talking about it but he never said anything. He assumed the facility knew about it. He said any witnessed abuse or allegations of abuse were to be reported to the nurse and the NH[NAME] The NHA, DON, and the ADON were interviewed on 1/29/2020 at 9:30 a.m. The NHA said she had been in the facility for four months and was not aware of the abuse allegations as no one had brought it to her attention. The DON said she had been in the facility for three months and was also unaware of the abuse allegation. The ADON said she was unaware of the abuse allegation. They said if abuse is observed or an allegation was made, it should be immediately reported to the NHA so an investigation can be started and the incident reported to the State survey agency in a timely manner. They said abuse of any kind would not be tolerated. They said they felt the breakdown in communication of reporting abuse through the proper channels had occurred as a result of the high turnover of NHAs, DONs, and having to use staff from outside agencies. They said over the last year there had been five different NHAs and DONs. V. Facility follow up After the facility was made aware of the above mentioned abuse allegation, the NHA provided documentation of the investigation of the allegation and interviews with both residents conducted on 1/27/2020 at 3:00 p.m. They read in part: Resident #5: Resident #5 was interviewed this afternoon regarding concerns she has about Resident #18. She states the other night she was coming back from taking her pill, had cramps related to her irritable bowel syndrome, and was making a face, and Resident #18 asked her are you pooping your pants, if you are you need to get your CNA to change you. She said a few weeks ago Resident #18 asked her why doesn't anyone get you out of the chair so you can walk and she continued to make comments about her feet. She said she does not take comments like this lightly due to being bullied as a child. She said she has resorted to eating in her room, won't eat lunch and waits until dinner to avoid Resident #18, or she will eat and leave right away. She states she also goes to her room and cries lately. She states she feels these comments are derogatory, belittling, uncalled for and abusive in nature. Resident #18: Resident #18 was interviewed this afternoon to discuss with her the concerns regarding her making comments to other residents. She was advised it was our understanding she was saying mean things to other residents. She immediately asked if we were talking about resident #5. She was asked about the comment made to Resident #5 about her pooping her pants. She states, no, why, did she say something? Then began talking about Resident #5s feet looking like she was wearing pointe shoes like ballerinas wear. She was asked about Resident #19, she had no comment. She states Resident #5 wants me to laugh at her. It was explained to her that Resident #5 does not do things for her benefit. She then asked if there were openings at another facility. Forty-three staff members were interviewed with three acknowledging Resident #18 made derogatory comments to other residents. Those incidents were reported to nursing staff and dining room staff. Twenty-six residents were interviewed with four acknowledging other residents, including Resident #18, were mean to them, and the incidents were reported to social services, CNAs, nurses, and the DON.

Based on observation, record review and interviews, the facility failed to ensure residents who display or are diagnosed with [REDACTED].#11) of 20 sample residents. The facility failed to ensure the resident was monitored and evaluated. A psych evaluation was not ordered/completed until 1/17/2020 after Resident #11 was found in multiple residents' beds. Behavior monitoring documentation was incomplete and did not encompass all of the behaviors the resident was experiencing which included wandering, aggressiveness, agitation and refusal of care. Furthermore, the failed to prevent Resident #11 from wandering into other residents' rooms and getting into other residents' beds before the one-on-one was initiated mid-January. These facility failures contributed to Resident #7 and other residents being subjected to abuse by Resident #11. Cross reference F600, failure to ensure residents were free from abuse Findings include: I. Facility policy and procedure Review of the Consultant Agreements and Responsibilities policy provided by the registered nurse lead (RNL) on 1/29/2020 at 11:22 a.m., revised on 7/24/18, revealed in part Consultant services may be used for, but are not limited to, the following areas: [MEDICAL CONDITION] and related dementia. The director of nurses (DON) was interviewed on 1/29/2020 at 11:29 a.m. She said the facility did not have any other policies related to dementia. II. Resident #11 status Resident #11, age 93, was admitted on [DATE]. According to the (MONTH) 2020 computerized physician orders [REDACTED]. The 12/23/19 minimum data set (MDS) assessment revealed the resident had severe cognitive deficit with a brief interview for mental status (BIMS) score of zero out of 15. No symptoms of mood were documented. The resident was documented as having rejection of care (daily); and wandering (daily). For wandering: the resident was not coded for placing resident at significant risk of getting to a dangerous place and not coded for significantly intruding on the privacy or activities of others. For functional status, the resident was coded as supervision with walking in room/in corridor, eating and bed mobility. The resident was limited assistance with dressing, toilet use and personal hygiene. III. Observations The resident was observed on 1/27/2020 at 9:07 p.m. There was a chair outside of the resident's room. The sitter was not sitting in the chair. After a few minutes; the resident's sitter was observed walking down the hall and then going into the resident's room. The resident was observed on 1/28/2020 at 8:32 a.m. He was observed eating at a table behind Resident #7, diagonally. He was ambulatory and was able to feed himself. The resident was observed on 1/28/2020 at 9:22 a.m. He was walking down the hallway towards his room, with his sitter next to him. The resident mentioned wanting to take a nap. IV. Record review and interviews Review of the care plan, revised on 1/27/2020, revealed in part, Resident is at risk for elopement related to: cognitive loss/dementia, secondary to [MEDICAL CONDITIONS]. Interventions included: Monitor the nature and circumstances of attempted elopement .(resident) has been placed on 1:1 due to his wandering behavior (initiated 1/17/2020) .utilize and monitor security bracelet per protocol .as appropriate redirect resident/patient if near exits or doorways. Review of the care plan, revised 12/29/19, revealed in part, Resident exhibits, or has the potential to exhibit physical behaviors related to: cognitive loss/dementia, poor impulse control, history of [MEDICAL CONDITION]: history of wandering into resident rooms, poor memory. Will forget clothes and often come out of the room with only incontinence items on. Needs frequent redirection, Unable to follow conversation or answer questions appropriately. Impulsiveness, agitation. Wanders into other residents' rooms frequently. Strips down to his undergarments in the lobby and other resident rooms. Interventions include: Resident has 1:1 assigned to him at all times by .or center staff .Remove resident/patient from environment, if needed .Social service visits to provide support, as needed and/or requested. Review of the social services initial assessment and documentation, dated 12/20/19, revealed: Resident presents with some confusion and has difficulty maintaining fluid conversation; speech is periodically nonsensical. Review of the medical doctor (MD) progress notes, dated 12/24/19, revealed in part, Reason for appointment: followup for wandering .The patient is currently doing well, but does have some wandering type of tendencies .The patient has been wandering more so at nighttime. He does not seem to be harmful to himself or other people. Review of the nurse practitioner (NP) progress notes, dated 12/26/19, revealed in part, He does continue to wander routinely especially during the nighttime .Nurse reported that patient was wandering frequently last night and hospice consultation has been ordered. Review of the progress notes revealed: -12/31/19: 21:18 (9:18 p.m.)- General note: Resident appears to be adapting to the unit well. -1/1/2020: 06:16- General note: Resident was wandering throughout most of the night entering different rooms. Redirected back into bed where he could quickly get up and wander again. -1/12/2020: 14:52 (2:52 p.m.)- General note: It was reported to this licensed practical nurse (LPN) via certified nurse aide (CNA) that resident had been climbing into several different womens beds throughout the night. -1/12/2020: 18:04 (6:04 p.m.)- eMAR (electronic medication administration record): Resident has been going into other resident rooms and climbing into bed with the women. -1/14/2020: 15:25- General note: Director of social service (DSS) made a phone call to .to inquire about a one-to-one for resident, no answer received. -1/17/2020: 8:34- eMAR: Resident has spent most of the morning wandering in and out of resident rooms and taking others belongings. Resident redirected multiple times and depends and pants changed. Resident is currently in the dining room eating breakfast. -1/17/2020: 13:00- Care plan meeting: Resident has been wandering into other resident's rooms daily. He is an elopement risk and has a wanderguard in place. Discussed alternate placement options. -1/22/2020: 12:40- Risk meeting: Noted to be wandering into another resident's room and sleeping at the foot of their bed. He has been placed on one-to-one. Care conference with family on 1/17/2020 and family advised that we would be seeking a secure placement due to his wandering. Review of the hospice social worker visit note, dated 1/17/2020, revealed in part, Due to .wandering around facility and going into other residents' rooms, he may require 1:1 sitter which hospice is not able to provide at this time. Facility staff will be working with getting . contracts with them for possible 1:1 sitter. Facility working with getting referrals sent to other facilities that are .contracted . Facility will be exploring getting (resident) a 1:1 sitter as he does wander a lot and goes into other residents' rooms. They also advised that if he is not able to be managed at the current facility .family will need to explore alternate placement. Review of the (MONTH) 2020 computerized physician order [REDACTED].>-1/17/2020: Consult with .for psychiatric evaluation. One time only for wandering behavior for five days. Review of the progress notes revealed: -1/26/2020: 21:58 (9:58 p.m.)- Practitioner note late entry. The resident was seen and evaluated on 1/17/2020 .He is severely impaired, and has had difficulties with boundary issues. He has entered others' rooms uninvited, which has resulted in other residents becoming frightened or angry. He has also intermittently become aggressive, especially when attempts at re-direction are implemented. His behaviors are frequently occurring in the evening and nighttime hours .He was unable to communicate his history and recent behaviors in any type of meaningful manner, due to his dementia. He is currently on [MEDICATION NAME] 15 mg (milligram) HS (at night) which he was taking in hospital prior to his admission here. Despite the sedating effects of [MEDICATION NAME], he continues to become more behaviorally difficult during the nighttime and rarely sleeps very long at night .Psych Diagnosis: [REDACTED].It appears that [MEDICATION NAME] has helped significantly with his appetite, but is not helping behaviorally .In an attempt to help attenuate his behaviors in the PM (afternoon) and HS, low dose [MEDICATION NAME] will be ordered at 100mg .and 200mg HS. [MEDICATION NAME] was chosen due to its fairly benign side effect profile and the property og being able to lower agitation and anxiety levels .After my order was written, there was another order written by the attending, for 15mg HS ([MEDICATION NAME]). Somehow an additional order was written for 7.5mg HS. Technically, this order was now written as 22.5mg of [MEDICATION NAME] HS, 3x greater than my original order .Also, it was noted that a PRN (as needed) [MEDICATION NAME] order was written by the attending, shortly after my med changes were ordered .Every intervention ordered by this writer was undone within 48 hours. This was signed by the geriatric psychiatrist. Review of the hospice nursing note visit, dated 1/19/2020, revealed in part, Received call from facility. Patient is 1:1 currently due to behavioral issues. Patient wanders into other patient's rooms and gets in their beds. Staff had been successful with redirection but this no longer works and the patient is becoming agitated and combative .Notified on call physician. [MEDICATION NAME] order received . Review of (MONTH) 2020 behaviors-interventions-side effects, revealed: -For other behavior not directed towards others: behavior was documented on 1/17/2020. No other behaviors documented. -For physical behavior directed towards others: no behaviors documented. -For rejection of care: no behaviors documented. -For verbal behavior directed towards others: no behaviors documented. -For wandering impact: behavior was documented on 1/17/2020. No other behaviors were documented. Behavior monitoring documentation was incomplete and did not encompass all of the behaviors the resident was experiencing which included wandering, aggressiveness, agitation and refusal of care. Review of the staff training, revealed that facility staff had been trained in dementia care 2019-2020. The registered nurse (RN) was interviewed on 1/27/2020 at 4:08 p.m. She said Resident #11 had a sitter. She said he went to bed around 9-9:30 p.m. She said he had a sitter related to an accusation. She said before the resident had a sitter, he would pace the halls and and he laid down anywhere. An outside program staff member was interviewed on 1/28/2020 at 8:30 a.m. She said Resident #7 continued to feel fearful. She said the facility had Resident #11 on a one-on-one sitter, but the resident had been observed wandering in the common areas and dining area without a sitter. She said the facility told her it was good enough that staff were around when he wandered. Resident #7 was interviewed on 1/28/2020 at 9:14 a.m. She said Resident #11 sat there near her in the dining room. She said she did not know his name. She said he was in her bed that one time. She said earlier, he had walked into her room and looked around. She said sometime after that, he got into bed with her. She said that Resident #11 touched her all over including her breasts and private areas. She said she did not know he was in her bed at first. She said she was not awake at first. She said it made her feel miserable. She said the staff had come into the room to get him out of her bed. When asked if she was fearful, she said oh yeah. She said she was still a little afraid. She said the staff swore they would keep him out of her room. She said he sat next to her in the dining room and it does bother me because they seat him right next to me. She said they were supposed to keep him away from her. She said she did not feel completely safe. She said she could sleep okay but she was still not eating well. CNA #5 was interviewed on 1/28/2020 at 9:20 a.m. She said Resident #11 had been wandering into resident rooms since he moved to walking stick hallway. She said she was aware of him going into three resident rooms. Resident #17 was interviewed on 1/28/2020 at 9:30 a.m. He said Resident #11 wandered into his room every once in a while. He said this resident had used his bathroom and had taken his shirt. CNA #6 was interviewed on 1/28/2020 at 12:43 p.m. She said she was doing rounds and found Resident #11 at the foot of Resident #7's bed. She said he was asleep and that whenever he was tired he would crawl into bed and go to sleep. Resident #16 was interviewed on 1/28/2020 at 1:12 p.m. She said resident #11 had come into her room. She said he would wander to her room in the middle of the night. She said it would take a while to get him out. She said he liked to touch things in her room, but did not get into her bed. She said this had happened about two weeks prior. A resident group meeting was held on 1/28/2020 at 11:21 a.m. with four (#12, #13, #14 and #15) resident's the facility deemed interviewable. Resident #14 said Resident #11 had tried to crawl into bed with her four times, when she first arrived at the facility (Around the beginning of (MONTH) 2020). She said she used the call light and had to bang on the wall. She said it took about 15 minutes for the staff to help her. She said every time she fell asleep, she heard someone come into her room. She said he would never say anything, but he would shuffle in. She said she told him to leave and the resident would tell her he just wanted to go to bed. She would say Not with me. She said resident #11 had gotten the covers completely off of her and sat down. She said he tried to get into bed with her, under the covers. She said it was better since the resident started one-on-one supervision. She said it took a week of complaining before they did anything to fix things. Resident #14 statement provided by the social work executive (SWE) on 1/28/2020 at 2:10 p.m. revealed, Resident #14 states that on the first night she was in the facility, Resident #11 came into her room four different times trying to get into bed with her and attempting to take her covers. Resident #14 states that this occurred every night for the first week that she was here. Resident #14 stated that one of the last times that it occurred, I was on the call light forever and was banging on the wall and hurt my wrist. Resident #14 is wearing wrist braces today for the first time since she was admitted and when asked about them, states I have carpal tunnel and wear them when they hurt. Resident #14 stated that each time the resident had to be escorted out of the room by staff and that CNAs (2 CNAs and one nurse named) were aware as they were the ones escorting him out. Each time telling her We're sorry, we'll get him out of here and we'll take care of it. Resident #14 states that this behavior typically occurs in the wee hours after midnight. She states that she is not fearful of him, I don't think that he could do anything. V. Additional interviews The SWE was interviewed on 1/28/2020 at 12:29 p.m. She said Resident #11 was approved to go to another facility. The nursing home administrator (NHA), the RNL and the DON were interviewed on 1/29/2020 at 9:04 a.m. They said the day they reported the occurrence regarding Resident #7, they had a meeting with Resident #11's family. They said they discussed alternate placement. They said the facility was too large for him and he needed a smaller environment. They said they would move him from the current assistive dining room to the larger dining room, but they did not think that would be beneficial for Resident #11.

Based on observations, record review, family and staff interviews, the facility failed to provide an environment that was as free of accident hazards as possible for two of six sample residents (#1 and #4). Specifically, the facility failed to: - Provide resident #1 with adequate staff and supervision while in the bathroom. The resident, while unattended in the bathroom, fell off the toilet and sustained a cervical fracture. - Follow interventions put in place to prevent falls for resident #4. The findings include: 1. Resident #1 Resident #1, an [AGE] year old female, was admitted to the facility on [DATE]. According to the admission face sheet, the resident had [DIAGNOSES REDACTED]. The resident expired [DATE], after she fell at the facility and sustained a odontoid (cervical spine) fracture. According to the discharge minimum (MDS) data set [DATE], the resident required extensive assistance of one staff member for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The resident had poor balance and required staff assistance for stabilization when moving from a seated to standing position, walking, turning around, moving on/off the toilet and surface to surface transfer. a. Known Fall Risk Review of the resident's care plan, revealed a problem dated [DATE] and last updated on [DATE], that identified the resident was at risk for falls related to impaired balance, unstable health condition, and generalized weakness. The goal read the resident would not experience significant injury related to a fall. Interventions included: - High/low bed - Resident to wear non slip footwear - When resident is in bed, place all necessary personal items within reach. - PT (physical therapy) evaluation - Place call light within easy reach of resident - Educate resident of safety risk Another problem identified [DATE] and updated on [DATE], was the resident's self care deficit related to mobility. The goal was to improve the resident's ADL (activity of daily living) function status. Interventions included: - Toileting: resident is continent of bowel and bladder, requires physical assist for all toileting needs. - Resident uses glasses. Clean as needed. - Therapy evaluation and treat as ordered. - Adjust level of care according to individual needs and report persistent changes to physician and family. - Allow sufficient time for dressing and undressing, since the task may be tiring, painful and difficult. - Baths and showers per schedule and as needed. Skin check, shower, shampoo hair, nail cares, and lotion as needed. - Call light within reach and answer promptly. - Oral cares twice a day and as needed. b. Change in condition [DATE] A nurse's note, dated [DATE], documented the resident's daughter had complained that her mother had increased lethargy. The physician was in the facility and assessed the resident and ordered a CBC (complete blood count) with differential, BMP (basic metabolic panel) and a UA (urinalysis). The nurse notified the certified nurse aide (CNA), that a urine sample was needed. Review of the 24-hour report on [DATE], for the day of [DATE], revealed that the nurse had documented that the resident had increased lethargy and a CBC with differential and a urinalysis had been ordered. Review of the 24-Hour report for [DATE], revealed that there was no further documentation regarding the resident's lethargy and lab work and no notes were entered alerting nursing staff of the status changes identified on [DATE]. Review of the nursing notes for [DATE], revealed that there were no nursing notes. There were no notes regarding the resident's lab results. Review of lab reports revealed the UA was completed [DATE], and did not indicate the presence of a urinary tract infection. c. Fall [DATE] Review of nurses' notes for [DATE] at 2:45 a.m., revealed documentation that the resident fell in the bathroom from the toilet. There was a small bruise noted to her left forehead and a small abrasion to her right shin, no other apparent injuries. Vital signs and neurological checks were initiated and found to be within normal limits (WNL). The resident was taken to the emergency room at 7:00 a.m. on [DATE] via ambulance, and was admitted with cervical spine second vertebrae (C2) fracture. The resident's daughter, the physician, and hospice were notified. Review of the facility Fall Incident/Investigation revealed: - Incident: On [DATE] at 2:45 a.m., "Pt (resident) fell in bathroom from toilet; a small bruise was noted on her left forehead and a small abrasion to her right shin, no other apparent injury. Vital signs and neurological checks were WNL. Resident was taken to the ER (emergency room ) on the morning of [DATE], and was admitted with a C2 fracture. The resident complained of neck pain, her daughter did not want her sent to the hospital." - Investigation: Review of the facility investigation, revealed the resident was found by the registered nurse (RN) off the toilet and the resident had performed an unassisted transfer. The following intrinsic factors were related to the fall: COPD, decline in function, depression, and unsteadiness. The resident was alert with no change in behavior. The resident was on anti-depressants, narcotics, and laxatives, but these were not a factor in this incident. The resident was wearing slipper socks, her wheelchair was present, and she had just voided. The resident had attempted to self transfer and fell while in the bathroom. The RN documented she completed range of motion (ROM) prior to moving the resident and the range was within normal limits. She assessed the resident for pain. The nurse and the CNA performed a two-person lift and placed the resident into bed. The nurse reported that at that time she completed neurological checks and vital signs and notified the hospice nurse, who came in later and assessed the resident. The resident was complaining of neck pain at that point, and the hospice nurse called the resident's daughter and suggested sending her to the emergency room (ER) twice, but the daughter refused, requesting that the facility watch her. The facility nurse thought that the hospice nurse notified the resident's physician at that time. The resident later showed signs of a change of condition after she requested to be toileted. The resident was sent via the ambulance to the ER, her daughter was notified and the resident was found to have a C2 fracture. The resident was on hospice prior to the fall; and on [DATE] the resident was admitted to inpatient hospice. Recommendations: Complete a full house review of residents assistance needs with toileting and those who needed assistance will have the care plan updated to ensure that they are not left alone in the bathroom. An assessment lab will be set up for the nurses to complete: i.e. assessing, fractures, head injuries, and seizures. This will also include documentation and notification of primary physicians even if hospice was involved. d. Failure to provide resident #1 adequate supervision to prevent a fall with injury Record Review: Although resident #1 was known to be at risk for falls related to impaired balance, unstable health condition, poor vision and generalized weakness, to have extensive assistance needs (see care plans above) and to have recently experienced increased lethargy (see nurses' notes above), the resident was left unattended in the bathroom at 2:45 a.m. on [DATE]. Specifically, review of the Summary in Facility Incident/Investigation revealed: The CNA on duty stated, "I put her on the toilet and told her I'd be right back as I had three other lights going off. I returned less than two minutes later and found her on the floor in the bathroom with her legs underneath her. It's possible that she may have been reaching for the call light when she fell . I'm only guessing at that because of the way she was laying, but her call light was not on, and I called the nurse who asked her about pain, then we two man lifted her into bed." Review of the facility timesheet dated [DATE], revealed that there were three nurses and five CNAs on duty for 93 residents. Resident #1 resided on Steel City unit and the census for that unit was 21. The timesheet revealed that there was one nurse and one CNA assigned for 21 residents and a CNA assigned to that unit had called off on this date. The timesheet also revealed that the nurse assigned to the unit was not regular staff, but was pool staff. Review of the [DATE] to [DATE] master staff schedule received from the Nursing Home Administrator (NHA) on [DATE], revealed that on a daily basis for the night shift, there was one nurse assigned to Steel City and two CNAs, except during the time period of [DATE] through [DATE], when there was only one CNA assigned to Steel City. Review of the staffing agency's calendar received [DATE] by fax, documented that during the month of October, agency staff covered 18 of the facility's nursing shifts that month. On [DATE], the staffing agency covered two nursing shifts one day and one evening and on the night of resident #1's fall, all three nursing shifts were covered by agency staff. Interview: On [DATE] at 5:00 p.m., the resident's daughter stated the resident was a fall risk and she did not understand why staff had left her alone in the bathroom. She stated that the resident was able to walk until May. Then the resident was hospitalized and from that time forward, she was unable to walk. The daughter stated that she felt like her mother got impatient while waiting on the toilet, and it was in the middle of the night and she probably was not thinking clearly and thought she could get up and do it (transfer and walk) on her own. The daughter stated that the resident suffered a lot after her fall. On [DATE] at 4:30 p.m., the CNA involved in the incident discussed that she was by herself with a nurse she had never met before and they did not have enough coverage as someone called off that night. The CNA stated, "I did the best I could with what I had." The CNA discussed that the nurse was not familiar with the resident and when she found the resident on the floor, she screamed for the nurse and the nurse did not respond to her yelling, so she had to leave the resident alone again to get the nurse. The CNA stated that she would not have left the resident alone in the bathroom while she was using the toilet if there had been more staff on duty; the CNA stated she always stayed with resident #1 unless the resident asked her to give her a moment of privacy. In that instance, she waited outside the door. The CNA stated that she was not aware that the resident had been documented to have increased lethargy earlier in the week. On [DATE] at 3:55 p.m., another CNA who worked with resident #1 stated she never would leave the resident unattended in the bathroom. She said that at times the resident was impulsive and would try to stand from the toilet, and although she could sometimes stand, her balance was poor. On [DATE] at 4:10 p.m., one of resident #1's nurses stated that she never would have left resident #1 alone, as she required extensive assistance with toileting, transfers and ADLs and it was her personal philosophy to never leave a resident who required that much assistance alone. The nurse stated that the resident was good about asking for help by using her call light and she did not consider her impulsive, but still, she would not have left the resident alone. On [DATE] at 4:18 p.m., the unit manager for Steel City stated she had worked with the resident and she required extensive assistance of one. She said that when she took the resident to the bathroom, she never left her alone. She said it was her practice to not leave anyone alone in the bathroom, whether or not they needed more assist or not, as she was not always on the floor and exercised caution. She expressed that the resident was good about using her call light, was alert and was not impulsive. The resident required a stand-pivot transfer with a gait belt. The unit manager stated that the resident did have a decline, hospice was notified and based on the resident's current condition, the CNA should not have left her alone. On [DATE] at 9:54 a.m., the agency nurse on duty the morning of resident #1's fall stated she had worked at that facility twice, once in July and the other time on [DATE] (night shift). The nurse stated that she was told by the CNA that there should have been two CNAs working, but one called off and she only had one CNA. The nurse stated that the CNA found the resident in the bathroom and came and got her as she was with another resident at the time of the incident. The nurse stated that she called hospice and the resident's family, but not the physician. The nurse reported that she was not notified that the resident had a change of condition the day earlier in the week. On [DATE], at approximately 2:00 p.m., the Regional Director of Clinical Operations stated that there was no documentation to show that the agency nurse involved in the incident had received any orientation regarding the facility's policy or procedures on falls and emergencies. 2. Resident #4 Resident #4, an [AGE] year old female, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly Minimum (MDS) data set [DATE], indicated the resident had adequate hearing and vision with glasses, with significant memory impairment, with inattention and disorganized thinking, and rated her need of assistance for all activities of daily living and toileting as extensive. The resident was incontinent of bowel and bladder. An undated quarterly nursing assessment in the resident's medical record, indicated that the resident was alert, used glasses for vision, had adequate hearing, clear speech, short-term memory problems, had moderate decision making skills, displayed behaviors of tearfulness, anxiousness and could be socially inappropriate. She utilized a wheelchair for mobility and required one person assistance. The Mental Illness/Mental Retardation assessment dated [DATE], indicated the resident received the following medications: [REDACTED]. a. Known Fall Risk - History of Falls Care plans: The resident's care plans included individual plans for risk for falls, anxiety, hospice care, skin tear on right elbow and wandering. - The care plan for falls dated [DATE], was reviewed on [DATE], with no changes. - The care plan for anxiety dated [DATE], included a handwritten notation, "Resident fell on [DATE], slid from W/C (wheelchair) - Therapy to eval(uate), ? lap tray." - The care plan for skin tear to right elbow included the following note: "[DATE] Resident had two falls out of bed. Rolled from low bed to mat." Interventions added were: 1) place bolsters on bed 2) promptly get resident out of bed when awake and 3) notify hospice of any changes. - The care plan for wandering dated [DATE], was updated on [DATE], to include 1) pressure motion alarm when up in wheelchair and 2) release for activities and meal times. - The care plan for hospice was dated [DATE], and included a note on [DATE] that indicated "therapy to eval s/p (post) falls, place ? lap tray." Also a note dated [DATE] indicated, "Place bolsters in bed, promptly get resident out of bed when awake, and notify hospice of any changes." Falls Documentation: Falls were recorded for the resident for [DATE], [DATE], and two falls on [DATE]. - A change of condition form was completed on [DATE], and indicated that at 1700 (5:00 p.m.) the resident was found on the floor by the CNA. The physician and family member were contacted. The resident complained of head and hip hurting and 911 was called for transport to an acute care facility for evaluation and treatment. The hospital contacted the facility at 1830 (6:30 p.m.) to report that x-rays were negative for fractures. Documentation recorded on the facility's occurrence form, indicated the resident sustained [REDACTED]. - A fall evaluation was completed on [DATE]. The facility's occurrence log indicated the resident slid out of her wheelchair. A change of condition report was recorded at 19:15 (7:15 p.m.) and indicated the resident had been sitting in her wheelchair and toppled out of the wheelchair to the floor. No injuries were noted; however, the resident was transported to the hospital for evaluation. -A fall evaluation completed on [DATE], indicated the resident had fallen twice on that day, with factors listed as need for assistance with mobility, cognition problems, and cardiovascular problems. b. Failure to implement care planned interventions A fall was recorded on [DATE] at 1630 (4:30 p.m.), and a pain assessment was completed and recorded as negative for pain. A change of condition form was also completed and recorded that when the resident called out for help, the licensed practical nurse (LPN) entered the room and found the resident lying on the floor. The resident was unable to describe what had happened. No injuries were noted. The investigation documentation recorded in the facility's occurrence log, indicated that the resident did not have the ? lap tray on as required by the health care plan. The record stated "resident did not have her lap tray in place, resident assessed for injuries, placed back in wheelchair and lap tray put back into place." A fall was recorded on [DATE] at 22:15 (10:15 p.m.) on that date and a pain assessment was completed and recorded as negative for pain. The note reported the nurses' aide had entered the room and found the resident on the floor on a mat next to the bed. The resident complained of pain in the middle of her back, but was unable to verbalize the cause of the fall. The hospice nurse was notified of the fall and instructed the staff to put the resident back to bed. The note indicated a pillow was applied next to the resident on her right side. The progress note included the notation, "Bolster should be in bed." A change of condition documentation note on [DATE] at 13:00 (1:00 p.m.), indicated the resident had been sitting in her wheelchair when the nurse noted a bruise on the inner aspect on the lower left leg. The resident was unable to describe what had caused the injury. c. Observation The resident was observed on [DATE] at 9:15 a.m., in a wheelchair, located directly in front of the nurses' station. No ? lap tray was observed in place. d. Interviews An interview with the registered nurse on [DATE] at 11:30 a.m., indicated that the staff had adjusted the resident's mattress to make it more cradle-like and repositioned the resident with bolsters after the last fall ([DATE]). On [DATE], the physical therapy assistant (PTA) provided additional statements regarding the resident's fall on [DATE]. The PTA stated the fall reports stated the resident did have her lap tray in place. She said the investigation report had not been completed when reviewed by the surveyors on [DATE], although this was not reported to the surveyors at that time.