Every finding on record at Boulder Canyon Health and Rehabilitation

Based on observations, record review and interviews, the facility failed to ensure residents were kept free from resident to resident physical abuse for one (#7) of five residents reviewed for abuse out of 11 sample residents.Specifically, the facility failed to protect Resident #7 from physical abuse by Resident #8. On 7/1/26, Resident #8 punched Resident #7 in the face multiple times. Resident #7 had severe cognitive impairments. After being punched by Resident #8, Resident #7 exhibited non-verbal signs of pain including being sad, frightened, frowning, negative vocalization with moaning and groaning. Resident #7 sustained significant bleeding from the nose and face.Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #7's physical abuse by Resident #8, prior to the onsite investigation on 8/10/26 to 8/11/26, which resulted in the deficiency being cited as past non-compliance with a correction date of 7/6/26.I. Incident of 7/1/26On 7/1/26 at 4:45 p.m. registered nurse (RN) #1 witnessed Resident #8 punching Resident #7 multiple times in the face while standing up against a wall. Resident #8 had a laceration to his right knuckle and Resident #7 was bleeding from his nose and mouth. II. Facility plan of correctionA. Immediate action to correct the deficient practiceResident #7 was assessed, evaluated and treated. His family was contacted and the resident spokewith his mother. He was placed on 15-minute checks. Psychosocial monitoring was initiated. He was placed on neurological checks. The resident was referred for counseling. The resident was seen by the dentist on 7/2/26. A facial Xray was completed and was negative for fracture.Resident #8 was placed on one-to-one supervision with staff. He was assessed, evaluated and a small skin tear to hand was treated. Psychosocial monitoring was initiated. The physician was notified and requested a visit to occur on 7/2/26. The psychiatric provider was notified and a telehealth visit was scheduled for 7/2/26. Labs were ordered and the resident was referred for counseling services.B. Identification of other residentsAll residents at the facility were at risk. Resident #8 remained on one-to-one supervision at the time. The social services director (SSD) completed an audit and reviewed the care plans for all residents with a known history of trauma.C. Systemic changesThe following was implemented:-A root cause analysis was completed; -Initiated/discussed with family referrals for Resident #7 to a memory care setting;-Attempted/offered a structure for success for Resident #8;-The facility encouraged conversations with Resident #8 and representative regarding referrals toother skilled nursing facilities and/or assisted living facility settings;-Education on abuse prevention initiated for all staff on 7/2/26 and completed on 7/6/26; and-Resident #8's care plan was updated to include triggers and non-pharmological interventions; and staff members were educated on the updated care plan.D. MonitoringThe nursing home administrator (NHA) or designee would interview the staff members weekly to ensure they were aware of proactive approaches to prevent abuse incidents and deescalate resident behaviors. There was an ad hoc quality assurance and performance improvement (QAPI) committee meeting 7/2/26 that reviewed and discussed the incident.The incident would be formally reviewed by the entire QAPI committee on 8/12/26. III. Facility policy and procedureThe Abuse Prevention of and Prohibition Against policy, revised/reviewed December 2025, was provided by the NHA on 8/12/26 at 2:17 p.m. It read in pertinent part, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriationof resident property, and exploitation. Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms include, but are not limited to, the following: Aggressive and/or catastrophic reactions of residents; wandering or elopement-type behaviors; resistance to care; and outbursts or yelling out.IV. Resident to resident physical altercation between Resident #7 and Resident #8A. Facility investigationThe facility abuse investigation report was provided by the NHA on 8/10/26 at 12:50 p.m.The investigation revealed the date of the incident was 7/1/26 at 4:45 p.m. RN #1 witnessed the physical altercation of Resident #8 hitting Resident #7 who was standing up against the wall. Resident #8 fell forward onto Resident #7. Resident #8 had a scratch to his hand, and Resident #7 was bleeding from his nose and mouth. The residents were separated by the nurse and skin assessments were initiated for both residents. Neurological assessments were initiated for Resident #7 due to facial bleeding. Xrays were ordered by the physician immediately. The police, physician, and family/guardian were notified. Treatment was provided to Resident #7 with pressure applied to stop the bleeding and ice to the nose. The investigation documented Resident #7 (victim) had severe cognitive impairment. He usually ambulated throughout the facility without an assistive device and needed cueing for daily activities related to dementia. Resident #7 had a history of confusion secondary to progressive dementia. Resident #7 was unable to make a statement or be interviewed due to expressive aphasia. Resident #8 (assailant) was cognitively intact. He ambulated mostly in a wheelchair and could walk with a walker and was independent in his room with all daily activities. Resident #8 had a history of behaviors and was quick to anger with staff. He yelled when preferences were not met immediately and cussed at staff, with poor coping skills.Resident #8 was interviewed and felt like he was the victim and had responded appropriately to Resident #7 tapping him on the shoulder. Resident #8 felt that he was protecting himself. After the interview the resident agreed to behavioral health services.The investigation documented RN #1 gave a witness statement on 7/1/26. She said was coming out of a resident's room from taking blood pressure and talking with them. RN #1 came out of room and was walking down the hall when she saw Resident #8 standing with his back toward her. Resident #8 was standing up and his hands were raised up by his face. She said Resident #7's hands were also raised up. RN #1 said she could see that there was tension and conflict and she rushed over. She said that Resident #8 lunged forward and started to hit Resident #7 in the face. She said Resident #7 hit the wall behind him and Resident #8 lost his balance, and he leaned forward and continued to punch Resident #7 maybe six to eight times. RN #1 said Resident #8 was standing and she did not know if his wheelchair was behind him or not. RN #1 said Resident #8 stood behind her for a while (after she separated them) and she called for him. RN #1 said she had a rag and was holding it and then help arrived. RN #1 said that prior to the incident she saw Resident #7 ambulating around and nothing was unusual. RN #1 said that earlier Resident #8 spent a lot of time in his room and came out to get coffee. RN #1 said that neither resident seemed outside of baseline except Resident #8 had maybe been a little more fussy and particular lately. RN #1 said Resident #8 was really particular and if he did not get things the way he wanted them he lost it. RN #1 said what she did to help Resident #8 was to tell him that she saw he was upset and try to ask him to articulate his needs and to make suggestions, but Resident #8 would reject all solutions. RN #1 said Resident #8 was not able to rationalize when he was upset. The investigation documented certified nurse aide (CNA) #2 gave a witness statement on 7/1/26. CNA #2 said she was sitting at the nursing station completing charting when she heard RN #1 call for help. At that time she walked to the north two unit and grabbed CNA #1 to come assist. The director of nursing (DON) asked CNA #2 if Resident #8 had complained about Resident #7 to which she said no. -However, the interview did not include what help or assistance she provided to the residents or what she saw or heard as a witness. The investigation documented CNA #1 gave a witness statement on 7/1/26. CNA #1 said she was the float CNA and was working on both north hallways. CNA #1 said that she provided care to Resident #7 and assisted with brief changes two times that morning. CNA #1 said that prior to the incident she was in the north hall, maybe after 2:00 p.m. because she thought that was when the CNA went on her break on that side. CNA #1 said Resident #7 was not around and he usually was in the dining room or walking around the facility. CNA #1 said Resident #8 usually stayed in his room but would come out for ice and that was when she would typically see him. CNA #1 said she did not see Resident #8 the day before but saw him in the morning when he was walking around and throughout the morning when he was getting ice. CNA #1 said she did not see Resident #8 after 2:00 p.m. but when she had seen him he had seemed pretty normal to her and earlier in the day he said good morning to her. CNA #1 said Resident #8 had seemed pretty okay to her that day. CNA #1 said she had seen Resident #8 with some behavior in the past and he had gotten upset about not getting a shower on time and not getting what he ordered from the kitchen. CNA #1 said she had seen Resident #8 be okay and then suddenly he was so upset. CNA #1 said when Resident #8 got upset, what she saw that worked was to just leave him alone because he seemed to get more upset if she tried to help the situation. CNA #1 said she also heard that if he did not get his shower at 6:00 a.m. or 7:00 a.m. and it got offered later he would be so upset. CNA #1 said what she thought happened was Resident #7 was walking by and got into Resident #8's way and Resident #8 could have told him to move and then it escalated. CNA #1 said that CNA #2 came and grabbed her and asked for help. She said when she came over, she saw Resident #7 with blood on his face. CNA #1 said RN #1 was there and she thought everyone got there at the same time and the DON was there as well. CNA #1 said she did not think she saw Resident #8. She said Resident #7 was getting his face cleaned up and all he said was the other guy is old.The investigation documented Resident #15 was interviewed by the social services staff on 7/2/26. Resident #15 said she was going down the hallway to smoke and went around Resident #8 and Resident #7. She thought they were talking behind her and then got louder. She heard Resident #8 say something like, don't hit me or you keep hitting me. Resident #15 said they were standing very close to each other. Resident #8 was not in his wheelchair and had walked out of his room without it. Resident #15 turned around and Resident #8 started throwing punches. She was shocked and said to stop but Resident #8 kept punching. She said she could see one of the CNAs start running toward them. She said Resident #7 was bleeding. Resident #15 said the CNA pulled Resident #8 off Resident #7. She said they were outside of Resident #7's room. Resident #15 said she was surprised that Resident #7 was still standing because Resident #8 was hitting him hard with his fists. She said not pushing or slapping, just hitting and only hit Resident #7 in the face. She said she did not recall him hitting his body. She said Resident #7 did not hit back and was trying to protect himself. She said Resident #8 went back to his room after the CNA broke up the fight. She said Resident #8 then came out of his room with a metal cup to go get coffee and Resident #15 asked him to stay where he was and said the CNA would get him coffee. Resident #15 said she was doing so-so afterwards and did not eat much dinner last night, but she said it was mostly the heat. She said she was a little upset about it after it happened. She gave her statements to the police.The behavioral health services nurse practitioner was interviewed on 7/2/26. The behavioral health services nurse practitioner said that Resident #7 did not seem to be experiencing any anxiety, or distress. All he said was I was on the left and he was on the right. The nurse practitioner did not think he was going to be stressing out over it. He said if he saw Resident #8 he would tell us. Resident #8 was not remorseful at all. He was very hostile, would not let the nurse practitioner talk. Resident #8 said if Resident #7 approached him again he would beat the expletive out of him again. His insight and judgement were so poor. He was not willing to start on any medications. He was not going to do anything. He refused a trauma screen and said staff favored Resident #7 and Resident #7 was the one who started it. Resident #8 was not willing to let anyone know if Resident #7 was bothering him.The investigation documented a root cause analysis was completed. The problem statement revealed Resident #8 had punched Resident #7 in the face. Resident #8 had Resident #7 up against a wall in the hallway. Resident #7 was not hitting and was unable to defend himself. Staff witnessed Resident #8 hitting Resident #7 in the face. Resident #8 said, He touched me, I told Resident #7 not to touch me, he raised his arm, I hit him. Resident #7 was unable to describe or participate in a meaningful way and unable to formulate complete sentences. Resident #8 had a history of being quick to anger. He had a difficult childhood and was illiterate. He may have a history of trauma, behavioral health services to evaluate. Root causes: Resident #7 was confused at baseline and could have touched him or tried to say something. Resident #7 could have triggered him. Resident #7 may benefit from a secured unit/memory care placement. A one-to-one caregiver was implemented for Resident #8 and behavioral health services was to see Resident #8.The conclusion of the investigation revealed a staff member witnessed Resident #8 and Resident #7 in an altercation and witnessed Resident #8 strike Resident #7. -Abuse occurred due to the willful actions of Resident #8 punching Resident #7 multiple times in the face causing him pain. V. Resident #7 (victim)A. Resident statusResident #7, age greater than 65, was admitted on [DATE], and discharged [DATE] to a memory care facility. According to the July 2026 computerized physician orders (CPO), diagnoses included encephalopathy, cognitive communication deficit, and dementia.The 5/22/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. He required supervision or touching assistance with shower transfers, walking 50 feet with two turns and walking 150 feet. He was independent with eating, bed mobility, bed to chair and sit to stand transfers and walking 10 feet.The assessment revealed he exhibited wandering behavior four to six days per week. B. Record reviewResident #7's cognitive function/dementia care plan, initiated 7/2/26, revealed the resident was at risk for impaired thought processes related to Alzheimer's disease and the resident had difficulty expressing his thoughts and feelings. Pertinent interventions included to engage in simple, structured activities that avoided overly demanding tasks. The resident preferred walking around, talking to his mom, and watching television (TV), revised 7/10/26.Resident #7's at risk for re-traumatization care plan, initiated 4/10/24, related to history of trauma/grief/loss due to his sister passing away from a drug overdose, he did talk about this often. Pertinent interventions included to avoid loud noises as this could be a trigger, provide a calm and quiet environment and stop and talk with the resident when passing by, initiated 4/25/24.Resident #7's wandering care plan, initiated 3/24/24, revealed he was at risk related to disorientation to place with impaired safety awareness. Pertinent interventions included to document wandering behavior, attempt diversional interventions, provide structured activities such as toileting, walking inside/outside, reorientation strategies including signs, pictures and memory boxes, initiated 3/24/24.Resident #7's intrusive wandering care plan, initiated 3/25/24, revealed he had a behavioral problem related to progressive dementia and was often found in the hallways or common areas. He wandered and would strike up conversations with staff/others as he walked passed in the hallways and common areas and inadvertently invaded others' space and exhibited intrusive wandering. Pertinent interventions included to talk with the resident when he passed by, to anticipate and meet needs and approach in a calm manner, initiated 3/25/24. The 7/1/26 nursing note revealed Resident #7 was involved in a physical altercation withResident #8, and was bleeding from the nose and mouth. An investigation was initiated and the physician was notified. The physician ordered a facial Xray. The residents were separated, placed on 15-minute checks with psychosocial monitoring.The 7/1/26 change in condition assessment revealed Resident #7 had new pain due to a physical altercation with another resident (resident #8). Resident #7 was punched in the face multiple times with resultant nose swelling and bleeding. Neurological assessments were initiated and the physician was notified. The physician ordered an Xray of the face/nose and ice to nose. Pain medication was ordered. The pain status evaluation revealed the resident was having acute pain but the resident was cognitively unable to rate their pain. It revealed the resident showed non-verbal signs of pain and had occasional negative vocalization with moaning and groaning. The resident had a low-level of speech with a negative or disapproving quality. Resident #7's facial expressions were sad, frightened and with a frown.The musculoskeletal pain was marked with localized bruising, swelling, and pain to the face and nose. The 7/1/26 skin check note revealed skin issues on the bridge of the nose that were swollen with purple and red bruising/discoloration. Multiple lacerations to internal bilateral nares. The resident had an abrasion to the chin measured one centimeter (cm).The 7/1/26 Xray report of the facial bones revealed there were no fractures or displacements.The 7/1/26 social services note revealed the social worker checked in with Resident #7 after the altercation with Resident #8. Resident #7 stated that he was doing okay and appeared to be at baseline. The social worker asked if she could do anything for Resident #7 and he stated to call mom. The social worker assisted Resident #7 in calling his mom. Resident #7 and his mom talked for a good while. Resident #7 remained on a 15-minute check and social services would follow.The 7/2/26 condition follow-up note revealed the resident was being monitored for facial trauma. Swelling of nose with faint purple and red discoloration to bridge of nose. Scheduled Tylenol was administered for pain. The 7/2/26 psychological services note by the nurse practitioner revealed her plan and recommendations following her assessment. The note documented given Resident #7's cognitive limitations, his ability to reliably de-escalate independently was limited and he requires staff support and redirection to maintain safety. The resident was counseled to avoid the other resident involved in the altercation. Instructed the resident to notify the facility nursing staff or staff in charge if the other resident approached or bothered him again rather than engaging physically. The facility staff were to monitor interactions between the residents to maintain safety of all residents. The 7/2/26 dental evaluation note revealed the resident was involved in an altercation over the weekend in which he was struck in the jaw. There were no signs of teeth fractures or chips, just a small traumatic lesion on his lip. VI. Resident #8 (assailant)A. Resident statusResident #8, age greater than 65, was admitted on [DATE] and discharged to another skilled nursing facility on 7/22/26. According to the July 2026 CPO, diagnoses included acute kidney failure, heart failure, morbid obesity, type 2 diabetes, and major depressive disorder.The 5/28/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He was independent with transfers and walking. The assessment revealed verbal behavioral symptoms directed toward others, such as threatening, screaming, and cursing at others, that occurred over one to three days.B. Record reviewThe at risk for re-traumatization care plan, initiated 9/23/25, related to history of trauma/adverse childhood experiences revealed the resident was unable to read or write at this time due to neverlearning how. Pertinent interventions revealed to anticipate and meet needs, approach in a calm manner, assist to develop more appropriate methods of coping/interacting and encourage to express feelings appropriately. Triggers: Resident #8 had a short fuse, he could become easily angered when preferences/requests did not occur immediately such as with showers or kitchen orders. Interventions include to agree with Resident #8 and offer to fix his concern, he may decline this, allow him to cool/calm down in his room, offer to call medical power of attorney (MDPOA), redirect to his room to watch TV, offer/encourage him to be outside, initiated 7/13/26. The potential for mood, behavior and psychosocial problems care plan, initiated 12/26/23, revealed the resident had a short fuse and was very particular about his schedule and preferences. He could become very agitated at staff if they were late with medications or showers. At times, Resident #8 would make up stories of any type to get out of going to activities or doing a task he did not want to do such as showers. He had exhibited physical aggression towards another resident. Pertinent interventions included to assist to develop more appropriate methods of coping/interacting, encourage to express feelings appropriately, document behaviors, and the resident response to interventions, and if reasonable, discuss behavior, explain/reinforce why behavior was inappropriate and/or unacceptable, initiated 12/26/23.The 5/13/26 nurse note revealed the resident began cursing at the staff stating his meal was cold and he continued to curse that he did not want it reheated or another meal.The 6/5/26 behavior note revealed the resident became extremely agitated and started yelling at the staff when the kitchen failed to send crackers on the lunch tray. The resident continued cursing that he did not want the crackers now and refused his lunch.The 6/8/26 social services summary note revealed in pertinent part that over the current quarter Resident #8 was reported to be verbally aggressive towards staff. The 6/12/26 behavior note revealed the resident was yelling and screaming out this morning. Not happy about not getting two orange juices with his breakfast, and then about his TV glitching. The 6/15/26 social services note revealed that the social worker followed up with Resident #8 and provided education to him to be patient with the nurses and to ask the nurses what he wanted instead of yelling. The 7/1/26 change of condition note revealed Resident #8 was seen punching Resident #7 multiple times in the face. The 7/1/26 nurses note revealed Resident #8 involved in a physical altercation with Resident #7. Resident #8 with scratch to hand. Area cleansed and bandaged. The residents were separated and the physician was notified. Resident #8 was placed on one-to-one supervision and the MDPOA notified. An investigation was initiated.The 7/1/26 skin check note revealed a laceration (2.5 cm in length) to the third knuckle. The 7/1/26 social services note revealed social services checked in with Resident #8 after the altercation with Resident #7. Social services asked what happened and Resident #8 pointed to a scratch on his hand and said, Look, he pushed me so I only hit him once. Resident #8 appeared to be at baseline and was very calm. He remained on one-to-one supervision. Social services requested that behavioral health services come to see Resident #8 for an urgent visit tomorrow.The 7/1/26 primary care physician (PCP) visit revealed nursing requested a visit due to the resident being involved in an altercation on 7/1/26. During the visit he called the other resident names and refused to explain why. During the visit, he was raising his voice to the physician, showing anger and refusing to answer further questions.Assessment: irritability and anger.The 7/2/26 psychological services note by the nurse practitioner revealed Resident #8 demonstrated escalating verbal and physical aggression toward peers and staff as evidenced by a recent physical assault resulting in injury to another resident. Resident #8 displayed poor impulse control, limited insight into his behavior and the seriousness of the incident, inconsistent recounting of events, and minimal remorse following the aggressive incident. Resident #8 had a history of interpersonal conflict. Resident #8 was presenting for an urgent psychiatric evaluation following a serious physical altercation on 7/1/26.According to staff reports, Resident #8 assaulted another resident by punching him multiple times in the face. The assault resulted in significant injuries, including prolonged bleeding from the nose and mouth that persisted until after 9:00 p.m., as well as facial swelling and bruising. Law enforcement responded to the facility and issued Resident #8 a citation, and he had been assigned a court date. Resident #8 reportedly smiled while discussing the altercation and stated that he had repeatedly told the other resident to leave him alone and that the resident failed to do so. He further remarked, Everybody at least knows now not to mess with me. Staff perceived his comments and demeanor as reflecting pride in the altercation rather than regret for the injuries sustained by the other resident. Earlier today, when the facility physician attempted to evaluate him, Resident #8 became verbally aggressive, cursed at the physician, and instructed him to leave. Staff reported an ongoing pattern of escalating behavioral concerns over recent weeks, including increasing difficulty in the facility environment,interpersonal conflicts with peers and roommates, verbal hostility, poor frustration tolerance, and impaired impulse control. He appeared irritable during this interview and continued to speak over the behavioral health nurse practitioner. Staff report of previously displayed behaviors directed at staff on 6/5/26, 6/8/26 and 6/12/26.The 7/2/26 social services noted revealed the licensed clinical social worker (LCSW) and the RN clinical resource met with Resident #8 following his telehealth appointment with psychiatry in which Resident #8 reported that he was not willing to cooperate with the recommendations. The social worker and RN clinical resource explained that if Resident #8 wanted to remain a resident at the facility, it was asked that he participate with behavioral health and his providers recommendations for this safety and the safety of other residents. Resident #8 became irritable stating that he would just leave right away and started to pack his belongings. The social worker and RN clinical resource explained to him that the facility did not want him to leave unsafely, however wanted him to participate in the process to find a different community or setting. Resident #8 continued to pack and refused to engage in further conversation. The social worker asked Resident #8 if he wanted her to try again to reach his MDPOA, he responded yes. The social worker left the room and was able to get a hold of the MDPOA. As the social worker was walking back to Resident #8's room, the DON and the police detective were headed to Resident #8's room. Prior to going into the room, the DON, social worker, police detective and MDPOA met to discuss concerns. The social worker explained that Resident #8 was refusing to participate in behavioral health support and that the facility wanted to explore alternative facilities for him. The police detective reported that Resident #7's power of attorney (POA) had declined to press charges, so Resident #8's ticket with a court summons was going to be revoked. The police detective expressed concerns about Resident #8's choices and lack of actions following the incident and stated that he wished to speak with him. The DON, LCSW and MDPOA who was on the phone, entered Resident #8's room. Resident #8's one-to-one caregiver was present as was a witnessing nurse. A group discussion occurred in which Resident #8 initially insisted he was leaving now to the streets. The desire for him to remain in the facility was discussed to get the care and services he needed while ensuring the safety of him as well as the other residents. The police detective explained to Resident #8 that if there were any further instances there would be no tickets, just jail. The MDPOA was able to convince Resident #8 to participate with behavioral health services. Resident #8 remained on one-to-one supervision, counseling referral was in place, behavioral health telehealth visit was scheduled on 7/2/26, pending recommendations. The 7/2/26 SSD note revealed she checked in with the resident and he was watching TV. The resident did not make eye contact with the SSD, stated that he was okay and then asked the SSD to leave his room. The SSD left and would continue to follow.The 7/3/26 condition follow-up note revealed the resident was verbalizing frustration related to the recent incident in an elevated and loud tone with curse words verbalized during the statement.The 7/3/26 SSD note revealed that she checked in with the resident. He was resting in bed and in a very pleasant mood. The resident stated that he was just sitting here, relaxing. The resident appeared to be in a very cheerful mood and was seen by behavioral health services today for an initial visit and did engage with them. Staff reported that the resident was bragging to everyone that he had a security guard now. The resident remained on one to one supervision and he started on sertraline hydrochloride (HCI) for anxiety and took his first dosage. The 7/4/26 SSD note revealed that the manager on duty checked in with the resident. The resident was at baseline for mood and stated, ain't nothing changed, I'm doing good. Social services would continue to follow.The 7/5/26 SSD note revealed that the manager on duty checked in on the resident and he was at baseline for mood and stated just another day for me, I'm doing good. The 7/6/26 psychological services follow up (behavioral health services) note by the medical doctor revealed the resident was being seen for an urgent appointment related to a recent serious physical altercation with another resident that occurred 7/1/26. According to staff reports, Resident #8 assaulted another resident by punching him multiple times in the face. The assault resulted in significant injuries, including prolonged bleeding from the nose and mouth that persisted until after 9:00 PM, as well as facial swelling and bruising. Resident #8 appeared irritable during this interview and continued to speak over the physician. He did not display remorse for his actions and was not able to come up with an appropriate plan to avoid or resolve co

Based on observations and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public in three of four shower rooms.Specifically, the facility failed to ensure shower rooms were maintained in safe, sanitary and working condition.Findings include:I. Facility policy and procedureThe Safe, Homelike Environment policy, reviewed December 2025, was provided by the nursing home administrator (NHA) on 1/14/26 at 3:08 p.m. It read in pertinent part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.The Housekeeping Services Infection Control policy, revised January 2009, was provided by the NHA on 1/14/26 at 3:30 p.m. It read in pertinent part, It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the facility's interior will aid in physically removing and reducing microorganisms' potential contribution to the incidence of health-associated infections (HAI). The housekeeping supervisor will implement effective systems of environmental sanitation, including a regular cleaning schedule for all areas. The housekeeping supervisor will work closely with the infection control team to establish and maintain consistent practices and high standards of cleanliness. Periodic inspection of the facility will be made by the housekeeping supervisor as a joint exercise with the infection control team. Common bathrooms and showers:-Bathrooms to be cleaned as needed or daily;-Common showers will be cleaned frequently; and,-Housekeeping will disinfect water fixtures and all touch surfaces.II. ObservationsDuring the initial walkthrough of the facility on 1/11/26 the following was observed:At 9:21 a.m. the 200 hallway shower room lights were on and the door was held open with a gait belt that was tied around the door handle and attached to the shower railing. The shower head tubing had a continuous drip of water which resulted in the shower floor remaining wet with a pool of water in the middle. There was a black substance observed in the silicon caulking of the shower.At 9:42 a.m. the shower head tubing was continuously dripping water in the secure unit shower room causing the shower floor to remain wet. There was a black substance observed in the silicon caulking of the shower. The floor was sticky.On 1/12/26 the following was observed:At 9:12 a.m. water continued to leak from the shower head tubing in the 200 hallway shower room. The floor was wet and the black substance in the silicon caulking of the shower was still present.At 9:19 a.m. the flooring in the 600 hallway shower room was cracked and peeling with an uneven surface. There was a black substance observed in what was left of the silicon caulking of the shower. All of the caulking was damaged; it had been ripped or torn out in some areas, and looked gummy and built up in other areas. The shower drain cover did not entirely cover the shower drain. A hard white substance was observed built up on the shower drain.At 11:35 a.m. water continued to leak from the showerhead tubing in the secure unit shower room. The floor was wet and the black substance in the silicon caulking of the shower was still present.III. Resident interviewResident #99 was interviewed on 1/11/26 at 12:45 p.m. Resident #99 said the flooring of the 600 hallway shower room needed to be updated because it was cracked and peeling. He said he thought he was the only resident bothered by the floor because he was the only resident who stood and independently showered, while the other residents used a shower chair or shower bed. Resident #99 said the facility would not listen to him about his concerns with the shower room.IV. Staff interviewsThe maintenance director (MTD) and the maintenance resource were interviewed together on 1/13/26 at 2:05 p.m. during a tour of the facility's four shower rooms. The maintenance resource said the continuous dripping of water from the shower heads in the shower rooms was an expected result of the backflow valves to prevent contamination of the water, and the black substance in the silicon caulking of the showers was residue. He said he did not believe the facility had mold test kits readily available, and he would follow-up regarding ordering one.The MTD and the maintenance resource observed the 200 hallway shower room floor and confirmed that it was wet. The maintenance resource said the shower head dripping was related to an issue with the shower cartridge. He said he did not think harm could be caused by the shower floor remaining wet without being able to fully dry.The 600 hallway shower room was occupied during the shower room tour. The maintenance resource said he did not know if he could say the flooring in the 600 shower room was not a sanitizable surface, even though it was cracked and not intact. He said he would recommend replacing the coating on the shower floor.The NHA was interviewed on 1/13/26 at 2:30 p.m. during a tour of the facility's four shower rooms. The NHA said he requested from maintenance a timeline of the status of repairs to the damaged floor in the 600 hallway shower room, as well as what the unidentified black substance was in and under the silicon caulking in the shower rooms. He said he would have to speak to maintenance regarding how often the MTD or the housekeeping supervisor checked the shower rooms and why the MTD had not identified the black substance under the caulking.The shower head tubing leaks in the 200 hallway, 600 hallway and the secure unit were observed with the NHA. The NHA agreed the shower floor being wet with the shower room door held open with a gait belt could have been a risk for wandering residents to slip and fall.The NHA and the maintenance resource were interviewed together on 1/14/26 at 2:00 p.m. The maintenance resource said the housekeepers cleaned and inspected the shower rooms daily, and there was an expectation for the housekeeping staff to report any leaks or concerns to the MTD, either verbally or by submitting a work order. The maintenance resource said there had not been any work orders written for the shower head tubing leaks. He said the results of the mold test kit would not arrive until after the survey exit, but the maintenance team was correcting the issue and would follow-up once the repairs were completed (during the survey).V. Facility follow-upOn 1/14/26 at 2:39 p.m. the facility's shower rooms were observed again along with the NHA and the maintenance resource. The tour of the 600 hallway shower room revealed the following:The flooring had been refinished/re-painted with a vinyl coating. The maintenance team had scraped the old silicone caulking out, cleaned the area and would be replacing the caulking. There was no longer a black substance in the shower. There was no water dripping from the shower head tubing and the vinyl coating was still drying.The tour of the 200 hallway shower room and the secure unit shower rooms revealed the following:The silicon caulking had been scraped out, cleaned and replaced in both shower rooms. There was no longer a black substance found in either shower. There was no water dripping from the shower head tubing, and the floor was dry.-However, the maintenance repairs in the shower rooms were not conducted until the concerns were brought to the facility's attention during the survey.

Based on observations and interviews, the facility failed to ensure adequate outside ventilation by means of windows or mechanical ventilation in three out of four shower rooms.Specifically, the facility failed to ensure the ventilation fans in the shower rooms were operational.Findings include:I. Professional referenceAccording to the U.S. Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021, retrieved on 1/20/26 from https://docs.nrel.gov/docs/fy21osti/79150.pdf, Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults. Good ventilation can improve the health and wellbeing of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can significantly enhance the safety and quality of life for their residents. II. Facility policy and procedureThe Safe, Homelike Environment policy, reviewed December 2025, was provided by the nursing home administrator (NHA) on 1/14/26 at 3:08 p.m. It read in pertinent part, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. General considerations: -Minimize odors by reporting bathrooms needing cleaning to Housekeeping Department;-Report any unresolved environmental concerns to the Administrator; and,-Have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two.The Housekeeping Services Infection Control policy, revised January 2009, was provided by the NHA on 1/14/26 at 3:30 p.m. It read in pertinent part, It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the facility's interior will aid in physically removing and reducing microorganisms' potential contribution to the incidence of health-associated infections (HAI). Periodic inspection of the facility will be made by the housekeeping supervisor as a joint exercise with the infection control team.III. ObservationsDuring the initial walkthrough of the facility on 1/11/26 the following was observed:At 9:21 a.m. there was no air flow coming from the ventilation fan in the 200 hallway shower room. The ventilation fan was not moving, and it was muggy and hot in the shower room.At 9:42 a.m. there was no air flow coming from the ventilation fan in the secure unit shower room. The ventilation fan was not moving, and it was muggy and hot in the shower room.On 1/12/26 the following was observed:At 9:12 a.m. there was still no air flow coming from the ventilation fan in the 200 hallway shower room.At 9:19 a.m. the 600 hallway shower room was muggy and hot.At 11:35 a.m. there was still no air flow coming from the ventilation fan in the secure unit shower room. The ventilation fan was not moving, and it was muggy and hot in the shower room.On 1/13/26 at approximately 3:30 p.m. the maintenance team was working in the secure unit shower room. The maintenance team brought in parts to work on the ventilation fan.On 1/13/26 at 2:30 p.m. the ventilation fan in the 600 hallway shower room would not suck a tissue that was held up to it.IV. Staff interviewsThe maintenance director (MTD) and the maintenance resource were interviewed on 1/13/26 at 1:51 p.m. during a tour of the facility's shower rooms. After inspecting the secure unit shower room, the maintenance resource said there was not any air flow.The maintenance resource searched for and found the switch to the ventilation fan in the 200 hallway shower room. When he flipped the switch, the ventilation fan was operating with a loud whirring noise. The maintenance resource said the fan would be repaired by the maintenance team. The maintenance resource said the bathrooms and shower rooms must be ventilated by a fan or a window. He said the ventilation fan in the secure unit should be operational since there was no window. The maintenance resource said the harm of the ventilation fans not working was uncomfortability related to foul orders and un-steaming the showers.The NHA was interviewed on 1/13/26 at 2:30 p.m. while touring the facility's shower rooms. The NHA observed the unoperational ventilation fan in the secure unit, the operational but loud ventilation fan in the 200 hallway shower room and observed the tissue being held up to the ventilation fan in the 600 hallway shower room (see observations above) without air flow. He said he would have to speak to maintenance and follow up regarding how often the MTD or the housekeeping supervisor checked the shower rooms.The NHA and the maintenance resource were interviewed together on 1/14/26 at 2:00 p.m. The maintenance resource said the housekeepers cleaned and inspected the shower rooms daily, and there was an expectation for the housekeeping staff to report any leaks or concerns to the MTD, either verbally or by submitting a work order. He said there had not been any work orders written for the ventilation fans in the shower rooms.V. Facility follow-upThe shower rooms were observed again, along with the NHA and the maintenance resource on 1/14/26 at 2:39 p.m. The shower room tour revealed the following:The ventilation fan in the 600 hallway shower room was operational. The ventilation fan in the secure unit shower room was operational. The maintenance resource said the motor needed to be replaced.The ventilation fan in the 200 hallway shower room remained operational, and was much quieter.-However, the repairs to the ventilation fans in the shower rooms were not conducted until the concerns were brought to the facility's attention during the survey.

Based on observations and interviews, the facility failed to provide a safe, clean, sanitary and comfortable environment on the secured unit. Specifically, the facility failed to:-Ensure the blinds in the secured unit's common area and in residents' rooms were in good repair;-Ensure lights in the residents' bathrooms were working properly; -Ensure each resident had hand towels available for use in their bathrooms; and,-Ensure maintenance and patchwork was completed in a timely manner on the secured unit and in residents' rooms.Findings include:I. Facility policy and procedureThe Safe and Homelike Environment policy, reviewed December 2025, was provided by the nursing home administrator (NHA) on 1/14/26 at 3:08 p.m. It read in pertinent part, The facility will create and maintain, to the extent possible, a homelike environment that deemphasizes the institutional character of the setting. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. The facility will provide and maintain bed and bath linens that are clean and in good condition. The facility will provide and maintain adequate and comfortable lighting levels in all areas. The maintenance director (MTD) will perform periodic rounds to ensure functioning lights.II. ObservationsDuring the initial tour of the facility's secured unit on 1/11/26 at 11:10 a.m. the following was observed:The last ceiling light at the end of the hall, outside of the common area which was the secured unit's dining room, was flickering. The hallway ceiling light fixtures had numerous dark particles in four of the eight light covers. The common area's blinds had many missing and broken slats.The entrance way to the common area and near the nurses' station had chipped paint and missing drywall at the lower end of the wall.In room [ROOM NUMBER] the blinds had missing and broken slats.Rooms #404, #405, #407, #408, #411, and #413 did not have hand towels available in the rooms.room [ROOM NUMBER] had a flashing bathroom light, one bathroom light bulb was not working and there were white paint splotches on the wall. On 1/12/26 at 9:15 a.m. the following was observed on the secured unit:Rooms #403, #404, #405 and #411 did not have hand towels available in the rooms. Rooms #403 and #411's blinds had broken and missing slats and white paint splotches on the bathroom wall. On 1/13/26 at 9:51 a.m. the following was observed on the secured unit:room [ROOM NUMBER] had blinds with broken slats hung on the windows. room [ROOM NUMBER] still had blinds with missing and broken slats. room [ROOM NUMBER] had holes in the wall above the television, paint was coming off the wall near the floor at the end of the bed, blinds with broken slats hung on the window and white paint splotches were on the bathroom wall.room [ROOM NUMBER] had white paint splotches on the bathroom wall. room [ROOM NUMBER] had blinds with broken and missing slats hung on the windows, the bathroom wall had white paint splotches, one light bulb in the bathroom was not working and the ceiling light in the room was missing the cover. room [ROOM NUMBER] had blinds with broken slats hung on the windows. There were many tiles missing from the bathroom wall and a tile missing next to the soap dispenser. room [ROOM NUMBER] had 16 tiles missing from the bathroom wall. The adjacent tiles from the missing tile pieces were sticking out from the wall with sharp edges. room [ROOM NUMBER] had dried, brown liquid marks on the bedroom wall, the blinds with broken slats hung on the windows and the bathroom wall had white paint splotches. room [ROOM NUMBER] the bathroom walls had white paint splotches.room [ROOM NUMBER] had a flashing bathroom light and one light bulb not working, the bathroom walls had white paint splotches and paint chipped off the bedroom walls near the door. Rooms #402, #403, #404, #405, #406, #407, #408, #411, #412 and #414 did not have any hand towels available in the rooms or bathrooms. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 1/13/26 at 10:22 a.m. LPN #1 said each room should have hand towels for the residents to use. She said the hand towels were kept in the shower room on the secured unit, however when she went to look for them, the hand towels were not stocked. She said the night shift was to restock the linens and pass out towels to each room. Certified nurse aide (CNA) #1 was interviewed on 1/13/26 at 10:25 a.m. CNA #1 said the night shift was responsible for passing out clean hand towels to each room and stocking the cart in the shower room with linens. He said if the night shift did not replace the hand towels the day shift was responsible for providing the hand towels, but this may not happen until later in the day.-However, observations made on the secured unit on 1/11/26, 1/12/26 and 1/13/26 revealed there were no hand towels delivered to any rooms on those days. The MTD and the maintenance resource were interviewed together on 1/13/26 at 1:50 p.m. The MTD and the maintenance resource were shown the missing bathroom wall tiles in room [ROOM NUMBER]. The MTD said he was not aware of the missing tiles. He said all staff were trained to use the electronic communication system to report any needed repairs. He said the system generates a report and gets prioritized by the maintenance department. He and the MTD resource also said the maintenance department did monthly audit rounds on the nursing units to look for any areas that needed to be repaired or replaced. He said after these rounds the maintenance department generated an electronic communication system report for the areas of concern. The MTD said the white paint splotches in the bathrooms were probably from someone from his team who repaired holes in the wall and would be returning to repaint the wall. The MTD said he was not sure when the repairs in the wall were started. He said the walls should be repainted within a couple of hours of the patching. -However, the splotches on the wall were observed on 1/11/26, two days prior to the interview with the MTD. -The audit round logs for the secured unit were requested but were not provided by the survey exit on 1/14/26. The maintenance resource provided the October 2025, November 2025 and December 2025 electronic communication system maintenance reports, however, none of the above areas of concern were documented in the reports. CNA #1 was interviewed a second time on 1/13/26 at 2:03 p.m. CNA #1 said he was aware of the electronic communication system and had used it to report the missing bathroom tiles in room [ROOM NUMBER], however he was not sure how long it had been since he made the report. He said he did not report the broken blinds in the rooms because he thought someone would have seen they needed to be repaired. The NHA was interviewed on 1/14/26 at 10:10 a.m. The NHA was shown the broken and missing slats on the window blinds in room [ROOM NUMBER]. He said the facility had replaced a few blinds but the residents broke them when they wanted to look out the windows because the residents did not know how to operate the blinds. He said the facility was looking for alternatives for window coverings. The NHA was interviewed a second time on 1/14/26 at 10:40 a.m. The NHA said the maintenance department was measuring the windows in the residents' rooms on the secured unit to replace the broken blinds and in the common area (during the survey). He said the blinds needed to be ordered because of the window size.The NHA and the maintenance resource were interviewed together on 1/14/26 at 2:39 p.m. The NHA and MTD resource said the window blinds in rooms #402 and #403 were replaced, the ceiling light at the end of the hall was fixed and was no longer flickering and the ceiling fixtures on the secured unit were cleaned out. The NHA and the maintenance resource said metal corner guards were applied to the walls near the nurses' station on the secured unit and the entrance to the common area. They said rooms #407 and #408 had the bathroom light bulbs replaced and the walls with the missing tiles in room [ROOM NUMBER] had been repaired.-However, all of the maintenance repairs were started during the survey, after the facility became aware of the maintenance concerns.

Based on record review and interviews, the facility failed to ensure one (#3) of two residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 43 sample residents. Specifically, the facility failed to ensure Resident #3, who expressed suicidal ideations, was provided psychosocial support.Findings include:I. Resident #3A. Resident statusResident #3, age [AGE], was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included amputation of the right leg above the knee, ostomy (a surgical procedure that creates an opening (stoma) in the abdomen, rerouting urine or stool from the digestive or urinary tract to exit the body into a collection pouch), chronic obstructive pulmonary disease and chronic viral hepatitis C.The 10/8/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The mood assessment revealed the resident expressed felt down, depressed, and hopeless. B. Resident observation and interviewResident #3 was interviewed on 1/12/26 at 1:45 p.m. in his room. Resident #3 said he had been at the facility for almost a year. Resident #3 said he used to receive occupational and physical therapy to get stronger but he was no longer receiving therapy. He said the staff would sometimes assist him out of his bed and into his wheelchair but then the staff just sat him in front of his television. Resident #3 said that all of his personal items were in storage and he could not reach his prior roommate to obtain any of his belongings. He said he did not want to live in the facility but no one was helping him to leave. He said he had been very depressed about not being able to leave and he had lost weight because he had lost interest in eating due to his depression. Resident #3 said he wanted to discharge home or to another facility, such as an assisted living facility, and he did not understand why the facility had given up trying to find him alternative living options. Resident #3 said he often thought about killing himself but did not have the ability, however he said he would do it if he could find a way. He said sometimes he thought about overdosing or obtaining a gun he hoped was in his stored belongings. He said he had not received any visits from a psychologist for his depression or his struggle to adjust to facility placement. C. Record reviewThe discharge care plan, revised 4/30/24, revealed Resident #3 would be staying at the facility for long-term care. Interventions, initiated 3/2/24, included establishing a pre-discharge plan with the resident, family/caregivers and evaluating the resident's progress and revising the care plan as needed.The mood care plan, initiated 11/6/24, revealed the resident had the potential for mood problems related to his disease process. The resident would at times state he wished he was dead. Interventions, initiated 11/6/24, included providing behavioral health consultants as needed and monitoring mood patterns of depression, anxiety or sad mood.-The mood care plan failed to reveal any updates after Resident #3's 10/14/25 suicide lethality assessment (see assessment below). The trauma care plan, revised 12/3/25, revealed Resident #3 was at risk for re-traumatization related to a history of trauma, grief and loss. The resident was especially sad around the holidays and wished to be back in his home. The resident's sister recently passed away. Interventions, initiated 12/3/25, included providing extra emotional support during the holidays and documentation of behaviors, and the resident's response to interventions.The January 2026 CPO revealed the following physician's orders:Refer to behavioral health for psychiatric and psychological evaluation and treatment as indicated, ordered on 10/17/24.-The CPO failed to reveal any monitoring for signs of depression, anxiety, sad mood, or suicidal ideations (see mood care plan above). Review of Resident #3's electronic medical record (EMR) from 10/1/25 through 1/12/26 revealed the following:A social services note, dated 10/13/25, revealed the resident expressed to the social worker that he missed being at home. A suicide lethality assessment, dated 10/14/25, revealed Resident #3 had expressed feeling bad about not being able to go home without a plan and was placed on 15-minute safety checks. A nursing condition note, dated 10/15/25, revealed the resident was noted to be depressed about his health.A social services note, dated 12/1/25, revealed Resident #3 expressed to the social worker that he was not feeling well after being informed that his sister had passed away.-There was no documentation in the resident's EMR to indicate the resident was offered behavioral health services to address the resident's feelings regarding his sister's passing. A social services quarterly note, dated 12/3/25, revealed the resident's older sister passed away, and he was very distraught. The resident had been seen by behavioral health in the past but currently was not being seen.-There was no documentation in the resident's EMR to indicate the resident was offered behavioral health services to address the resident's feelings regarding his sister's passing, despite the resident voicing that he was very distraught. A weight summary, dated 12/3/25, revealed the resident's weight was 161.4 pounds (lbs).A weight summary, dated 12/16/25, revealed the resident's weight was 159.9 lbs.A weight summary, dated 12/31/25, revealed the resident's weight was 153.4 lbs.-There was no documentation to indicate the resident's lack of appetite had been addressed to see if the resident was not eating due to depression (see staff interviews below). -Despite the physician's order to refer Resident #3 to behavioral health for psychiatric and psychological evaluation and treatment as indicated (see physician's orders above), the resident's EMR failed to reveal psychological services had been provided to the resident.II. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 1/13/26 at 11:06 a.m. CNA #5 said Resident #3 refused care and sometimes he would not eat very much of his food or any at all. CNA #5 said she was not instructed to monitor him for depression or suicidal ideations and she was not aware he had a history of thoughts of self harm. Registered nurse (RN) #1 was interviewed on 1/13/26 at 11:18 a.m. RN #1 said Resident #3 had multiple forms of cancer and had told her that he knew he would die. She said he did not want to eat anything, had no appetite and only wanted to smoke and drink soda. RN #1 said she was the one who had to tell the resident that his older sister died in a car accident last month (December 2025) and he was devastated. She said he told her he was now completely alone and had nothing to live for. RN #1 said sometimes he verbally expressed not wanting to live anymore and sometimes his depression was displayed as refusals or verbal aggression. She said when Resident #3 expressed suicidal ideations, the staff would put him on 15-minute checks. She said there was no current monitoring for his suicidal ideations. -However, per CNA #5, she was not aware the resident had a history of self harm or that he was supposed to be monitored for depression or suicidal ideation (see interview above).The social services director (SSD) and the social services assistant (SSA) were interviewed together on 1/13/26 at 3:32 p.m. The SSA said Resident #3 did not have a discharge plan back into the community because he was unable to care for himself and did not have anyone to assist him in his apartment. She said physical and occupational therapy were discontinued because he was unable to make progress. The SSA said she talked with Resident #3 every few months regarding his desire to discharge and his inability to do so, but she said he continued to want to leave the facility. The SSA said the suicide lethality assessment completed on 10/14/25 (see record review above) was completed after Resident #3 made statements about wanting to overdose on his medications, however there was no means for him to obtain enough medication from the nurse to overdose and the staff watched the residents take their medications.The SSD said the psychologist provider the facility used had been seeing Resident #3 previously when he expressed suicidal ideations in November 2024. However, the SSD said when she researched (during the survey) why he was no longer being seen, she was informed there had been an issue with the resident's insurance but the facility had not followed up on this loss of services in 2024. The SSD did not know why there had not been any follow up. III. Facility follow-upThe nursing home administrator (NHA) sent an email on 1/15/26 at 4:39 p.m. which included a timeline the facility had created documenting Resident #3's history. It revealed the following;Resident #3 had been admitted to the facility on [DATE] for short term rehabilitation with the goal to return home after being hospitalized and having his right leg amputated above the knee. The resident's therapy stopped on 5/14/24 and it was recommended he stay in the facility for long term care, however he wanted to return home. A discharge plan was established with home healthcare services, but when the ambulance arrived to transport Resident #3 home the ambulance staff refused to transport him for safety reasons and he had to remain in the facility. After this, the resident began displaying behaviors of using drugs, perseverating on his condition, and being sexually inappropriate towards staff. On 10/17/24, Resident #3 began seeing the behavioral health provider, but only saw the mental health provider a total of three times and therapy ended on 12/10/24. The timeline concluded by documenting Resident #3 was not seen by a mental health provider in 2025 due to insurance coverage.

Based on observations, record review and interviews, the facility failed to provide one (#94) resident of five sample residents with a nourishing, palatable and well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences out of 43 sample residents. Specifically, failed to provide Resident #94 a nourishing, well-balanced diet that met his daily nutritional dietary needs, taking into consideration the resident's vegan preferences.Findings include:I. Resident #94A. Resident statusResident #94, age [AGE], was admitted to the facility on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included displace fracture of shaft of humerus on left arm, obsessive-compulsive disorder (OCD), disease of digestive system and unspecified protein-calorie malnutrition.The 12/30/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. He required set up assistance with eating. B. Record reviewA review of the January 2026 physician`s order revealed the resident was prescribed a regular diet, regular texture, thin liquids consistency and preferred a vegan diet. The physician`s order indicated for staff to honor resident rights to make personal dietary choices and provide dietary education as needed.A review of the weekly menu revealed that there was no available vegan menu developed by a registered dietitian (RD). Review of the alternative food item menu revealed the facility had highlighted or hand written additions that were considered vegan.Resident #94's nutrition care plan, dated 12/24/25, revealed he consumed a regular diet, regular texture, thin liquids consistency and preferred a vegan diet. The nutrition assessment, dated 12/30/25, revealed that Resident #94`s estimated nutritional need was 1614 to 1935 calories per day, 65 to 77 grams protein per day, and 1614 to 1935 ml fluid per day. -However, there was no documentation that indicated the facility assessed his current menu to see if it was providing adequate nutrition. C. Resident interview and observationResident #94 was interviewed on 1/13/26 at 12:05 p.m. The resident said he had been a strict vegan for many years. He said he ate plain boiled or steamed vegetables, beans and grains. He said he did not use any animal products or vegetable oils. He said it was important to him that salt and other spices were not added to his food. Resident #94 said the facility tried to provide foods per his preference initially, however the food always came either with added salt or oil. He said the only meal he was able to eat at the facility was breakfast that consisted of apple sauce, almond milk and oatmeal. He said his sister brought him food every day for lunch and ate the leftovers for dinner.During the interview, the resident had six 12 ounce deli containers in front of him. The containers had the following foods: chopped avocado, steamed broccoli, boiled [NAME], steamed squash, boiled potatoes and cooked beans. The resident was eating from deli containers. He said he would eat some for lunch and kept the remaining in the ice box. He said he would finish the remaining food for dinner.D. Family interviewThe resident's sister was interviewed on 1/13/26 at 12:05 p.m. She said she was responsible for bringing food daily to the facility for the resident and that put a significant strain on her life. She said her brother previously stayed in other medical facilities that were able to accommodate his diet. She said she was bringing food daily out of fear that he would lose weight as he already was under weight and prolong his stay at the facility. II. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 1/14/26 at 10:34 a.m. She said Resident #94 was on a vegan diet. She said the resident did not like refined sugar, meat or processed food. CNA #6 said the resident only ate breakfast at the facility which was usually applesauce, almond milk and oatmeal. She said Resident #94`s sister brought lunch and dinner for Resident #94. She said the facility offered string cheese and yoghurt for a snack, but he refused. She said the facility had fruits to offer for snacks for vegans. She said Resident #94 would not eat fruit because it was high in sugar. She said Resident #94 would occasionally eat raw carrots. She said Resident #94`s sister usually brought five bowls of different food items daily for lunch and dinner. She said the staff just gauged his intake by percent and tracked that information. Licensed practical nurse (LPN) #2 was interviewed on 1/14/25 10:25 a.m. She said she was not sure if the resident ate meat or dairy. She said Resident #94`s sister brought food into the facility daily for him. She said Resident #94 had anxiety and OCD, so he was very particular about his meals. The dietary manager (DM) was interviewed on 1/14/26 at 10:49 a.m. She said the facility`s vegan menu was created by the dietary software. She said she would provide a copy of the vegan menu.-However, documentation indicating the facility ensure the resident was provided with a nourishing, well-balanced diet that took into consideration Resident #94's dietary preferences were not provided. The regional dietary consultant and the RD were interviewed together on 1/14/26 at 4:30 p.m. The regional dietary consultant said that the facility did not have daily menus for residents who were on vegan diets. She provided a document titled alternate food item menu with highlighted vegetarian items. She said Resident #94 could choose his meals from this list. She said this list was provided to him upon admission. She said this was the menu that CNAs were to follow when offering a resident his meal. -The vegetarian diet print out did not have extensions with serving size, ingredients or calculated nutritional value of meals.The RD said she did not have a vegan menu for the Resident #94 that included the calculations of nutritional value of his meals to ensure he met his estimated nutritional needs. She said she was in the facility on 1/13/26 during the lunch time, but she did not know what the resident ate for lunch or dinner. She said the family brought all the meals for the resident except for breakfast. III. Facility follow-upThe facility provided a letter on 1/14/26 at 4:29 p.m. that documented the facility indicated the resident chose to follow a vegan diet. The letter indicated a vegan diet was not a therapeutic diet to address a disease state and rather a preference. The letter documented the facility should honor this preference by offering appropriate alternative food substitutions within the standard menu framework. The letter documented all substitutions provided to accommodate a vegan preference should be reviewed by the director of food and nutrition services to ensure appropriateness, nutritional adequacy and alignment with facility standards. The letter documented the resident's preference should be documented and communicated to dietary and nursing staff, with ongoing monitoring to ensure satisfaction and nutritional status are maintained.-However, the facility failed to ensure the resident's nutritional needs were assessed based on his dietary preferences.

Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of disease, including COVID-19 in one of four shower rooms and one resident room.Specifically, the facility failed to:-Ensure the sharps container in the 600 hallway shower room was not overfilled;-Ensure staff members wore the appropriate personal protective equipment (PPE) when entering Resident #68's room, who was COVID-19 positive; and,-Ensure visitors were encouraged to wear N-95 masks when entering a COVID-19 positive resident room.Findings include:I. Sharps container failureA. Facility policy and procedureThe Sharps Disposal Infection Control policy, revised April 2020, was provided by the nursing home administrator (NHA) on 1/14/26 at 1:55 p.m. It read in pertinent part, It is the policy of this facility to discard contaminated sharps into designated containers. During use, containers for contaminated sharps will be sealed and replaced when they are 75-80 percent (%) full to protect employees from punctures and/or needle sticks when attempting to push sharps into the container. Incorrect disposal or handling of contaminated sharps should be reported to the infection control designee.B. ObservationOn 1/12/26 at 9:19 a.m. the sharps container in the 600 hallway shower room was overflowing with used razors. Additional used razors were sitting on top of a cabinet which was beneath the sharps container as a result of the container being too full.C. Staff interviewsCertified nurse aide (CNA) #6 and licensed practical nurse (LPN) #2 were interviewed on 1/14/26 at 12:45 p.m. LPN #2 said the nurses were responsible for managing their own sharps containers, and not emptying the containers timely imposed the risk of needle sticks or punctures and the transmission of bloodborne pathogens.LPN #5 was interviewed on 1/14/26 at 12:54 p.m. LPN #5 said Resident #99 told her the sharps container was full one week ago, and she meant to change it sooner but she got busy. She said she switched the full sharps container for an empty one on 1/12/26 (during the survey). LPN #5 said the nurses were responsible for managing the sharps containers, and she did not know if housekeeping had access to the key to unlock the sharps containers. She said an overflowing sharps container would increase the risk of pokes or pricks and transmission of bloodborne infections.LPN #4 was interviewed on 1/14/26 at 12:56 p.m. LPN #4 said he had never come on shift to a full sharps container, but if it were full he would have emptied it right away. He said the nurses had the keys to the sharps containers and were responsible for emptying and managing the containers. LPN #4 said the risk of not emptying the container timely could lead to pokes and cause infections, such as Hepatitis A or Human immunodeficiency virus (HIV)/Acquired immunodeficiency syndrome (AIDS).The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 1/14/26 at 1:05 p.m. The IP said the nurses were responsible for managing the sharps containers and were expected to lock the container before placing them in the biohazard room and replacing the container with an empty one. She said it was important to empty the containers timely in order to prevent needle sticks.II. Personal protective equipment (PPE) failuresA. Facility policy and procedureThe Personal Protective Equipment (PPE) policy, revised August 2025, was provided by the NHA on 1/14/26 at 1:55 p.m. It read in pertinent part, This facility promotes appropriate use of PPE to prevent the transmission of pathogens to residents, visitors and other staff.All staff who have contact with residents and/or their environments must wear PPE as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely.Respiratory protection: wear a National Institute for Occupational Safety and Health (NIOSH)-approved N95 or higher-level respirator to prevent inhalation of pathogens transmitted by the airborne route.B. ObservationsDuring a continuous observation on 1/13/26, beginning at 11:15 a.m. and ending at 12:42 p.m., the following was observed:At 12:19 p.m. CNA #7 approached Resident #68's (who was COVID-19 positive) room. CNA #7 was wearing a surgical mask over her nose and mouth, and donned gloves, a gown and goggles prior to entering the resident's room.While CNA #7 donned her PPE, three visitors arrived to visit a resident in the COVID positive room. Before they entered, they put on gloves and surgical masks over their nose and mouths. Staff members in the hallway nearby did not intervene or encourage N95 mask use. CNA #7 entered the room with the visitors, all wearing surgical masks.-No staff members encouraged the visitors to put on a N95 mask prior to entering the COVID-19 positive room.Upon exiting the room, CNA #7 doffed the goggles, gown, and gloves and changed her surgical mask.-However, CNA #7 failed to don a N95 mask prior to entering Resident #68's COVID-19 positive room.At 12:37 p.m. CNA #8 approached Resident #68's COVID-19 positive room wearing a surgical mask over her nose and mouth, and asked if she had to gown-up to enter the room. She was advised by an unidentified staff member to wear a mask and gloves, but it was okay if she did not wear goggles since there were no goggles in the PPE cart by the COVID-19 positive room. CNA #8 donned a N95 mask (over her surgical mask), a gown and gloves. Before she entered the room, she walked down the hallway to another PPE cart and donned goggles.-CNA #8 failed to remove her surgical mask prior to donning an N95 mask and before she entered a COVID-19 positive resident room.C. Staff interviewsCNA #7 was interviewed on 1/13/26 at 12:42 p.m. CNA #7 said as far as she was aware, the facility's PPE policy for providing care in COVID-19 positive rooms was as long as you were masked up you were okay. She said she did not know if it was necessary to put on a N95 mask when entering a COVID-19 positive room.LPN #5 and registered nurse (RN) #1 were interviewed together on 1/13/26 at 4:04 p.m. RN #1 said the nursing staff were educated to perform hand hygiene with sanitizer and to wear a mask, gloves, goggles and gown when providing care in COVID-19 positive resident rooms. Both RN #1 and LPN #5 said a N95 mask should be worn in a COVID-19 positive room. LPN #5 said there was a physician's order that notified the staff of the PPE that was required when entering the resident's room.The DON and the IP were interviewed together on 1/14/26 at 1:05 p.m. The IP said a resident with COVID-19 would receive a physician's order for contact/droplet precautions so that all staff members know which pieces of PPE were appropriate. She said the appropriate pieces of PPE, when to wear the PPE and how to put on and take off the PPE was found on the resident's door. The IP said a N95 mask should be worn in a COVID-19 positive resident room, even if direct patient care was not to be provided at that time. She said a surgical mask should not be worn beneath the N95 mask, and wearing the incorrect PPE, or incorrectly wearing PPE, could cause the staff member to get sick with or spread COVID-19.The IP said the nursing team notified her about the visitors that entered the COVID-19 positive room wearing surgical masks, rather than N95 masks. She said she had not spoken with the family about their masking preferences, and had not asked if the nurses had inquired with the visitors about their masking preferences.

Based on observations, record review 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 disease. Specifically, the facility failed to: -Follow transmission-based precautions when entering and exiting droplet precaution rooms; and, -Ensure vital signs machines were sanitized between each use to prevent the spread of infection. Findings include: I. Failure to follow transmission-based precautions when entering and exiting droplet precautions rooms A. Professional reference The Centers for Disease Control and Prevention (CDC) Viral Respiratory Pathogens Toolkit for Nursing Homes, revised 1/8/25, was retrieved on 3/10/25 from https://www.cdc.gov/long-term-care-facilities/hcp/respiratory-virus-toolkit/index.html#:~:text=HCP%20who%20enter%20the%20room,i.e.%2C%20goggles%20or%20a%20face. It revealed in pertinent part, HCP (healthcare personnel) who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved (National Institute for Occupational Safety and Health) particulate respirator with N95 filters or higher, gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face). This PPE can be adjusted once the cause of the infection is identified. B. Facility policy and procedure The Infection Control policy, last updated October 2022, was provided by the nursing home administrator (NHA) on 3/6/2025 at 6:56 p.m. It read in pertinent part, Transmission-based precautions are the second tier of basic infection control and used in addition to Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status and include proper selection and use of PPE (gowns, gloves, facemasks, respirators, and eye protection) based on predictive interactions between staff and resident and the potential for blood, body fluids or pathogens, hand hygiene, safe injection practices, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and reprocessing of reusable medical equipment. Droplet precautions are used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking (this includes influenza and COVID-19). Precautions include implementing source control by placing a mask on the patient, ensure appropriate patient placement in a single room if possible (in long term care make decisions on a case-by-case basis considering infection risks to other patients in the room and available alternatives), use PPE appropriately (don mask, and eye protection if indicated, upon entry into the patient room or patient space), and limit transport and movement of patients outside of the room for medical purposes (if necessary, instruct the resident to wear a mask and use proper respiratory hygiene and cough etiquette). Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. C. Observations During a continuous observation on 3/3/25, beginning at 9:35 a.m. and ending at 10:30 a.m. the following was observed: At 9:35 a.m. licensed practical nurse (LPN) #1 donned (put on) a gown, eye protection and gloves before entering room [ROOM NUMBER] to administer medications. There was a sign that indicated the resident in room [ROOM NUMBER] was on droplet precautions and a personal protective equipment (PPE) bin outside the door. She was wearing a N95 mask. At 9:40 a.m. LPN #1 exited room [ROOM NUMBER] with her gown, gloves, and mask on.She no longer had her eye protection or gloves on. She washed her hands in the common area then went to her medication cart where she doffed (removed) her gown and placed it in the overflowing medication cart trash bin. She then performed hand hygiene. She did not remove her N95 when she then began gathering and administering medications for other residents who were not COVID-19 positive. At 10:23 a.m. certified nursing assistant (CNA) #1 stood outside of resident toom #506. There was a sign on the door that indicated the resident was on droplet precautions. CNA #1 donned a gown and gloves. She removed her surgical mask and placed it on the PPE bin outside the door and put on a N95 mask. CNA #1 did not put on a face shield or goggles prior to entering the room. At 10:26 a.m. while in resident room [ROOM NUMBER], CNA #1 opened the door, removed her gloves, gown and mask while still in the room and put them in a trash bin in the room. The resident in the room had a productive cough (cough that produces mucous). She performed hand hygiene, exited the room and put the surgical mask that she had placed on the PPE bin back on. At 10:25 a.m. an unidentified nurse practitioner (NP) entered room [ROOM NUMBER] after applying a gown and gloves. The NP put an N95 on over her surgical mask. She did not apply eye protection. At 1:18 p.m. CNA #2 applied a gown and gloves before entering room [ROOM NUMBER] (a droplet precautions room). She did not apply eye protection and kept her surgical mask on. She performed hand hygiene and exited the room. She continued wearing the same surgical mask. B. Staff interviews LPN #1 was interviewed on 3/3/25 at 10:10 a.m. LPN #1 said that after she exited room [ROOM NUMBER], she did not remove her gown while in the room because there was not a separate receptacle in the room for PPE. She said she did not want to throw it in the trash bin near the resident so she chose to throw it in the medication cart trash. LPN #1 said that, when doffing PPE, she was taught to remove her gloves, eye protection or face shield and gown in the room and the N95 mask once she exited the room. She said she would ensure a PPE trash receptacle would be available for dirty PPE in the resident's room. CNA #2 was interviewed on 3/3/25 at 1:20 p.m. CNA #2 said, to prevent the transmission of infection, all PPE was applied before entering a droplet precaution room and removed before leaving the room except for her mask. She said the mask was removed outside of the room. -However, she did not apply a mask when entering and exiting a droplet precaution room (see observations above). The director of nursing (DON) was interviewed on 3/3/25 at 2:44 p.m. The DON said the staff were expected to don PPE before they entered an isolation room. The DON said if a resident was on droplet precautions , the staff were expected to don a N95 mask, face shield or goggles, gown and gloves. She said that before they exited the room, they were expected to take off their PPE in no particular order. She said the staff needed to ensure it was removed immediately after performing care, except the N95 mask which should remain on until they exit the room. The DON said she provided LPN #1 education today (3/3/25) regarding donning and doffing PPE for droplet precautions. The DON said LPN #1 said she was nervous and did not want to get in trouble taking the used gown out with the resident's trash so she chose to remove it when at the medication cart. The DON said the staff should throw away the N95 once they exited a droplet precaution room. The DON said when COVID-19 first emerged masks were being reused due to supply shortages. She said an inservice was held last week about PPE use. She said the staff were told that there was enough supplies to not have to reuse any of it. The DON said that staff should not apply N95s over surgical masks because it did not provide an adequate seal to protect the mouth and nares. She said she would provide the NP with training. II. Failure to clean vital sign machines between uses A. Professional reference According to the CDC Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last updated September 2024, retrieved on 3/10/25 from https://www.cdc.gov/infection-control/hcp/isolation-precautions/index.html It revealed in pertinent part, Noncritical equipment (including medical equipment used on residents'skin but not exposed to the bloodstream or other orifices) must be thoroughly cleaned and disinfected before use on another patient. All such equipment and devices should be handled in a manner that will prevent healthcare workers (HCW) and environmental contact with potentially infectious material. In all healthcare settings, providing patients who are on Transmission-Based Precautions with dedicated noncritical medical equipment has been beneficial for preventing transmission. When this is not possible, disinfection after use is recommended. According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, revised 12/7/23, retrieved on 3/10/25 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html. It revealed in pertinent part, Perform low-level disinfection for noncritical patient-care equipment that touch intact skin. Disinfect noncritical medical devices with an environmental protection agency (EPA)-registered hospital disinfectant using the label's safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. However, multiple scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least one minute. By law, all applicable label instructions on EPA-registered products must be followed. Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). B. Facility policy and procedure The Cleaning and Disinfection of Resident Care Equipment policy, revised in December 2024, was provided by the NHA on 3/6/25 at 6:56 p.m. It read in pertinent part, It is the policy of the facility that when staff is utilizing equipment for resident care to clean and disinfect resident care equipment, such as vital signs equipment, in between each resident use. Only approved cleaning products may be used and cleaning products manufacturers' recommendations will be followed in the cleaning and disinfection of equipment. Preferred cleaning methods available include Bleach wipes and Sani wipes. Please follow manufacturers' recommendations on dwell times for each wipe. To disinfect, if needed, use a properly mixed approved disinfectant and a clean cloth, wiping all surfaces. C. Observations and interviews At 12:20 p.m. CNA #1 was walking out of room [ROOM NUMBER] with the vital signs machine. CNA #1 then entered room [ROOM NUMBER] with the same vital signs machine.When she exited the room, she said she wiped the machine down with an alcohol wipe. -CNA #1 failed to wipe down the vital sign machine with the correct sanitizing wipes between room [ROOM NUMBER] and room [ROOM NUMBER] (see professional reference above). D. Staff interviews CNA #1 was interviewed on 3/3/25 at 12:22 p.m. CNA #1 said when she entered room [ROOM NUMBER], after leaving room [ROOM NUMBER], she used alcohol wipes while in room [ROOM NUMBER] to wipe down the vitals machine while in the room. CNA #1 said she wiped down the vital sign machine with alcohol wipes after exiting and before entering each room to obtain vital signs. The DON was interviewed on 3/3/25 at 2:44 p.m. She said that the 2-inch by 2-inch alcohol wipes available at medication carts and alcohol-based hand rubs were ineffective in cleaning medical equipment. She said the sanitizing wipes labeled sani-wipes were the appropriate and preferred sterilization method used to wipe down vital sign machines between each use.

Based on observations, record review and interviews, the facility failed to ensure one (#9) of three residents received treatment and care in accordance with professional standards of practice out of 12 sample residents. Specifically, the facility failed to: -Ensure the emergency crash cart containing essential resuscitation equipment and a backboard was utilized during a resuscitation attempt for Resident #9; -Ensure a timely call was placed to emergency medical services (EMS) for immediate assistance when Resident #9 experienced a life threatening change of condition; and, -Ensure a licensed nurse remained with Resident #9 until EMS arrived. Findings include: I. Professional reference According to the American Heart Association (AHA), (2020). Basic Life Support Provider Manual eBook, retrieved from https://ebooks.heart.org on [DATE] at 12:15 p.m, The two key components of cardiopulmonary resuscitation (CPR) are chest compressions and breaths. High quality CPR improves a victim's chances of survival. Immediate activation of the emergency response system, early high-quality CPR, and rapid defibrillation are essential. In the workplace, every employee should know how to activate the emergency response system in their setting. A high performance team, three emergency responders who are called to assist in cardiac arrest will perform multi-rescuer coordinated CPR: rescuer one performs chest compression, rescuer two gives breaths with a bag-mask device, rescuer three uses the automated external defibrillator (AED). Rescuer three also assumes the role of CPR coach. The coach helps team members perform high quality CPR and minimize pauses in chest compressions If the victim is not breathing normally or is only gasping and has no pulse, begin high quality CPR. Start cycles of CPR with 30 chest compressions followed by two breaths. Position the victim face up on a firm, flat surface, such as the floor or a backboard. This will help ensure that the chest compressions are as effective as possible. If the victim is on a soft surface, such as a mattress, the force from the chest compressions will simply push the victim's body into the soft surface. A firm surface allows compression of the chest and the heart to create adequate blood flow. For breaths to be effective, the victim's airway must be open. Two methods (for opening the airway): head tilt/chin lift and jaw thrust. Use a bag-mask device if available to provide positive pressure ventilation to victim who is either not breathing or not breathing normally. Because every second matters during a resuscitation attempt, it is important to define clear roles and responsibilities as soon as possible. II. Facility policy and procedure The Emergency Procedures, Cardiopulmonary Resuscitation (CPR) policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 1:42 p.m. It read in pertinent part, It is the policy of this facility to provide basic life support (BLS), including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel. Only staff members with current CPR certification for Healthcare Providers should perform the procedure. If unresponsive, not breathing (occasional gasps are not breathing) and no pulse, activate the EMS system. Page or yell loudly Code Blue to the area. Call 911. Position the resident face-up on a firm, flat surface. Start chest compressions. Open airway (tilt head back and lift the chin up), give two rescue breaths. May use a bag valve mask (BVM) or Ambu bag (a hand held device used to provide ventilation to someone who is not breathing) to give rescue breaths. Continue cycles of 30 chest compressions to two rescue breaths. III. Resident #9 A. Resident status Resident #9, age 82, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included respiratory failure, dementia, Parkinson's disease (disorder of the central nervous system that affects movement) and dysphagia (difficulty swallowing). The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He required partial assistance with eating, hygiene and dressing. He required substantial assistance with transferring. The MDS assessment indicated he had loss of liquids/foods from his mouth when eating, held food in his mouth/cheeks or had residual food in his mouth after meals and had complaints of difficulty swallowing. B. Observations The [NAME] hallway unit emergency crash cart was observed with the director of nursing (DON) on [DATE] at 9:40 a.m. A bag-mask device and airway supplies (including suction) were present on the cart. Two backboards were present next to the cart. -However, interviews during the survey revealed the supplies observed on the emergency crash cart on [DATE] were not utilized in the attempt to resuscitate Resident #9 on [DATE] (see interviews below). C. Record review A nursing progress note documented on [DATE] at 1:40 p.m. revealed Resident #9 had a change of condition which included nausea, vomiting, abnormal vital signs and shortness of breath. The nursing note revealed a report was provided to the primary care physician (PCP) at 1:50 p.m. The nursing note documented an emergency call was made to 911. -The progress note did not indicate what time 911 was called. -A review of the electronic medical record did not reveal any further documentation, details or timeline regarding the resuscitation/code of Resident #9. The Nurse Comprehensive Clinical Competency Review Skills Checklist was provided by the NHA on [DATE] at 9:49 a.m. The following items were included on the checklist: Ambu bag, this is used in an emergent situation. Attach 15 liters (of oxygen) per minute to the ambu bag. Suctioning and airway management. Oral suctioning, trach suctioning, and deep suctioning (RN only). The Emergency Crash Cart Daily Check Log was provided by the NHA on [DATE] at 11:35 a.m. Review of the daily check log revealed documentation indicating the following items were present on the [NAME] hallway crash cart on [DATE]: -Suction machine (and documentation that it worked properly); -Suction kit; -Ambu Bag (bag/mask device); -Rebreather mask; and, -Oxygen mask. -However, none of the supplies present on the emergency crash cart on [DATE] were utilized in the attempt to resuscitate Resident #9 (see interviews below). IV. Staff interviews. Registered nurse (RN) #1 was interviewed on [DATE] at 2:01 p.m. RN #1 said she was Resident #9's nurse on [DATE]. She said after lunch on [DATE], Resident #9 called for assistance with positioning. RN #1 said she and certified nurses aide (CNA) #1 assisted the resident with positioning. She said Resident #9 asked for a drink of water which was thickened per the dietary department. RN #1 said all of the liquids on the resident's bedside table were thickened. RN #1 said Resident #9's condition deteriorated after he drank the liquids. She said he began having difficulty breathing and his color was blue. RN #1 said she yelled out for staff to call 911. She said CNA #2 came into the room and the staff checked Resident #9's vital signs (heart rate, respiratory rate, oxygen saturation and blood pressure). RN #1 said Resident #9's oxygen saturation (oxygen level in the blood) was less than 85% and it was difficult to obtain other vital signs. RN #1 said she went to the door of the room and asked if anyone had called 911. RN #1 said there was no response from other staff. RN #1 said she left the room to call 911 since there was no response from other staff. She said Resident #9's color was blue when she left the room. -RN #1 failed to delegate CNA #1 or CNA #2, who were in Resident #9's room with her, to go call 911 while she remained with the resident. RN #1 said while she was calling 911, CNA #2 had started chest compressions. RN #1 said she did not know when Resident #9 stopped breathing or when his pulse stopped. RN #1 said the director of rehabilitation (DOR) was doing chest compressions when she returned to the room. RN #1 said she had a current Basic Life Support (BLS) for Healthcare Providers certification. -CNA #2 was unavailable for an interview during the survey. CNA #1 was interviewed on [DATE] at 2:16 p.m. CNA #1 said CNA #2 completed chest compressions on Resident #9. She said Resident #9 was turned to his side when he began vomiting with chest compressions. She said she never saw the emergency crash cart in or near the room. CNA #1 said, during the resuscitation, she never saw staff use a bag-mask device for providing breathing assistance for Resident #9. CNA #1 said there was not a backboard underneath Resident #9 during compressions. She said someone came in the room with an AED between two to four minutes after RN #1 called for help. The DOR was interviewed on [DATE] at 2:57 p.m. The DOR said she when she was informed Resident #9 was coding she brought the AED to the room. The DOR said when she arrived to Resident #9's room, CNA #2 was providing chest compressions and the resident was vomiting. The DOR said she used the AED for two cycles and provided chest compressions between cycles. She said the staff in Resident #9's room at the time did not ask for the emergency crash cart. The DOR said RN #1 was out of the room calling 911 when she arrived with the AED. The DOR said she did not know if anyone had suctioned Resident #9. The DOR said she had a current BLS for Healthcare Providers certification. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 3:19 p.m. LPN #1 said she arrived to the resident's room shortly after the DOR arrived. She said there was not a backboard under Resident #9 when the facility staff was performing CPR on Resident #9. LPN #1 said she asked for a non-rebreather mask and she thought staff were bringing the emergency crash cart to the room when the paramedics arrived. LPN #1 said EMS immediately put Resident #9 on the floor when they arrived. She said the paramedics intubated (insertion of a tube into a person's airway to enable oxygen to get through) the resident and used the AED several more times to shock the resident's heart. LPN #1 said the facility staff were aware of Resident #9's code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) and desire to be a full code, which included CPR. The DON was interviewed on [DATE] at 9:00 a.m. The DON said there was not a root cause analysis or investigation done after the unexpected death of Resident #9 at the facility. The DON said she was not at the facility during the resuscitation attempt of Resident #9. She said she received a text from CNA #4 which revealed Resident #9 was coding. She said she called CNA #4 and was told resuscitation attempts were still ongoing by staff and EMS had not arrived at the facility yet. The DON said based, on her phone information, Resident #9 had coded at approximately 1:44 p.m., staff were still resuscitating the resident at 1:51 p.m and EMS had not arrived (at least seven minutes). She said she did not have a timeline of events during the code and staff should have documented the events as they occurred. The DON said residents should be placed on a hard surface during chest compressions. She said certified staff were expected to perform CPR based on the BLS for Healthcare Providers standards. The DON said there was a bag-mask device on the cart and staff should have asked for it. She said it would have been difficult to use, however, as several staff told her Resident #9 was vomiting much of the time during the code. The DON said all staff knew where the emergency crash cart was located and the DON had not been aware until the survey that the cart was not in the room prior to EMS arrival. The DON said CNA #2 told her she provided chest compressions but did not ventilate (use bag-mask device) or manage the airway of Resident #9. The DON said she provided a staff inservice in early [DATE] to review how to respond to a code. She said the education included the need for the nurse to stay in the room to lead the code and to delegate responsibilities to other staff, including delegation to an individual for the responsibility to call 911. She said she had not been tracking who had BLS for Healthcare Provider certification but would start tracking it. CNA #4 was interviewed on [DATE] at 10:36 a.m. CNA #4 said she sent a text message to the clinical team (nursing staff), which included the DON, when the code was in progress. CNA #4 said EMS was not yet in Resident #9's room when the DON called CNA #4. -Based upon the DON's and CNA #4's interviews, Resident #9 was coding for at least seven minutes prior to the arrival of the EMS team without using a backboard or having airway equipment in the room to be available for use. The CPR Instructor (CPRI) was interviewed on [DATE] at 11:55 a.m. The CPRI said if a resident did not have a pulse and was not breathing, she would expect the staff to initiate chest compressions. The CPRI said if a bag-mask device and suction were available, she would expect them to be used if needed. She said students were taught to be prepared for and manage emesis (vomiting) during a code. The CPRI said if the resident was not actively throwing up, the staff should provide positive-pressure ventilation with a bag-mask device if the airway was clear. The primary care provider (PCP) was interviewed on [DATE] at 3:15 p.m. The PCP said if Resident #9 had no pulse, chest compressions were indicated. She said she would have expected the staff to take care of the airway and provide ventilations whenever possible. The PCP said ideally there should have been an ambu bag (bag-mask device) at the bedside during resuscitation for use if needed. The PCP said she would have expected the staff to use a backboard if there was one available as it could make chest compressions more effective. The PCP said she did not think the outcome would have been different due to Resident #9's medically fragile state. The DON was interviewed again on [DATE] at 8:38 a.m. The DON said she was told the team was considering using the emergency crash cart supplies when the paramedics arrived. She said she would have expected resuscitation equipment to be available in the room as soon as possible after a code had begun to be able to be used if the airway was able to be cleared. The DOR was interviewed again on [DATE] at 9:00 a.m. She said Resident #9 was vomiting most of the time while she was present. She said she did not see airway supplies or the emergency crash cart in the room. V. Facility follow-up An In-Service Training Report titled CPR and dated [DATE] (during the survey) was provided by the NHA on [DATE] at 1:42 p.m. The training was conducted by the DON and included the following: -The resident's nurse should remain at the bedside with the resident throughout the code, or until the resident is transferred to the hospital. The nurse should delegate the following activities: - 911 call -retrieval and set up of the crash cart (obtaining and setting up the resuscitation equipment needed) -documentation and timeline of events during the code. The DON planned to utilize mock codes (scenarios to simulate a real emergency code) to provide additional learning opportunities to the staff.

Based on observations and interviews the facility failed to provide a comfortable and homelike environment for the residents on three of five units in the facility. Specifically, the facility failed to: -Residents were provided with clean washcloths and hand towels in their rooms on the West, Flatiron and North units; and, -Ensure holes in the residents' bathroom doors and ceiling were fixed. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, revised December 2020, was provided by the nursing home administrator (NHA) on 2/6/24 at 1:47 p.m. It read in pertinent part: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The facility will create and maintain, to the extent possible, a homelike environment that de -emphasizes the institutional character of the setting. The facility will provide and maintain bed and bath linens that are clean and in good condition. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment as the resident allows. II. Lack of washcloths and hand towels in resident rooms A. Observations On 1/31/24 beginning at approximately 8:40 a.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; and, -room [ROOM NUMBER] had no hand towels or washcloths. On 2/1/24 beginning at approximately 9:35 a.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; and, -room [ROOM NUMBER] had no hand towels or washcloths; On 2/5/24 beginning at approximately 3:12 p.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; and, -room [ROOM NUMBER] had no hand towels or washcloths; On 2/5/24 at 3:05 p.m., two linen supply closets were observed with certified nurse aide (CNA) #4. The observations revealed the following: -Flatiron hall linen supply closet contained some hand towels and no washcloths; -West hall linen supply closet contained only six washcloths, no bath towels and no hand towels; and, -The North Hall linen supply closet contained only two hand towels and five washcloths. B. Resident interviews The resident group interview was conducted on 2/1/24 at 11:00 a.m. The group consisted of six residents (#90, #162, #57, #59, #5, and #72) who were interviewable based on facility assessment. Resident #72, #90 and #59 said hand towels and washcloths were not delivered to their rooms unless they asked for them. All the other residents agreed. Resident #72 was interviewed on 2/5/24 at 9:14 a.m. Resident #72 said the facility did not have enough linen hand towels or washcloths. He said staff were too busy to bring hand towels and washcloths to the residents' rooms. Resident #72 said he had to keep asking staff repeatedly for the linens. He said he did not even have paper towels in place of a linen hand towel to dry his hands in his room. -There were no hand towels or washcloths observed in Resident #72's room during the resident's interview. Resident #32 was interviewed on 2/5/24 at 3:16 p.m. Resident #32 said the facility did not have enough hand towels or washcloths. Resident #32 said she did not like to use paper towels to dry her face but most of the time she had to because there were no hand towels in her room. Resident #32 said she had to yell before someone would get her washcloths and hand towels. She said linen hand towels and washcloths would make her room feel more comfortable. The resident said she used wet wipes to wash with because she did not often have a washcloth. -There were no hand towels or washcloths observed in Resident #32's room during the resident's interview. III. Holes in residents' bathroom doors and ceiling A. Observations On 1/31/24 beginning at approximately 10:14 a.m., the following observations were made: -The bathroom doors in room [ROOM NUMBER] and room [ROOM NUMBER] had holes on both the outside and inside at the bottom part of the door; and, -room [ROOM NUMBER] had a hole in the ceiling right above where the resident's bed was positioned. B. Staff interviews CNA #4 was interviewed on 2/1/24 at approximately 4:15 p.m. CNA #4 said hand towels and washcloths were stocked in the linen supply closets by the laundry personnel. CNA #4 said it was the responsibility of the unit CNAs to ensure residents' rooms were stocked with hand towels and washcloths. CNA #4 said it was important for resident's dignity to provide them with hand towels and washcloths. The NHA and the maintenance supervisor (MS) were interviewed on 2/6/24 at approximately 12:40 p.m. The MS said the facility was working on a maintenance schedule to fix the holes on the residents' bathroom doors and the ceiling. He said holes in the ceiling and bathroom doors were safety concerns and did not represent a homelike environment for residents. The NHA said the maintenance project had begun with the front part of the building and would proceed gradually to individual residents' rooms.

Based on interviews, observations and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain personal hygiene for five (#66, #24, #72, #54 and #26) of eight residents reviewed for ADLs out of 38 sample residents. Specifically, the facility failed to: -Ensure Residents #66, #24, #72, #54 and #26, who required assistance with bathing, were showered or bathed according to their preferences in order to maintain personal hygiene; -Provide Resident #24 assistance with shaving; and, -Provide Resident #54 assistance with shaving and nail care. Findings include: I. Facility policy and procedure The ADL policy, which was undated, was received from the nursing home administrator (NHA) on 2/6/24 at 1:37 p.m. It read in pertinent part: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility will maintain individual objectives of the care plan and periodic review and evaluation. II. Resident #66 A. Resident status Resident #66, age 74, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included history of transient ischemic attack and cerebral infarction (stroke), aphasia (affects a person's ability to express and understand written and spoken language) and left hip pain. The 11/2/23 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. He required substantial to maximum assistance for bathing. B. Resident interview Resident #66, who had difficulty with communicating verbally due to his aphasia, was interviewed on 1/31/24 at 4:00 p.m. He indicated he had not been offered a shower in seven days by using his hands to hold up seven fingers. He indicated that he was to receive two showers a week by holding up two fingers. C. Record review The bathing plan of care for Resident #66 revealed the resident's preferred shower days were Wednesdays and Sundays. The ADL care plan, initiated on 7/12/22 and revised on 7/19/22, revealed Resident #66 had a self care deficit related to right sided weakness, stroke and impaired cognition.Pertinent interventions included encouraging the resident to participate to the fullest extent possible with interactions and requiring one to two staff members participation with bathing tasks. Review of Resident #66's shower records from 1/8/24 to 2/6/24 revealed the resident received one shower on 1/24/24 and refused showers on 1/17/24 and 1/28/24. -There was no further documentation to indicate whether Resident #66 received a shower or was offered and refused a shower for the other seven opportunities he had for showering during the time frame reviewed. On 2/1/24, during the survey, a grievance form was completed with Resident #66 by an unknown facility staff member. It revealed Resident #66 was upset regarding not getting a shower for more than five days. He enjoyed showering and being clean and would like to receive showers twice weekly. The grievance revealed follow up was conducted with the infection preventionist (IP) who confirmed Resident #66's shower days were Wednesdays and Sundays and he had not been offered a shower on 1/21/24 (Sunday). The grievance documented staff would be educated on offering residents showers on their scheduled days. The grievance further documented social services (SS) #1 spoke with Resident #66 to confirm his preferred shower days were Wednesdays and Sundays. SS #1 informed the resident staff would be educated on offering showers. -However, Resident #66's electronic medical record (EMR) revealed there was no documentation to indicate the resident had been offered or refused a shower on 2/4/24, three days after the staff was supposed to be educated, according to the grievance form D. Staff interviews Certified nursing assistant (CNA) #1 was interviewed on 2/5/24 at 4:00 p.m. She said resident bathing preferences were posted in the nurses station as well as on the bathing plan of care. She said resident refusals of bathing were documented in the EMR and there was an option to indicate a reason for refusal. She said it was important to document refusals so staff knew to continue offering showers. She said consistent showers were important for resident hygiene and honoring preferences. The infection preventionist (IP) was interviewed on 2/5/24 at 4:00 p.m. She said bathing tasks were primarily completed by the CNAs. She said bathing tasks were documented in the EMR. She said there was an option to indicate refusals and why a resident refused. She reviewed the bathing plan of care for Resident #66 and said his scheduled bathing days were Wednesdays and Sundays. She said he last received a shower on 1/24/24. 43950 III. Resident #24 A. Resident status Resident #24, age 70, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 CPO, diagnoses included quadriplegia (paralysis affecting all limbs and body from the neck down), paraplegia (Paralysis affecting the lower half of the body), bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood), and cauda equina syndrome (damaged nerves below the end of spinal cord). The 10/16/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was dependent with two person assistance for toileting, shower/bathing, dressing, personal hygiene, bed mobility and transfers. B. Resident observations and interviews On 1/31/24 at 11:39 a.m., Resident #24's hair was greasy and pulled back into a ponytail and his face was unshaven. Resident #24 said he last received a shower approximately 12 weeks ago. He said he thought he had bugs or lice in his hair. He said he wanted to receive a shower and get his hair washed at least once a week but twice a week would be better. Resident #24 said he preferred a shower before going to bed between 9:00 p.m. and 10:00 p.m. Resident #24 said he had to beg to get a staff member to shave him. He said the beard style he wanted was to keep his mustache, sideburns, a small part of the goatee and have the rest of his face shaved. Resident #24 said he did not refuse showers or shaves. On 2/6/24 at 9:29 a.m., Resident #24 was lying in bed, his ponytail was removed, his hair was long, dirty and greasy. Resident #24 said he still had not received a shower although the social worker had visited him yesterday (2/5/24) and said he would get one (see record review below). Resident #24 said a shower was not offered by the staff on 2/5/24. Resident #24 said he would not refuse a shower because showers were important to him for his personal hygiene. C. Record Review The shower preference sheet dated 12/27/22 revealed the resident preferred a shower one time per week on Tuesday evenings. Resident #24's ADL self care performance deficit care plan, revised 7/26/23, revealed the resident was totally dependent on staff to provide a bath, required a mechanical lift for transfers and required total assistance with transfers with two staff members. The 1/27/24 nursing progress note revealed the resident was offered and refused a shower this shift. -However, a reason was not documented as to why the resident refused his shower so that a root cause could be identified. -It was not documented on the shower task documentation that a shower was offered or refused. The 2/5/24 social services progress note revealed in pertinent part, He also agreed to a shower tonight at nine or 10 pm only. I then passed that along to his care team today as well. He then told the writer that he will be happy to get a shower tonight because the bugs that crawl from head to his eyes while he sleeps, and that the bugs crawl to his eyes and drink the moisture from his eyes and then leave salt in his eyes and it burns. Then the bugs crawl back to his head when he wakes up. This writer asked him what bugs he was talking about? He stated, The microscopic ones This writer tried to assure him that he does not have bugs in his hair, but he stated they are microscopic, you'll never see them without a microscope. SS (social services) then left his room. SS to follow. -There was no documentation which indicated the resident was offered or refused a shower on 2/5/24. The visual/bedside kardex (a tool utilized by staff to provide consistent care for residents) report, dated 2/1/24, revealed the resident was totally dependent on staff to provide a bath or shower on Tuesday evenings and he preferred female caregivers. Resident #24's bathing task records were reviewed from 12/1/23 to 2/6/24. The records revealed the resident was scheduled for one shower per week on Tuesday evenings, and he preferred a female caregiver. The bathing task records further revealed the following: From 12/1/23 to 12/31/23, there were no showers documented for Resident #24. -The records documented the resident refused bathing on 12/3/23 (a Sunday), 12/4/23 (a Monday), 12/7/23, (a Thursday), 12/20/23 (a Wednesday) and 12/29/23 (a Friday). -None of the showers documented as offered and refused occurred on a Tuesday, which was Resident #24's preferred shower day. From 1/1/24 to 1/30/24, there was one shower documented for Resident #24 on 1/23/24. -The resident received a full body bath on 1/3/24, however, the resident's preference for bathing was a shower. -The records documented the resident refused bathing on 1/24/24 (a Wednesday) and 1/30/24 (a Tuesday). -The refusal on 1/24/24 occurred on a Wednesday, which was not Resident #24's preferred shower day. From 2/1/24 to 2/6/24, there were no showers documented as given or refused for Resident #24. -According to review of Resident #24's bathing task records from 12/1/23 to 2/6/24 the resident received one shower in 68 days. D. Staff interviews CNA #5 was interviewed on 2/5/24 at 4:26 p.m. CNA #5 said the CNAs documented showers on the computer in the resident' electronic medical records (EMR). She said if a resident refused their shower she would tell the nurse and the nurse asked the resident a second time if they wanted a shower. CNA #5 said the nurse would chart in the progress note why the resident refused. CNA #5 said it was important for the residents to have a shower in order to stay clean. Licensed practical nurse (LPN) #3 was interviewed on 2/5/24 at 4:29 p.m. LPN #3 said the CNAs completed the showers and there was a list at the nurses station of which residents were scheduled for showers each day. LPN #3 said if a resident refused a shower the CNA should ask the resident a second time and then tell the nurse so the nurse could try to convince the resident and educate them about the importance of a shower. LPN #3 said she would chart in the progress note why the resident refused to see if there was a pattern or problem. LPN #3 said regular showers were important to prevent infections, skin breakdown and to promote cleanliness. The IP was interviewed on 2/6/24 at 1:55 p.m. The IP said she assessed Resident #24's hair/head upon receiving the report of possible bugs in his hair. She said she did not find any bugs but the resident needed to have his hair/head washed and cleaned. She said Resident #24 had requested a special shampoo due to his head being itchy. 47150 IV. Resident #26 A. Resident status Resident #26, over the age of 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease, muscle weakness, severe obesity, and unsteadiness on feet. The 9/12/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He required supervision with bathing, and toileting and had no rejection of care. B. Resident observations and interviews On 2/1/24 at 10:35 a.m., Resident #26 was sitting at the edge of his bed wearing an adult incontinent brief. The resident's room had a strong odor of urine. On 2/5/23 at 3:23 p.m., Resident #26 was in his room with food debris on his pants and shirt. Resident #26 was interviewed on 2/5/2 at 3:30 p.m. He said he required assistance with his shower/bath due to weakness and his inability to reach some areas of his body. The resident said the staff were not assisting him with his showers. C. Record review The care plan, revised on 10/31/21, identified an ADL self-care performance deficit such as bowel and bladder incontinence related to diagnoses of COPD, muscle weakness and impaired mobility. Interventions included one staff assistance with bathing. The shower/bath records revealed Resident #26's preferred shower days were Mondays and Fridays. A review of Resident #26's shower/bath records from 12/5/23 to 2/5/24 revealed Resident #26 received two showers out of nineteen opportunities, refused seven shower sections, and ten none applicable (N/A). V. Resident #54 A. Resident status Resident #54, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2024 CPO, diagnoses included schizoaffective disorder, major depressive disorder, problems related to care provider dependency, abnormalities of gait and mobility,s and the need for assistance with personal care. The 9/12/23 MDS assessment revealed Resident #54 was cognitively intact with a BIMS score of 15 out of 15. He was independent with toilet use, and oral hygiene and required supervision with touching assistance with showers. Rejection of care and other behavioral symptoms were not exhibited. B. Resident observations and interviews On 2/1/23 at 10:35 a.m., Resident #54 was laying on his bed. Resident #54's fingernails were half an inch long, jagged, and untrimmed with dark brown matter underneath the resident's nails. The resident had food stains on his clothes, an unshaved beard, and his hair was unkempt. On 2/5/24 at 3:28 p.m., Resident #54 was returning to his room from an activity program. The resident had on the same clothes he was wearing on 2/1/24, four days prior. There were food stains on both his pants and sweater. The resident's fingernails were, and untrimmed with dark brown matter underneath his fingernails. The resident's hair was unkempt and he was not shaved. Resident #54 was interviewed on 2/5/24 at 3:38 p.m. Resident #54 said he would like his fingernails, trimmed but no one had offered to assist him. Resident #54 said he did not remember the last time he showered. The resident said he preferred his fingernails short and clean. The resident said he would prefer to have clean clothes on. C. Record review The ADL care plan, revised on 11/22/23, revealed the resident had an ADL self-care performance deficit, however, he was independent with ADL care in bathing, grooming, personal hygiene, dressing, transfer, bed mobility, and toileting. The care plan focus documented the resident had the potential for a behavior problem related to wearing visibly soiled clothing and refused offers for personal hygiene and showers. Interventions related to bathing, grooming, and personal hygiene included staff to negotiate a time for ADLs so the resident could participate in the decision making process and staff to offer to wash the resident's clothes. -The care plan excluded fingernail care support for the resident. A progress note dated 1/30/24 at 1:44 p.m. documented Resident #54 clipped and cleaned his fingernails. -However, Resident #54's fingernails were observed to be long, jagged and dirty during the survey on 2/1/24 and 2/5/24 (see observations above). The shower/bath records revealed Resident #54 preferred to shower once a week on Mondays. A review of Resident #54's shower/bath records from 11/5/23 to 2/5/24 revealed out of fourteen bathing opportunities, Resident #54 received one sponge bath, one shower, refused six showers and six opportunities were documented as N/A (not applicable). D. Staff interviews CNA #5 was interviewed on 2/5/24 at 5:10 p.m. CNA #5 said CNAs were responsible for providing fingernail care except when the resident was diabetic. CNA #5 said dirty and long fingernails could cause skin issues such as skin tears, scratches and transfer of germs. LPN #3 was interviewed on 2/5/24 at 5:16 p.m. LPN #3 said the CNAs and floor nurses were responsible for providing fingernail care for all residents. LPN #3 said nail care should be provided nail care with their showers. LPN #3 said nurses were responsible for cutting for residents who were diabetic. LPN #3 said it was important for residents to have regular fingernail care for good personal hygiene and to prevent the transmission of infectious diseases. VI. Resident #72 A. Resident status Resident #72, over the age of 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included fibromyalgia, paroxysmal atrial fibrillation, weakness, abnormalities of gait and mobility, muscle weakness and need for assistance with personal care. The 1/16/24 MDS assessment revealed Resident #72 was cognitively intact with a BIMS score of 15 out of 15. She required supervision with toileting, personal hygiene and moderate assistance with showers. Rejection of care and other behavioral symptoms were not exhibited. B. Resident interview Resident #72 was interviewed on 1/31/24 at 10:05 a.m. The resident said her shower preference was once a week on Wednesdays, however, she had not been receiving her showers. The resident said she had not been offered a shower since she was admitted to the facility on [DATE]. The resident said the staff always told her there was no time to complete her shower. C. Record review The ADL care plan, revised 1/17/24, revealed Resident #72 had an ADL performance deficit related to weakness and required one staff assistance with toileting and bathing. She preferred to bathe once per week on Wednesdays. -A review of the January 2024 and February 2024 progress notes revealed there was no documentation to indicate Resident #72 had refused any of her showers since her admission. -The shower/bath records revealed Resident #72 had received one shower in 27 days. VII. Additional interview The director of nursing (DON) was interviewed on 2/6/24 at 10:00 a.m. She said CNAs were mainly responsible for assisting residents with bathing and bathing was documented in the EMR to include refusals and reasons for refusal. She said residents were asked about bathing preferences, to include what days of week they preferred to bathe as part of the admission process, and preferences were available to staff in the bathing plan of care. If residents did not have a preference, staff would suggest bathing at least twice a week and tell residents what days were available. The DON said documenting refusals was important for recognizing trends that aided in implementing effective interventions. She said CNAs should document the reason a resident refused their shower and also re-approach the resident to offer them the opportunity for bathing again. She said CNAs should attempt to bathe a resident three times and inform the unit manager if a resident continued to refuse. The DON said resident refusals of bathing were discussed in the morning meetings with the interdisciplinary team (IDT) to determine possible interventions which might encourage a resident to bathe. She said consistent bathing was important for residents to promote cleanliness and dignity. The DON reviewed the EMR from 1/16/24 to 2/6/24 for Resident #66 and said he received one shower on 1/24/24. She said he refused bathing on 1/17/24 and 1/28/24but she was unable to find a reason for the refusals documented in the EMR. The DON reviewed the EMR for Resident #24 and said the documentation reflected the resident received one shower, on 1/23/24, in 30 days. The DON was unable to find documentation in the EMR to explain why only one shower within 30 days had been provided to the resident. The DON said CNAs should be providing showers, shaving assistance and nail care to Resident #54. She said untrimmed, long and dirty fingernails could cause skin issues such as skin tears, scratches and the transmission of germs and infectious diseases. She said Resident #54 had behaviors that made providing bathing and personal hygiene for the resident difficult at times. The DON said Resident #72 should receive assistance from staff for bathing per her care plan. The DON said she became aware of resident concerns regarding not receiving showers during the week of 1/28/24 to 2/3/24. She said she had begun education with staff on the importance of documenting resident's bathing refusals and the reason for the refusal.

Based on observations, record review 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 disease and infection on four of five units. Specifically, the facility failed to: -Wear the appropriate personal protective equipment (PPE) when entering transmission based precaution rooms (entire memory care unit with COVID-19 outbreak); -Follow infection control practices when administering feeding via jejunostomy tube (J-tube); and, -Ensure residents personal hygiene items were labeled. Findings include: I. Facility status: On [DATE], the facility was in a COVID-19 outbreak contained to the memory care unit. Signage on the entrance to the locked unit doors revealed PPE for droplet precautions, including N95 respirator mask, eye protection, mask, and gloves were necessary prior to entering the unit. The outbreak began [DATE], and as of [DATE], 16 residents (including two deceased residents on hospice) and eight staff members had tested positive. No residents or staff had tested positive for COVID-19 outside of the memory care unit. II. Failed to wear personal protective equipment A. Professional reference According to the Centers for Disease Control and Prevention (CDC), Recommended Infection Prevention and Control Practices when Caring for a Patient with Suspected or Confirmed SARS-COV2 Infection, revised [DATE], retrieved on [DATE] from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, HCP (healthcare personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). B. Facility policy The Transmission Based Precaution policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 5:18 p.m. It read in pertinent part: The facility will provide appropriate PPE for each specific infectious disease. The facility will follow CDC guidelines for all isolation measures and PPE use. C. Observations On [DATE] at 3:30 p.m., certified nurse aide (CNA) #7 was talking to Resident #91 on the memory care unit. -CNA #7 was not wearing proper eye protection (goggles or face shield) and the top of her N95 mask was resting on the tip of her nose which did not create a full seal around her nose. On [DATE] at 3:40 p.m., CNA #8, who identified herself as a hospice CNA, entered the memory care unit with only a N95 mask on. -CNA #8 did not apply eye protection, gown, or gloves prior to entering the unit. D. Staff interviews The infection preventionist (IP) and director of nursing (DON) were interviewed together on [DATE] at 12:08 p.m. The IP said all staff were to wear N95 masks, goggles or face shield, gown and gloves when they entered the memory care unit. She said hospice CNAs and nurses were aware of the COVID-19 outbreak on the unit and the requirements for appropriate PPE upon entering the unit. E. Facility follow-up On [DATE] at 3:16 p.m., additional signage was present near the entry keypad to the memory care unit. The signage included stopping and applying all PPE for droplet precautions prior to entering the unit. The DON said the additional signage was added to reinforce teaching. III. Failed to follow infection control practices for J- tube feeding A. Facility policy The Gastrostomy Tube Policy, revised [DATE], was provided by the nursing home NHA on [DATE] at 5:18 p.m. It read in pertinent part: Clean all accessories after each use. Change entire tube feeding set every time a new formula is hung or at least every 24 hours. Ensure either bottle or tube set is dated. B. Observation and interviews On [DATE] at 10:02 a.m., registered nurse (RN) #1 administered a tube feeding to Resident #13. RN #1 said the previous feeding was stopped and disconnected on [DATE] at 3:00 a.m because the continuous feeding was ordered for 18 hours per day and that day's feeding had been completed. She picked up the previously used tubing (which was attached to the feeding pump) off of the resident's bed and connected the tip of the tubing to the resident's tube feeding port. The tip was open to air on the bed and was not capped. -RN #1 did not clean the end of the tubing, which had been resting on the bed uncapped, prior to connecting the tubing to Resident #13's tube feeding port. C. Staff interviews The IP and DON were interviewed together on [DATE] at 12:08 p.m., The IP said there should have been a protective cap or cover for the tubing used for Resident #13's feedings. She said if the feeding was disconnected for any reason, the tip of the tubing should not rest on a dirty surface without the cap on. She said the bed was a dirty surface and could contaminate the tubing. RN #1 was interviewed on [DATE] at 1:30 p.m. She said the tube feeding set should be discarded after 24 hours. She said she did not know how long the tube feeding set had been in use because it had not been labeled with the date and time it was hung . IV. Failed to ensure personal hygiene supplies were labeled A. Facility policy The Infection Prevention and Control Program policy was provided by the NHA on [DATE] at 2:35 p.m. It read in pertinent part: Goals of the facility include decreasing the risk of infection to residents. The facility will investigate, control, and prevent infections in the facility, and decide what measures/interventions should be applied in individual circumstances. B. Observations On [DATE] at 11:00 a.m. and again on [DATE] at 3:15 p.m., the following shared resident rooms did not have personal hygiene supplies labeled and contained or separated: -room [ROOM NUMBER] had unlabeled toothbrushes, a hairbrush and toothpaste on the sink counter in the residents' room; -room [ROOM NUMBER] had an unlabeled comb, toothbrushes and two unbagged urinal containers hanging on the bathroom grab bar; -room [ROOM NUMBER] had one unlabeled and unbagged urinal container, unlabeled toothbrushes, hair brushes and body wash -room [ROOM NUMBER] had unlabeled comb, body wash, deodorant, hygiene container and toothbrushes; -room [ROOM NUMBER] had unlabeled toothbrushes, two unlabeled hygiene containers with unlabeled personal hygiene items such as hair brushes, toothbrushes and toothpaste; -room [ROOM NUMBER] had unlabeled toothbrushes, toothpaste and a comb; -room [ROOM NUMBER] had unlabeled toothbrushes, toothpaste. hair brushes, deodorant and body wash; -room [ROOM NUMBER] had unlabeled toothbrushes, toothpaste. hair brushes and body wash. Unlabeled hygiene supplies were on the residents' sink; -room [ROOM NUMBER] had unlabeled toothbrushes, toothpaste. hair brushes, shampoo, deodorant and body wash; -room [ROOM NUMBER] had unlabeled toothbrushes, toothpaste. hair brushes, deodorant and body wash; -room [ROOM NUMBER] had unlabeled toothbrushes, toothpaste. hair brushes, deodorant and body wash; An unlabeled hairbrush was on the sink counter; -room [ROOM NUMBER] had unlabeled toothbrushes, toothpaste. hair brushes and body wash. The hygiene containers in the residents' room were not labeled; and, -room [ROOM NUMBER] had unlabeled toothbrushes, toothpaste. hair brushes and body wash. The hygiene containers in the residents' room were not labeled. C. Staff interviews CNA #5 was interviewed on [DATE] at 1:40 p.m. She said the personal hygiene items in room [ROOM NUMBER], #503 and #505 were unlabeled and the urine containers were not bagged and properly stored. She said the CNAs were responsible for labeling residents' hygiene items and storage of urine containers. The CNA said labeling was important to prevent the spread of germs. The IP was interviewed on [DATE] at 2:15 p.m. The IP said the CNAs were responsible for labeling personal hygiene items and hygiene containers/bags. The IP said it was important to label personal hygiene items to prevent the possibility of residents using each others' items and to prevent the spread of diseases. The IP said she would ensure the facility staff were retrained. The DON was interviewed on [DATE] at 10:43 a.m. She said personal hygiene items should be labeled when rooms were shared. She said the facility did a clean sweep in [DATE] and personal hygiene items were placed in bags and labeled. The DON said the process was not being followed consistently. She said the CNAs knew the residents but they should not have relied upon residents to identify their personal items. She said it was important to label the items so the residents would not use each other's items, as this could transmit disease. D. Facility follow up On [DATE] at 5:16 p.m., the IP provided documentation of staff inservice education signed by 22 staff which was provided to ensure residents who shared rooms had labeled personal hygiene items. On [DATE] at 10:50 a.m. the DON said the facility had separated and labeled all residents' personal hygiene items and the facility would be rounding at least weekly to ensure the process continued. She said the facility ordered hooks to assist with hanging and separating items.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in two of five medication carts. Specifically, the facility failed to ensure expired or discontinued medications were removed from medication carts in a timely manner. Findings include: I. Facility policy and procedure The Medication Access and Storage Policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 2:56 p.m. The policy read in pertinent part: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. II. Professional references According to the manufacturer Sanofi Aventis US, Using Lantus? Learn How to Inject Insulin (2023), retrieved on [DATE] from https://www.lantus.com/how-to-use/how-to-inject, Lantus vials should be thrown away after 28 days even if it still has insulin left in it. According to the manufacturer [NAME] Lilly and Company, Humalog-Insulin Lispro Injection, Solution ([DATE]), retrieved on [DATE] from https://uspl.lilly.com/humalog/humalog.html#ug, Throw away all opened vials after 28 days of use, even if there is insulin left in the vial. III. Observations and interviews On [DATE] at 2:39 p.m., the [NAME] One medication cart was observed with licensed practical nurse (LPN) #1. The following items were found: A vial of Insulin Glargine (Lantus) 100 units/milliliter (ml) was dated as opened on [DATE]. -The insulin vial should have been discarded on [DATE], 28 days after it was opened. Humalog insulin (Lispro) 100 units/ml was dated as opened on [DATE]. -The insulin vial should have been discarded on [DATE], 28 days after it was opened. LPN #1 said if insulin was used more than 28 days after opening it could be ineffective. The registered pharmacist (RPH) was also present and said she knew both medications were good for 28 days after opening. The RPH said after 28 days it was unknown whether the medications were effective. On [DATE] at 11:26 a.m., the North medication cart was observed with LPN #2. The following item was found: A Fluticasone 50 microgram (mcg) nasal spray bottle was dated as opened on [DATE]. Instructions on the bottle label directed use for seven days. LPN #2 said the nasal spray was discontinued on [DATE] and should have been discarded when it was discontinued. She removed the medication from the cart for disposal. IV. Additional interview The director of nursing (DON) was interviewed on [DATE] at 10:47 a.m. She said insulins were to be discarded 28 days after opening. She said discontinued medications should be removed from the medication cart within 24 hours.

Based on observation, record review and interviews, the facility failed to consistently provide activities of daily living (ADL) support for four (#29, #23, #7, and #92) of 10 dependent residents reviewed for ADL care out of 41 sample residents. Specifically, the facility failed to: -Provide or offer showers according to the bathing schedule or provide fingernail cleaning and trimming for dependent and diabetic Residents #29 and #23; and, -Provide timely incontinence care and reposition Residents #7 and #92 who were dependent on staff for all cares. Findings include: I. Facility policy and procedures The Nursing Clinical Bath, Shower policy and procedure, revised March 2022 was provided by the director of nursing (DON) on 11/3/22 at 3:05 p.m. It read in pertinent part, It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation. Residents have the choice between bed bath, shower or bath. When residents admit please review the preference sheet with the Resident. Complete a shower preference form. Residents may choose the days of the week they choose to bath or shower. Residents may choose the time that they can bath or shower. We offer the following options to the residents, shower, tub bath, bed bath. Residents may change their preferences at any time during the stay. Nursing will upload preferences into the POC (point of care) task. If a resident does not have a preference, the facility will utilize their default schedule. The default schedule will include offering twice weekly. Facility is transitioned to electronic on bathing documentation. Facility no longer using bathing sheet. The Activities of Daily Living policy and procedure, revised March 2022 was provided by the DON on 11/3/22 at 3:05 p.m. It read in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming, and oral care; transfers and ambulation; toileting; nail care; eating to include meals and snacks; and using speech, language or other functional communication systems. A resident who is unable to carry out ADL's will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. II. Resident #29 A. Resident status Resident #29, age 63, was admitted on [DATE], and readmitted on [DATE]. According to the November 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/23/22 minimum data set (MDS) assessment revealed the resident with moderate cognitive impairment with a brief interview for mental status (BIMS) score of 9 out of 15. He required extensive assistance with two persons for bed mobility and transfers. Total dependence with one person for locomotion on unit, dressing, and bathing. Extensive assistance with one person for toilet use, and personal hygiene, and supervision with set up help for eating. Physical and verbal behavioral symptoms directed toward others occurred one to three days with no rejection of care exhibited. B. Resident observations and interviews On 10/31/22 at 10:03 a.m. Resident #29 was observed in his bed. His fingernails were a half inch long, on both hands, with brown matter under the nails. His hair was greasy and wet looking. On 11/1/22 at 3:29 p.m. Resident #29 was observed. His fingernails were a half inch long and dirty with brown matter under the nails. His left hand brace had been applied but the caregiver did not attend to the length and dirty condition of his fingernails. Resident #29 said he liked to have his nails short and he liked to receive a shower two times per week. Resident #29 said when he did have a shower his caregiver transfers him to a wheelchair in order to go to the shower. On 11/2/22 at 9:12 a.m. Resident #29 was observed with half inch long fingernails on both hands. The fingernails were dirty with brown matter under the nails. Resident #29 hair was greasy and wet looking. C. Record review The care plan for ADL's, revised 5/31/22, revealed self care performance deficit related to left [CONDITION(S)] and left hand contracture. The interventions related to showers and nail care revealed bathing required one to two staff participation (revision 11/22/21). Transfers require total assistance with hoyer lift and requires two person assistance with transferring. -There were no interventions related to nail care or shower preferences on the care plan. The bathing preference sheet, dated 8/5/21 revealed Resident #29 preferred a shower, two days per week on Wednesday and Friday, in the evening. The electronic medical record (EMR) task documentation completed by certified nurse assistants (CNA's) revealed to offer showers on Monday and Wednesday evenings. August 2022: Revealed zero showers, two sponge baths 8/10/22 and 8/24/22, and one full-body bath 8/17/22. There were no resident refusals documented. September 2022: Revealed zero showers, one sponge bath 9/14/22, two full-body baths 9/26/22 and 9/28/22. There was one resident refusal 9/2/22. October 2022: Revealed two showers on 10/19/22, and 10/28/22 and one sponge bath 10/26/22. There were no resident refusals documented. Resident #29 had received a total of nine baths, of any type, in the last three months since 8/1/22. Resident #29 preferred a shower and received a total of two in the past three months. Resident #29 should have received a minimum of 24 showers. He received four out of 24 scheduled showers, with one refusal, since August 2022. The October 2022 EMR task documentation section revealed the question was nail care provided? The task section was empty with no documentation and said no data found. A review of all progress notes from 8/1/22 to 11/2/22 related to showers revealed: On 9/3/33 at 6:30 a.m. alert note that resident did not have a bath or shower documented in POC within four days due to refusals, continues to refuse showers. On 10/10/22 at 8:06 a.m. alert note that resident will grab CNA arm and twist it hard while bathing him, making it hard to clean him properly. -However, there were no other interventions related to why the resident refused and no updates to the care plan with interventions for bathing behaviors. III. Resident #23 A. Resident status Resident #23, age 57, was admitted on [DATE], with readmission 9/24/22. According to the November 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/27/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance with two persons for bed mobility, dressing, transfers and personal hygiene. She is totally dependent on two people for toilet use. Bathing itself did not occur during the entire seven day period. Verbal behavioral symptoms directed toward others occurred one to three days, with no rejection of care exhibited. B. Resident observations and interviews On 10/31/22 at 1:53 p.m. Resident #23 left hand was observed in a fist position. It was mildly swollen and the nails could not be seen due to being in a fist position. Resident #23 said she is unable to move her left hand and it hurts all the time. On 11/1/22 at 9:25 a.m. Resident #23 said she needed her left hand fingernails trimmed. There was old fingernail polish on her hands, Resident #23 said the polish lasted a long time due to not using her left hand. The left hand was a little swollen, and resting on a small round pillow. Resident #23 said she was diabetic and the staff trimmed her finger nails when they noticed they were long. Fingernails were one fourth to a half an inch long and Resident #23 said sometimes the nails dig into her palms. On 11/2/22 at 10:02 a.m. Resident #23 said she had asked the nurse last night to trim her fingernails but Resident #23 said the nurse replied that she could not find any nail clippers. The DON and assistant director of nursing (ADON) were present and acknowledged that the nails should have been trimmed by the nurse because Resident #23 was diabetic and her fingernails were long. Resident #23's left hand was swollen on top of the hand, the DON said she would check on the care plan for hand swelling. The DON elevated Resident #23's left arm/hand with a bed pillow. C. Record review The care plan for ADL's, revised 8/30/21, revealed self care performance deficits related to decreased mobility, obesity, and [CONDITION(S)]. The interventions related to showers and nail care revealed resident required one to two staff assistance with bathing/showering. Transfers require total assistance with hoyer lift and requires two person assistance with transferring. The care plan for diabetes mellitus, revised 8/3/32, revealed that nails should always be cut straight across, never cut corners. File rough edges with emery board, initiated 5/4/21. -There were no interventions related to her shower preferences on the care plan. The bathing preference sheet, dated 8/6/21, revealed Resident #23 preferred to take a shower, three days per week, Monday, Tuesday, and Wednesday during the day. The EMR task documentation completed by CNA's revealed Resident #23 prefers showers on Tuesday, Thursday, and Sunday during the day. August 2022: Revealed four showers 8/2/22, 8/9/22, 8/11/22, 8/25/22 and zero bed baths. There was one resident refusal 8/30/22. September 2022: Revealed two showers 9/18/22, 9/29/22 and one full body bath 9/6/22, and zero sponge baths. There were two resident refusals 9/8/22, and 9/27/22. October 2022: Revealed three showers 10/6/22, 10/11/22, and 10/27/22, and zero bed baths. There were two resident refusals 10/4/22, and 10/13/22. Resident #23 had received a total of 10 baths, of any type, in the last three months since 8/1/22. Resident #23 preferred a shower and received a total of nine in the past three months. Resident #23 should have received a minimum of 39 showers. She received nine out of 39 scheduled showers, with five refusals, since August 2022. The October 2022 EMR task documentation section revealed the question was nail care provided? The task section was empty with no documentation and said no data found. The DON provided documentation on 11/2/22 at 11:08 a.m. of nail care provided on 8/9/22, 8/29/22 and 9/12/22 during one on one activities. The DON provided progress note documentation on 11/2/22 at 11:08 a.m. it revealed: -On 8/30/22 at 10:46 a.m. that Resident #23 refused her shower because she said it was too cold. -On 9/27/22 at 10:10 a.m. that Resident #23 refused her shower due to her ribs hurting. -On 10/4/22 at 7:41 a.m. that Resident #23 refused her shower due to knowing that there was COVID-19 in the building and not wanting to get it. A review of all progress notes from 8/1/22 to 11/2/22 related to showers revealed: On 9/6/22 at 11:51 a.m. nursing note revealed when attempting to transfer resident into the shower bed, the resident complained of her left leg and calf hurting really bad. Staff checked it out and saw no signs of redness or abnormal swelling anywhere on the residents body. Staff attempted to transfer the resident onto the shower bed three times, with her consent and each time, the resident requested to be put back down on her bed due to her leg hurting so bad in the hoyer. The resident then refused her shower and and staff gave her a bed bath instead. The resident was not upset and was in good spirits. Plan to try again on the next shower day (Thursday), the nurse on duty was notified. On 9/29/22 at 3:08 p.m. nursing note revealed resident was pleasant and took her bed bath and did not refuse any care that shift. On 10/5/22 at 6:31 a.m. alert note that resident did not have a bath or shower documented in POC within four days due to refusals, continues to refuse showers. -However, the reason for refusal and intervention for refusals were not provided in the progress note. IV. Staff interviews CNA #2 was interviewed on 11/2/22 at 8:54 a.m. She said she works for an agency but did give showers. CNA #2 said she asked the residents if they want their hair shampooed or she sees if it needs to be done. CNA #2 said she charts the showers on the computer. If a resident was not a diabetic the CNAs were allowed to cut fingernails. LPN #1 was interviewed on 11/2/22 at 9:05 a.m. She said showers were usually given two times per week. LPN #1 said when a resident was admitted to the facility they were asked about their bathing preferences. Shampooing hair was standard unless the resident did not want to. The CNA's chart the showers given in POC, viewed in the task section. Sometimes the activities department takes care of the fingernails when painting the nails, otherwise the CNAs will tell the nurse if the resident needs a nail trim, but the nurse will trim if they were diabetic. The care plan will have which days the resident preferred to shower. The DON was interviewed on 11/2/22 at 9:25 a.m. She said that the CNA's complete the showers including washing hair unless the resident declines. The DON said fingernail care depends on the resident preference and the nurse may notice if nails were too long during the weekly skin check. The DON said if a resident was diabetic it was important to make sure fingernails were kept trimmed due to risk of scratching themselves and if residents get a wound it can be hard to heal. The DON said if fingernails were dirty and not cleaned they can cause infections. The DON said newly admitted residents were asked their shower preferences and uploaded to the miscellaneous section of electronic medical record (EMR). The DON said the shower preferences were also on the resident's care plan. The DON said regular showers were important to keep the residents clean and smelling better and for good skin hygiene. -The DON and ADON observed Resident #29's fingernails and acknowledged that they were very long and dirty with brown matter under the nails and that they should be trimmed and cleaned for hygiene purposes. The DON and ADON said that sometimes Resident #29 did not cooperate with nail trimming and pulled away and said the staff were hurting him, however the DON and ADON acknowledge that this was not in the care plan but should be. -The ADON said we need to come in regularly to keep nails cleaned and trimmed especially since Resident #29 uses his right hand to eat. V. Facility follow up On 11/2/22 at 10:41 a.m. the DON said she received a new ordered for Resident #23 to elevate her left arm/hand and they will be conducting a house audit today on showers and nail care. New order for Resident #23, elevate left leg and left arm on pillows as patient tolerates. Start date 11/2/22. On 11/3/22 at 3:55 p.m. The DON provided documentation of the fingernail care facility audit completed on 11/2/22, after being brought to the facility's attention. An inservice was also conducted 11/2/22 concerning nail care, showers and refusal of care and signed by staff. VI. Resident # 7 A. Resident status Resident #7, age 90, was admitted on [DATE]. According to November 2022 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/19/22 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for a mental status score (BIMS) of four out of 15. She required extensive assistance of two people with transferring. She required extensive assistance of one person with one-person assistance with locomotion in wheelchair, personal hygiene, and toilet use. B. Observations 11/2/22 the resident was continuously observed beginning at 8:51 a.m. -At 8:51 a.m. the resident was in the dining room in a Broda wheelchair at a 90 degree angle. -At 9:29 a.m. an unidentified CNA assisted the resident to her room. However, no personal care was provided. -At 10:02 a.m. the resident remained in her room, no one had entered and she remained in the same position. -At 11:17 a.m. the resident remained in the same position in her room. -At 11:21 a.m. CNA #3 assisted the resident to the dining room table. The resident was not changed or checked for incontinence and remained at 45-degree angle without any repositioning. -At 12:00 p.m. the resident was served her noon meal. -At 12:44 p.m. CNA#3 assisted the resident to her room and changed her incontinence brief. CNA #3 said the resident was incontinent of urine and the brief was wet. The soiled brief was observed in a trash bag. The brief was heavy, sopping wet, and the moisture could be felt through the bag with a gloved hand. C. Record review The activities of daily living (ADL) and incontinence care plan, reviewed on 10/28/22, documented the residents interventions included the resident required one staff assistance when toileting, bathing, dressing, hygiene and eating. The resident is incontinent of bowel and bladder and checks were required. D. Staff interviews CNA #3 was interviewed on 11/2/22 at 12:45 p.m. CNA #3 said Resident #7 was incontinent of urine when she was changed. He said the staff typically changed the residents when they get in at 6:00 a.m. and when they leave before 2:00 p.m. He said residents were changed more frequently if there was a smell or noticed the resident needed to be changed but did not typically check the residents. He said he thought hospice came today and changed her. The hospice registered nurse (HRN) was interviewed on 11/2/22 at 3:47 p.m. The HRN said she said they had arrived at facility to see Resident #7 (after the observation) and therefore had not provided incontinence care. She said during the visit, the resident would receive a bath. The DON was interviewed on 11/3/22 at 1:55 p.m. The DON said Resident #7 was incontinent of both bowel and bladder and needed to be checked and changed every two hours. She said the residents needed to be checked before or after a meal, if a resident was sleeping the staff should check them before or after a meal or if they notice that the resident was incontinent. She said that checking a resident when staff got on shift and before they leave was inappropriate. VII. Resident #92 A. Resident status Resident #92 age 75, was admitted on [DATE]. According to November 2022 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/4/22 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for a mental status score (BIMS) of one out of 15. She required two-person assistance with transferring, personal hygiene, bed mobility, dressing, and toilet use. B. Observations 11/2/22 the resident was continuously observed beginning at 8:52 a.m. -At 8:52 a.m. the resident was in the hallway in her wheelchair. -At 9:12 a.m. the resident remained in the same position. -At 10:04 a.m. the resident remained in the same position. -At 11:04 a.m. the resident remained in the same position. -At 11:40 a.m. the resident remained in the same position. -At 1:54 p.m. CNA #3 and CNA#4 assisted the resident to her room. They changed her and said that the brief was wet and she had a bowel movement. The brief was heavy and the moisture could be felt with a gloved hand. C. Record review The activities of daily living (ADL) and incontinence care plan, reviewed on 8/30/22, documented the resident's interventions include: Resident #92 required staff assistance with toileting. The resident was incontinent of both bowel and bladder and checks and changes were required. D. Staff interviews CNA#3 was interviewed on 11/2/22 at 1:54 p.m. CNA #3 said Resident #92 required full care and two people needed to help change her. He said she was changed when she woke up and before the end of their shift unless they could tell she was incontinent. The DON was interviewed on 11/3/22 at 1:55 p.m.The DON said Resident #92 required two person assistance to help her with incontinent care. She said that Resident #92 should be checked every two hours or changed as needed.

Based on record review, observations and staff interviews, the facility failed to ensure food items were stored and served under sanitary conditions. Specifically, the facility failed to ensure: -The snack/nourishment refrigerators on two of three units were maintained and food items were dated, labeled, and discarded before the expiration date; and, -Opened containers of potentially hazardous foods or leftovers were dated and used within seven days or according to facility policy to prevent potential foodborne illness. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/Reg_BOH_RetailFoodRegulations.pdf, read in pertinent part, Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food) served in facilities providing food to highly susceptible populations shall adhere to the following date marking requirements: Refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 F (5 C) or less for a maximum of 7 days. Potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (1) of this section and: a. The day the original container is opened in the food establishment shall be counted as Day 1; and b. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. II. Facility policy The Foods Brought by Family or Visitor Personal Food Storage policy, undated, was provided by the dietary manager (DM) on [DATE] at 10:28 a.m. It read in pertinent part: Food or beverages brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigeration units or designated resident public refrigerators will be monitored by designated facility staff for food safety. Foods in unmarked or unlabeled containers should be marked with the current date the food item was stored. Designated facility staff will be assigned to monitor individual room storage and refrigeration units for food or beverage disposal at least weekly. Designated facility staff will monitor cleanliness of individual refrigeration units and ensure cleaning is completed as needed. Foods or beverages that have past the manufacturer's expiration date should be thrown away. Food or beverage items without a manufacturer's expiration date should be dated upon arrival in the facility and thrown away seven days after the date marked. Foods in unmarked or unlabeled containers should be marked with the current date the food item was stored. III. Observations The following items were observed on [DATE] at 10:45 a.m. while inspecting the flatirons unit refrigerator and freezer: -Cookies and cream ice cream with an expiration date of [DATE]; -Two [NAME] daz ice cream containers with expiration dates of [DATE] and [DATE]; -Breyers ice cream container with an expiration date of ,d+[DATE]; -Frozen drink in clear plastic cup with plastic lid and straw; had no company identifiable label or expiration date; -Coffee mate 64 oz creamer with no expiration date; -Disposable four ounce cup with a clear lid that contained ice cream and no identifiable label or expiration date; -A fresh apple, unwrapped and bruised in a refrigerator drawer that contained individual condiment packets and food crumbs; -Partially open Hershey candy bar wrapper that was not covered, rewrapped or labeled with an expiration date; and, -The refrigerator had a dried, sticky yellow substance under the drawers. The following items were observed on [DATE] at 8:40 a.m. while inspecting the secured unit snack refrigerator and freezer: -Ziploc plastic container that had fresh carrots and a packaged food item inside, with no label or expiration date; -Noosa yogurt with an expiration date of [DATE]; -Cottage cheese in the original container with an expiration date of [DATE]; -Partially eaten and uncovered a magic cup supplement in the freezer, with no label that contained a resident's name or expiration date; and, -The freezer had excessive dried food crumbs on the bottom shelf. IV. Staff Interviews Certified nursing assistant (CNA) #1 was interviewed on [DATE] at 9:05 a.m. She said she was unsure who was responsible for cleaning out the snack refrigerators on the units, so she sometimes tried to clean them and sorted out the expired items. She said the food in containers from restaurants, for example, had a three day expiration date, sometimes more, but the food did not usually last that long. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on [DATE] at 10:22 a.m. The ADON stated usually the dietary department was responsible for cleaning the unit refrigerators and the CNA's were helping. She said right now there was not a posted cleaning schedule. She said the CNA's get snacks from the refrigerators so should be checking the refrigerators every day. She also said supplements should be dated when they are opened, and the residents name should be written on the supplement with a marker. The DON stated the CNAs were trained on cleaning the unit refrigerators, and the training process is usually part of the initial training. The DM was interviewed with the registered dietitian (RD) on [DATE] at 10:29 a.m. The DM stated the dietary staff were responsible for cleaning the unit refrigerators and it was on the evening dietary aide task sheet. She said the task sheets were posted in the kitchen and the unit refrigerators and should have been checked yesterday and the day before. She said initially the staff were trained to go to each of the stations to learn the protocol for stocking, checking the dates of food items and removing what needs to be removed. The RD said she did try to pull food out of the refrigerators if she saw it was outdated or old. She said a half eaten magic cup should be thrown out if it is not labeled. She said she did clean the flatirons and west unit refrigerators earlier that day on [DATE], and stated the west unit refrigerator was often overlooked. V. Facility follow up The task sheet for the evening dietary aide was requested from the DM and not provided before exit. On [DATE] at 10:45 a.m. the flatirons and secured unit snack refrigerators were inspected an additional time with the facility RD. Expired food items were shown to the RD which she discarded in the trash. The ADON provided in-service training on CNA assignments from [DATE]. The inservice included the following tasks: -Refrigerators free of expired food and all food labeled; and, -Wipe down refrigerator. The ADON stated they were going to reeducate the staff and do another in-service.

Based on record review and interviews, the facility failed to ensure one (#51) of seven residents reviewed of 41 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to timely schedule a computed tomography (CT) scan for Resident #51 as it was recommended one week after the fall. CT scan was completed a month after a fall revealing a pelvic fracture. Findings include: I. Resident # 51 A. Resident status Resident #51, age 87 , was admitted on [DATE]. According to November 2022 computerized physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/21/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for a mental status score (BIMS) of four out of 15. She required extensive assistance of two people with bed mobility, transfer, dressing, and toilet use. She required extensive assistance of one person with locomotion in a wheelchair, eating and personal hygiene. It indicated the resident had one fall with major injury after admission. B. Record review The care plan for falls initiated on 9/15/22 revealed Resident #51 was at a high fall risk due to impaired cognitive function, incontinence and poor vision. On 7/13/22 interventions included therapy to screen the resident and for staff to be aware of the resident and what is in her surroundings. On 8/1/22 interventions put into place were to encourage resident to wear non-skid socks and to have a night light in her room. On 8/29/22 new interventions included that therapy needs to screen, they will assist her out of bed at 5:45 a.m. for her morning routine, encourage participation in physical activities, encourage her to wear her glasses, follow facility fall policy, keep needed items within reach, maintain a clear pathway, and review information on past fall to find the root cause. Progress note dated 8/1/22 documented Resident #51 had an unwitnessed fall on 8/1/22. She developed pain in her left hip and knee right after the fall and was unable to bear weight on her left leg. The x-ray was completed the same day and the results were negative for fractures. The recommendations included to complete a CT scan one week later. Nursing progress note dated 8/10/22 documented a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/4/22 (over one month later) CT scan was completed and results showed a subacute fracture of the inferior left pubic ramus with associated periosteal new bone formation identified. II. Staff interviews The director of nursing (DON) was interviewed in the presence of the nursing consultant (NC) on 11/3/22 at 4:00 p.m. She said after the fall on 8/1/22 Resident #51 was assessed by a registered nurse and the physician was notified. He ordered an x-ray that was completed on the same day and revealed no injury. She said the resident was not in pain and continued to work with physical therapy. The resident did not display any signs of discomfort and CT was not scheduled on an urgent basis. After the resident had her second fall on 8/29/22, the resident's functional status did not change and she continued to work with physical therapy. She said that they did not feel like the CT scan was needed because of current treatment plan. She said the CT scan was completed on 9/4/22 when therapy identified a lack of progress in residents weight bearing status. The NC said that Resident #51 ' s medical record was reviewed by the medical director. She said the facility staff followed proper protocol. Resident #51 was assessed after every fall, her falls were reviewed by the IDT team and her care plan was updated with new interventions. She said the CT scan was not completed one week after an x-ray (as was advised by the outside physician who reviewed the x-ray) because the resident did not display any signs of pain and discomfort and she continued to work with the therapy. The DON and NC acknowledged the delay in following a physician order.

Based on record review and interviews, the facility failed to ensure one (#18) of five sample residents reviewed for respiratory services out of 41 sample residents received respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the facility failed to ensure Resident #18 who had a [CONDITION(S)] was routinely assessed by a respiratory therapist (RT). Findings include: I. Facility policy The [CONDITION(S)] Tube Care policy, dated 4/1/21 and revised on 3/1/22, was provided by the assistant director of nursing (ADON) on 11/2/22 at 4:45 p.m. It read in pertinent part, The facility will ensure that residents who need respiratory care, including [CONDITION(S)] care and tracheal suctioning, are provided with such care consistent with professional standards of practice. The policy guidelines included, 1. In collaboration with the attending practitioner, the facility must perform a comprehensive assessment of the resident's respiratory needs. 2. The facility will provide necessary respiratory care and services, such as oxygen therapy, treatments, mechanical ventilation, [CONDITION(S)] care, and/or suctioning. 3. [CONDITION(S)] care will be provided according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Based on the resident assessment, attending physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . II. Resident status A. Resident #18 Resident #18, age 61, was admitted on [DATE]. According to October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/19/22 quarterly minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) was not conducted as the resident was in a consistent vegetative state. He was on oxygen therapy and had a [CONDITION(S)]. B. Record review The respiratory care plan, initiated on 5/4/21 revealed that the resident was on oxygen therapy due to respiratory failure and had a [CONDITION(S)]. Interventions included administering oxygen via [CONDITION(S)], monitoring, and documenting respiratory rate, depth, and quality every shift, and to provide [CONDITION(S)] care per facility protocol. The care plan was not updated with the most current interventions after the resident was readmitted to the facility on [DATE]. A comprehensive assessment of the resident's respiratory needs was requested on 11/3/22 from the director of nursing (DON). The [CONDITION(S)] care plan revised on 7/22/22 included interventions to monitor for signs and symptoms of respiratory distress by a qualified specialist and report to the physician. A review of the care plan revised on 7/22/22 failed to include an updated respiratory therapist assessment. The last assessment was completed on 4/1/21. Progress notes were reviewed between 10/1/22 and 11/2/22. The progress notes did not mention the resident's respiratory rate, depth, quality, oxygen therapy, [CONDITION(S)] care or if the resident required suctioning. The November 2022 CPO included: -Cleanse [CONDITION(S)] site with sterile normal saline, and change drain sponge everyday shift; -Apply oxygen via [CONDITION(S)] at three liters per minute continuously, to keep saturation at or above 90% every shift; -Suction [CONDITION(S)] as needed for excessive secretions; -Check each shift to ensure that the emergency [CONDITION(S)] kit is in the room and that all supplies are in it. D. Staff interviews Registered nurse (RN) #1 was interviewed on 11/2/22 at 3:10 p.m. She said the respiratory therapist (RT) came in every Tuesday to evaluate the resident. She did not know where the RT documented his/her assessment with recommendations. The DON was interviewed in the presence of ADON on 11/2/22 at 5:15 p.m. The DON said the resident was evaluated by a practitioner every week. Nurses were assessing the resident every shift and documented on the medication administration record (MAR) when they completed dressing changes for the resident's [CONDITION(S)]. She said respiratory rate, depth, and quality were assessed at that time. However, the assessment was not documented in the progress note and did not include lung sounds and the condition of the trachea. In addition, she said the resident's respiratory status was assessed every shift and documented on the MAR through September 2022 as a part of the assessment for COVID-19. In October 2022 this monitoring was discontinued and a new order for the respiratory evaluation was not initiated. She said she would make sure MAR included a respiratory assessment for Resident #18 and RT was on his way to complete the assessments. The DON was interviewed a second time in the presence of the ADON on 11/3/22 at 10:20 a.m. She said an assessment by an outside RT should be completed each month, however, the practitioner did not have access to their system and therefore the facility had no documentation to indicate the evaluation and assessment were completed. She said the RT was assigned access to the system and was able to document his assessment in the resident's electronic record. She provided a copy of the respiratory assessment completed on 11/3/22. III. Facility follow-up On 11/3/22 DON provided a respiratory assessment for Resident #18. The assessment read: [CONDITION(S)] changed with no complication. The patient is on three liters of oxygen via a [CONDITION(S)] collar. Suctioned large amounts of white secretions. The patient has a strong cough.

Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one out of three units. Specifically, the facility failed to provide wound care and [CONDITION(S)] care to Resident #18 in a sanitary manner. Findings include: I. Facility policy and procedure The Infection Control Prevention and Control Program policy, revised March 2022, received from the nursing home administrator (NHA) on 11/3/22. The section for wound care read in pertinent part, Establish a clean field, place the clean equipment on the clean field, wash and dry hands or use hand sanitizer, and apply clean gloves. The section for [CONDITION(S)] care read: Perform hand hygiene, put exam gloves on both hands; mask and eyewear should be worn if there is a likelihood of splashes and splattering. Remove old dressing; remove gloves, and perform hand hygiene. II. Wound care and [CONDITION(S)] care observations Registered nurse (RN) #1 was observed completing wound care and [CONDITION(S)] care to Resident #18 on 11/2/22 at 9:14 a.m. The resident was positioned on his back. RN #1 reached into her pocket, pulled out wound care supplies (calcium alginate dressing and wound cleanser) and placed both on top of the resident's blanket. RN #1 removed the old dressing from the resident's wound to his abdomen. The dressing was saturated with moderate yellow to red discharge. RN #1 placed the soiled dressing in the trash, and cleaned the wound with a wound cleanser. She changed gloves, but did not sanitize her hands prior to putting clean gloves on. She cleaned the wound a second time with the wound cleanser, she did not change her gloves and proceeded to apply calcium alginate dressing to the wound and covered it with foam dressing. She reached into her pocket, pulled out a marker and dated the new wound dressing. RN #1 removed her gloves, she did not wash or sanitize her hands. She then applied regular gloves, on top of the regular gloves she applied sterile gloves, removed soiled dressing around the [CONDITION(S)], threw it to the trash, retrieved a sterile dressing and placed it around the [CONDITION(S)] site. She did not change gloves after she removed soiled dressing, and did not wash or sanitize her hands after she removed gloves. RN #1 picked up wound cleanser and calcium alginate dressing from the resident's blanket, and placed them back into a medication cart. III. Staff interview RN #1 was interviewed on 11/3/22 at 2:30 p.m. She said she should have washed her hands after she changed gloves and she forgot to do so. She said she also was aware that gloves should be changed after removing old dressing. She said she was nervous and forgot to do so. She said she carried all the supplies in her pocket for convenience and did not know why supplies were not kept at the bedside. She said some supplies were kept at the bedside and some in medication cart. The director of nursing (DON) was interviewed on 11/3/22 at 4:10 p.m. She said nurses were expected to follow the facility's policies and procedures for dressing changes. She said gloves should be changed after removal of an old dressing and hands must be washed or sanitized prior to the application of clean gloves. She said a clean field must be set up for wound care supplies to keep the supplies clean. She said all wound care supplies were resident specific and must be stored in the resident's room. She said she would provide education to all nurses to make sure they were following proper infection control techniques during wound care.

Based on observations and interviews, the facility failed to provide sufficient space to accommodate residents during meal times. Specifically, the facility failed to accommodate residents during meals on the memory care unit. Findings include: A. The memory care unit dining room The memory care unit dining room was small with two dining tables that were pushed together and one single table. B. Observations Observations during the morning and lunch meal revealed the following; -On 10/31/22 at 12:01p.m. some residents were observed lined up against the wall in the hallway eating lunch on rolling tables. The other half of residents were in the dining room eating and one resident was eating in their room; -On 11/1/22 at 9:00 a.m. and 12:00 p.m. some residents were observed in the hallway lined up against the wall eating their lunch on rolling tables. The other half of residents were in the dining room eating and one resident was eating in their room; and, -On 11/2/22 at 9:00 a.m. and 12:00p.m. some residents were observed in the hallway lined up against the wall eating their lunch on rolling tables. The other half of residents were in the dining room eating and one resident was eating in their room. C. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 11/2/22 at 12:23 p.m. She said the resident ate their meals at the same time. She said dining room was very crowded so they had residents eat on rolling tables. She said the dining room was crowded and this would cause residents to have too many resident-to-resident altercations. The director of nursing (DON) and the nurse consultant (NC) were interviewed on 11/3/22 at 4:00 p.m. The DON said that several residents ate in the hallway and seemed to be fine with it. She said they did not allow several residents in the dining together because they would have altercations. She said they did not consider staggering meal times to ensure residents could eat in dining area. She acknowledged there was not enough space in the dining room and the facility staff should consider decluttering the area. The NC acknowledged there was not enough space in the dining room because it was too cluttered and the facility staff should consider decluttering the area.

Based on record review and interviews, the facility failed to test residents, facility staff, and individuals providing services under arrangement and volunteers for COVID-19. Specifically, the facility failed to test all facility staff for COVID-19 after a staff member tested positive for COVID-19. Findings include: I. Facility policy The Resident and Staff Testing for COVID-19, dated April 2022, was provided by the regional clinical resource (RCR) on 6/1/22 at 11:39 a.m. The policy documented in pertinent part, It is the policy of the facility that all residents and staff will be offered to be tested for COVID-19 with a PCR (polymerase chain reaction) test if the facility identified one positive staff or resident in the facility and/or if the facility is in a COVID-19 outbreak or outbreak testing according to the outbreak testing schedule. For staff the policy read in pertinent part, Staff is required to participate in the COVID-19 testing after the identification of one positive resident or staff member and/or if the facility is in a COVID-19 outbreak or outbreak testing according to the outbreak testing schedule. If a staff member refuses testing for any reason, that staff member will be required to stay out of work for 14 days and will be required to test again and restart the surveillance outbreak testing prior to being allowed to come back to work. II. Record review According to the documentation of staff testing provided by the director of nursing (DON) on 6/1/22, six staff members out of 118 were not tested during the mandatory universal testing conducted on 5/20/22 and on 5/21/22. On 5/20/22 one staff member tested positive for COVID-19 and the facility started mass testing of all staff and residents. The documentation provided revealed there were six staff members who did not test or whose test results were not found out of the 118 facility staff tested . III. Staff interviews The DON was interviewed on 6/1/22 at 12:20 p.m. She said she discovered yesterday (5/31/22) that not all staff were tested on the 5/20/22 mandatory mass testing. She said she did not know that they were missing test results for six out of the 118 staff members until she reviewed the documentation yesterday. She said the infection preventionist (IP) said she tested the staff in question and was not sure what happened to their test results. She said unfortunately the facility was missing the test results for the six staff members. The DON said zero residents tested positive for COVID-19 in the 5/20/22 mandatory testing. She said the last time a resident was positive for COVID-19 in the building was during their last outbreak in February 2022. The IP was interviewed on 6/1/22 at 12:25 p.m. She said she remembered testing the six staff members. She said she did not know what happened to those tests and could not find the missing test results for the six staff members in question. She said there were no residents who tested positive during their mass testing on 5/20/22 and there have not been any positive COVID-19 cases for residents in the building since the staff member tested positive on 5/20/22.

Based on observations, interviews, and record review, the facility failed to ensure five (#156, #107, #45, #9 and #8) of eight residents reviewed out of 45 sample residents remained free from physical, verbal and psychosocial abuse and neglect and/or did not abuse other residents. The facility failed to ensure Resident #156 remained free from physical, verbal, and psychosocial abuse from Resident #107. Resident #107 targeted, intimidated and repeatedly hit Resident #156 who expressed fear of harm from Resident #107. The facility failed to keep the residents separated and protect Resident #156 after a physical abuse incident. The facility further failed to ensure: -Resident #45 remained free from resident-to-resident physical abuse; -Other residents were free from abuse by Resident #9; and -Resident #38 was free from staff-to-resident verbal abuse/neglect. Findings include: I. Facility policy and procedure The Abuse and Neglect Prohibition policy, revised July 2018, was provided by the nursing home administrator (NHA) on 1/13/2020. It read, in pertinent part, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abused facilitated or enabled through the use of technology. Injuries of unknown origin may occur as a result of abuse. Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. Staff will be instructed to report any signs of stress from employees, family, and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property, and to intervene as appropriate. Residents identified by staff as being self-injurious or exhibiting abusive behavior which require professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate. II. Failure to keep Resident #107 free from physical, verbal and psychosocial abuse by Resident #156 Cross-reference F740, failure to ensure behavioral health services were provided to maintain the highest practicable physical, mental, and psychosocial well-being. A. Resident #156 (victim) status Resident #156, age below [AGE], was admitted on [DATE] and discharged on [DATE]. According to the December 2019 computerized physician orders [REDACTED]. The 11/26/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BI[CONDITION]) score of 15 out of 15. He required limited one person assistance with bed mobility and transfers, and he required extensive one person assistance for dressing. He used a wheelchair for mobility. He had a fracture and experienced frequent pain. B. Resident #107 (assailant) status Resident #107, age below [AGE], was admitted on [DATE] and discharged on [DATE]. According to the December 2019 CPO, [DIAGNOSES REDACTED]. The 10/10/19 MDS assessment revealed the resident had severe cognitive impairment with no BI[CONDITION] score. She experienced hallucinations and delusions. There were no physical or verbal behaviors identified on the assessment. C. Record review Progress notes and facility investigative documentation for Resident #107 revealed the following behavior incidents: -On 11/19/19; the resident refused laboratory draws and became loud and aggressive. -The 11/21/19 facility reported incident investigation revealed Resident #107 physically abused Resident #156. The investigation description revealed an ambulatory resident (#107) struck a wheelchair bound resident (#156) in the back. It caused discomfort but no major injury. There were no previous incidents prior to this date. -On 12/1/19; the resident was reported to the nurse because she offered male residents sexual favors in exchange for cigarettes and money. -On 12/7/19; the resident was in the dining room and seen by staff going through another resident's change bag. When she was questioned by staff she said the resident gave her permission. The resident was educated on boundaries and respect of other people's belongings. -On 12/13/19; Resident #156 reported that Resident #107 chased him through the dining room this morning screaming. He said the resident had hit him before and threatened him. He stated he believed the resident would actually attempt to harm him again, and he did not want her to know where his room was for that reason. -On 12/13/19; the nurse observed the resident was outside of Resident #156's room and knocking on the door. She was redirected without incident at this time. -The 12/13/19 facility reported incident investigation revealed Resident #107 verbally abused Resident #156. The investigation description revealed Resident #156 reported to a nurse that Resident #107 chased him through the dining room screaming at him and threatened to kill him. He reported she had physically hit him and threatened him before and he believed she would actually attempt to harm him again. He did not want Resident #107 to know where his room was for fear of being harmed again. Resident #107 was then observed by a nurse outside this resident's room knocking on his door. She was redirected from Resident #156's room until she was removed from the facility on an emergency M-1 mental health hold. Resident #156's comprehensive care plan, revised 12/2/19, failed to document the resident was a victim of physical abuse and had ongoing concerns with Resident #107. There was no care plan to ensure the resident's physical and psychosocial well-being after he was first physically abused on 11/21/19. E. Interviews Licensed practical nurse (LPN) #10 was interviewed on 1/14/2020 at 2:58 p.m. She said Resident #107's behaviors were controlled upon admission to the facility. She said she was aware the resident was on court ordered medications, however, the facility could not force medications on the resident and they did not send her to a facility that was able to do so. She said the resident had more delusions and frequently stole from other residents after she refused medications. She said the resident frequently went into other residents' rooms and would become agitated when nursing staff redirected her. She said the resident fixated on Resident #156 and had a physical altercation with him. The nursing home administrator (NHA) was interviewed on 1/15/2020 at 2:49 p.m. She said when Resident #107 started to refuse medications she fixated on Resident #156 and had delusions that he was her ex-husband. Resident #107 displayed very agitated behaviors and frequently yelled at Resident #156. She said the facility moved Resident #156 to another room to prevent interactions between the two residents, however they frequently interacted in the smoking area because they were both unsupervised smokers. She said the facility did not have a plan to keep them separated because they were both independent residents. III. Failure to protect and prevent resident-to-resident abuse A. Resident #45 1. Resident status Resident #45, age [AGE], was admitted to the facility on [DATE] and readmitted on [DATE]. The January 2020 computerized physician orders [REDACTED]. The 11/5/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BI[CONDITION]) score of 2 out of 15. The resident demonstrated verbal behaviors, specifically yelling and screaming, which were identified as impacting the resident's risk for physical injury, intrude on the privacy of others and being disruptive in the living environment. 2. Resident representative interview The resident's representative was interviewed on 1/13/2020 at 9:54 a.m. She said she was contacted by the life enrichment coordinator (LEC) on 12/31/19 about the incident regarding the resident. She was told Resident #45 had an outburst at the doors to the unit resulting in another resident hitting her multiple times. When Resident #45 turned around to see what was going on both residents fell to the floor. She was told neither resident could remember the incident after it happened. She said she met with Resident #45 on 1/6/2020 and she appeared at baseline. She said the resident gets agitated easily but can be redirected with one on one engagement. 3. Observations The resident was observed on 1/13/2020 at 1:15 a.m. The resident was wandering the halls and would stop at the exit doors to the unit and stare out the semi-mirrored doors. She tried to open the door, but could not. As she was wandering the halls she was called out loudly for her grandfather and father. She did not respond to staff when they tried to interact and redirect her. She continued to yell down the hall to her room. The resident was observed on 1/14/2020 at 12:00 p.m. She was talking loudly in the hallway outside her room. She asked where her grandfather and father were. She became flustered, yelled out, threw her hands up and went back into her room. The resident was observed on 1/15/2020 at 11:30 a.m. She was standing at the exit door to the memory care unit, staring out the glass. She tried to open the door but it did not open. When the staff came to assist her away from the door she readily went with him as they chatted down the hallway to the common room. She was observed at 2:30 p.m. by the exit doors socializing with another resident. Staff redirected both residents away from the doors down to the common room for a snack. 4. Record review The revised care plan from 3/29/19 documented the resident's wandering and elopement behavior related to dementia and a history of elopement from the home. The goal was, the resident would demonstrate happiness with (her) daily routine through (the) review date. Interventions included identifying a pattern and cause of her wandering, nursing staff to offer emotional and psychological support, nursing staff to provide activities, including walking, reorientation, and talking with the resident about her pictures and memory boxes. The revised care plan also documented the resident's potential to be verbally aggressive related to dementia. The goal was the resident would have fewer episodes of verbal aggression through the review date. Interventions included assessing the resident's understanding of the situation and allow her time to express herself and feelings, give her as many choices as possible about care and activities, and provide feedback for good behavior. The nursing home administrator provided the abuse investigation on 1/14/2020 at 2:00 p.m. The investigation revealed the facility substantiated the abuse between residents as evidence by one resident deliberately striking the other in an aggressive manner. They found the cause of the aggression toward the victim (Resident #45) was due to her disruptive behavior of banging on the exit doors and yelling. The facility's immediate intervention was to separate the residents and occupy their attention on opposite ends of the memory care unit. Measures put in place to prevent recurrence were to redirect the victim (Resident #45) when she became loud or banged on the door. If she was not redirectable, the staff were to stay near her to prevent negative interaction with others. These measures were not reflected in the care plan. 5. Staff interviews Licensed practical nurse (LPN) #8 was interviewed on 1/15/2020 at 11:10 a.m. He said he witnessed and reported the abuse to the NHA on 12/30/19. He said he was working on the north unit and was outside the doors to the memory care unit. He said he saw Resident #45 standing just inside the doors of the locked unit and could hear her yelling. He said he saw Resident #9 come up behind Resident #45 and raised her hand to hit Resident #45 and struck her twice on the back of the head. He said he rushed into the unit. He said when he got onto the unit both residents were on the floor. Resident #45 was outside room [ROOM NUMBER] on the floor and Resident #9 had fallen against the shower door and was rubbing her shoulder. He said he called for the nurse on the unit who came to assess the residents. He said the residents seemed more concerned with getting up then what had just happened between them. He said the facility held yearly abuse training and abuse was discussed every couple of months at the staff meetings. He said he reported allegations or observations of abuse to the NHA. The rehabilitation manager (RM) was interviewed on 1/16/2020 at 9:50 a.m. She said she was outside the memory care unit doors and heard yelling than a clunk like something hit a door. She said when she got onto the unit both residents were on the floor and were trying to get up. She said she waited with the residents until the nurse came to assess them. She said she received abuse training during orientation four months prior. She said they taught prevention, what constitutes abuse, mandatory reporting rules, and follow up for allegations. She said she would report any allegations or observations of abuse to the NHA. Registered nurse (RN) #1 was interviewed on 1/16/2020 at 9:57 a.m. She said she assessed the residents after the abuse incident and subsequent fall. She said she checked the resident's vitals, orientation, and for injuries. When she asked the residents about what happened, neither could remember and reported not being afraid of one another. She said she was on break during the abuse incident and came back to the unit right after it happened. She said she received yearly abuse training from the social services department at the facility. She said she would report abuse allegations or observations to the NHA. Certified nurse aide (CNA) #2 was interviewed on 1/15/2020 at 10:40 a.m. He said he received yearly abuse training and abuse was discussed at their monthly all-staff meetings. He said he has not observed any fear between residents. He said many of the residents forget about the incidents they experienced with their peers due to their dementia. He said if he witnessed abuse he would report it to the NHA. The director of nursing (DON) was interviewed on 1/16/2020 at 8:30 a.m. She said after the incident between Resident #45 and Resident #9 they were separated and monitored for 48 hours. She said Resident #9 was having a bad day and staff were supposed to be with her. She said the CNA who was with Resident #9 had just completed care with the resident, was washing her hands and had not realized the resident had left the room. She said they were going to try to conceal the doors better so they did not look like exit doors. She said she believed this would help residents who exit seek. She said corporate came to the facility for abuse training and it was discussed at the monthly staff meetings. She said abuse allegations and observations were to be reported to the NHA. B. Resident #9 1. Resident status Resident #9, age [AGE], was admitted to the facility on [DATE]. The January 2020 CPO revealed a [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed the resident had severe cognitive impairment with a BI[CONDITION] score of two out of 15. The resident needed extensive two-person assistance with bed mobility, supervision with one person assistance for ambulating the unit and the use of a walker. The resident displayed delusions, verbal and physical aggression and wandering behaviors one to three days of the seven-day look-back period. 2. Record review The revised care plan from 4/26/19 revealed the resident had behavior problems related to [MEDICAL CONDITION] activity and dementia. During these episodes, she would place herself on the floor and experience panic attacks. The goal was the resident would have fewer episodes of behavioral induced [MEDICAL CONDITION] activity. Interventions included medications as ordered and documentation of effectiveness and side effects; caregivers were to provide positive interactions, attention, and stop to talk with her as they passed by; explain all procedures before begun and allow time for the resident to adjust to changes; discuss with the resident why her behavior was inappropriate or unacceptable; intervention as appropriate to protect the safety and rights of others; approach and speak to her in a calm manner and remove her from the situation; observe and attempt to determine the underlying cause of her behavior; praise her improvement with behaviors and provide a program of activities that interest and accommodate the resident. The care plan revealed the resident experienced delusions related to dementia, specifically that she was possessed, the devil followed her and needed to go to church. The associated goal was the resident would have fewer episodes of [MEDICAL CONDITION] or delusions. Interventions included consultation with interdisciplinary team (IDT) and family to establish her baseline; discuss and educate the resident, family, and caregivers about recognizing delusional episodes; have family and friends around during episodes for familiarity and support; engage the resident in simple structured activities, observe; record and report signs and symptoms of delusional episodes and redirect and reorient the resident as required. A behavior note dated 12/30/19 revealed the resident was combative that morning with staff. She had wandered into the hallway where another resident was yelling at the exit doors. She hit the yelling resident on the back of her head. After she struck the resident she was separated from the other residents for their safety. The police, nursing home administrator (NHA) and family were contacted. 3. Resident representative interview The resident representative was interviewed on 1/13/2020 at 11:36 a.m. She said she received calls from the facility when the resident fell and about the incident from 12/30/19. She said the facility informed her the resident hit another resident and she was being monitored for safety with others. 4. Staff interviews Licensed practical nurse (LPN) #8 was interviewed on 1/15/2020 at 11:10 a.m. He said he witnessed and reported the abuse to the NHA on 12/30/19. He said he was working on the north unit and was outside the doors to the memory care unit. He said he saw Resident #45 standing just inside the doors of the locked unit and could hear her yelling. He said he saw Resident #9 come up behind Resident #45 and raised her hand to hit Resident #45 and struck her twice on the back of the head. He said he rushed into the unit. He said when he got onto the unit both residents were on the floor. Resident #45 was outside room [ROOM NUMBER] on the floor and Resident #9 had fallen against the shower door and was rubbing her shoulder. He said he called for the nurse on the unit who came to assess the residents. He said the residents seemed more concerned with getting up then what had just happened between them. He said the facility held yearly abuse training and abuse was discussed every couple of months at the staff meetings. He said he reported allegations or observations of abuse to the NHA. The rehabilitation manager (RM) was interviewed on 1/16/2020 at 9:50 a.m. She said she was outside the memory care unit doors and heard yelling than a clunk like something hit a door. She said when she got onto the unit both residents were on the floor and were trying to get up. She said she waited with the residents until the nurse came to assess them. She said she received abuse training during orientation four months prior. She said they taught prevention, what constitutes abuse, mandatory reporting rules, and follow up for allegations. She said she would report any allegations or observations of abuse to the NHA. Registered nurse (RN) #1 was interviewed on 1/16/2020 at 9:57 a.m. She said she assessed the residents after the abuse incident and subsequent fall. She said she checked the resident's vitals, orientation, and for injuries. When she asked the residents about what happened, neither could remember and reported not being afraid of one another. She said she was on break during the abuse incident and came back to the unit right after it happened. She said she received yearly abuse training from the social services department at the facility. She said she would report abuse allegations or observations to the NHA. Certified nurse aide (CNA) #2 was interviewed on 1/15/2020 at 10:40 a.m. He said he received yearly abuse training and abuse was discussed at their monthly all-staff meetings. He said he has not observed any fear between residents. He said many of the residents forget about the incidents they experienced with their peers due to their dementia. He said if he witnessed abuse he would report it to the NHA. The director of nursing (DON) was interviewed on 1/16/2020 at 8:30 a.m. She said after the incident between Resident #45 and Resident #9 they were separated and monitored for 48 hours. She said Resident #9 was having a bad day and staff were supposed to be with her. She said the CNA who was with Resident #9 had just completed care with the resident, was washing her hands and had not realized the resident had left the room. She said they were going to try to conceal the doors better so they did not look like exit doors. She said she believed this would help residents who exit seek. She said corporate came to the facility for abuse training and it was discussed at the monthly staff meetings. She said abuse allegations and observations were to be reported to the NHA. IV. Failure to protect Resident #38 from verbal abuse/neglect by staff A. Resident status Resident #38, age over 50, was admitted on [DATE]. According to the January 2020 CPO, pertinent [DIAGNOSES REDACTED]. The 10/29/19 MDS assessment revealed Resident #38 was cognitively intact with a BI[CONDITION] score of 15 out of 15. The resident had no hallucinations or delusions. The resident had no rejection of care presence or frequency. She required extensive assistance from two or more persons with bed mobility, dressing, and toilet use. She required one person assistance with personal hygiene. The resident was frequently incontinent of bowel and bladder. B. Resident interview Resident #38 was interviewed on 1/13/2020 at 9:00 a.m. When discussing abuse and neglect, Resident #38 said when she asked to be changed, certified nurse aide (CNA) #8 told her to clean and change yourself. The resident said she felt degraded by CNA #8, and said, I do not want to work with (CNA #8) again. Resident #38 was interviewed a second time on 1/15/2020 at 8:30 a.m. She said CNA #8 worked on the floor the night of 1/13/2020 and 1/14/2020. Resident #38 said this bothered her since she did not want CNA #8 to work with her. C. Facility failures The facility failed to protect the resident from verbal abuse. Record review revealed the facility was aware of the resident's allegation of verbal abuse but failed to investigate thoroughly and in a timely manner. The facility failed to protect the resident, continuing to assign CNA #8 to care for the resident, creating the potential for further abuse. 1. Record review a. Care plan The resident's behavior and trauma care plan, initiated on 11/6/17 and most recently revised on 3/12/18, documented the resident had experienced multiple losses, with a goal for her to be able to cope. Interventions included if the resident expressed any allegation of abuse or neglect, all allegations would be reported and investigated immediately. The care plan further revealed the resident had an elimination deficit. The goal was the resident would have dignity maintained with staff assistance with incontinence needs and would remain clean and dry with staff intervention. Interventions included to check and the change the resident with all activities of daily living (ADL) rounds, as needed (PRN), and upon request. b. Resident concern form A 10/26/19 concern form documented Resident #38 stopped me and said a CNA (name not mentioned) came into her room and turned off the call light. (Resident #38) said she needed to be changed. The unknown CNA said, 'I don't have time for that.' This was reported previously to another staff member. The documented action taken on 10/28/19 was that Resident #38 had a history of [REDACTED]. c. Behavior note A 1/11/2020 behavior note read Resident #38 was refusing care from the agency aide that we currently have on the unit, saying that the aide is giving her attitude and arguing with her about how to clean her up properly. No grievance/concern or investigation was documented regarding this incident. d. Facility investigative report An investigation on the verbal abuse reported by the resident (during the interview above) was requested on 1/13/2020 at approximately 2:00 p.m. from the nursing home administrator (NHA). The report, provided on 1/15/2020, revealed the following: The facility did not initiate an investigation until the resident's statements above were reported to the NHA by the surveyor on 1/13/2020. The facility's verbal abuse investigation, initiated 1/13/2020 and dated 1/15/2020 at 5:39 p.m., documented in part, Resident did not repeat allegations. She said she thought the staff was rude. Fifteen residents were interviewed on the three units that CNA #8 worked. One of the residents reported that CNA #8 makes smartass comments. Eight staff members were interviewed and two supported the resident's allegation, saying that CNA#8 raised her voice and said the resident should change herself. However, the facility concluded since the resident had a pattern of allegations against staff, and CNA #8 did not have any behavior or performance related actions in her records, that the allegation was unsubstantiated. The facility documented that CNA #8 was assigned to another unit as the resident did not originally wish to continue to receive care from her. The facility also stated that CNA #8 was returned to her shift only after training for improved customer service. e. Failure to protect Review of time sheets and resident and interview revealed the facility allowed CNA #8 to work on the resident's unit on 1/13/2020 and 1/14/2020. A 1/14/2020 concern form, based on the resident's allegation regarding CNA #8, documented that the action taken was CNA #8 did change the resident and did not talk to the resident because she was not feeling well. There was no further investigation included with the concern form. Although the resident said she was verbally abused by CNA #8, another resident complained about the CNA's demeanor, and two staff interviews corroborated Resident #38's allegation, the facility determined without further investigation that the resident's allegation was unsubstantiated. CNA #8 was not trained and reassigned to a different unit away from the resident until the survey. V. Staff interviews CNA #2 was interviewed on 1/15/2020 at 10:40 a.m. He said residents should not be verbally abused and it should be reported immediately. He said he had no knowledge of Resident #38's allegations not being reported. CNA #5 was interviewed on 1/16/2020 at 10:42 a.m. He said, Residents should be allowed to fill out concerns to be investigated. He said he had no knowledge of Resident #38 allegations not being reported. CNA #6 was interviewed on 1/16/2020 at 10:53 a.m. She said staff should report concerns of residents regardless of how many times they reported. She said she had no knowledge of Resident #38 allegations not being reported. Licensed practical nurse (LPN) #1 was interviewed on 1/16/2020 at 10:27 a.m. She said it was staff responsibility to report allegations of abuse timely. She said he had no knowledge of Resident #38 allegations not being reported. LPN #2 was interviewed on 1/16/2020 at 10:11 a.m. She said it was staff responsibility to report allegations of abuse timely. She said residents had concerns frequently and they should be investigated immediately. She said she was a PRN (as needed) nurse and did not know concerns were not reported. The director of nursing (DON) was interviewed on 1/16/2020 at 4:01 p.m. She said overall she felt the facility was investigating allegations of abuse. She said residents made allegations frequently but should still be investigated. She said Resident #38 made allegations against several CNAs she did not want to do her cares, but she did not think they rose to the level of abuse.

Based on observations, record review, and interviews, the facility failed to ensure seven (#35, #45, #[AGE], #9, #68, #38 and #61) of 45 sample residents received quality care in accordance with professional nursing standards of care. The facility failed to ensure Resident #35 was assessed by a registered nurse (RN) after a fall with major injury. Additionally, the resident did not receive timely treatment after she fell and expressed pain and discomfort in her ankle. The resident did not get an x-ray ordered until over 24 hours after she fell . The facility failures resulted in delayed treatment for [REDACTED]. The facility further failed to: -Complete neurological assessments after falls with potential head injuries for Residents #45, #[AGE], #9 and #68; and -Ensure medications for Residents #38 and #61 were administered per physician orders and/or not left at their bedside. Findings include: I. Failure to ensure timely treatment after a fall and complete a timely RN assessment. A. Resident #35's status Resident #35, age above 70, was admitted on [DATE]. According to the January 2020 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 10/25/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BI[CONDITION]) score of three out of 15. She required extensive two person assistance with transfers and dressing, extensive one person assistance with bed mobility, toilet use, and personal hygiene. She had a lower extremity impairment on one side and she required a wheelchair for mobility. B. Record review The resident's electronic medical record revealed the resident sustained [REDACTED]. The [DATE] fall assessment, completed by licensed practical nurse (LPN) #11 and no registered nurse, revealed the resident sustained [REDACTED]. She was observed by the LPN walking with her walker when she lost her balance and went down to her knees and her left leg went underneath her. She complained of some discomfort to her left ankle and a Hoyer lift was used to assist the resident back into bed. -This assessment documented the resident had no injuries, despite the discomfort to the resident's left ankle requiring a Hoyer lift to get back to bed after she was unassisted to ambulate in the hallway prior to the fall. The October 2019 medication administration record (MAR) revealed the resident experienced pain in the evening on [DATE] and in the morning on 10/19/19. The nursing progress notes revealed approximately eight hours after the fall, the resident complained of pain and had a mild fever. On 10/19/19, there was no documentation of fall follow-up until 3:10 p.m. The note documented the resident's range of motion was within normal limits and she had no pain. On 10/19/19 at 10:15 p.m., over 24 hours after the fall occurred, the nursing progress note revealed the resident had left ankle swelling, bruising, and discomfort. an order for [REDACTED]. On 10/20/19 at 4:48 a.m., the nursing progress note revealed the resident continued to complain of pain to her left ankle and the ankle was swollen. On 10/20/19 at 1:54 p.m., the nursing progress note revealed the facility received results of the x-ray and the resident was positive for a fracture to her left ankle. The resident was in bed and non-weight bearing to her left lower extremity. She had dark purple discolored areas and non-[MEDICAL CONDITION]. The physician was notified and the resident was transferred to the hospital at 4:10 p.m. for treatment. The facility failed to obtain timely x-ray orders when the resident sustained [REDACTED]. She did not receive treatment until two days after she sustained the fall with injury. C. Interview The director of nursing (DON) was interviewed on 1/16/2020 at 3:39 p.m. She said the resident should be monitored every shift for [AGE] hours after a fall. She said the post fall assessment should be completed by an RN. She said she expected additional documentation to monitor pain for this resident after her fall. She said she did not assess the resident so she was unsure of the resident's status immediately after the fall. II. Neurological checks A. Facility policies and procedures The policy Fall Management System, revised November 2017, was received from the nursing home administrator (NHA) on 1/15/2020 at 10:00 a.m. It read in pertinent part, In the event a resident has a fall and it has been determined they hit their head (i.e. fall was witnessed, it is obvious there is a head injury, or the patient can verbalize they hit their head), or it cannot be determined if they hit their head (i.e., the fall was unwitnessed or the patient cannot verbalize if they hit their head), the nurse initiates the following actions: 1. All items listed under Fall Event are completed. 2. Neurological checks are completed and documented per instructions. The policy Neurological Assessment, Long-Term Care, revised August 2019, was provided by the director of nursing (DON) on 1/15/2020 at 2:00 p.m. It read in pertinent part, A neurological assessment is an indispensable tool for quickly checking a resident ' s neurological status. This procedure (neurological assessment) supplements the routine measurement of vital signs (such as temperature, pulse rate, blood pressure, and respirations) by evaluating a resident ' s level of consciousness (LOC), pupil activity, motor response, and orientation to time, place, and person. Changes in vital signs alone rarely indicate neurological compromise. Thus, any changes should be evaluated in light of a complete neurological assessment. Because vital signs are controlled at the medullary level, changes in vital signs can signify ominous neurological compromise. LOC, a measure of environmental awareness and self-awareness, usually provides the first signs of central nervous system deterioration. LOC assessment involves observing the level of awareness and arousal. A focused neurological assessment is necessary after a fall, if the resident may have sustained a head injury or is receiving anticoagulant therapy. The neurological (neuro) records forms, revised October 2011, were received from the NHA on 10/15/2020 at 10:00 a.m. The instructions for neuro checks read in pertinent part, Frequency: every 30 minutes X(times) 4, every 1 hour X 4 hours, every 4 hours X 24 hours, every 8 hours X for remaining [AGE] hours or as ordered by physician. B. Resident #45 1. Resident status Resident #45, age [AGE], was admitted to the facility on [DATE] and readmitted on [DATE]. The January 2020 computerized physician orders (CPO) revealed [DIAGNOSES REDACTED]. The 11/5/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BI[CONDITION]) score of two out of 15. The resident needed extensive support from staff for bed mobility, required staff supervision while ambulating on the unit and used a walker for ambulation. 2. Record review The neurological (neuro) records following the resident's falls on 10/4/19, 10/10/19, and 12/30/19 were received from the nursing home administrator (NHA) on 1/15/2020 at 10:00 a.m. The neuro records revealed that nursing staff failed to complete the scheduled neuro assessments on: -10/5/19 at 4:30 a.m., 5:30 a.m. and 9:30 p.m. -10/6/19 at 1:30 a.m. and 5:30 a.m. -10/8/19 for the noc (overnight) shift check. -10/10/19 at 9:45 a.m. and 11:45 a.m. -10/11/19 at 12:45 a.m., 4:45 a.m, check for the 2-10p.m. shift and the check for the 10 p.m.-6 a.m. shift. -10/12/19 for the 6 a.m.-2 p.m. shift check. -10/12-10/13/19 for the 10 p.m.-6 a.m. shift check. -10/13/19 for the 6 a.m.-2 p.m. shift check -12/31/19 at 1:00 a.m. and 5:00 a.m. -1/1/2020 for the 10 p.m.- 6 a.m. shift check -[DATE] for the noc (overnight) shift check. 3. Family interview A family member of the resident was interviewed on 1/13/2020 at 9:33 a.m. He said the resident had fallen three or four times since she had been there. He said the facility called him when the resident fell . He said last time he visited she seemed slower than usual but was still walking around. He said sometimes she would forget her walker and walk around the unit without it. C. Resident #[AGE] 1. Resident status Resident #[AGE], age [AGE], was admitted to the facility on [DATE]. The January 2020 CPO revealed a [DIAGNOSES REDACTED]. The 12/24/19 MDS assessment revealed the resident had short and long term memory problems with severe impairment for daily decision-making skills. The resident required supervision while ambulating on the unit and required extensive, one person assistance for bed mobility. 2. Record review The neuro records following the resident's falls on 12/26/19 and 1/6/2020 were received from the NHA on 1/15/2020 at 10:00 a.m. The neuro records revealed that nursing staff failed to complete the scheduled neuro assessments on: -12/26/19 at 11:00 p.m. -[DATE] at 1:00 am, 3:00 a.m.and 7:00 a.m. -1[DATE] for the noc (overnight) shift check. -12/29/19 for the noc (overnight) shift check. -1/6/2020 at 3:45 a.m., 4:15 a.m., 6:15 a.m. and 8:15 p.m. -1/7/2020 at 1:15 a.m. and 5:15 a.m. The facility did not provide the complete neurological assessment for this fall. The documents provided ceased during the every 4 hours X 24 hours section of the checks. 3. Family interview A family member of the resident was interviewed on 1/13/2020 at 10:49 a.m. She said the facility contacted her after any incident. She said the resident had had multiple falls while residing at the facility. She said some of the falls had resulted in injuries and hospital visits. She said the resident was not super steady on her feet and had jerky movements that impacted her balance. She said when staff noticed these movements they would stay close by for safety. She said the facility had tried a wheelchair and a walker but the resident was not compliant with using either. She said she had discussed fall interventions with the facility and hospice and there were limited options left to try, without over-medicating the resident. D. Resident #9 1. Resident status Resident #9, age [AGE], was admitted to the facility on [DATE]. The January 2020 CPO revealed [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed the resident had severe cognitive impairment with a BI[CONDITION] score of two out of 15. The resident needed extensive two-person assistance with bed mobility, supervision with one person assistance for ambulating the unit and the use of a walker. 2. Record review The neuro record following the resident's falls on 12/24/19, 12/30/19 and 1/1/2020 were received from the NHA on 1/15/2020 at 10:00 a.m. The neuro records revealed that nursing staff failed to complete the scheduled neuro assessments on: -12/24/19 at 3:00 p.m. -12/25/19 at 1:00 a.m. and 5:00 a.m. -12/26/19 for the noc (overnight) shift check -[DATE] for the noc shift check -1[DATE] for the noc shift check -12/31/19 at 5:00 a.m. -1/1/2020 at the beginning of the every-eight-hour checks, unreadable times were documented. -1/1-1/2/2020 for the noc shift check -1/2/2020 for the eve (evening) shift check -1/2-[DATE] for the noc shift check -[DATE] at 5:00 a.m., 6:00 a.m., 7:00a.m., and 8:00 a.m. -[DATE]20 at 12:00 a.m., and 4:00 a.m. -1/6/2020 for the day shift check. 3. Resident representative interview The resident representative was interviewed on 1/13/2020 at 11:36 a.m. She said she received calls from the facility when the resident fell . She said the resident used a walker to help her unsteadiness while walking. E. Resident #68 1. Resident status Resident #68, under age 65, was admitted to the facility on [DATE]. The January 2020 CPO revealed a [DIAGNOSES REDACTED]. The 11/25/19 MDS assessment revealed the resident had severe cognitive impairment with a BI[CONDITION] score of zero out of 15. The resident required extensive two-person assistance for bed mobility and transfers and required supervision and one person assistance while ambulating the unit. 2. Record review The neuro record following the resident's fall on 1/6/2020 was received from the NHA on 1/15/2020 at 10:00 a.m. The neuro records revealed that nursing staff failed to complete the scheduled neuro assessments on: -1/6/2020 at 4:30 a.m. and 5:00 a.m. -1/7/2020 at 1:00 a.m., 5:00 a.m. and for the noc shift check. -1/8-[DATE] for the noc shift check. 3. Resident representative interview The resident representative was interviewed on 1/14/2020 at 11:30 a.m. She said the facility called her about the fall and that the resident had no injuries. F. Staff interviews Licensed practical nurse (LPN) #8 was interviewed on 1/15/2020 at 11:10 a.m. He said neuro checks were supposed to be done after a fall with head injury or unwitnessed. He said neuro checks were to be done for 30 minutes for two hours, hourly for four hours, every four hours for 24 hours then once a shift for the remaining time. He said if the residents were asleep he awakened them for the neuro assessments. He said if he noticed he missed a check time, he would do the check immediately and continue the designated check schedule. Registered nurse (RN) #1 was interviewed on 1/16/2020 at 9:57 a.m. She said if the resident hit their head during a fall or the fall was unwitnessed, neuro checks would be initiated. She said she looked at eye movement, mobility, pain, and vitals while doing neuro checks. She said if the resident was asleep at the designated check time, she would wake them to complete the check. She said she would complete the check immediately after she noticed she missed it. The director of nursing (DON) was interviewed on 1/16/2020 at 8:30 a.m. She said in the event of a fall the RN was to do an assessment and check for injuries. She said if the resident hit their head or the fall was unwitnessed neuro checks were to be initiated. She said neuro checks were to be done according to the schedule on the neuro assessment form and should be continued for [AGE] hours after being initiated. She said residents needed to awaken for neuro checks. She said checks were not supposed to be missed but if they were, checks needed to be done immediately after the nurse realized they had been missed. III. Medication administration A. Facility policy and procedure The Medication Administration policy, revised June 2008, was provided by the district director clinical services (DDCS) on 1/16/2020 at 4:00 p.m. The policy read in pertinent part, Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the facility. Observe that the resident swallows oral drugs. Do not leave medications with the resident to self-administer unless the resident is approved for self-administration of the medication. B. Resident #38 1. Resident status Resident #38, age over 50, was admitted on [DATE]. According to the January 2020 computerized physician orders, pertinent [DIAGNOSES REDACTED]. The 10/29/19 minimum data set (MDS) assessment revealed Resident #38 was cognitively intact with a brief interview for mental status (BI[CONDITION]) score of 15 out of 15. The resident had no hallucinations or delusions. The resident had no rejection of care presence or frequency. She required extensive assistance from two or more persons with bed mobility, dressing, and toilet use. She required one person with personal hygiene. Supervision and setup help with eating. 2. Observation Resident #38 was observed on 1/13/2020 at 9:00 a.m. The resident's 6:00 a.m. medications were observed on the resident's bedside table in the medication cup. 3. Resident interview Resident #38 was interviewed on 1/13/2020 at 9:05 a.m. The resident said the pills were brought to her at 6:00 a.m. The resident said she liked to take medication with meals and the morning nurse just put them beside her bed. 4. Record review The care plan, initiated on 8/14/17 and most recently revised on 5/10/18, documented medications were to be administered as ordered by the medical doctor (MD). Review of Resident #38's January 2020 medication administration record (MAR) revealed the following medications were administered at 6:00 a.m. on 1/13/2020: -[MEDICATION NAME] tablet 10 mg (milligrams). Give one tablet by mouth one time a day for allergies [REDACTED]. -[MEDICATION NAME] tablet extended release 12 hour [AGE]0 mg. Give [AGE]0mg by mouth in morning related to asthma. -[MEDICATION NAME] capsule 300 mg. Give 300mg by mouth two times a day related to chronic pain. -[MEDICATION NAME] tablet [AGE]0 mg. Give one tablet by mouth two times a day for pain related to chronic pain. -[MEDICATION NAME] tablet, delayed release. Give 40mg by mouth two times a day related to [MEDICAL CONDITION] reflux disease without esophagitis. Review of the resident's January 2020 CPO revealed no physician orders authorizing the resident to self-administer medications. The January 2020 progress notes were reviewed and did not reveal any documentation of the resident requesting 6:00 a.m. medications to be administered at 9:00 a.m., or to be left at the bedside. C. Resident #61 1. Resident status Resident #61, age over 65, was admitted on [DATE]. According to the January 2020 CPO, pertinent [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed Resident #61 was cognitively intact with a BI[CONDITION] score of 15 out of 15. The resident had no hallucinations or delusions. The resident had no rejection of care presence or frequency. He required extensive assistance from one person with toilet use. He required supervision with personal hygiene. He was independent for eating. 2. Observation Resident #61 was observed on 1/15/2020 at 8:20 a.m. Resident was observed to have upset stomach medication and nasal decongestant medication at the bedside table. 3. Resident interview Resident #61 was interviewed at 1/15/2020 at 8:25 a.m. The resident said, I told the nurse, I had a terrible cold and went to the store last night to get medication because she would not call the medical doctor or give me anything. 4. Record review The care plan, initiated on 10/21/15 and not revised, documented the resident had major [MEDICAL CONDITION], hypertensive heart and [MEDICAL CONDITION] without heart failure. The goal was for the resident to have fewer episodes of verbal aggression. Interventions included administering medications as ordered, and observe and document for side effects and effectiveness. The resident's January 2020 MAR revealed no order to authorize the resident to self-administer medications. The January 2020 progress notes revealed no documentation of the resident requesting and self-administering over-the-counter medications. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 1/16/2020 at 10:11 a.m. She said residents should not have medications left at bedside. She said medication should be given according to doctor orders. She said any medication not given according to its scheduled time could have adverse effects on residents, especially pain medications. She said she did not know who left medications at the resident's bedside. LPN #1 was interviewed on 1/16/2020 at 10:27 a.m. She said nursing staff should not leave medications at bedside or let residents purchase medications from the store. She said nursing should know what extra medications a resident was taking. She said some medications had interactions when taken close together or in combination with other medications. The director of nursing (DON) was interviewed on 1/16/2020 at 4:25 p.m. The DON agreed that over the counter medications should not be left at bedside unless there was a physician order. She said her staff should not leave medications at bedside and if a resident refused medications this should be documented on the MAR and in a progress note.

Based on observations and interviews the facility failed to ensure the environment for two (#50 and #[AGE]) of eight residents reviewed out of 45 sample residents, remained as free from accident hazards as possible to prevent major injury. The facility failed to ensure heat treatment applied during physical therapy for Resident #50 was applied correctly and free from hazardous materials. This contributed to resident harm as the resident experienced a burn with blisters on his leg from the misuse of physical therapy equipment. Additionally, there was a delay in treatment to the burned area and it was unknown when the blisters opened to the air which exposed the resident to a risk of infection. The facility further failed to protect Resident #[AGE] from multiple falls with injuries, including skin tears and abrasions, a trauma wound, broken teeth, and a head injury. The facility's failure to provide supervision and assistance contributed to the resident suffering falls and ultimately sustaining a head wound that required a visit to the emergency room for sutures. Findings include: I. Burn resulting from diathermy treatment A. Facility policy and procedure The Skin Management policy, revised July 2017, was provided by the director of nursing (DON) on 1/16/2020 at 10:30 a.m. The policy and procedure failed to [MEDICAL CONDITION] treatment expectations. B. Professional reference According to Hermans, M.H. E. (2019). An Introduction to Burn Care. Advances in Skin & Wound Care: The Journal for Prevention and Healing, 32 (1). pgs 9-18. Retrieved from: https://www.nursingcenter.com/cearticle?an= 334- 1000- &Journal_ID= &Issue_ID= 23 (January 28, 2020), in pertinent part, [MEDICAL CONDITION] caused by contact with a hot surface. In many cases, these injuries are not deep, although this depends on the temperature of the surface touched and the length of exposure. Major injuries may be caused by the combination of pressure and prolonged exposure to the heat source. C. Resident #50's status Resident #50, age above 70, was admitted on [DATE]. According to the January 2020 computerized physician orders [REDACTED]. The 11/12/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BI[CONDITION]) score of six out of 15. He required one person physical assistance with bed mobility and transfers and used a wheelchair for mobility. He had second or third degree burns. D. Record review The 10/10/19 facility investigation, reported to the state agency, revealed Resident #50 received a burn with blisters on his right outer leg due to the misuse of diathermy heat treatment. The heat was paired with a weight on his leg which had a metal substance in it. The therapy heated up the metal and resulted in a burn on the resident's leg. The report revealed the incident occurred on [DATE] and was reported to the state on 10/10/19, nine days after the incident occurred. The resident's situation background assessment recommendation (SBAR) was completed on [DATE] at 10:33 p.m. by licensed practical nurse (LPN) #11, when the blisters appeared on the resident's leg. The SBAR revealed the resident had two red marks with blistering in the middle to his right outer knee. The therapist stated the burn might have occurred when weight was used in connection with heat for the area. The physician was notified that day at 10:30 p.m. Orders specified on the change of condition form were to monitor the area for changes. The October 2019 treatment administration record (TAR) revealed the following pertinent orders: -On [DATE]; Monitor areas times two to right knee for changes every shift for skin trauma. This task was checked off as completed on 10/2/19, however, there was no identification of changes to the skin trauma. On 10/3/19 there was no morning skin monitoring checked off on the TAR. -On 10/3/19; Monitor wound to right lateral knee for abnormalities or changes to the dressing, skin, or pain associated with the wound. Document (-) if there were no observed abnormalities and (+) if abnormalities were observed and document findings in nurses notes every evening shift for skin trauma. -On 10/3/19; Wound to right lateral knee, cleanse with wet cloth, pat dry, apply xeroform and cover with dry protective dressing every day and as needed if removed. -On 10/14/19; Wound to right lateral knee, cleanse with wet cloth, pat dry, apply [MEDICATION NAME] followed by calcium alginate and cover with dry protective dressing every day and as needed if soiled or removed. The 10/7/19 weekly skin assessment revealed the resident had a burn on his right knee 4.5 centimeters (cm) long by 3.0 cm wide. It was described as a cluster burn wound to the right lateral knee with serous drainage noted and 20 percent skin. The 10/14/19 weekly skin assessment revealed the resident's wound progress deteriorated and the treatment plan was changed. It was described as a cluster burn wound to the right lateral knee 1.8 cm by 3.2 cm with moderate serous drainage. It was 20 percent slough and [AGE] percent skin. The initial wound evaluation and management summary, documented by the wound physician, was completed on 10/14/19, two weeks after the burn occurred. The summary revealed the resident acquired [MEDICAL CONDITION] of the right knee and required a surgical excisional debridement procedure on the area of the burn to excise 5.76 cm squared of devitalized tissue which included slough, biofilm and non-viable subcutaneous fat and surrounding connective tissue at a depth of 0.2 cm. According to wound treatment documentation, the wound was treated weekly by the wound specialty physician until it was resolved on 11/25/19. The resident required wound treatment for 56 days due to the misuse of heat treatment during physical therapy. The facility failed to monitor appearance and document any changes to the trauma wound from [DATE] until 10/3/19 when wound treatment orders were placed. There were no measurements or wound descriptions until 10/7/19, six days after the burn occurred. V. Interviews The physical therapist (PT) was interviewed on 1/16/2020 at 9:44 a.m. She said the physical therapy assistant was stretching the resident's hamstring contracture with shortwave diathermy heat treatment. She said the physical therapy assistant placed a weight on top of the resident's leg to increase heat to the area but the facility was unaware there was metal in the weights. She said the shortwave diathermy treatment heated up the metal and burned the resident's leg. She said there was not a barrier placed between the weight and the resident's skin which led to a burn. She said an in-service training was completed with all therapists to ensure proper use of the diathermy heat treatment. Licensed practical nurse (LPN) #1 said when the nurse identified a change in skin condition or open wound they should notify the physician, the wound team, and the assistant director of nursing (ADON) immediately to obtain treatment orders. She said the nurse should complete the SBAR for a change of condition and obtain measurements and description of the wound. LPN #2, who also completed wound rounds with the wound physician, was interviewed on 1/16/2020 at 10:17 a.m. She said she noticed drainage to the resident's burn when she saw the resident on 10/3/19. She said she noticed the burn was open and needed treatment, but she was unsure when the blisters opened to air. She said there was no documentation of when and how the blister trauma changed on the resident. She said the blister needed to be covered as soon as it opened to air to prevent infection in the wound. She said there was no documentation of when the wound changed prior to 10/3/19 when she obtained new treatment orders at 12:45 p.m. The director of nursing (DON) was interviewed on 1/16/2020 at 4:31 p.m. She said the burn occurred in physical therapy and the therapist did not notice it burned his leg. She said she expected the burn to be monitored every shift and documented plus if there were changes and minus if there were no changes. She said the physician should be contacted as soon as any changes in the wound occurred to see if new treatments were needed. She said she would expect for the nurse to document and notify the physician as soon as the blister opened to air. II. Failure to prevent falls with injuries A. Resident #[AGE]'s status Resident #[AGE], age [AGE], was admitted to the facility on [DATE]. The January 2020 CPO revealed a [DIAGNOSES REDACTED]. The 12/24/19 MDS assessment revealed the resident had short and long term memory problems with severe impairment for daily decision-making skills. The resident required supervision while ambulating on the unit and required extensive, one person assistance for bed mobility. The resident had one fall with no injury and two or more falls with injury since the prior assessment. B. Record review The nursing home administrator provided a fall investigation regarding Resident #[AGE] on 1/16/2020 at 2:00 p.m. The fall investigation dated 11/23/19 revealed the resident suffered an unwitnessed fall. When discovered by staff the resident was bleeding from the back of her head and from a skin tear on her left arm. After being assessed by the nurse the resident was sent to the emergency room via ambulance. The nurse informed the resident's representative and the hospice provider. A nursing note dated 11/23/19 revealed the resident returned from the hospital via ambulance. The resident was documented to have eight stitches to the wound on the back of her head. The revised care plan dated [DATE] revealed the resident suffered multiple falls resulting in injuries while on the memory care unit. The focus revealed the resident had a risk of skin injuries from falls: -8/14/19: wound to right elbow from a fall (resolved 9/3/19) -8/14/19: wound to left elbow from a fall (resolved 9/3/19) -[DATE]: wound to left elbow from a fall (resolved 9/23/19) -[DATE]: wound to the left knee from a fall (resolved 9/30/19) -9/22/19: wound to right wrist (resolved 10/28/19) -11/3/19: wound to the right side of her face from a fall (resolved [DATE]) -11/14/19: wound to the left wrist (resolved 12/2/19) -11/21/19: wound to the left side of her face from a fall (resolved 12/9/19) -11/23/19: wound to the back of scalp from a fall (resolved 12/9/19) -11/23/19 trauma wound to left elbow from a fall. The goal associated with this focus documented the resident's wounds would heal by the review dates. Interventions included to keep skin clean and dry and document wounds. The revised care plan documented the resident's risk for falls related to dementia. The associated goal documented the resident's risks and injury potential would be minimized through the next review date. Interventions included to anticipate and meet the resident's needs; continued supervision while walking and during activities; educate the resident, family, and caregivers about safety and what to do in the event of a fall; follow facility protocol; low bed with fall mat; medication review; and staff to monitor the hallway and attempt to intercept possible risky physical contact. The facility failed to consistently implement the care plan intervention to provide supervision while walking and during activities. C. Resident representative interview The resident representative was interviewed on 1/13/2020 at 10:49 a.m. She said the facility contacted her after any incident. She said the resident had had multiple falls while residing at the facility. She said some of the falls had resulted in injuries and hospital visits. She said the fall on 11/3/19 resulted in two broken teeth (however, this injury was not documented in the resident's medical record). She said the resident was not super steady on her feet and had jerky movements that impacted her balance. She said when staff noticed these movements they would stay close by for safety. She said the facility had tried a wheelchair and a walker but the resident was not compliant with using either. She said she had discussed fall interventions with the facility and hospice and there were limited options left to try, without over-medicating the resident. D. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 1/15/2020 at 10:40 a.m. He said the staff knew who the fall risk residents were. He said Resident #[AGE] was always a fall risk. He said her jerky movements contributed to falls and staff tried to stay close to her when they noticed the movements. He said she sometimes would fall when the staff was not around and the staff found out after. He said she benefited from one-on-one staffing to prevent falls. He said they had a hard time getting extra help to do one-on-ones. He said fall interventions could be found in the resident's care plan. Licensed practical nurse (LPN) #8 was interviewed on 1/15/2020 at 11:10 a.m. He said in the event of a fall a registered nurse (RN) should assess the resident immediately. The RN would check for injuries, cognitive state, and vitals. The RN would initiate neurological assessments in the case the resident hit their head if the fall was unwitnessed. If there was an injury the resident would be sent to the hospital after the physician was called. The family and the hospice agency were also notified. He said fall interventions and precautions could be found in the care plan. He said the care plan was updated by the interdisciplinary team and then relayed to the nursing staff. The director of nursing was interviewed on 1/16/2020 at 8:30 a.m. She said the RN was to do an assessment immediately after the fall. She said the physician should be called and consulted about injuries and if the resident needed to be sent to the emergency department.

Based on record review and interviews, the facility failed to ensure one (#107) of five residents reviewed out of 45 sample residents received the behavioral health services needed to maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to ensure Resident #107 received the behavioral health services needed for medication management. The facility failures contributed to the resident repeatedly refusing medications, decompensating, and suffering a mental health decline which resulted in the resident being re-hospitalized . Cross-reference F[AGE]0, failure to ensure residents remained free from abuse. Findings include: I. Facility policy and procedure The Behavioral Health Management policy, revised [DATE], was provided by the district director of clinical services (DDCS) on [DATE]. It read, in pertinent part, Residents receive behavioral health care and services, including those residents diagnosed with [REDACTED]. The resident's behavioral health needs are assessed, monitored, and evaluated on an ongoing basis to review the effectiveness of the interventions in place. Facility has sufficient staff members that have the competencies and skill sets necessary to provide direct nursing care and other services to residents. Facility staffing is sufficient to address the behavioral health care needs identified on the residents' assessments and care plans, and takes into account the facility's overall acuity, diagnoses, and facility population. These competencies and skill sets include, but are not limited to: a) Non-pharmacologic interventions and support when residents are expressing or indication feelings of distress; b) Communication and interaction that promote well-being and meaningful engagement; c) Care of cognitively impaired residents; and d) Reporting of changes in condition, including changes in resident's social interactions and behaviors. II. Resident status Resident #107, age below [AGE], was admitted on [DATE] and discharged on [DATE]. According to the [DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with no brief interview for mental status (BI[CONDITION]) score. She experienced hallucinations and delusions. There were no physical or verbal behaviors identified on the assessment. II. Record review The Preadmission Screening and Resident Review Level II assessment revealed Resident #107 had psychiatric risks which included physical aggression, poor medication compliance, and transition difficulty. She had a history of [REDACTED]. The comprehensive care plan, revised [DATE], revealed the resident had a behavior problem due to [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. She experienced delusions and believed she was pregnant. Interventions included, ensure resident received interaction to distract away from other residents whom she becomes fixated on, if resident refused medications and/or destabilized mentally plan a transfer back to psychiatric facility. - The comprehensive care plan failed to address the resident's court ordered medications and threatening behaviors towards other residents while she was a resident in the facility. The resident's order summary report revealed the following pertinent physician orders: - Ordered on [DATE], if resident refused labs and psychiatric medications two consecutive days, may transfer back to psychiatric health facility. - Ordered on [DATE], if the resident was not accepted back to psychiatric health facility, then refer to hospital for psychiatric admission. - Ordered on [DATE]; monitor behaviors, if the resident became a danger to herself or others send out for emergency. The [DATE] Medication Administration Record [REDACTED] -[MEDICATION NAME] tablet 100 milligrams (mg) in the morning for [MEDICAL CONDITION]. This dose was refused three times ([DATE], [DATE], and [DATE]) out of 20 opportunities -[MEDICATION NAME] tablet 400mg at bedtime for [MEDICAL CONDITION]. This dose was refused three times ([DATE], [DATE], and [DATE]) out of 20 opportunities. The [DATE] MAR indicated [REDACTED] -[MEDICATION NAME] tablet 100 milligrams (mg) in the morning for [MEDICAL CONDITION]. This dose was refused 17 times ([DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE]) out of 30 opportunities. -[MEDICATION NAME] tablet 400mg at bedtime for [MEDICAL CONDITION]. This dose was refused 21 ([DATE]-[DATE], [DATE]-[DATE], and [DATE]) times out of 30 opportunities. The [DATE] MAR indicated [REDACTED] -[MEDICATION NAME] tablet 100 milligrams (mg) in the morning for [MEDICAL CONDITION]. This dose was refused six ([DATE], [DATE], [DATE], [DATE], and [DATE]-[DATE]) times out of 13 opportunities. -[MEDICATION NAME] tablet 400mg at bedtime for [MEDICAL CONDITION]. This dose was refused ten times ([DATE]-[DATE], [DATE]-[DATE]) out of 12 opportunities. The nursing behavior progress notes revealed the following behavior incidents: -On [DATE]; resident was at medication cart for her night meds, she took a couple of pills and threw the rest of them away. The nurse re-poured her medications and reminded the resident she had a court order to take the medications. The resident replied in a different monotone voice and walked away without taking her medications. The resident did not display aggressive behaviors but she was observed talking to herself and answering herself in a different person. -On [DATE]; resident refused to her night medications, she insisted she already had her medications. Nurse attempted to tell the resident she had an extra dose because her levels were down and routine needed to be maintained. The resident said I have camera eyes and I know that they took extra blood from me to feed the dead babies. Nurse left the resident in bed and she did not take medications. -On [DATE]; resident refused to have her laboratory blood draws done. -On [DATE]; resident refused to have her laboratory blood draws done again. The nurse used a calm approach with positive reinforcements to encourage the resident to allow laboratory draws. The resident refused again and became loud and aggressive. -On [DATE]; the resident was reported to the nurse because she offered male residents sexual favors in exchange for cigarettes and money. -On [DATE]; the resident refused her [MED] and said it made her tongue thick, the nurse practitioner tried to explain to her that she had dry mouth and to rinse her mouth with water and hold before she spits out the water. She agreed to rinse her mouth but still refused her medications. -On [DATE]; the resident was in the dining room and seen by staff going through another resident's change bag. When she was questioned by staff she said the resident gave her permission. The resident was educated on boundaries and respect of other people's belongings. - On [DATE]; the resident increased laughing and having conversations with herself. She was crying and said she stuck something up her buttocks and needed something to remove it. She stopped crying but had a panicked tone and reiterated she needed to get the item out of her buttocks. -On [DATE]; Resident #156 reported that Resident #107 chased him through the dining room this morning screaming. He said the resident had hit him before and threatened him. He stated he believed the resident would actually attempt to harm him again, and he did not want her to know where his room was for that reason. -On [DATE]; the nurse observed the resident was outside of Resident #156's room and knocking on the door. She was redirected without incident at this time. The [DATE] facility reported incident investigation revealed Resident #107 physically abused Resident #156. The investigation description revealed an ambulatory resident (#107) struck a wheelchair bound resident (#156) in the back. It caused discomfort but no major injury. There were no previous incidents prior to this date noted in the investigation. The [DATE] facility reported incident investigation revealed Resident #107 verbally abused Resident #156 when she threatened homicidal ideations to him and said she wanted to kill his mom too. The resident was transferred to the hospital at this time for a psychiatric evaluation. The facility failed to update Resident #107's care plan with behavioral health interventions related to her fixation on other residents, misappropriation of other resident's property, and physical and psychosocial harm towards other residents. They failed to care plan her refusal of medications and interventions to encourage court ordered medications. Review of the facility behavior management training report provided by the DDCS on [DATE] revealed 59 out of [AGE] employees available did not receive the behavior management training conducted on [DATE] as stated by the nursing home administrator (NHA). (See interview below) III. Interviews Licensed practical nurse (LPN) #10 was interviewed on [DATE] at 2:58 p.m. She said the resident's behaviors were controlled upon admission to the facility. She said she was admitted from a behavioral health facility with a bag of goodies which consisted of hair ties, chapstick, lipstick, and small accessories to bribe the resident to take her meds. She said this method worked until the facility ran out of goodies. She said the facility could not refill the bag of goodies and the resident started to refuse her medications. She said she was aware the resident was on court ordered medications, however, the facility could not force medications on the resident and they did not send her to a facility that was able to do so. She said the resident had more delusions and frequently stole from other residents after she refused medications. She said the resident frequently went into other resident's rooms and would become agitated when nursing staff redirected her. She said the resident fixated on Resident #156 and had a physical altercation with him. The nursing home administrator (NHA) was interviewed on [DATE] at 2:49 p.m. She said the resident often had delusions that she was pregnant with either Satan's baby or God's baby. She said she started to refuse medications based on this delusion and she fixated on Resident #156 because she thought he was her ex-husband. She said the resident's behavior became very agitated and aggressive towards Resident #156. She said they tried to separate the residents but they would see each other in the smoking area and around the building. She said Resident #107 would actively seek out Resident #156 and ask for cigarettes. LPN #2 was interviewed on [DATE] at 10:08 a.m. She said when the resident was first admitted to the facility they were aware of her court ordered medications, however, the facility accepted her anyway. She said the resident's behaviors were manageable when she first admitted but she declined rapidly when she refused her medications. She said there were no additional interventions done when the resident refused her medications and the resident became a threat to other residents. The facility did not have a social services director to interview. The NHA was interviewed on [DATE] at 2:06 p.m. She said the court ordered meds were an expired order and they planned to transfer Resident #107 back to the behavioral health facility if she refused medications. She said the facility made a verbal agreement with the behavioral health facility but they refused to take her back until she met criteria for transfer. The criteria the resident had to meet was to be actively homicidal, suicidal, or in grave disability due to acute illness. She said the facility did not have a plan to care for the resident if she was not transferred back to the behavioral health facility. She said they did not have a written agreement with the behavioral facility to transfer the resident back when she refused medications again. She said she was aware the resident may need to be hospitalized again after she was admitted to the facility and she was a high risk to admit to the facility. The NHA was interviewed again on [DATE] at 3:31 p.m. She said behavior management training was completed on [DATE] which included trauma informed care and crisis interventions. She said several training sessions were conducted to reach multiple shifts of staff members. She said in [DATE] the facility trained staff on recognizing and reporting changes in a resident's mental condition which included depression, [MEDICAL CONDITION], and dementia behaviors.

Based on observations, record review and interviews the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to the development and implementation of QAPI plans of action to correct quality deficiencies, potentially affecting all of the residents in the facility, and causing harm to at least four residents and potential harm to all facility residents. Harm-level deficiencies were cited regarding abuse/neglect, falls and accidents, timely assessment and treatment after accidents with injury, and behavioral and mental health services. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement (QAPI) plan, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at approximately 2:00 p.m. the plan had been reviewed by the NHA on [DATE]. The plan revealed the governing body was responsible for the development and implementation of the QAPI program. The governing body was responsible for: (1) Identifying and prioritizing problems based on performance indicator data. (2) Evaluating clinical and operational metrics that reflects facility processes, functions, and services provided to residents. (3) Ensuring that corrective actions address gaps in the system and were evaluated for effectiveness. (4) Setting clear expectations for safety, quality, rights, choice and respect. (5) Ensuring adequate resources exist to conduct QAPI efforts. The facility would use a through and highly organized, structured root cause analysis approach to determine if and how identified problems may be caused or exacerbated by the way care and services were organized or delivered. This systematic approach would help to determine when in-depth analysis was needed to fully understand the problem, its causes, and implications of a change. These systematic actions would look comprehensively across all involved systems to prevent future events and promote sustained improvements. The focus would be on continuous learning and improvement. Performance Improvement Projects (PIP) provide a concentrated effort on a particular problem in one area. Information would be gathered systematically to clarify issues or problems and then there would be intervention for improvements. PIPs examine and improve care or services in areas that were identified as needing attention. II. Failure to prevent repeat citations Cross-reference F[AGE]0 (free from abuse and neglect, F658 (services provided meet professional standards), F658 (nursing standards of practice), F6[AGE] (treatment/services to prevent/heal pressure ulcers), F6[AGE] (increase/prevent decrease in ROM/mobility), F689 (free of accident hazards/supervision/devices), F[AGE]5 (sufficient nursing staff), F744 (treatment/services for residents with dementia), F[AGE]9 (free of medication error rates of 5% or more), and F761 (label/store drugs and biologicals). These deficiencies were cited previously during a recertification survey ending on [DATE]. Although the facility corrected the deficiencies, based on the finding below, the facility had not maintained compliance with these regulatory requirements with additional failures of reporting of alleged violations, services provided meet professional standards, quality of life, sufficient nursing staff, free of medication error rates of 5% or more, and labeling of stored drugs and biologicals. II. Failure to identify quality deficiencies and initiate effective action plans to correct Cross-reference F[AGE]0, F[AGE]4, F658, F6[AGE], F6[AGE], F689, F[AGE]5, F740, F744, F[AGE]9, F761, F812, F[AGE]8, F[AGE]2, F[AGE]7 and F921. The following deficiencies were cited on the recertification survey completed on [DATE]: -F[AGE]0, abuse and neglect, cited at harm level. The facility failed to ensure residents were free from resident-to-resident and staff-to-resident abuse, resulting in residents experiencing verbal, physical and psychosocial abuse. A resident expressed fear after being repeatedly pursued and verbally and physically abused by another resident. Residents on the secure unit suffered resident-to-resident physical abuse, and a resident experienced verbal abuse/neglect by staff that the facility failed to prevent and investigate. -F[AGE]4, right to be free from physical restraints. A resident's wheelchair brakes were repeatedly locked so the resident struggled and was unable to maneuver away from the dining room table. Staff said they typically locked residents' wheelchair brakes so they would not leave the dining room before meals were served. -F658, professional nursing standards, cited at harm level. The facility failed to provide timely assessment and treatment after a resident fell and sustained a fractured ankle. Assessment and treatment were delayed, causing the resident undue pain. The facility further failed to perform neurological checks after falls with potential head injuries, and administer medications per physician orders. -F6[AGE], treatment/services to prevent/heal pressure ulcers. A resident was readmitted to the facility with a stage II pressure ulcer and nursing staff failed to provide treatment for [REDACTED]. -F6[AGE], increase/prevent decrease in ROM/mobility. The facility failed to provide physician-ordered treatment for [REDACTED]. -F689, free of accident hazards/supervision/devices, cited at harm level. A resident suffered second [MEDICAL CONDITION] misuse of diathermy equipment during therapy. A second resident, who needed supervision for ambulation, fell multiple times culminating in a fall with head injury resulting in a hospital visit and sutures. -F[AGE]5, sufficient nursing staff. The facility failed to provide sufficient and competent staff to meet residents' needs. Residents in a group interview said they had been complaining for months about short staffing and the facility failed to respond. -F740, behavioral health services, cited at harm level. A resident with court-ordered medications refused and did not receive medications, decompensated, experienced a mental health decline, and was hospitalized as a result. -F744, treatment/services for residents with dementia. The facility failed to provide person-centered dementia care to residents to ensure their needs were met, which contributed to resident-to-resident abuse. -F[AGE]9, failure to ensure the medication error rate was 5% or less -F761, failure to properly label/store drugs and biologicals -F812, failure to ensure resident snacks were not expired, creating the potential for foodborne illness -F[AGE]8, facility assessment and failure to ensure plans were developed and followed for residents who required court-ordered medications -F[AGE]2, failure to document complete and accurate medical records -F[AGE]7, QAPI/QAA improvement activities. The facility failed to identify and create effective action plans to prevent recurrence and address quality of life and quality of care deficiencies. -F921, safe/functional/sanitary/comfortable environment. The facility failed to ensure resident rooms and showers were safe, clean, functional and homelike. III. Review of QA action plan/staff interview The nursing home administrator (NHA) and the district director of clinical services (DDCS) were interviewed regarding QA correction plans on [DATE] at 4:33 p.m. The NHA said the QA committee met monthly. She said the committee members were herself, the medical director, the director of nursing, the social services director, the dietary manager, the medical records director, the activities director, the pharmacy consultant, the resident care management director, the life engagement coordinator and one certified nurse aide. The NHA said the facility collected data for the QA committee by looking at all systems both clinical and non-clinical for trends. She said the facility also reviewed resident concern forms, performed mock surveys, reviewed hospitalization reports, reviewed resident/family/staff satisfaction surveys, and reviewed internet reviews. The NHA said once an issue was identified by the QA committee, the issue would be put on an action list, so the issue could be tracked and reviewed for trends. She said the facility utilized a performance improvement plan (PIP) to develop a root cause analysis and a four point correction plan. She said the root cause analysis was used to try to find the specific cause of the issue/concern and the four point correction plan addressed the immediate issue/concern. She said the facility would also perform an audit to identify other individuals that were impacted by the issue/concern. She said system changes would be made and the changes would be monitored in correlation to the original problem. The NHA said if the four point correction plan was not reaching the desired outcome, changes could be made to the plan anytime during the process. Regarding abuse/neglect, the NHA said the facility had a QAPI in place. However, this issue was still identified and a deficiency was cited at harm level during this recertification survey. Regarding sufficient nursing staff, the NHA said they had a recruitment plan and staff retention had improved. She said there was an active QAPI. However, this issue was still identified and a deficiency was cited during this recertification survey. The NHA said the facility had QAPI plans in place for each of the care areas cited during the survey. Review of the facility's QAPI program, deficiencies cited during the recertification survey and the NHA interview revealed the facility had not effectively identified and developed correction plans to address the quality deficiencies, including the repeat deficiencies, identified above.

Based on record review, observations and staff interviews, the facility failed to ensure one (#4) of three residents reviewed for hydration of 43 sample residents, was provided sufficient fluids to maintain hydration and health. Specifically, the facility failed to provide sufficient fluids to Resident #4 who was dependent on tube feeding and staff to provide sufficient hydration needs to prevent dehydration. Based on the facility failing to provide sufficient fluids to a dependent resident who received tube feedings, the resident was discharged from the facility to the emergency room following a change in condition and was found to be significantly dehydrated by the emergency room physician. Findings include: I. Facility policy The Enteral Nutrition policy and procedure, revised (MONTH) (YEAR), was provided by the nursing home administrator at approximately 3:00 p.m., which read in pertinent part: Each resident is provided with sufficient fluid intake to maintain proper hydration and health .The nurse irrigates the feeding tube every four to eight hours to provide water to maintain adequate hydration of the resident. II. Resident status [NAME] Resident #4 Resident #4, age 75, was admitted to the facility on [DATE]. According to the (MONTH) 2019 physician orders, [DIAGNOSES REDACTED]. The resident had not been in the facility long enough for a minimum data set (MDS) assessment to be completed. According to a 10/26/19 nursing progress note, the resident was alert, but orientation was difficult to assess. According to a 10/25/19 care plan, the resident had a communication problem, the goal was for the resident to make her basic needs known. The pertinent approaches included staff anticipating and meeting the residents needs. B. Record review The (MONTH) 2019 physician orders [REDACTED]. Bolus TF (tube feeding) of [MEDICATION NAME] 1.5 275 ml (militiliter) QID (four times a day) via PEG (percutaneous endoscopic gastrostomy). Free water flush 30 ml before and after each bolus and 250 ml Q (every) six hours (separate from bolus). The nutrition care plan, initiated 10/25/19, identified the resident as requiring a tube feeding. The pertinent goals for the resident were to maintain adequate nutritional and hydration status as evidenced by stable weight, no signs or symptoms of malnutrition or dehydration through the next review date. The pertinent approaches included providing the resident with tube feeding and water flushes. The admission nutrition assessment was completed on 10/28/19 (one day after the resident had discharged from the facility, and was admitted to the hospital) and documented the following, in pertinent part: Resident admitted to hospital due to change of condition 10/27/19. RD (registered dietitian) to reassess upon return to facility. A 10/27/19 nursing note documented the following: .Patient ' s mentation had declined significantly since her admission and incision site was very inflamed. There was also exudate (a fluid that filters from the circulatory system into [MEDICAL CONDITION] or areas of inflammation) coming from the incision .an order was received from (name of doctor) to transport patient emergently to (name of hospital) for evaluation. A 10/27/19 nursing note documented the following: Called (name of hospital). Patient being admitted with a [DIAGNOSES REDACTED]. The hospitalist history and physical from the emergency room physician, dated 10/27/19, documented the following: She appears to be significantly dehydrated clinically and on lab findings C. Staff interviews The registered dietitian (RD) was interviewed on 11/21/19 at 9:25 a.m. The RD said she worked in the facility typically one time a week on Thursdays. She said she was not notified when Resident #4 was admitted to the facility, and did not complete the initial nutrition assessment until after the resident had been discharged to the hospital. The RD said when a resident is admitted to the facility who is nutritionally at risk, which included any resident on a tube feed, she needed to be notified of the admission to ensure the facility was meeting the residents nutrition and hydration needs. The RD said she reviewed Resident #1 orders, and they would have met her nutrition and hydration needs, but were written in a way that could have caused possible confusion or errors. The RD said had she reviewed the residents orders she would have separated the tube feeding from the 250 ml free water, to ensure the resident received both. The unit manager (UM) was interviewed on 11/21/19 at 9:54 a.m. She confirmed she had entered Resident #4 admission orders [REDACTED]. The UM said she had decided to wait until the RD was in the building to inform her about Resident #3, but has now begun notifying the RD anytime there was a new admission that might have unique nutrition needs. The director of nursing (DON) was interviewed on 11/21/19 at 10:00 a.m. She said the order should have been separated to ensure clarification of the order, and to ensure that both get done. The DON said the RD should have been notified of Resident's #4 admission to the facility, and moving forward the facility had begun emailing the RD regarding admissions.

Based on staff interviews and record review, the facility failed to ensure one resident (#6) out of three sampled for wounds, out of 13 total sample residents, received care consistent with professional standards of practice to prevent the development of pressure ulcers. Specifically the facility failed to: - Follow hospital discharge orders to provide an air mattress upon admission for the resident; - Complete accurate skin assessments; - Complete accurate Braden score assessments; - Monitor the resident's red area on her coccyx which she had upon admission and which progressed to a Stage IV pressure injury when she discharged to the hospital; - Ensure the resident was seen by the wound team timely; and - Implement a performance improvement project which comprehensively addressed the facility's skin assessment program starting at admission. The facility failures resulted in actual harm; resident #6 developed three unstageable pressure injuries that worsened. She was discharged to the hospital 3/24/17 and admitted with a Stage IV pressure injury that required debridement. The findings included: I. Professional Reference The National Pressure Ulcer Advisory Panel, NPUAP Pressure Ulcer Stages/Categories 2014, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stages-categories (May 2017), revealed the following pertinent information: - .International NPUAP-EPUAP Pressure Ulcer Definition-A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear . -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. - Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. - Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. II. Resident #6 A. Resident profile Resident #6, age 93, admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The admitting diagnoses, according to the face sheet, included fracture of left femur, hypertension, muscle weakness, dysphagia, cognitive deficit, [MEDICAL CONDITION] and constipation. According to the 2/2/17 Nursing Admission Data Collection form, the resident had no skin issues. According to the 2/2/17 Braden Scale for Predicting Pressure Sore Risk, the resident was at no risk for pressure sores. According to the 2/15/17 minimum data set (MDS) assessment the resident was not cognitively impaired. She needed assistance of one to two people for most activities of daily living (ADL). The MDS indicated she was at moderate risk of developing a pressure ulcer and during the time of the assessment did not have any pressure ulcers. According to the 2/28/17 MDS assessment, the resident was at moderate risk of developing a pressure ulcer and during the time of the assessment did not have any pressure ulcers. According to the 3/17/17 Braden Scale for Predicting Pressure Sore Risk, the resident was at moderate risk for pressure sores. According to the 3/17/17 MDS assessment, the resident was at moderate risk of developing a pressure ulcer and during the time of the assessment had three unstaged (due to slough or eschar present) pressure ulcers. According to the 3/24/17 MDS assessment, the resident was at moderate risk of developing a pressure ulcer and during the time of the assessment had three unstaged (due to slough or eschar present) pressure ulcers. B. Evidence of decline in resident #6's pressure injury after admission 2/2/17 1. The wound care progress note from the hospital prior to the resident's 2/2/17 admission, dated 1/31/17, documented, Tissue on sacrum and coccyx presently red, intact and blanching. No injury noted at this time. Given patient's low BMI (body mass index) and L (left) hip fx (fracture), however, I recommend keeping site covered with an Allevyn Life sacral dressing (a foam dressing) for [MEDICATION NAME]. In addition, I put in an order for [REDACTED]. 2. A physician visit progress note dated 3/22/17 read, Chief Complaint: Day nurse reports that coccyx wound does not look good. The resident was discharge to the hospital two days later, on 3/24/17. 3. The hospital history and physical, dated 3/24/17, documented, The patient also has a stage four buttock decubitus identified on examination, present on admission coming from nursing facility. Additional Diagnosis: [REDACTED]. 4. The hospital consultation dated 3/28/17 documented, in pertinent part: - The resident was found to have a stage IV pressure ulcer of her sacrum; - The patient reports the ulcer is tender; - The sacral wound is approximately 7 x 7 cm; - The depth is unstageable. 4. The hospital discharge summary dated 4/11/17 documented, Pressure injury, stage IV. This was present on admission . Doctor (name) had seen her and evaluated her during her care. They recommended further debridement in the OR (operating room) but she preferred to have it done a the bed side. C. Record Review Record review revealed the facility failed to follow hospital discharge orders to provide the resident an air mattress upon admission, failed to complete accurate skin assessments and Braden score assessments, failed to monitor the resident's coccyx, intact but reddened on admission, and failed to ensure, once the condition of the resident's coccyx worsened with unstageable pressure injuries, to have the resident promptly seen by the wound team. As noted above in the resident's 4/11/17 hospital discharge summary, the resident developed a Stage IV pressure injury after admission to the facility on [DATE]. 1. Failure to ensure air mattress was in place on admission a. Care plan The skin care plan initiated on 2/15/17 and revised 4/3/17 (resident no longer resided at the facility on this date) documented: - The resident had potential and actual skin issues related to impaired mobility related to left [MEDICAL CONDITION] with routine healing and moisture incontinence; - Frequently refuses to get out of bed; - Refuses turning and repositioning at times and prefers to lay on back; and - Three unstageable wounds to coccyx as of 3/9/17. The goal was for the resident's skin to remain intact without signs of breakdown through the next 90 days. Interventions included to provide an air mattress (initiated on 3/2/17), provide wound care per order, weekly skin checks per facility protocol, and turn and reposition frequently to decrease pressure as resident allows. b. Kardex The Kardex (a summary of clinical information used to care for the resident) printed on 6/9/17 documented: - Turn and reposition frequently to decrease pressure as resident allows; and - 3/2/17 Air Mattress. c. Telephone Orders (TO) The nurse practitioner's TO dated 3/9/17 documented Sacral/coccyx wound dressing - cleanse with wound cleanser, pat dry, apply Allyvan Sacral/coccyx foam dressing every shift, wound team to see this patient (the resident was seen by the wound team on 3/16/17). The nurse practitioner's TO dated 3/16/17 documented DC (discontinue) previous tx (treatment) to coccyx - TX to coccyx: Apply 2-guard peri wound. Apply [MEDICATION NAME] and moistened Silver Alginate to wound bed, then cover with Border gauze QD (every day). The 3/23/17 TO signed by the nurse without a nurse practitioner or physician signature documented DC previous wound orders - Cleanse coccyx with w/c (wound cleanser), pat dry, apply honey and silva alginate, apply ABD (a thick and highly absorbent dressing) and fix with hypofix, change every day (day shift) . There was no TO for an air mattress for the resident. 2. Failure to ensure prompt evaluation by wound team. Wound team documentation revealed: Weekly Wound Evaluation: Upon review of the medical record, there was one Weekly Wound Evaluation, completed on 3/16/17. The document revealed: - Right coccyx 1.5 cm (centimeters) x 0.9 cm x 0.1 cm, 100% slough; - Middle coccyx 4 cm x 2 cm x 0.6 - 60% slough and 40% bruised tissue upper margin; - Left coccyx 2.5 cm x 1.0 cm x 0.1 cm - 80% fibrn (sic) and 20% red tissue; - All 10 cm x 9 cm cluster; - Wound stage - Stage 3; and - Recommended Treatment - Two guard peri-wound, silver alginate and [MEDICATION NAME] border gauze daily. Wound Care Team Notes: The visit report for 3/16/17 documented the resident was seen on 3/16/17 and the initial evaluation revealed the patient had multiple unstageable pressure ulcers to the coccygeal region, which started after the patient had hip surgery to repair a [MEDICAL CONDITION]. The report documented, under Integumentary; - Wound #1 was a chronic unstageable pressure injury with a moderate amount of serous drainage noted which had a mild odor; - Wound #2 was an acute unstageable pressure injury with a moderate amount of serous drainage noted which had a mild odor; and - Wound #3 was an acute unstageable pressure injury with a moderate amount of serous drainage noted which had a mild odor. The visit report for 3/23/17 documented the resident was seen on 3/23/17 and the initial evaluation revealed the patient had multiple unstageable pressure ulcers to the coccygeal region, which started after the patient had hip surgery to repair a [MEDICAL CONDITION]. The report documented, under Integumentary; - Wound #1 was a chronic Stage 3 pressure injury with a moderate amount of serous drainage noted which had a mild odor; - Wound #2 was an acute Stage 3 pressure injury with a moderate amount of serous drainage noted which had a mild odor; and - Wound #3 was an acute unstageable pressure injury with a moderate amount of serous drainage noted which had no odor. There were no other wound care team reports included in the resident's medical record. 3. Failure to adequately monitor coccyx a. Progress Notes (PN) The 2/2/16 admission PN documented skin is intact; there is a Allevyn Sacral dressing on coccyx [MEDICATION NAME]. The 2/5/17 nursing PN documented patient requires one person assist with bed mobility. The 3/1/17 nursing PN, the next PN that addressed any skin concerns, documented in pertinent part: Patient is noted to have a pressure area on her coccyx and left buttock area. The reddened area is approximately 5 cm in diameter starting at the coccyx and going over onto the L buttock. Right at the coccyx there is a darkened purple area that is approximately 1 cm in diameter and appears to have an open blister on top of it that is open approximately 0.5 cm. On the left buttock there is another dark purple area that is approximately 1.5 cm in diameter with an intact blister over it. Patient has been turned to the side and a foam dressing was applied. The 3/9/17 nursing PN documented, patient's sacral/coccyx wound was inspected and found to be fully open not. The wound appears to be superficial over most of the wound base, but there are two areas of eschar one over the coccyx and another 2 cm to the right lateral of the coccyx. The 3/10/16 nursing PN documented, The wound team is to see patient when they are here. See above; the resident was not seen by the wound team until 3/16/17. b. Treatment Administration Record (TAR) The February 2017 TAR did not reveal any orders related to skin issues on the coccyx or for Allevyn Life sacral dressing for [MEDICATION NAME], which was an order from the hospital upon admission. c. Skin Assessments Skin assessments were completed on 2/2/17, 2/13/17, 2/16, 2/23/17, 2/28/17, 3/9/17, 3/16/17 and 3/23/17. The only skin assessment which documented the resident had a wound on her coccyx was completed on 3/23/17. D. Staff interviews On 6/9/17 at 8:36 a.m., the speech language pathologist (SLP) was interviewed. She said she worked with resident #6 on diet and appropriate texture during meals in her room while the resident was in bed. She said she had not seen an air mattress for the resident when she was working with her. On 6/9/17 at 10:00 a.m. the Director of Nurses (DON) was interviewed. She said she started as DON in February 2017 and was not aware of the skin issues related to resident #6 until after the resident discharged (3/24/17) and the facility was notified of the wounds by the police. She said the police called her on a Saturday (3/27/17) to notify her that the resident had been admitted to the hospital with [REDACTED]. III. Quality Improvement Plans to Address Skin Issues Review of facility records and staff interviews revealed the facility failed to implement a performance improvement project (PIP) which comprehensively addressed the facility's skin assessment program starting at admission. A. Performance Improvement Project (PIP) The director of nursing (DON) provided the facility PIP initiated on 3/21/17, on 6/9/17 at approximately 9:50 a.m. The goal was to improve the skin system as evidenced by a decrease in pressure ulcers and improvement in current facility pressure ulcers. The facility had identified they were missing weekly head to toe skin assessments, had inaccurate skin assessments, Braden Scores, weekly pressure and non-pressure assessments and a delay in interventions. The root cause was identified as Staffing challenges, newly hired staff, lack of oversight, and lack of staff education. The facility projected they would have staff education completed by 4/12/17, would have Braden Scores and weekly head to toe skin assessments completed by 3/29/17, measurements and assessments started 3/24/17 and would be ongoing and a skin sweep completed by 4/7/17. The DON would identify interventions in place by conducting a daily audit, Monday through Friday, to ensure appropriate interventions were in place for residents who were identified at risk. The start and completion date of the PIP were blank. B. PIP Documentation Training attendance records were provided by the staff development coordinator. The records documented nurses had received training on wound measurements, skin medications, pressure ulcer care, and skin care management on 4/5/17. Education was provided by the DON. The DON was asked on two occasions during the morning of 6/9/17 for any other documentation to show the facility had completed the other action items indicated in the facility's PIP. No other documentation was provided. C. Staff Interviews On 6/9/17 at 10:00 a.m., the DON was interviewed. She said she began reviewing charts and identified issues with skin in the facility after her employment in February 2017. She said the PIP was initiated on 3/21/17. She said she went around the facility and educated staff, but confirmed she did not have the initial training documented. She agreed the staff nurse upon admission should complete a skin assessment and talk to the discharge nurse at the hospital to identify any skin issues. She said the registered dietician would also be contacted to implement any nutritional supplements. She confirmed the admission process related to skin issues was not captured in the PIP and she would be implementing another PIP to ensure this would be addressed. IV. Summary of facility failures A. Individual resident failures The resident admitted on [DATE] with notes from the hospital that indicated she had redness on her coccyx, to use a [MEDICATION NAME] barrier cream and an air mattress. The barrier cream was used, at least one time, as indicated by a progress note, although it was not on the TAR; however, the air mattress was not ordered until 3/2/17 according to the care plan and Kardex. There was not a TO to indicate the physician was aware of the need for an air mattress. The facility noted on 3/9/17 the resident's coccyx wound was worsening and an order for [REDACTED]. On 3/23/17, the wound treatment was changed by the wound team; however, the next day the resident went to the hospital as the resident was having difficulty breathing. Hospital admission records documented the resident admitted with a Stage IV pressure injury that required debridement. B. System failures On 3/21/17 the facility staff identified issues the facility had related to skin, 12 days after an order was written for resident #6 to see the wound team. Although the facility identified a number of skin issues, their PIP was not complete as it failed to address issues raised in the management of resident #6, such as the timeliness for wound team visits and review and implementation of discharge orders received on admission.

Based on record review and interviews the facility failed to ensure two (#53 and #101) out of three residents whose nutritional status' were reviewed, out of 41 sampled residents maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless clinical conditions demonstrated it was not possible; and received a therapeutic diet when there was a nutritional problem. Specifically, the facility failed to: - Consult the dietician regarding resident #53's significant weight loss as ordered by the physician; - Obtain and clarify physician orders [REDACTED]. - Obtain resident #53's weight as ordered; - Update/revise resident #53's care plan to reflect the resident's significant weight loss; - Appropriately assess residents ' food preferences; - Provide appropriate assistance for resident #101 during meals; - Provide variety of nutritional supplements to resident #101 to prevent weight loss and appropriately document intakes or refusals; - Provide regular laboratory monitoring for causes of weight loss and symptoms of under-nutrition for resident #101; and - Timely address residents #101's significant weight loss with the IDT (interdisciplinary team). As a result resident #53 sustained a significant weight loss of 33 pounds (22%) within 40 days of her admission to the facility and was discharged home on hospice services 3/7/15. Findings include A. Professional Reference According to Long Term Care Medicine, A Pocket Guide dedicated to the American Medical Directors Association (AMDA) staff, by Pamela A. Fenstemacher MD and Peter Winn MD (2011), chapter nine, Weight and Nutrition, by Todd H. Goldberg MD, CMD and Joel L. Levine MD, Chief of [MEDICATION NAME], West Virginia University, read in pertinent part: As with persons of all ages, proper nutrition and maintaining a healthy weight are very important in elderly long-term care residents . Optimal nutrition should ideally improve health, functioning, and quality of life and reduce the risk of morbidity, mortality, and complications such as weakness, impaired immunity . Weight loss is a negative quality indicator and risk factor for poor outcomes - survival is markedly improved with appropriate and adequate nutrition . Every resident has important and individual nutritional needs, but those with chronic illness and disability require extra attention to diet and nutritional assessment and need for assistance . Serum [MEDICATION NAME] is the single most commonly used indicator of protein undernutrition and the level is correlated with mortality in older person. (Serum [MEDICATION NAME] level less than 3.5 mg/dl indicating abnormal laboratory result) . The laboratory tests should be ordered not only when problems are reported but perhaps considered periodically in all elderly residents at risk for poor nutrition, and are often abnormal in the elderly requiring changes in medications or supplements . AMDA's Clinical Practice Guideline on Altered Nutritional Status; available from http://www.amda.com recommends that treatment should address underlying issues identified, tailoring meals/food to individual preferences and function, limiting unnecessary dietary restrictions, adding supplements, and as a last resort, tube feeding on an individual basis. Individuals at facilities must further be continually monitored for maintenance and improvement of nutrition. It should be noted that caloric supplements optimally might need to be given between meals to minimize appetite suppression. B. Facility Policy The facility's weight/hydration management policy, last revised 2/2010, read in part, resident's nutritional status will be monitored on a regular basis. According to Federal Regulations (F-Tag 325), residents are expected to maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. The measurement of weight is a guide in determining nutritional status. Therefore, the evaluation of the significance of weight gain or loss is a crucial part of the assessment process. Nutritional status, including weight, is influenced by calories, protein, and fluid . Accurate weights are obtained by having staff follow a consistent approach to weighing and by using an appropriately serviced and functioning scale. The facility will establish a weight management plan that includes: a. Completion of monthly weights by the 10th calendar day; b. Consistent day for completion of weekly weights; c. Consistent day for weekly at risk reviews; d. Staff members assisted to: i. Obtain weight and re-weight data; ii. Determine residents that should be re-weighed; iii. Enter final, validated weight data in medical record; iv. Enter data into designated weight tracking program; and v. Print, evaluate and verify weight data; and e. Equipment that Is functioning and serviced routinely As residents are weighed, staff can compare current weight to previous weight. Residents with weight variance are reweighed within 24 hours. Weight variances include weight changes of 5 lbs or a weight change of 3 lbs if weight is less than 100 lbs. Weight data will be provided to the staff member designated to enter data into weight tracking program. After review of weight data, a re-weight may be requested (completed within 24 hours of request), based on resident's weight status and weight history which includes weight change of five percent (5%) within one month (30 days); 7.5% in three months (90 days) or 10% in six months (180 days). Final weight (validated weight after re-weight) is documented in medical record on the vital sign and weight flow sheet with the date the weight was obtained. The facility will designate a staff member to enter weight data into the medical records. Significant weight variance is defined as five percent (5%) within one month (30 days); 7.5% in three months (90 days) or 10% in six months (180 days). C. Resident #53 a. Resident Status Resident #53, age 90, admitted to the facility on [DATE]. Her pertinent admission diagnoses, according to the resident face sheet, included rehabilitation, [MEDICAL CONDITIONS] reflux, and ,[MEDICAL CONDITION].-difficile (C. diff, an intestinal infection which causes severe diarrhea). According to the admission minimum data set (MDS) assessment dated [DATE] the resident had moderately impaired cognition. She had clear speech, was able to make her needs known and was able to understand others. She required extensive assistance from two staff members with bed mobility, transfers, dressing, toileting, and personal hygiene. She required supervision (oversight, encouragement or cueing) from one staff member for eating. The resident weighed 151 pounds (lbs) upon admission and her height was 67 inches (five feet six inches). Section K (swallowing/nutritional status) was coded 0 (no or unknown) for weight loss or gain of 5% or more over the last month or loss or gain of 10% or more in the last six months. The resident had no natural teeth and was not on a therapeutic diet. According to the 30 day MDS assessment dated [DATE] section K was coded 0 (no or unknown) for weight loss or gain of 5% or more in the last month or loss or gain of 10% or more in the last six months. However, the facility weighed the resident on 2/12/15 (see below) and she weighed 128 lbs, which was a 22.5 lb weight loss within 22 days from the resident's admission (1/21/15). b. Record Review i. physician progress notes [REDACTED].>The physician's history and physical (H&P) dated 1/22/15 revealed the resident admitted from the hospital after having an open reduction and internal fixation (ORIF) for a fracture left hip, which was due to a fall. The resident weighed 150.5 lbs, was well nourished and in no acute distress. The hospital records were reviewed by the physician. The H&P did not address any concerns regarding a history of weight loss or a reported decreased appetite. The 1/23/15 physician progress notes [REDACTED]. The 1/26/15 physician progress notes [REDACTED]. The 1/28/15 physician progress notes [REDACTED]. She denied any abdominal pain, nausea, vomiting and her appetite was noted as 'okay.' She was a well nourished adult in no acute distress. The assessment/plan revealed the resident completed a course of antibiotics and she was making gains with therapy. The note failed to identify the resident had concerns with weight loss or poor appetite. The physician progress notes [REDACTED]. diff. and the resident was noted to have poor oral intake. The assessment/plan for weight loss included: She has lost significant weight. She'll be started on supplements. This does portend (indicate by signs) a poor prognoses in this elderly woman who is very sick. The physician progress notes [REDACTED]. Appetite continues to be fair to poor. The assessment/plan was to continue to monitor weight loss and continue with supplements. The physician progress notes [REDACTED]. She was having some nausea and continued to have diarrhea despite the [MEDICATION NAME]. She was noted as having a really good appetite previously. The assessment and plan revealed the resident was going to bring in some foods that she liked. The note read, Continue with supplements and [MEDICAL CONDITION] could be contributing. The physician progress notes [REDACTED]. She had no nausea and no complaint s of abdominal pain. She was on dietary supplements. The assessment and plan revealed the resident was started on [MEDICATION NAME] (an appetite stimulant). The overall prognosis was very poor and the daughter agreed that if she did not gain weight in the next week then the resident should be considered for hospice at home (her desire). ii. Care Plan According to the weight loss/nutritional risk care plan initiated on 1/29/15 and last reviewed on 3/5/15, the resident had actual and potential weight loss/nutritional risk related to mental status (confusion), change in fluid status ([MEDICAL CONDITION]), medications, lab values ([MEDICATION NAME]) skin conditions, [MEDICAL CONDITION]/surgery, dementia, increased age, [DIAGNOSES REDACTED] and hospice end of life (as of 3/6/15). The care plan interventions directed staff to provide the diet as ordered, offer preferred foods, meal assistance as needed (PRN), medications as ordered, provide supplements as ordered, house shake three times a day (TID), interdisciplinary team (IDT) referral, Registered dietician (RD) as needed, weigh monthly or as indicated, determine individual likes and dislikes, encourage fluids with and between meals. iii. Physician's Telephone Orders (TOs) The TOs dated 1/23/15 through 3/6/15 revealed the following pertinent orders: -1/22/15: Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) -1/23/15: [MEDICATION NAME] (anti-nausea medication) 25mg suppository as needed (PRN) every (q) 12 hours PRN for nausea and vomiting, UA with culture and sensitivity (C&S) -1/26/15: two sets of blood cultures today, CBC, CMP, Iron panel, and C reactive protein -1/26/15: weigh the patient now and three times a week (3/week), consult dietary -1/27/15: [MEDICATION NAME] (antibiotic) 250mg pot three times a day (TID) for ten days -2/2/15: [MEDICATION NAME] 500mg twice a day, vitamin D3 1000 units q day -2/6/15: discontinue (D/C) weights 3/week, obtain weekly weights and weigh the resident now. Consult dietician for a [DIAGNOSES REDACTED]. (The physician's orders [REDACTED].) -2/9/15: Promod (liquid Protein) 30ml po daily for wound healing -2/12/15: [MEDICATION NAME] 500 mg 1 po tid for 20 days -2/18/15 discontinue [MEDICATION NAME] and start [MEDICATION NAME] 250mg po four times a day (qid) times (x) ten days for [DIAGNOSES REDACTED] -2/18/15: Schedule a care conference as soon as possible (ASAP, next few days), CBC, CMP, pre-[MEDICATION NAME] related to [DIAGNOSES REDACTED]. -3/3/15: [MEDICATION NAME] 15 mg po q bedtime (hs) for a [DIAGNOSES REDACTED]. -3/4/15: Hospice to eval(uatate) and treat the resident -3/5/15: House-shake 4 ounces PO TID between meals related to weight loss. Record amount consumed -3/6/15: Discharge home with medications, 24 hour private duty and hospice care. iv. Resident weights -1/21/15 - 150.5 (admission) -1/26/15 - 149.3 (1.2 lbs weight loss since 1/21/15) -2/4/15 - 148.9 (0.4lbs weight loss since 1/26/15 and 1.4 lbs weight loss since admission) -2/6/15 - 138.8 (9.2 lbs weight loss since 2/4/15 and 11.2 lbs weight loss since admission) -2/9/15 - 134.0 (4.4 lbs weight loss since 2/6/15 and 16 lb weight loss since admission) -2/12/15 - 128.0 (6lbs weight loss since 2/9/15 and 22.5 lbs weight loss since admission) -2/16/15 - resident refused -2/18/15- weight was not obtained as ordered (see above) -2/19/15- 125.9 (2.2 lbs weight loss since 2/12/15 and 24 lbs weight loss since admission) -2/20/15- 125 (25 lbs. weight loss since admission (16.7% loss) -2/21/15- weight was not obtained as ordered (see above) -2/22/15 122.6 (2.4 lbs weight loss since 2/20/15 and 27.4 lbs weight loss since admission -2/23/15- 125.9 is recorded on the weight flow sheet and 119.5 is recorded on the treatment administration record (TAR) -3/2/15 - 117.0 (33 lbs. weigh loss since admission and a total 22% loss) The resident's clinical record failed to reveal the staff re-weighed the resident when weight loss was noted. However, the facility policy directed staff to re-weigh the resident and record the highest weight (see above) in the resident's clinical record. Additionally, the physician ordered the resident to be weight daily on 2/18/15 (see above) and the clinical record failed to reveal that weights were obtained daily. v. Medical Nutritional Therapy Review The medical nutritional therapy review dated 1/29/15 revealed the resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident was five foot seven inches tall and weighed 150.5 lbs. She did not have any known food allergies [REDACTED]. She had dentures, was alert and verbal; however, she was disoriented and confused. She was independent with feeding with tray preparation. She was receiving antibiotics and [MEDICATION NAME] for [DIAGNOSES REDACTED]. She was a do not resuscitate (DNR) and did not desire a feeding tube. Her estimated calorie needs were 1700 and her estimated calorie intake was 1700. Her estimated Protein needs were 68 grams and her estimated protein intake was 70 grams. The resident reported having a good appetite/intakes and was without complaints at the time of the evaluation. Her intakes were good and appeared to meet estimated needs. She states her diarrhea was improving . low [MEDICATION NAME], increased C - reactive protein. vi. Meal Detail Reports The resident's meal intakes records dated 1/22/15 through 3/5/15 revealed out of 129 meals the resident ate 100% of her meals 13 times, 75 % of her meal 36 times, 50% of her meals 41 times, 25% of her meals 28 times, she refused her meals eight times and there were three meals not documented (breakfast 2/4/15, lunch 2/4/15 and dinner 1/24/15). The nursing notes 1/22/15 through 3/5/15 revealed staff encouraged snacks and other food items; however this was inconsistent. There was no indication that when the resident refused her meals or at less than 50% that staff offered her an alternate. C. Facility Failures: 1. Failure to consult the dietician regarding weight loss On 2/6/15 a physician's orders [REDACTED]. The clinical record failed to reveal the resident received a consult from the dietician, except when she was initially seen on 1/29/15. Additionally, the clinical record failed to reveal the dietician had been notified regarding the physician's orders [REDACTED].>A nutritional note dated 3/3/15 (only nutritional note since admission) completed by the previous dietary manager (DM) revealed the residents' weight was 117 lbs and was down 22% since her admission (1/21/15). The resident's intakes only averaged 46% per meal. She received wound care for a pressure ulcer on her coccyx, which was discussed with the registered dietician (RD) who recommended a health shake three times a day between meals. A nutritional note dated 3/6/15 revealed the resident was on hospice services and [MEDICATION NAME], an appetite stimulant, was added to the resident's medication regimen. The resident's medical nutritional therapy review and follow up note failed to reveal the resident's nutritional needs had been re-evaluated when the resident experienced significant weight loss. Interviews The director of nursing (DON) was interviewed on 6/11/15 at approximately 4:00 p.m. The DON acknowledged the presence of physician order [REDACTED]. The DON stated she was not aware of the order and stated that the nurse who signed off on the order probably notified the RD. The DON reviewed the clinical record and acknowledged the record did not contain a consult by the dietician. The DON stated that the facility had identified concerns regarding weights, meals, and lack of follow through; however the DON stated that she did not identify physicians orders not being followed up on and would have expected the RD to be notified and be consulted regarding the residents weight loss. The Registered Dietician (RD) was interviewed on 6/11/15 at 5:00 p.m. via a conference call in the presence of the nursing home administrator (NHA) and director of nursing (DON). The RD stated that she was not aware of the order for a consult. She stated that the previous DM may have heard about the order in the morning meeting and may have followed up with the resident. The RD stated the DM could make some dietary changes and address them with the interdisciplinary team (IDT) as an intervention. The RD stated if the DM followed up on the physician's orders [REDACTED]. The RD stated if she would have known about the order for a consult, she would have come in to re-assess the resident and make changes to the resident's plan of care. The previous DM was not available for an interview. 2. Failure to obtain and clarify physician orders The resident's clinical record revealed the resident had a significant weight loss of 11.2 lbs within the first 16 days of admission (see above). On 2/6/15 a physician's orders [REDACTED]. However the order did not reveal the type, amount and frequency of the nutritional supplement to be administered. Additionally, the facility staff failed to clarify the order. The medication administration records (MARs) for 2/6/2015 through 3/7/15 revealed the resident was started on a four ounce vanilla house shake twice daily that had been signed out as being administered daily. However two days (2/17 and 2/18) were circled with no indication why. Additionally, on 2/20/15 the MAR indicated [REDACTED]. Review of the physician's orders [REDACTED]. Additionally, the MAR failed to reveal the staff was tracking the amount nutritional supplement the resident consumed. The nursing notes did reveal that staff would occasionally and sporadically document the amount consumed. Interviews The DON was interviewed on 6/11/15 at approximately 4:00 p.m. The DON acknowledged the physician's orders [REDACTED]. She stated the facility had several types of nutritional supplements (house shakes, juices and magic cups) that could be used. She stated the nurse who signed off on the physician's orders [REDACTED]. She stated the nurse must have received a verbal order and forgot to write the order. The DON acknowledged the house shake was changed to house nutritional juice on 2/20/15 without an order and that the documentation for the amount of the supplement consumed was sporadic. The DON stated she would expect the nurse to write an order for [REDACTED]. The Registered Dietician (RD) was interviewed on 6/11/15 at 5:00 p.m. via a conference call in the presence of the nursing home administrator (NHA) and director of nursing (DON). The RD stated she was not sure who the physician was who wrote the order for the nutritional supplement or where staff received the type, amount and frequency of the nutritional supplement. She stated staff may have received a verbal order from the physician. She stated that many of the facility's buildings would use a house supplemental shake or juice, which has the same nutritional value. She stated she was not sure where staff obtained the order to change the nutritional supplement from a vanilla shake to the nutritional juice. The RD stated that the staff may have changed the nutritional supplement because of the resident's diarrhea and thought it was good that staff changed it to the juice if the resident was refusing the vanilla shake. The RD stated staff would document the amount of the nutritional supplement consumed if there was an order. She stated that the nurses know their residents and if the amount consumed was not documented she would talk to the nurses. 3. Failure to obtain weights as ordered According to the physicians order dated 2/18/15 staff were to weigh the resident today and then daily. A review of the resident's clinical record failed to reveal the facility weighed the resident daily according to the physicians order. The following weights were not available in the resident's clinical record: 2/21/15, 2/24/15 through 3/1/15 and 3/3/15 through 3/7/15. The DON was interviewed on 6/11/15 at approximately 4:00 p.m. The DON acknowledged the physicians order dated 2/18/15 (see above). The DON stated she would expect staff to weigh the resident according to the physician's orders [REDACTED].> The DON stated that the facility had identified concerns regarding weights not being completed, completed a performance plan and had since designated one person (resident advisor) to obtain resident weights and complete and obtain re-weights when needed. 4. Failure to update/revise the residents care plan The resident's weight loss/nutritional risk care plan initiated on 1/29/15 and last reviewed on 3/5/15 (see above) failed to reveal the care plan had been updated or revised to reflect the residents significant weight loss or other interventions to address the resident's significant weight loss until 3/5/15, when the nutritional supplement was increased to TID and hospice was ordered to evaluate and treat the resident. The DON was interviewed on 6/11/15 at approximately 4:00 p.m. The DON stated that the RD or DM would be responsible for updating the residents care plan. The DON stated that the DM familiar with the resident was no longer employed by the facility. The DON reviewed the resident's care plans and acknowledged that the care plan had not been updated to address the resident's significant weight loss. The DON acknowledged the facility did not identify concerns regarding nutritional care plans not being updated or revised. Facility Follow Up: On 6/12/15 during the post survey grace period the facility provided additional information regarding a performance improvement project, dated 4/22/15 (46 days after this resident discharged home on hospice), which identified dietary concerns that included resident complaints about food (started 3/16/15), running out of food (started 3/6/15), late meals (started 3/9/15), and inconsistent clinical follow up (started 4/1/15 with expected date of completion of 7/1/15), providing weights to RD (started 3/9/15). Actions included a food committee to discuss concerns with food, interview resident to assess food satisfaction, retrain DM to order sufficient food supplies, timely service through adjustment of staffing, DM training regarding clinical charting (start date 4/1/15 target completion date 7/1/15) a new DM was hired 3/16/15 with plans for his training per HSG (undefined) and RD and nursing to provide weekly weights to the RD. Additionally, the facility provided a statement from the resident's physician who stated the resident experienced weight loss, confusion, multiple falls, and elevated international ratios (INR) results and the resident had [DIAGNOSES REDACTED] and received several rounds of antibiotic therapy. The physician suggests that the resident's demise started long before her arrival to the facility; however the physician's statement does not address the failure to obtain a consult from the dietician as ordered and weights not being obtained as ordered. D. Resident #101 Resident#101, age 84, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 30 day assessment, dated 5/11/15 revealed the resident had clear speech, was understood and was able to understand others. The brief interview for mental status (BIMS) score was 14 out of 15 and indicated intact cognition. No presence of hallucinations, delusions or rejection of care was documented. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene, and supervision of one person physical assistance with eating. Section K documented the resident's weight was 166 lbs and no weight loss was noted at the time of the assessment. He received a regular texture diet and did not have a swallow disorder. His routine/daily medications included an antidepressant and an anticoagulant. 1. Record Review The RD assessment dated [DATE] documented: Resident is [AGE] years old English speaking male with [DIAGNOSES REDACTED]. Able to make own needs known, alert and oriented x4, PERRLA (pupils equal, round, reactive to light). 2 (two) person assist in transferring with complaints of pain when transferring. General assessment made. Skin is intact with bruises noted on right arm and abdominal area. No other complaints made by the resident. On 4/14/15 the resident's weight was documented as 257 lbs. On 4/14/15 a correction weight was noted as 157 lbs and the RD note documented, Resident reports fair appetite which is baseline. Is able to feed self and make needs known. Dx (diagnosis) include: hip fx (fracture)/ surgery, h/o (history of) ETOH. Suspect weight of 157# (pounds) based on usual weight of 165#. Reweight requested. Usually does not eat breakfast per norm. Encouraged good intakes for healing. Suggested drinking juice/milk with meals and requesting snacks prn (as needed). Was hungry for lunch. To proceed to care plan and f/u (follow up) prn. The 4/14/15 RD assessment documented, Potential for inadequate energy intake r/t fair appetite (as evidenced by) doesn't eat breakfast and intakes vary. Review of the resident's Care Plan (CP), created 4/14/15, revealed the resident was at nutrition risk related to h/o ETOH, variable meal intakes, and does not normally eat breakfast. Interventions included (in part): Offer preferred foods. Assist with meals as needed. Offer snacks prn. Monitor weights monthly or as indicated. Monitor labs as available. Encourage fluids with and between meals. Refer to RD prn. Encourage milk/juice with meals. Encourage intakes r/t healing. On 4/20/15 the physician's TO (telephone order) noted, Weekly weights. The physician's orders [REDACTED]. Review of the resident's medication and treatment administration records (MAR), revealed weekly weights were not filled, with missing weights and signatures on 4/21/15, 4/28/17, 5/1/15, 5/8/15, 5/15/15, 5/22/15, and 5/28/15. Review of the documentation revealed the facility failed to obtain and document weights weekly as ordered by the physician. A nursing note dated 4/21/15 documented, pt (patient) aware new order for daily weights (order was not seen in resident chart) and is not happy to be awakened at 0600 (6:00 a.m.) every day. Talked with him and discussed that the MD (physician) he may get the time changed but will need to talk with the day shift. advsd (advised) him that we are happy to help him. The resident's weights were ordered weekly not daily as documented by the RN. review of the resident's medical record revealed [REDACTED]. The laboratory test included Serum [MEDICATION NAME] level at 2.6 g/dl (range 3.5 - 5.7). On 4/22/15 the physician's TO noted: [MEDICATION NAME] 2.6 Dx (diagnosis): Protein Malnutrition, RD consult please. The order was signed by NP (nurse practitioner). Review of the physician (NP) Progress Notes dated 5/1/15, 5/13/15, and 5/20/15 revealed no follow-up addressing the resident's weight loss or low [MEDICATION NAME] level. On 5/6/15 the RD note documented, On admission in April, resident reported weight of 165#. RD suspected April weight was inaccurately recorded. Refer to admission nutrition data collection for details. Current weight of 166# is consistent with resident's reported weight on admission. The RD assessment did not address the resident's low [MEDICATION NAME] level nor suggested protein supplementation for a [DIAGNOSES REDACTED]. The Diet History/Food Preference List was completed by the facility cook on 5/22/15 (40 days after resident's admission to the facility) and did not include/specified resident's preferences for each meal. On 6/9/15 the RD documented: Monthly weight of 149# (lbs) is down 10% (percent) x 1 (one) month. Met with resident to discuss and notified MD. Resident reports good appetite and says he is eating more here than he did at home. Says his legs were swollen on admission and now are not. Intakes only average ~50% per meal. Encouraged intakes and will also offer house shake BID (twice daily) to which resident is agreeable. Will continue to monitor for changes and f/u prn. On 6/9/15 the physician's TO documented, House Shake 4 oz po BID (four ounces orally two times per day) between meals r/t (related to) wt (weight) loss. Record amt (amount) consumed. There was no nursing documentation in the resident's medical record indicating severe lower extremity [MEDICAL CONDITION] or diuretic medication prescribed by the physician to address the presence of [MEDICAL CONDITION]. 2. Observations The resident was observed on 6/10/15 and 6/11/15 during his lunch meal. He was observed without staff assistance or encouragement. The food intake was approximately 30% both days. 3. Interviews On 6/11/15 at 12:55 p.m. the resident stated that prior to his admission to the facility, his usual weight at home was 174 lbs and he was d

Based on resident interview, record review and staff interview, the facility failed to ensure two (#14 and #111) of 39 sample residents were free from neglect and/or mistreatment. Specifically: -Resident #111, who was dependent on staff for transfers, reported that night staff ignored his requests to be transferred to the commode in a timely manner which contributed to pain, anxiety, and anger. A certified nurse aide (CNA #9) who worked the night shift reported he had been told to not respond to resident #14's call light and to turn it off after she fell asleep. Resident #111 and #14 both resided on the facility's west unit, staffed by licensed practical nurse (LPN #3) and CNAs #9 and #17. The findings include: A. Facility Policy 1. The facility's Abuse Policy (undated) read in pertinent part: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. -Abuse means the willful infliction of injury, unreasonable confinement, or punishment with resulting harm, pain, or mental anguish. -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 2. Procedure (in pertinent part): The Company will screen for potentially abusive staff members. -Training The company will train each employee regarding these policies. -Prevention Residents, family and staff will be able to report concerns, incidents and grievances without fear of retribution. The company supervisors will immediately correct and intervene in report of identified situations in which abuse, neglect, or misappropriation of residents' property (is) at risk of occurring. Identification The Company Quality Assessment and Assurance (QA&A) Committee will investigate occurrences, patterns, trends that may indicate the presence of abuse, neglect, or misappropriation of property and to determine the direction of the investigation through analysis, audits and reports. Investigation The company will conduct an investigation of any alleged abuse/neglect or misappropriation of property accordance with state law. The Company will investigate all patterns, trends, or incidents, that suggest the possible presence of abuse, neglect, or misappropriation of residents' property identified through analysis, conducted by the QA&A committee with intervention, reporting policy/procedure modification conducted as appropriate. Protection The Company will protect residents from harm during the investigation. B. Resident Failures 1. Resident #111 Resident #111, [AGE] years old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident resided on the west unit in a room directly across from the west unit nurses' station. a. Resident Status The resident's Minimum (MDS) data set [DATE] revealed the resident was able to understand and be understood. His cognitive ability was intact. He needed total assist with transfers and bathing and extensive assist with dressing, toileting and personal hygiene. The resident was always continent of bowel and bladder. A care plan for Bowel Elimination, dated 5/27/14, identified the potential for alteration in bowel function due to decreased mobility and disease process. An Evaluation for Bowel and Bladder Training form was completed, but not dated. It read that contributing factors to bowel and bladder training would be advanced MS. The resident's ability to communicate was very good. Functional status was maximum assist and Hoyer lift needed. Description of bowel pattern was documented as: (Resident) would like to be placed on BSC (bedside commode) between 5:00 and 6:00 every morning with a cup of coffee with sugar and cream. b. Resident Interview On 6/23/14 at 12:25 p.m. while in the dining room, the resident asked if he could meet with the surveyor and at 1:30 p.m., an interview was conducted in the resident's room. The resident asked that the door be closed and stated he had concerns with his stay. He stated most of the staff is caring and concerned but there have been problems. He stated he was having problems being toileted by the night shift staff, licensed practical nurse/LPN #3, and certified nurse aide (CNA) #17. He explained that with MS, there is a 'window' of time to go to the bathroom. He said if he is not toileted during that window, it closes. He reported the following incidents and concerns: 5/23 or 5/24/14: The resident stated he was not put on the toilet the Thursday or Friday (5/23 or 5/24/14) before Memorial Day during the window of time he can go the bathroom. As a result, he was constipated the next day. He stated he had asked the night shift nurse, licensed practical nurse/LPN #3, who was at the nurses' station, to place him on the commode and for help with toileting. He said the LPN told him the certified nurse aide (CNA) was busy with other residents and it would be an hour before staff could get to him and assist him to the bedside commode. He added LPN #3 did not appear busy and she made no attempt to assist him. 5/27/14: The resident stated that on the Tuesday after Memorial Day (5/27/14), he again asked to be put on the commode at 5:05 a.m. Staff did so; however, it was 5:50 a.m. before he was taken off the commode and no one checked on him during that time. When he asked LPN #3 why he had to wait so long for assistance off the commode, LPN#3 stated they were busy with other things. He said he went to the nursing home administrator (NHA) the next day (5/28/14) to complain about being left on the commode for an extended period of time. The NHA told him she would take care of it and added that being left on the commode that long was 'not acceptable.' He said he asked the NHA about staff retribution because he had complained; he said the NHA stated it would not be a problem. 5/29/14: The resident said the next day (5/29/14) about 45 minutes before sunrise, he again asked the night shift staff to place him on the commode. However, no one came to transfer him until the morning shift came on duty at 6:00 a.m. and they put him on the commode around 6:30 a.m. 5/30/14: The resident said the following morning, 5/30/14, he put his call light on at 4:30 a.m. for toileting assistance. He said no staff responded from 4:30 a.m.- 6:30 a.m. except CNA #17. However, when he asked CNA #17 to place him on the commode, the CNA said she was busy taking care of other residents. 6/1/14: The resident said the following day 6/1/14, he put his call light on around 4:30 a.m. to request assistance from the night shift staff to place him on the commode. He said CNA #17 came into his room and stood in the room as he asked to be placed on the commode. He said CNA #17 told him she was getting other residents up. He said he was not put on the commode until the day shift came on, sometime after 6:00 a.m. The resident said CNA #9, who also worked the night shift on the west unit, told him he (CNA #9) had asked CNA #17 why she did not put the resident on the commode; CNA#17 responded to CNA #9 that it was because the resident's light was not on. Resident #111 became visibly upset - his breathing increased and he spoke rapidly - while discussing this incident. He said CNA #17 was standing next to him in his room when he asked to go to the commode and he did not know how she could say his call light was 'not on' when she responded to the call light and was standing in his room as he made his request for assistance. The resident said he went again to the NHA to complain about staff's failure to provide him timely assistance with toileting on 6/1/14. The resident said he told the NHA that he thought LPN #3 was instructing the night shift staff not to assist him. The resident said he was assured by the NHA that LPN#3 would not be working with him again. However, he said that he felt LPN #3 was still directing his care even though he had been assigned to another licensed nurse. Resident #111 asked that his concerns not be reported to the NHA, the Director of Nurses (DON), the Assistant DON (ADON), or the nurse on the night shift until he left the next day around noon. He stated he feared retribution and, as a quadriplegic, there was no way he could defend himself. He said he worried, too, about residents, unlike himself, who are unable to speak up for themselves. c. Staff Interview and Review of Facility Investigation of Resident Complaint (1) On 6/23/14 at 2:30 p.m. the Regional Clinical Director (RCD), the DON, and the NHA were informed of the resident's concerns with night shift staff and, in particular, LPN #3. They were informed at this time that resident #111 was afraid of retribution from LPN #3. On 6/23/14 at approximately 5:05 p.m. the NHA was interviewed. She said she was aware of the resident's concerns with LPN #3. She stated when resident complained on 5/28/14 about lack of care, she moved his care to the rehab unit. On 6/23/14 at 5:30 p.m. the NHA, RCD and DON were interviewed again and said they had reviewed the investigation of the resident's 5/28/14 complaint conducted by the ADON, which included a concern form and care plan meeting notes. -The NHA stated that according to the care plan meeting notes (dated 6/3/14), the resident was satisfied and had no concerns at that time. -The ADON stated they had met with the resident. She said toileting him was a big process and staff was trying to get the resident on a schedule so he would have a bowel movement later in the morning, between 8:00 a.m. and 9:00 a.m. She stated they tried to offer the resident a suppository to regulate his bowel movements but he declined. (2) Review of the facility investigation revealed: The facility notes dated 5/28/14, documented the resident had a lot of concerns with LPN #3. The resident stated LPN #3 gave him a hard time about using the toilet at night and how long it takes. The notes read that the resident reported he was on the toilet for 45 minutes Sunday night (5/25/14) and 50 minutes last night (5/27/14). He would discuss having a set schedule for his bowel movements. A report was given to the resident's power of attorney. The care plan meeting notes, dated 6/3/14, read a care conference was held with the NHA, social services, ADON, resident, therapy, and two friends involved in his care. The resident's concerns were addressed. -Goals were discussed for bowel movements and how to promote independence related to the resident's goal to discharge home. -The resident expressed that he would prefer to not have LPN #3 take care of him anymore. This was discussed and a decision was made that LPN #3 would no longer be responsible for his care. The resident was satisfied with this solution. Further review of the resident's care plan for bowel elimination dated 5/27/14 read the resident wanted to be left on the bedside commode (BSC) for an hour and that he preferred to be toileted between 8-9 a.m. d. Failures in facility response (1) On 6/23/14 at approximately 5:05 p.m. the NHA, when reporting that the resident's care had been moved to the rehab unit after he complained on 5/28/14 about staff's lack of response, further explained that resident #111's call light does not ring at the rehab nurses' station, however. Rather, it still rings at the west nurse station even though the west unit nursing staff are no longer providing his care. The facility provided no explanation, either during interview or in the facility investigation and care plan meeting notes, how the resident's request for assistance was to be timely conveyed to staff on the rehab unit. Moreover, there was no evidence of follow up with the resident to see if staff response to his call light and assistance during his 'window of time' for bowel elimination had improved after the resident's care was transferred to the rehab unit. See above; the resident complained of incidents after 5/28/14. Finally, there was no evidence night shift staff on the west unit had been interviewed about the resident's complaints about lack of assistance. (2) The resident was contacted on 7/2/14 at 4:30 p.m. about his care plan for bowel elimination (see above), indicating he wanted to be left on the bedside commode for an hour and that he preferred to be toileted between 8-9 a.m. The resident stated these interventions did not represent his plan or his understanding of his care. He stated he wanted to use the commode between 5:00 a.m. and 6:00 a.m. as documented on the Evaluation for Bowel and Bladder Training form. He stated he was enraged that the facility would document these interventions on his care plan, stating the administration was aware that the issue always had been over toileting at night. He stated by making him wait to transfer to the commode, he had pain, had the urge to go, and had to hold it until someone put him on the toilet. It made him anxious to hold his bowel movement and he worried about having an accident. He stated he felt this type of care was demeaning, cruel and insensitive with no regard for the resident. e. Facility follow up during survey On 6/23/14 the NHA presented a completed 'Suspected Abuse Investigation Checklist/Guide' form, with a timeline as follows: -6/23/14 at 5:05 p.m.the Abuse Prevention Coordinator and the House Supervisor were notified -6/23/14 at 5:45 p.m. file immediately started for all information gathered. -6/23/14 at 5:30 p.m. residents assessed and findings documented in the IDT (interdisciplinary) progress notes. Documentation addresses physical, emotional psychological status. Skin check done. Roommates of resident also physically assessed for abuse. (The resident did not have a roommate however.) Summary of interviews/investigation: "Does not meet elements required for abuse reporting. The resident is very distressed however so the nurse has been suspended pending investigation. Does meets elements for neglect. Occurrence report to be submitted 6/24/14. Conclusion: Possible neglect. Plan of action Pursue termination of nurse r/t ( related to) insubordination and causing the resident distress with her reaction and behavior." 2. Resident #14 According to the facility admission record, resident #14, an [AGE] year old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident resided on the west unit. a. Resident Status According to the Minimum Data Set ((MDS) dated [DATE], the resident required extensive assist of one for bed mobility, transfers, toilet use and personal hygiene. Her BIMS (brief interview for mental status) score was 13, indicating she was cognitively intact. According to the Activities of daily living (ADL) care plan, the resident required staff assistance (limited to extensive assist of one staff member) and intervention for completion of ADL needs.. The approaches included: -Gather and provide needed supplies -Allow individual adequate time to complete tasks -Encourage active participation in tasks -Praise all efforts -Provide cueing with tasks as needed -Refer to therapy services as indicated -Individual/caregiver education as needed -Ensure effective pain management prior to ADL activities -Resident prefers showers b. Resident Interviews On 6/24/14 at 8:54 a.m. the resident was interviewed. She said that sometimes there is only one person on at night and they have to wait a long time to get help to go to the bathroom or to get assistance. She indicated the time wait varies, but it can be over an hour. On 6/24/14 at 4:16 p.m. the resident was interviewed again. She said there is a lady who works at night who seems like she just doesn't want to be there. When asked if she could explain or give some examples, she was unable to do so. c. Staff Interview On 6/24/14 at 1:21 p.m. CNA #9 was interviewed. He stated he worked the night shift on the west unit with LPN #3 regularly until about a month ago. -He said, "I'm a new CNA and I'm trying to impress everyone." He indicated he had noticed a few things about LPN #3 that he'd kept tight lipped about; he explained she was 'kind of ignoring' one of the residents (resident #14) who resided on the west unit. He said resident #14 calls for assistance potentially up to five times per night. He said the resident always wanted to go to the bathroom, every time. -He said LPN #3 suggested they would just leave the call light on until she fell asleep and then LPN #3 told him to turn the light off. -He said he never reported this and he should have reported it, but he wanted to impress his superiors and wanted to have a good working relationship with LPN #3. He said, "I just did what she told me."

Based on record review, observation, and interview, the facility failed to ensure six (#111, #14, #42, #46, #96, #93) of 39 sample residents received the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Specifically: --Resident #111's toileting needs were not met when he called for assistance resulting in pain, anxiety and anger; --Resident #14 placed her call light on when she required toileting assistance and her needs were not met due to staff knowingly withholding care; --Resident #42's [MEDICAL TREATMENT] activities were not monitored by the facility due to failure to maintain the communication logs between the outside [MEDICAL TREATMENT] center and the facility; --Resident #46's pain was not numerically rated after the administration of pain medication to ensure effectiveness as ordered; --Resident #96's pain was not accurately reassessed following the administration of pain medications; --Resident #93's pain was not accurately reassessed and blood glucose levels were not appropriately monitored following blood glucose readings outside of the established parameters; The findings include: I. Delay of, denial of, or improper resident care 1. Resident #111 Cross reference F224 and F225. A 5/28/14 grievance filed by the resident's representative and confirmed with the resident during an interview on 6/23/14 revealed a licensed practical nurse (LPN #3), "Gave him a hard time about using the toilet at night and left him on the toilet for 45 minutes and 50 minutes on two separate occasions." During interviews on 6/23/14 and on 7/2/14 (after survey), the resident declared being left on the toilet and the facility staff withholding his placement on the toilet, he suffered from constipation, pain and anxiety and felt he was subjected to cruel, demeaning, and insensitive treatment. 2. Resident #14 Cross reference F224 and F225. A 6/24/14 at 1:21 p.m. interview with a certified nurse aide (CNA #9) revealed he was instructed by LPN #3 to withhold toileting assistance to resident #14 and he complied with this instruction on more than one occasion. When asked specifically if he had any concerns about LPN #3's treatment of [REDACTED].#14)." He said LPN #3 instructed him not to answer the resident's call light. He stated, "She calls potentially up to five times per night to go to the bathroom. Sometimes we would just leave the call light on until she fell asleep. After (resident #14) fell asleep, (LPN #3) would tell me to turn her light off." Cross reference F224 - Neglect and F225 - Investigation of Abuse for further information and interviews for resident #111 and resident #14. II. [MEDICAL TREATMENT] Coordination 1. Resident #42 a. Facility Policy According to the facility's [MEDICAL TREATMENT] policy, in pertinent part: "The facility provides residents with safe, accurate, and appropriate care assessments and interventions to improve resident outcomes ... ...A [MEDICAL TREATMENT] communication record is initiated and sent to the [MEDICAL TREATMENT] center each appointment; ensure it is received upon return ..." b. Resident Status According to the face sheet, the resident was a [AGE] year-old male readmitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The 4/21/14 admission Minimum Data Set (MDS) showed the resident was cognitively intact and diagnosed with [REDACTED]. He received [MEDICAL TREATMENT] treatments. The [MEDICAL TREATMENT] care plan, dated 4/22/14, showed the resident received [MEDICAL TREATMENT] three times per week and had an AV (arteriovenous) fistula. Pertinent approaches included: --[MEDICAL TREATMENT] communication record is sent to the [MEDICAL TREATMENT] center with each appointment and return of form is ensured after appointment is completed. --Resident refuses to go on occasion and refuses assessment post treatment at times b. Record Review On 6/25/14, the resident's clinical record was reviewed. Only three [MEDICAL TREATMENT] communication records, dated 4/16/16, 4/18/14, and 4/21/14, were located in the record. A patient review report was sent by the outside [MEDICAL TREATMENT] center to the facility on [DATE]. This report showed the resident missed [MEDICAL TREATMENT] treatments on 5/12/14, 5/19/14, 5/25/14, 5/26/14, 5/30/14, and 6/4/14. c. [MEDICAL TREATMENT] Nurse Interview The registered nurse assigned to work with the resident at the outside [MEDICAL TREATMENT] center (DRN) was interviewed via telephone on 6/25/14 at 4:15 p.m. The DRN was asked about the [MEDICAL TREATMENT] communication records. She stated, "In the past he brought a book but he hasn't been bringing it. I asked him if he forgot the book and he said no one brought him the book. I've been trying to contact the unit (at the facility) and they said they didn't know where the book is. I don't know where that book is going." The DRN stated she was going to print off the post treatment sheets and fax them to the facility. d. Staff Interviews --On 6/25/14 at 2:58 p.m., a registered nurse (RN #5) and a licensed practical nurse (LPN #7) who were assigned to work with the resident on their respective shifts were interviewed about the [MEDICAL TREATMENT] communication records. RN #5 stated, "We brought him a book but he tells me it's none of my business. I have to plead with him to look at his shunt. He doesn't bring the book (to [MEDICAL TREATMENT]) and it's been hard communicating with them (the outside [MEDICAL TREATMENT] center) as well. (The resident) is resistant to being in this place anyway." When asked how they were aware of what medications the resident received while at [MEDICAL TREATMENT], LPN #7 said, "We don't really know what he gets there." --On 6/25/14 at approximately 4:00 p.m., the director of nursing (DON) stated she had become aware communication was not occurring with the [MEDICAL TREATMENT] center on around 6/23/14 (during survey). However, she had not yet taken any action to ensure the communication occurred. She said, "The night nurse will initiate the communication sheet and it will be sent off with the resident before he departs." She stated even if the resident was resistant to bringing the communication book, "We should still be attempting to send it with him." III. Pain Assessments 1. Resident #46 a. Resident Status According to the face sheet, the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The 4/28/14 quarterly MDS showed the resident was cognitively intact, scoring 15 out of 15 possible points on the brief interview of mental status (BIMS). She required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. According to the pain care plan, dated 1/16/14 and revised on 2/23/14, the resident had actual and potential pain related to skin ulcer/wound, joint pain, chronic disease process, neuropathic pain, musculoskeletal, spinal stenosis, and chronic pain. Approaches included: --Positioning/support --Massage --Relaxation --Music --Administer [MEDICATION NAME] as ordered --See physician orders --Implement pain management flow sheet --Observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions every shift and as needed --Notify physician if interventions are not effective b. Resident Interview --On 6/23/14 at 11:25 a.m., the resident was observed in her room. She was sitting on her bed and was alert and oriented. The resident was asked if she had any discomfort such as pain, heaviness, burning, or hurting without relief. She said, "Yes. After the medication my pain only gets down to a 5 or a 6 (out of 10 with 10 being the worst pain). My hands and knees always hurt." The resident was asked what her goal for pain management was on a 1-10 scale. She said, "My goal is a 5 to 6. I've become complacent with that because I know it's not going to get any better. --On 6/24/14 at 4:37 p.m., the resident was again observed sitting on her bed. She was watching television. The resident was asked about her pain. She said, "The pain is still in my knees. They have been giving me a hard time with the weather and the storms." The resident stated her pain never went down below a 5 or a 6 out of 10 and was at that time around a 6 out of 10. --On 6/25/14 at approximately 9:30 a.m., the resident stated she had never rated her pain as a zero (0) and stated the nurses rarely asked her to rate her pain after she was administered pain medication. c. Record Review According to the June 2014 computerized physician orders, the resident was prescribed the following, pertinent medications: [REDACTED] --[MEDICATION NAME] 10 milligrams every six hours as needed for pain as of 4/22/14 --[MEDICATION NAME] 10 milligrams four times daily for pain; chart pain level before and and 1 hour after routine pain med as of 4/22/14 --[MEDICATION NAME] 40 milligrams every eight hours for joint pain. Chart level of pain 1 - 10 before giving med and 1 hour after. The June 2014 Medication Administration Record [REDACTED]. Following the administration of the [MEDICATION NAME], the resident's pain level one hour after administration was consistently documented as 0 on a 1-10 scale. The June 2014 MAR indicated [REDACTED]. The resident's pain level one hour after administration was consistently rated as a 0 on a 1-10 scale. d. Staff Interviews --On 6/25/14 at 2:49 p.m., a licensed practical nurse (LPN #7) who worked with the resident was interviewed. She admitted she did not always ask the resident to numerically rate her pain. When asked the reason she documented a 0 in the MAR, she stated it was because when she asked the resident if she was having pain, the resident would respond, "Do I look like I'm in pain?" --On 6/25/14 at 3:08 p.m., a registered nurse (RN #5) who worked with the resident was interviewed. When asked if she reassessed the resident after administering the routine pain medication she said she did. When asked what she asked the resident, she said she asked the resident if she was still in pain or if she could get her something else. She said, "I'm not consistently asking her to rate her pain numerically." --On 6/25/14 at 3:08 p.m., the director of nursing (DON) stated the nurses should follow the order as written. She stated they should have consistently asked the resident to numerically rate her pain. 2. Resident #96 a. Resident Status According to the face sheet, the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to the 5/28/14 Minimum Data Set (MDS), the resident was independent in her decision making. A [DIAGNOSES REDACTED]. She was totally dependent on two-plus person physical assistance with her transfers. She requires extensive assistance of two-plus person for bed mobility, dressing, toileting and personal hygiene. Resident #96 was total dependence of two-plus person's physical assist for her bath. Review of physician orders [REDACTED]. A review of the resident's care plan dated 11/21/13 documented pain actual and potential; related to chronic disease process, neuropathic pain, musculoskeletal, myalgia, [MEDICAL CONDITION], chronic pain, Left ankle. Approaches included: - positioning/support, exercise program, -stretching exercises, - massage, recreational therapy/activity programming, music, relaxation, counseling/support via psychology, -administer [MEDICATION NAME] as ordered, see physician orders, implement pain management flow sheet, -observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing, other), -notify physician if interventions are not consistently effective, -medicate resident for pain prior to treatments and therapy, if indicated, therapy referral as indicated. A pain evaluation dated 5/22/14 documented present pain/hurting rating = four (4); worst pain/hurting gets = nine (9); best pain/hurting gets = two (2); what is your goal for managing your pain or hurting = two (2) to four (4); are you satisfied with your current level of pain/hurting control = yes. b. Resident Interviews --On 6/23/14 at 2:00 p.m., the resident was interviewed. Resident #96 stated she has pain in her paralyzed limbs on the left side. The resident stated the best her pain gets with pain medication is a level 5 (on a 1-10 scale with 10 being the worst pain) and her goal for pain is a level 0. --On 6/25/14 at 11:30 a.m., the resident was interviewed again. The resident stated her pain level can be a 5 after pain medication is given. She also stated out of the routine [MEDICATION NAME] given twice daily, (14 times a week), the nurse may come back only once after the pain medication is given to check on her level of pain. She stated she does not call again to let the nurses know that she is still in pain. She stated "I'm just used to the pain." --On 6/26/14 at 9:17 a.m., the resident was interviewed a third time. The resident stated she had received her routine [MEDICATION NAME] at 8 a.m. today and the nurse had not as of yet come to ask her what her pain level is. c. Record Review --On 6/25/14 at 11:15 a.m. and on 6/26/14 at 9:20 a.m., a review of the pain assessments on the resident's MAR for [MEDICATION NAME] 2 milligram(MG) given at 8:00 a.m. and at 8:30 p.m. for the month of June 2014 (through 6/25/14), documented 0 pain for pre and post administration pain levels. --On 6/26/14 at 9:20 a.m., observation of the MAR for the [MEDICATION NAME] 2 MG given at 8:00 a.m., revealed a 0 documented for post medication administration pain level. d. Staff Interviews --On 6/25/14 at 2:20 p.m., the RN #5 was interviewed. RN #5 stated after she gives a pain medication, she will wait 30 minutes to one hour and then go back in to the resident to check the effectiveness of the pain medication. She said she also will check the resident's respirations if she gives them an opiate [MEDICATION NAME]. If the resident is still having pain, she will check to see if the resident has something else to give or try other interventions listed on the care plan. --On 6/25/14 at 2:25 p.m., the LPN #7 was interviewed. The LPN #7 stated after giving a pain medication, she would go back after 30 minutes to one hour after the pain medication was given to ask the resident what her pain level was. And, if there was not adequate relief, she would check for another pain medication to give or offer some other intervention like ice or take the resident to an activity. --On 6/26/14 at 9:25 a.m., the DON was interviewed. She reviewed the resident's MAR for the administration of the routine [MEDICATION NAME] administered on 6/26/14 at 8 a.m. The DON agreed the post pain level was documented as a 0. The DON was informed resident stated she had not been asked about her pain level after pain medication was given that morning. The DON stated the nurse should have gone back to the resident to re-evaluate her pain. She stated it is her expectation the nurse re-evaluate a resident's pain 30 minutes to one hour after a pain medication is given. e. Facility follow up On 6/26/14 at 10:30 a.m., observation of the MAR indicated [REDACTED]. On 6/26/14 at 10:48 a.m., the DON was interviewed again. The DON stated she had the nurse who had administered the resident's [MEDICATION NAME] that morning go back and ask the resident what her pain level was. The DON agreed the nurse should have not changed the 0 to 4 on the MAR; rather, she expected the nurse to make a note in the nurse's notes. The DON stated she will be educating the nurse. 3. Resident #93 Resident #93 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. a. Resident Status Her Minimum Data Set ((MDS) dated [DATE] revealed she was able to understand and be understood. She had no hearing loss and no impairment in decision making ability. Her care plan for pain dated 5/30/14 listed the problem as actual pain related to skin ulcers, chronic disease process, [MEDICAL CONDITION] and [MEDICAL CONDITION] joint disease. -An undated note on the care plan read that the resident frequently states her pain is at a level 8, 9, or 10 when requesting pain medication. The resident most often does not present with physical signs/symptoms of pain. Asked resident to point the face that denotes her pain by the Wong Baker Scale. Face picked did not indicate (she) was in pain at a 9-10. -The goal for the pain care plan noted the resident verbally expresses increased satisfaction with pain control. -The approaches in pertinent part included: positioning, massage, relaxation, music, counseling via psychology and social services. Administer [MEDICATION NAME], implement pain flow sheet. Observe resident for signs/symptoms of pain every shift and prn (as needed) The treatments section of the physician's orders [REDACTED]. Chart level of pain 1-10 every shift. (start date 12/5/12). Pain medications listed from the resident's physicians orders included: -[MEDICATION NAME] 500 mg every 4 hours as needed for pain. -[MEDICATION NAME] 2 mg every 2 hours as needed for pain. Chart on prn pain sheet. -[MEDICATION NAME] 100 mcg/hour -[MEDICATION NAME] 30 mg 4 times per day. b. Record Review Review of the PRN Pain Medication Administration Record [REDACTED]. Further review revealed the medication was administered 64 times in May. The resident's pain level score after administration of the prn medication was 0, indicating the resident was pain free. Review of the PRN Pain Medication Administration Record [REDACTED]. Each time, the pain level after administration was documented as 0, indicating the resident was pain free. c. Resident Interview On 6/23/14 at 2:36 p.m. the resident stated she had pain continually. She stated the worst pain was at a 9-10 due to [MEDICAL CONDITION] and pain in her spine. On 6/25/14 at approximately 4:00 p.m., the resident was interviewed again and asked if she was ever pain free after she is administered [MEDICATION NAME]. She stated she was never pain free; she said generally her pain at its lowest level was at level 5-6. She further stated the [MEDICATION NAME] took the edge off but she still had pain. IV. Diabetic management - Blood Sugars A. Reference According to American Diabetes Association, [DIAGNOSES REDACTED] is characterized by low blood glucose (blood sugar) levels, usually less than 70 mg/dl. Treatment includes (1) having the resident consume 15-20 grams of glucose or simple carbohydrates; (2) recheck blood glucose 15 minutes later and if [DIAGNOSES REDACTED] continues, to repeat steps (1) and (2). After the resident's blood glucose returns to normal, having the resident eat a small snack if the next meal or snack is more than 1-2 hours away. B. Resident #93 a. Resident Status See above. The resident had a [DIAGNOSES REDACTED]. b. Resident Interview During an interview on 6/23/14 at 2:15 p.m. the resident stated she was awakened at 4:30 a.m. every morning because her blood sugar (Blood glucose/BG) was dropping too low and historically drops low at that time. The resident stated she is on insulin and if her BG falls below 70-75, she starts to feel shaky and requires some intervention to raise her BG level. c. Record Review Review of the physician's orders [REDACTED]. The resident was on [MEDICATION NAME] 75 units at 8:00 a.m. and 58 units at 9:00 p.m. She was also on Humalog 15 units at 5:00 p.m. Review of the Blood Glucose (BG) Tracking/ Sliding Scale Insulin Administration Record (BG record) revealed for the month of May 2014, there were 10 days when the resident's BG was low enough to require administration of a snack. According to the BG record, the physician was to be contacted if the resident's BG was below 60 or above 600. Of the following days requiring a snack, the following was recorded: -5/3/14 at 5:30 a.m. the BG was 64 juice was administered. -5/8/14 at 5:00 a.m. the BG was 67 juice was administered. -5/9/14 at 6:00 a.m. the BG was 68 snacks were given. -5/10/14 at 6:00 a.m. the BG was 59 juice was administered. -5/12/14 at 6:00 a.m. the BG was 60 juice was administered. -5/13/14 at 6:00 a.m. the BG was 63 juice was administered. -5/15/14 at 5:00 a.m. the BG was 64 juice was administered. -5/22/14 at 5:00 a.m. the BG was 67 juice was administered. -5/26/14 at 5:00 a.m. the BG was 63 juice was administered. -5/29/14 at 5:30 a.m. the BG was unreadable juice was administered. For the month of June through 6/26/14, the following 8 times snack/ juice was administered. -6/5/5/14 at 5:00 the BG was 70 juice was administered. -6/10 at 6:00 a.m. the BG was 61 juice was administered. -6/11/14 at 6:00 a.m. the BG was 67 juice was administered. -6/14/14 at 5:00 a.m. the BG was 66 juice was administered. -6/15/14 at 5:00 a.m. the BG was 69 juice was administered with a snack. -6/18/14 at 6:00 a.m. the BG was 56 juice was administered. -6/20/14 at 5:00 a.m. the BG was 66 juice was administered. -6/24/14 at 5:00 a.m. the BG was 68 juice was administered. Review of the BG records for May and June revealed no follow up to recheck BG when juice was administered or other documentation on the resident's status. Review of the nurses notes (5/14 - 6/24/14) in the medical chart revealed no entries documenting the resident's BG was rechecked. Finally, there was no indication on the BG record or in the nurses' notes (5/14 - 6/24/14) that the physician was contacted on 5/10/14 and 6/18/14 when the resident's BG was below 60. d. Staff Interview A nurse who wished to remain anonymous was interviewed on 6/25/14 at approximately 9:00 a.m. -S/he said there was no place on the BG record for recording the BG after administering juice. -S/he explained staff only gave juice for low blood glucose. with no follow up with a snack (see reference above) because there was no snack on hand. S/he said to keep residents from having peaks and valleys in BG, protein should also be administered with the juice. Review of the refrigerators on 6/25/14 at approximately 8:15 a.m. and again at 10:30 a.m. with the regional registered dietitian (RRD) at the four nursing stations revealed no food available for anyone. There was orange juice in one refrigerator. There was applesauce and a small amount of yogurt in all the refrigerators for medication administration. The food service supervisor was interviewed on 6/25/14 at approximately 8:30 a.m. He stated he sent food on the carts to each of the four nurses station about 8-8:30 p.m. He stated nursing took care of passing the snacks.

Based on observation, record review and interview, the facility failed to provide care and services to ensure one (#23) of three sampled residents achieved their highest practicable level of well-being. Specifically, the facility failed to follow physician orders [REDACTED]. The findings included: Resident #23, 70-years-old, was admitted to the facility on [DATE]. According to the face sheet, the resident was admitted with [DIAGNOSES REDACTED]. The resident ' s current, 8/14 computerized physician orders [REDACTED]. The CPO also contained an order dated 10/12/09 directing staff to notify the doctor for any blood glucose values less than 60 milligrams/deciliter (mg/dL) or greater than 300 mg/dL. The resident ' s diabetic care plan, last revised on 4/18/14 and last reviewed on 7/3/14, listed as the goal, " ...blood sugar ranges will remain stable within MD prescribed parameters of 60 to 300 ... " The facility ' s " Diabetic Management " policy/clinical practice standard noted that, upon admission, the interdisciplinary team evaluated the diabetic resident and implemented a plan of care to ensure: " orders are received and are accurate related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow and when to notify the physician. " Review of blood glucose tracking records revealed that, although, the 2009 order directed staff to notify the doctor for blood glucose values less than 60 mg/dL or greater than 300 mg/dL, staff utilized parameters of 60 to 350 mg/dL from January 2014 to May 2014 to direct physician notification. Beginning in June 2014, staff utilized blood glucose parameters of 60 to 400 mg/dL to direct physician notification, despite lacking an order for [REDACTED]. The Director of Nursing (DON) was interviewed on 9/5/14 at 10:45 a.m. The DON confirmed that no order to change the blood glucose notification parameters existed. The DON explained that the resident was currently being followed by an endocrinologist due to the instability of the resident ' s blood sugar values, which she stated were getting under control. The DON was unable to produce any orders or consult notes from the endocrinologist, but noted she called the resident ' s Physician Assistant that day who stated he only wanted to be notified of blood glucose values below 60 mg/dL or above 400 mg/dL. The DON wrote a clarification order that day changing the blood glucose parameters requiring physician notification. The resident was observed receiving an insulin injection on 9/5/14 at 11:30 a.m. After the resident received the insulin, the DON entered the room and asked the resident to sign a release form for the endocrinologist visit notes. On 9/5/14 at 11:43 a.m., the endocrinologist ' s office faxed a visit note from the resident ' s 8/18/14 visit. The consultation note identified that a hemoglobin A1c was drawn that day and was high at 8.6% (normal range: 4.0 - 5.7%). According to www.mayoclinic.org <http://www.mayoclinic.org>, "a hemoglobin A1c test reflects an average blood sugar level for the past two to three months and is used to gauge how well an individual ' s diabetes is managed. The endocrinologist identified that previous hemoglobin A1c tests were also high at 9.0% and 10.9% (dates unknown). The endocrinologist documented, " Blood sugar control can probably be improved, but I think it is unlikely that tight control can be achieved. (The resident ' s) diet is much too variable in terms of carbohydrate intake to be able to prevent fluctuating blood glucose readings. " The endocrinologist directed staff to monitor the resident ' s blood sugar pre-meal and at bedtime, noting staff should fax the glucose log to the endocrinologist at two-week intervals for review. However, the day to day values were monitored by staff using practitioner-established parameters for practitioner notification when out of range.