Every finding on record at Brookdale Skyline

Based on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards for one (#4) of three residents reviewed for change in condition skin assessments out of nine sample residents.Specifically, the facility failed to complete thorough documentation of new skin discoloration/bruising. Findings include:I. Facility policy and procedureThe Change in Condition policy, revised March 2026, was received from the nursing home administrator (NHA) on 8/11/26 at 11:11 a.m. It read in pertinent part, When a resident is evaluated as having a change in condition, the nurse should document notification of the healthcare provider and other nurses in order to facilitate the appropriate plan of care. An associate would communicate information about a resident's status change to appropriate personnel upon observation. Upon receiving notification of a difference in the resident's physical status, the nurse should -Perform a comprehensive evaluation, consulting the care path as indicated;-Administer basic first aid; and,-Complete documentation based on the comprehensive assessment for the current situation and notify the healthcare provider. Implement treatment interventions and document the healthcare provider recommendations as indicated. A resident's change in condition may include skin. The nurse should record follow-up information related to the resident's change in condition in the electronic medication record.II. Resident #4A. Resident statusResident #4, age greater than 90, was admitted on [DATE]. According to the August 2026 computerized physician orders, diagnoses included heart failure and dementia, chronic lymphocytic leukemia not in remission, anemia, atrial fibrillation (abnormal heart rhythm), and vitamin D deficiency, and had a history of severe bruising from cancer treatments.The 7/4/26 minimum data set assessment revealed the resident had moderate cognitive impairments with a brief interview for a mental status score of 12 out of 15. Resident #4 required partial to moderate assistance from staff for bed mobility and was dependent on staff for transfers.B. Record reviewThe skin integrity care plan, initiated 5/29/26, revealed Resident #4 had a risk for impaired skin integrity and discoloration related to anemia. Pertinent interventions included assisting with turning and repositioning as needed, evaluating Resident #4's skin condition on a daily and weekly basis, and educating Resident #4 on repositioning and turning during care.-The care plan did not include interventions for monitoring Resident #4 for severe bruising.The 6/20/26 Braden Scale, a tool to predict pressure sore risk, revealed Resident #4 had no impairment of skin perception, had very moist skin, was chairfast, had limited mobility, probably inadequate nutrition, had a skin problem from friction and shearing, and the Braden score was less than 16. The 6/20/26 Braden Scale revealed a care plan updated and identified Resident #4 was at risk for impaired skin integrity. The skin integrity care plan was updated for staff to provide assistance for Resident #4 with turning and repositioning.-The Braden Scale assessment is a tool used to determine a risk for skin injury due to pressure and did not include documentation or assessment of new bruising/skin discoloration.The 6/22/26 7:02 p.m. change in condition nurse progress note revealed Resident #4 told a staff member that a caregiver handled her roughly the night before when she was providing incontinence care. The nurse documented Resident #4 had a discoloration to her left arm that was light purple in color. The progress note revealed Resident #4 denied pain and was able to move her arm appropriately. The progress note revealed the resident told the nurse she had a discolored area that could have been from a transfer and did not feel like a staff member had abused her.The progress note documented that the nurse contacted the provider regarding the change in condition, and the provider gave an order to monitor the resident for any worsening in her condition. -The assessment failed to include measurements of the discolored skin area.The 6/23/26 8:27 a.m. nurse progress note revealed the nurse documented Resident #4 had a discoloration on the left arm that was light purple in color. Resident #4 denied pain and was able to move her arm appropriately.-The assessment failed to include measurements of the discolored skin area.III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 8/11/26 at 2:15 p.m. RN #1 said when a nurse completed an assessment of bruising, the nurse should document the size, shape, color, and location of the bruising. RN #1 said the assessment should include a review of possible causes of the bruising and the nurse should implement interventions to prevent repeated or worsening of the bruising. RN #1 said if a bruise increased in size, that could mean the injury was worse, or the bruising was more visible as it healed. RN #1 said possible causes of the bruising should be considered as part of the nursing assessment. RN #1 said she was familiar with Resident #4. She said Resident #4 had no changes in her behaviors or mood and had no changes in using her left arm after she reported a staff member was rough with her.The NHA and the director of nursing (DON) were interviewed together on 8/11/26 at 3:06 p.m. The DON said she was new to her position and had not been involved in the review of the incident with Resident #4. The DON said she was unable to locate skin discoloration/bruising assessments with measurements until 6/22/26. The DON said a nurse assessment for new skin injury should include measurements to be used to monitor the status of the injury. The DON said the facility had completed education and training for the skin measurements on 6/20/26.The NHA said the facility had completed education and training with nursing staff that included turning and repositioning and the abuse policy. The NHA said the facility had additional internal documentation related to the incident and did not produce documentation that included change in condition assessment for discolored/bruised skin measurements for 6/20/26 to 6/23/26.IV. Facility follow-upThe facility's past non-compliance quality of care document, undated, was received by email from the NHA on 8/13/26 at 3:48 p.m. The document revealed the facility took the following actions in response to Resident #4 reporting she was handled roughly by a staff member during care. On 6/12/26, staff re-education was initiated and ongoing to include monitoring for the skin management process, change in condition, and skin assessments.The education was provided prior to the incident on 6/20/26 with Resident #4. The record review for Resident #4 revealed that skin assessments after Resident #4 were not thorough and did not include measurements of new bruising. -However, the facility's documentation revealed the education and training did not include documenting measurements of new skin discolorations/bruises when residents have been injured and are at high risk of bleeding. The education and training was provided from 6/20/26 to 6/24/26. The Resident #4's record revealed that on the days of the training, the skin discolorations/bruising assessments did not include measurements for monitoring worsening or healing.

Based on record review and interviews, the facility failed to ensure supervision and monitor assistive devices to prevent accidents for one (#2) of five residents reviewed for accidents out of seven sample residents. The facility failed to ensure staff transferred Resident #2 appropriately with a mechanical lift which resulted in a fall with major injury for the resident.Resident #2 was admitted to the facility for rehabilitation services on 10/7/25. The resident's care plan directed staff to utilize a mechanical lift (a sit to stand lift) for transfers. On 10/11/25 certified nurse aide (CNA) #1 and CNA #2 used a gait belt (a belt that fastens around the waist, used for someone with mobility issues) to transfer Resident #2 from the toilet to her wheelchair. Resident #2 stood, and then lost the ability to bear weight in one of her legs and fell to the floor.Immediately after the incident, Resident #2 complained of right knee pain. The pain worsened and the resident was transported to the hospital on [DATE] where it was revealed that the resident had sustained a fracture to her right femur. Resident #2 discharged from the hospital and returned to the facility on [DATE].The facility investigation after the incident revealed CNA #1 and CNA #2 attempted to transfer Resident #2 using a gait belt instead of the mechanical lift.Due to the facility's failure to adequately supervise and use a mechanical lift, Resident #2 fell and sustained a fracture to her right femur. Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #2's fall prior to the onsite investigation on 10/27/25 to 10/28/25. The deficiency was cited as past non-compliance with a correction date of 10/17/25.I. Incident on 10/11/25The nursing home administrator (NHA) provided an investigation on 10/27/25 at 4:31 p.m. regarding Resident #2's fall incident on 10/11/25 while being transferred by CNA #1 and CNA #2. The investigation documented that on 10/11/25 Resident #2 sustained a fall while being transferred from the toilet to the wheelchair. It documented Resident #2 was sent to the hospital on [DATE] after an Xray was done at the facility for Resident #2's report of increased right knee pain. The hospital found Resident #2's injury included a fracture of the right femur.The investigation included a statement by CNA #1 on 10/13/25. It documented CNA #1 said the night before the incident, Resident #2 had complained of discomfort with use of the mechanical lift. It documented on the night of the incident, CNA #1 said she and CNA #2 used the mechanical lift to transfer the resident from the bed to wheelchair, but then used a gait belt to assist the resident onto the toilet. The statement documented when the resident stood up from the toilet, she began to fall and CNA #1 and CNA #2 assisted Resident #2 to the floor. It documented Resident #2's leg was bent when it reached the floor.-The statement revealed CNA #1 and CNA #2 had transferred the resident without the use of the mechanical lift.The investigation included a statement by CNA #2 on 10/14/25. It documented CNA #2 said she was in orientation and in training, She said CNA #1 was training her. It documented CNA #1 was apprehensive to use the mechanical lift due to Resident #2's discomfort with previous use of the mechanical lift. The statement documented CNA #2 suggested they use a gait belt for a two person transfer. It documented CNA #1 and CNA #2 proceeded with transferring the resident using the gait belt. It documented when the resident stood from the toilet she began to fall and her right leg bent inward while being assisted to the ground.The investigation included a statement by licensed practical nurse (LPN) #1 on 10/14 25. It documented CNA #1 notified LPN #1 that Resident #2 had fallen in her bathroom. It documented LPN #1 found Resident #2 on the floor in the bathroom with a gait belt on. The statement documented CNA #1 told LPN #1 that she was upset because she should have used the mechanical lift for the transfer. The investigation documented nine interviews with residents at the facility and revealed no concerns with transfer assistance.The investigation documented that Resident #2's fall resulted in a right femur fracture.II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #2The facility provided documentation of staff education completed after the incident which included the following:A document titled Safe Patient Transfers and Kardex (staff directive tool) inservice, documented as an in person inservice provided by CNA #4 on 10/16/25. The document included 26 CNA, six LPN and four registered nurse (RN) signatures. The document included resident transfer education was reviewed during the meeting. It also included the importance of not transferring the resident without knowing their care plan status (not relying on information provided by others verbally), notification of the nurse if any concerns with transferring a resident including if the resident required reassessment and following the care plan regardless of the type of transfer the therapist was working on with a resident.A document titled Use of Therapy to Nursing Communication Form, dated 10/17/25, documented the director of rehabilitation services (DOR) would use the form to report resident functional changes to include transfer status, diet changes, bed mobility apparatus and therapy frequency. It documented the DOR would give the form to the DON and MDS coordinator after every resident evaluation or status change. It documented the MDS coordinator would update the resident care plan and Kardex. A document titled Use of Therapy to Nursing Form Review, documented an inservice provided by the DOR on 10/17/25. The document included 11 therapy department and nurse signatures. The inservice included when to use the therapy to nursing form, reporting patient functional changes but not limited to transfer status, diet changes, bed mobility apparatus, therapy frequency. The inservice also included completion of the form for every evaluation and status change and requirement for the form to be given to DON and the MDS to input in the resident's care plan/Kardex.Documents titled CNA Skills Checklist and User Training were provided by the NHA on 10/27/25 at 6:06 p.m. The documents revealed CNA #1 demonstrated performance of resident transfers and completed online education by 4/17/25 and CNA #2 demonstrated performance and completed education of transfers by 9/22/25.B. Identification of other residentsA document titled Transfer Status was provided by the NHA on 10/27/25 at 6:06 p.m. The document, dated 10/13/25, revealed an audit of the transfer status for 48 residents who required transfer assistance at the facility and included the type of transfer required and confirmation that the care plan reflected the type of transfer required.C. Systematic changesAll nursing staff were re-educated on resident transfers using mechanical lift procedures. This was completed by 10/16/25. D. MonitoringAn audit tool titled ADLs for Dependent Residents/Transfers was provided by the NHA on 10/2/25 at 6:06 p.m. The document included instruction to complete three observations weekly for 12 weeks. The audit tool included documentation for four resident transfer observations on 10/21/25 and four observations on 10/27/25 completed by the DON, and included the type of resident transfer observed and confirmed that the care plan and Kardex had been updated. Interviews and record review during the investigation revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence and monitoring to ensure sustained corrections were in place.III. Facility policy and procedureThe Mechanical/Assistive Lifts policy, revised September 2017, was provided by the NHA on 10/28/25 at 4:57 p.m. It read in pertinent part, For residents that require the use of mechanical or assistive lifts, a therapy order is requested from the health care provider for evaluation and treatment care recommendations. Mechanical/assistive lifting equipment is considered as a full body or sit to stand lift that aids the associate and the resident in transfer and/or care procedures. It is recommended that mechanical/assistive lifting equipment is used for those residents who have been evaluated for the use of this equipment. Education should be provided on the proper use of the assistive mechanical lifting equipment prior to its use.IV. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD, a lung disease), cirrhosis (disease of the liver), duodenal ulcer, chronic respiratory failure and low back pain .The 10/23/25 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. Resident #2 required set up assistance with eating and was dependent on staff for toileting, showering, dressing and transfers, including from the bed to chair and from a sit to stand position.B. Resident interviewResident #2 was interviewed on 10/27/25 at 11:20 a.m. Resident #2 said on the night she fell, the CNAs used a gait belt to transfer her to and from the toilet. Resident #2 said when she was standing her right leg gave out and her right leg twisted around the toilet while she slid to the floor. Resident #2 said the right knee pain developed overnight and she told staff the next day that it was getting worse. C. Record reviewThe activities of daily living (ADL) care plan, initiated 10/7/25, revealed Resident #2 had a self-care performance deficit and was dependent on staff for ADLs (bathing, dressing, toileting and mobility). The fall care plan, initiated 10/7/25, revealed Resident #2 was at high risk for falls and required a physical and occupational therapy evaluation.The Kardex (staff directive tool), revised 10/9/25, was provided by the NHA on 10/28/25 at 11:41 a.m. It revealed Resident #2 required a sit to stand mechanical lift for transfers.A nursing progress note, dated 10/12/25 at 1:04 a.m., documented Resident #2 was evaluated for a change of condition due to a fall. It documented Resident #2 had pain and the on-call physician was notified. The note documented the physician recommendation to continue to monitor for injuries.A nursing progress note, dated 10/12/25 at 4:00 p.m., documented Resident #2 had increased pain and swelling of her right knee. It documented the physician was contacted and a physician order was received for an Xray and pain medication (oxycodone) was provided to Resident #2.Resident #2's hospital history and physical record, dated 10/12/25 at 9:30 p.m., documented Resident #2 had an admission diagnosis of a closed fracture of the right femur.An interdisciplinary team (IDT) post-event analysis form, dated 10/15/25 at 10:55 a.m., documented Resident #2 required a sit to stand mechanical lift. It documented on 10/11/25, CNA #1 and CNA #2 used a gait belt for transfer and Resident #2 fell while standing up after using the toilet. It documented Resident #2 was later transferred to the hospital for a possible fracture.V. Staff interviewsRN #1 was interviewed on 10/27/25 at 11:45 a.m. RN #1 said Resident #2's knee would sometimes give out and for this reason she required a sit to stand lift prior to the fall. RN #1 said upon return from the hospital, Resident #2 required a full body mechanical lift.CNA #10 was interviewed on 10/27/25 at 11:53 a.m. CNA #10 said she took care of Resident #2 the day after she fell. CNA #10 said Resident #2 began to have more pain with movement and her right leg was swollen. She said Resident #2 could no longer use the sit to stand lift and she required the full body mechanical lift after the fall.CNA #1 was interviewed on 10/27/25 at 4:55 p.m. CNA #1 said she was training CNA #2 on the night of 10/11/25. CNA #1 said she was told that Resident #2 wanted to use the bathroom. CNA #1 said she and CNA #2 used the sit to stand mechanical lift to transfer the resident from the bed to the wheelchair. She said Resident #2 did not refuse to use the sit to stand lift, however, CNA #1 said she remembered the night before, Resident #2 complained that the sit to stand bothered her under her arms. CNA #1 said she and CNA #2 were also having difficulty maneuvering equipment in Resident #2's bathroom and CNA #1 was concerned she did not have the room for the sit to stand lift. CNA #1 said she obtained a gait belt to transfer the resident and she and CNA #2 used the gait belt to transfer Resident #2 onto the toilet. CNA #1 said Resident #2 could not maintain a standing position after using the toilet and she began to fall to the floor. CNA #1 said she and CNA #2 assisted the resident to slide to the floor. CNA #1 said she then notified LPN #1 and the LPN also had an RN come to the room for assessment. CNA #1 said a full body lift was used to lift Resident #2 and return her to her bed. CNA #1 said Resident #2 should have been transferred with the sit to stand mechanical lift. She said if the sit to stand lift had been used, Resident #2 likely would not have slid down onto the floor.CNA #1 said she had previous training for transferring residents and the use of mechanical lifts, including the sit to stand lift. CNA #1 said after Resident #2's fall incident, she received additional education from the facility's resident transfer and mechanical lift trainer, CNA #4. CNA #1 said CNA #4 provided demonstrations and CNA #1 returned demonstrations for how to use the sit to stand mechanical lift in a resident restroom.CNA #2 was interviewed on 10/27/25 at 5:16 p.m. CNA #2 said she was on orientation on the night Resident #2 fell, and she and was being trained by CNA #1. CNA #1 said the day shift CNA had reported that the physical therapist was working with the resident on stand and pivot transfers. CNA #2 said Resident #1 had reported pain under her arms when using the sit to stand mechanical lift the previous night. CNA #1 said Resident #2 did not refuse to use the sit to stand lift at any time. CNA #1 said when the resident wanted to use the restroom, CNA #1 and CNA #2 used the sit to stand mechanical lift to transfer the resident from the bed to the wheelchair. CNA #1 said the previous day, the CNAs had used the sit to stand lift for Resident #2 in the bathroom, but had a lot of difficulty maneuvering the equipment, so she and CNA #1 proceeded to transfer Resident #2 onto the toilet using a gait belt instead of the sit to stand lift. CNA #1 said when they stood Resident #2 up with use of the gait belt, Resident #2's right leg gave out, and she was lowered to the ground by the CNAs. CNA #1 said one of Resident #2's legs crossed inward beneath the other as she was lowered to the floor.CNA #2 said she had training training prior to Resident #2's fall regarding transferring residents with use of mechanical lifts. CNA #1 said she was provided extensive reeducation after Resident #2's fall which included the use of the sit to stand mechanical lift, full body mechanical lift and slide board. She said the education also included the importance of adhering to what the resident's care plan kardex designated for method of transfer and never rely on what another CNA thought could be done. CNA #2 said she learned it was important to never use a less supportive means to transfer a resident than what the Resident's kardex demonstrated, and the gait belt with two person assist was less supportive than the sit to stand mechanical lift.LPN #2 was interviewed on 10/28/25 at 8:28 p.m. LPN #2 said she had received education about transferring residents several times this year, most recently within the past two weeks. LPN #2 said most recent training included a review and demonstration of mechanical lift equipment. CNA #8 was interviewed on 10/28/25 at 8:31 a.m. CNA #8 said she had previous mechanical lift training at the facility and had additional training within the past week. CNA #8 said the mechanical lift training included a return demonstration of the equipment.CNA #7 was interviewed on 10/28/25 at 8:48 a.m. CNA #7 said she had received education about transferring residents, including mechanical lift training during her orientation and again within the past two weeks. CNA #7 said the sit to stand mechanical lift and full body mechanical lifts were reviewed and she completed return demonstrations of the equipment. CNA #7 said it was important to follow the resident's care plan and Kardex for resident transferring instructions, as it was always the accurate way to transfer a resident.CNA #6 was interviewed on 10/28/25 at 8:52 a.m. CNA #6 said she needed to check the resident's Kardex each time prior to transferring a resident, as it had the correct information regarding how to transfer the resident. CNA #6 said she was on orientation, and had recently received a four hour inservice regarding resident transfers with mechanical lift demonstrations included. CNA #6 said if a resident could not or did not want to transfer as per the kardex, she would notify the nurse prior to transferring the resident.LPN #3 was interviewed on 10/28/25 at 8:55 a.m. LPN #3 said when transferring residents, she reviewed the resident's care plan and Kardex prior to transferring a resident, as it revealed the safest way for the resident to transfer. LPN #3 said if she did not think the method of transfer was safe enough for a resident at a particular time, she would transfer using additional support, or upgrade to a full body lift. LPN #3 said a resident could not be provided less assistance than what the care plan and Kardex noted. LPN #3 said she had previous education at the facility about transferring residents with mechanical lifts and received additional education within the past two weeks.CNA #4 was interviewed on 10/28/25 at 9:24 a.m. CNA #4 said she had been a CNA, restorative aide and trainer for the facility. CNA #4 said she provided education to all nursing staff regarding transferring residents. CNA #4 said the CNAs initially had online education and then their competencies for transferring residents were checked off during their orientation. CNA #4 said in addition to shadowing another CNA during training, all new CNAs completed a resident transfer training session with CNA #4. CNA #4 said both CNA #1 and CNA #2 had received scheduled competency training, including resident transfers a week prior to Resident #2's fall. She said the competency training included the need to review the care plan and kardex prior to transferring a resident, and that a resident could not be transferred with less support than what was directed per the kardex. CNA #4 said the sit to stand lift was helpful for those residents who were unable to stand and turn.CNA #4 said after Resident #2's fall she provided reeducation to both CNA #1 and CNA #2 on 10/21/25, including having the CNAs return demonstrations for use of sit to stand mechanical lift and full body mechanical lift from both the bed to wheelchair and wheelchair to the toilet. The DOR was interviewed on 10/28/25 at 10:10 a.m. The DOR said prior to Resident #2's fall, she was designated as a maximum assist with two transfer status, which automatically meant the CNAs needed to use a mechanical lift to move Resident #2. The DOR said Resident #2's Kardex indicated she required a sit to stand mechanical lift. The DOR said Resident #2 should not have been transferred using a two person assist with a gait belt at any time. The DOR said even if the physical therapist was working on transfers with a gait belt, it does not mean the CNAs can change the status of the required mode for transferring the resident. The DOR said the process for changing a resident's mode of transfer included an evaluation by the therapist who then reported to the DOR, the DOR brought to the interdisciplinary team, the MDS coordinator was notified and then the transfer status could be changed. The DOR said a resident could be full weight bearing, yet not have the strength or tolerance to do it for any length of time. The DOR said the CNAs must follow the care plan and Kardex for transferring a resident. The DOR said Resident #2 required a full body mechanical lift after she returned from the hospital.The MDS coordinator (MDS) was interviewed on 10/28/25 at 10:45 a.m. The MDS said Resident #2 was at high risk of falls and required a sit to stand mechanical lift for transfer on 10/9/25. The MDS said she would not have expected CNAs to use a gait belt with two person assist to transfer the resident at any time.LPN #1 was interviewed on 10/28/25 at 11:03 a.m. LPN #1 said the night of 10/11/25, CNA #1 came to her and said that Resident #2 fell in the bathroom. LPN #1 said she found the resident on the floor in her bathroom sitting with a gait belt around her waist. LPN #1 said she informed RN #2 who came to Resident #2's bathroom and assessed the resident's condition. LPN #1 said Resident #2 was transferred back to her bed with the use of a full body mechanical lift. LPN #1 said Resident #2 should have been transferred using the sit to stand mechanical lift per her kardex. LPN #1 said CNA #1 should have contacted her if the resident could not be transferred as directed by the resident's kardex. LPN #1 said it was important to follow the recommendations of the therapy department, and if the recommendations were not followed, residents could be injured or fall.The DON was interviewed on 10/28/25 at 11:45 a.m. The DON said the CNAs used a gait belt to do perineal hygiene care and to stand Resident #2 from the toilet. The DON said CNA #1 and CNA #2 should have used the sit to stand mechanical lift because the Resident's care plan indicated it was required and therapy evaluation revealed the resident required use of the mechanical lift. The DON said if the care plan was not followed, residents or staff could get injured.The DON said CNA #4 had completed reeducation for all CNAs regarding transferring residents. The DON said the education began on 10/16/25 and was completed by 10/21/25. The DON said she had been conducting audits since Resident #2's fall, and the plan was to conduct at least three observations of resident transfers per week for 12 weeks. The DON said the audits were reviewed at the facility's quality assurance performance improvement (QAPI) meeting on 10/24/25, and would continue to be reviewed monthly.The nurse practitioner (NP) was interviewed on 10/28/25 at 12:24 p.m. The NP said CNA #1 and CNA #2 should have checked with the nurse prior to changing the mode of transfer for Resident #2. The NP said even if the physical therapist was working with the resident on stand and pivot transfers, her transfer status would be what was written on the Kardex.CNA #9 was interviewed on 10/28/25 at 2:15 p.m. CNA #9 said she had received education about mechanical lifts and transferring residents when she began working at the facility. CNA #9 said within the past two weeks the facility again reviewed transferring residents. CNA #9 said it was important to check the resident's kardex and confirm the status of the equipment used for resident transfers. CNA #9 said if a resident did not like or want to transfer with certain equipment she would explain to the resident why it had been determined to be the safest method for transferring and she would contact the nurse for any resident concerns.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene for three (#6, #8 and #9) of seven residents reviewed for ADLs out of 13 sample residents. Specifically, the facility failed to: -Ensure staff used a gait belt when transferring Resident #6 from a recliner to the wheelchair while taking the resident to his room to provide incontinence care; -Ensure staff properly used a Hoyer lift (mechanical lift) when transferring Resident #8 to her bed to provide incontinence care; and, -Ensure Resident #8 and Resident #9 were provided with timely incontinence care. Findings include: I. Professional reference According to the Joerns Hoyer manufacturer guidelines, 2021, retrieved on 6/16/25, from https://www.https://www.joerns.com/product/hoyer-pro-slings/, A sling is an item of moving and handling equipment that is used with a mechanical lift in order to facilitate the transfer of a patient. It comprises a specially designed and constructed piece of fabric that is placed under and/or around a patient before being attached to the spreader bar/cradle of a lift to raise, transfer and lower the patient. When selected and used correctly, a sling and lift combination will achieve a safer transfer and reduce the risks associated with manual handling. Cross over leg straps, pass one leg strap through the other and attach to the hoist on the front hooks. II. Facility policy and procedure The Supporting the Activities of Daily Living policy, revised February 2024, was provided by the assistant director of nursing (ADON) on 6/11/25 at 5:10 p.m. It read in pertinent part, Residents who are unable to carry out activities of daily living independently should receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. Appropriate care and services should be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and/or resident representative and in accordance with the plan of care, including appropriate support and assistance with: -Hygiene (bathing, dressing, grooming, and oral care); -Mobility (transfer and ambulation, including walking); -Elimination (toileting); -Dining (meals and snacks); and, -Communication (speech, language, and any functional communication systems). The Gait/Transfer/Walking Belts policy, revised May 2022, was provided by the ADON on 6/11/25 at 5:10 p.m. It read in pertinent part, Gait/transfer/walking belts are safety devices used for assisting a resident with transfer and/or ambulation with mobility needs. These devices are used with residents who may have an unsteady gait, are at risk for falls, or other health conditions that affect ambulation. Staff providing resident care should have access to gait/transfer belts and receive training in proper body mechanics. Gait/transfer belts should be used when needed, while providing care, assisting with ambulation, or transferring a resident. The Mechanical/Assistive Lifts policy, revised September 2017, was provided by the ADON on 6/11/25 at 5:10 p.m. It read in pertinent part, The use of all mechanical/assistive lift equipment should be according to manufacturer's recommendations. Staff should be educated on proper use of the equipment. Education should be provided on the proper use of the assistive mechanical lifting equipment prior to its use. The Perineal Care procedure, issued October 2016, was provided by the ADON on 6/11/25 at 5:10 p.m. It read in pertinent part, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Use a washcloth with warm water and soap or a disposable moist cloth. Wash perineal area, wiping from front to back. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same washcloth/water or moist disposable cloth to clean the labia. Discard disposable items into designated containers. Remove gloves and discard into designated containers. Wash and dry your hands thoroughly. III. Failure to transfer Resident #6 appropriately using a gait belt A. Resident #6 1. Resident #6, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included dementia, history of falling, unspecified lack of coordination, abnormal gait and mobility. The 5/9/25 minimum data set (MDS) assessment revealed Resident #6 had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. Resident #6 required assistance for transfers, toileting and personal hygiene. The MDS assessment documented Resident #6 was frequently incontinent of urine and occasionally incontinent of bowel. 2. Observations On 6/11/25 at 10:41 a.m. Resident #6 was assisted by certified nurse aide (CNA) #3 to transfer from a recliner to his wheelchair in order to go to the resident's room to provide incontinence care. Resident #6 was slow to respond to questions and did not open his eyes during the transfer. -CNA #3 did not use a gait belt while providing a stand pivot transfer from the recliner to the wheelchair. After Resident #6's incontinence care was finished, CNA #3 applied the resident's gait belt and requested assistance from CNA #5 in order to transfer Resident #6 back to the recliner. CNA #3 and CNA #5 commented on how tired Resident #6 appeared to be this morning. -Despite the placement of the gait belt to transfer Resident #6, CNA #3 did not hold onto the gait belt to transfer the resident, instead placing her arms under Resident #6's armpits and lifting the resident by the shoulders during the transfer. 3. Record review The comprehensive care plan, updated 6/3/25, documented Resident #6 required assistance from staff for transfers, toileting, bathing and personal hygiene. Interventions included the use of appropriate assistive devices and for staff to provide frequent cues to the resident when ambulating to reduce the risk of falls. 4. Staff interviews The director of rehabilitation (DOR) was interviewed on 6/11/25 at 3:38 p.m. The DOR said she provided hands-on training on the use of gait belts and assistive devices for the nurses and CNAs. The DOR said she instructed the staff to use a gait belt with any ambulation or stand-pivot transfers for the safety of the staff and the residents. The DOR said holding the resident under the shoulders could dislocate the resident's shoulder if the resident started to fall. IV. Failures with Resident #8 and Resident #9 A. Resident #8 1. Resident #8, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included Alzheimer's dementia and heart failure. The 4/3/25 MDS assessment revealed Resident #8 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #8 was dependent on staff assistance for dressing, bathing, toileting, repositioning and personal hygiene. The MDS assessment documented Resident #8 was always incontinent of urine and always incontinent of bowel. 2. Observations During a continuous observation of Resident #8 in the dining room and common area on 6/11/25, beginning at 8:50 a.m. and ending at 12:45 p.m., the following was observed: At 8:50 a.m. Resident #8 was being assisted with eating breakfast by an unidentified CNA in the dining room. Resident #8 was seated in her wheelchair with her Hoyer lift sling underneath her. At 8:59 a.m., after the meal was complete, an unidentified CNA wheeled Resident #8 in her wheelchair to sit in front of the television (TV) in the common area. From 8:59 a.m. until 12:45 p.m. Resident #8 remained in her wheelchair in the common area. During this time Resident #8 was not checked for incontinence by staff. -Resident #8 was not offered or provided with incontinence care between 8:50 a.m. and 12:45 p.m., a period of three hours and 55 minutes. On 6/11/25 at 12:57 p.m. CNA # 1 and CNA #2 transferred Resident #8 from her wheelchair to her bed using a Hoyer lift. During the transfer, the lower straps of the Hoyer lift sling were not crossed over each other to secure the resident per the manufacturer's guidelines (see manufacturer's guidelines above). After transferring Resident #8 to her bed, CNA #1 and CNA #2 proceeded to provide the resident with incontinence care. When CNA #1 removed the resident's brief, the brief was heavily saturated with urine in the front and back of the brief. -While providing incontinence care to Resident #8, CNA #1 used the same disposable moist cloth for multiple wipes on Resident #8's backside without folding the cloth to expose a new clean area of the cloth for each wipe. After Resident #8's brief was changed, CNA #1 and CNA #2 repositioned Resident #8 in bed. -CNA #1 and CNA #2 did not remove their soiled gloves and perform hand hygiene prior to repositioning the resident. 3. Record review The care plan, updated 4/4/25, identified Resident #8 was incontinent of both bowel and bladder. Interventions included checking Resident #8 for incontinence, assisting Resident #8 with toileting as needed, providing incontinence care and applying barrier cream after each incontinence episode. B. Resident #9 1. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included dementia, altered mental status and urinary tract infection. The 4/28/25 MDS assessment revealed Resident #9 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. Resident #9 required substantial assistance for transfers, toileting, dressing and personal hygiene. The MDS assessment documented Resident #9 was always incontinent of bowel and bladder. 2. Observations During a continuous observation of Resident #9 in the dining room and common area on 6/11/25, beginning at 8:50 a.m. and ending at 12:45 p.m., the following was observed: At 8:55 a.m. Resident #9 wheeled herself in front of an open window. From 8:55 a.m. until 11:41 a.m. no staff approached Resident #9 to offer incontinence care to the resident. At 11:41 a.m. CNA #1 assisted Resident #9 in her wheelchair to the dining room CNA #1 and LPN #1 repositioned Resident #9 in her wheelchair in the dining room. CNA #1 and LPN #1 hooked their arms underneath Resident #9's armpits to pull her up in the wheelchair. At 12:30 p.m. CNA #4 began providing eating assistance to Resident #9. Resident #9 was not offered or provided with incontinence care between 8:50 a.m. and 12:45 p.m., a period of three hours and 55 minutes. -At 12:45 p.m., upon prompting, staff attempted to check Resident #9 for incontinence, however, Resident #9 refused. 3. Record review The care plan, updated 3/19/25, identified Resident #9 was incontinent of both bowel and bladder. Interventions included checking Resident #9 for incontinence, assisting Resident #9 with toileting as needed, providing incontinence care and changing the resident's clothing after each incontinence episode. C. Staff interviews LPN #1 was interviewed on 6/11/25 at 12:45 p.m. LPN #1 said Resident #8 was incontinent of both bowel and bladder and required staff to check and change her because Resident #8 was at risk for pressure injuries. LPN #1 said the last time Resident #8 was provided with incontinence care (on 6/11/25) was before breakfast. LPN #1 said Resident #9 was incontinent and changed by staff before breakfast (on 6/11/25). LPN #1 said Resident #9 became agitated easily and often refused care. LPN #1 said when Resident #9 refused care, LPN #1 or another staff member would offer the care again a few minutes later. CNA #1 was interviewed on 6/11/25 at 2:54 p.m. CNA #1 said Resident #8 was changed for the first time on her shift before breakfast, usually between 7:30 a.m. and 8:30 a.m. CNA #1 said she typically checked and changed all of the residents three times a shift; once before breakfast, once after lunch and once at the end of the shift. The DOR was interviewed on 6/11/25 at 3:38 p.m. The DOR said she provided hands-on training to staff on how to use assistive devices and lifts, but she had not provided an in person all-staff education on safe Hoyer lift use since starting as the DOR for the facility a few months prior. The DOR said she was not sure if the previous DOR provided in-person education on safe Hoyer lift use. The DOR said the only time staff should not cross the lower straps of the transfer sling when using a Hoyer lift was if the resident had a full body sling with a seat. The DOR said she was not sure what type of sling was being used for Resident #8. The DOR said staff should not pull up Resident #9 by hooking their arms under Resident #9's shoulders. She said one staff member should hold the resident under the legs and push the resident up in the wheelchair while another staff bear hugged the resident from behind to safely reposition the resident in the wheelchair. -After the interview, the DOR confirmed that Resident #8 was in a normal Hoyer lift sling and staff should have crossed the lower straps of the sling, as was recommended by the manufacturer. The ADON and the clinical consultant (CC) were interviewed together on 6/11/25 at 4:20 p.m. The ADON said residents who were unable to inform staff when they needed incontinence care should be checked every two hours. The ADON said untimely incontinence care increased the residents' risk for skin breakdown or urinary tract infections (UTI). The ADON said she was not aware of any in-person training provided to staff on incontinence care since starting as the ADON for the facility a few months prior. She said professional standards for cleaning residents after an incontinence episode included using a new clean disposable moist cloth with each wipe, or folding the cloth to a clean side between each wipe. The ADON said staff should only clean in one direction, from front to back, when providing incontinence care on female residents. The CC said training modules on staff expectations for incontinence care and the use of assistive devices and lifts were completed during new employee orientation.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12-months and provide regular in-service education based on the outcome of these reviews for two of two certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews and provide regular in-service education based on the outcome of the reviews for CNA #2 and CNA #3. Findings include: I. Facility policy and procedure The Annual Performance Planning Guide, undated, was provided by the nursing home administrator (NHA) on 4/17/25 at 4:47 p.m. It read in pertinent part, Performance planning is a critical part of the performance management process. While annual reviews are a look back, performance plans are a look forward. A collaborative process between associate and supervisor, they set the foundation for performance management by establishing clear and defined individual performance and development goals for the year. Revisit the performance plan throughout the year to measure progress, discuss obstacles, give feedback, and coach to success. At annual review time, measure performance against the goals set in the performance plan. Performance planning is a process conducted by a supervisor and their direct reports in which together they plan the performance goals for the upcoming year and discuss developmental goals. II. Record review Annual performance reviews were requested on 4/16/25 at 10:35 a.m. The facility was unable to provide annual performance evaluations for CNA #2 (hired 2/17/2020) and CNA #3 (hired 7/8/08). -CNA #2 and CNA #3 did not have an annual performance review completed and did not have an in-service education plan based on the outcome of the review. III. Staff interviews The director of nursing (DON) was interviewed on 4/17/25 at 3:21 p.m. The DON said the facility should complete a performance review of the CNAs at least once every 12 months and provide regular in-service education based on the outcome of the review. The DON said the facility had not completed it yet but their policy said it should be done. The DON said she could not locate the reviews for CNA #2 and CNA #3. The DON said the purpose of completing the performance review was to see how the CNAs were doing, what they needed help with and to give feedback and set expectations. The DON said she would be doing a skills fair and regular in-service education based on the outcomes of the review. The DON said the plan now was to do the annual reviews and skills fair. She said she would start that within the next quarter to get everyone reviewed.

Based on observations and interviews, the facility failed to ensure an infection prevention and control programs (IPCP) was maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of three units. Specifically, the facility failed to ensure staff wore the appropriate PPE when providing wound care for Resident #50 who was on enhanced barrier precautions (EBP) related to an abdominal wound. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs, retrieved on 4/22/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts, EBP are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. II. Facility policy and procedure The Isolation Precautions policy, revised September 2022, and the Enhanced Barrier Precautions Policy, revised February 2025, was received from the director of nursing (DON) on 4/17/25 at 1:45 p.m. The policy read in pertinent part, EBP should be used as an infection prevention and control intervention to reduce the spread of MDROs to residents. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to associate hands and clothing. Gloves and gown may be applied prior to performing high-contact resident care activity. PPE is changed before caring for another resident. EBPs are indicated with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. III. Observations On 4/15/25 at 11:25 a.m. there was a sign on Resident #50's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. On 4/16/25 10:43 a.m. registered nurse (RN) #2 was completing wound care for Resident #50, who had a. abdominal wound. RN #2 had gloves on. RN #2 failed to put on a gown. IV. Resident interview Resident #50 was interviewed on 4/16/25 at 2:36 p.m. Resident #50 said the nurses never put on gowns when changing his abdominal wound dressing or when changing his abdominal wound vacuum machine. Resident #50 said they only wore gloves. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/16/25 at 2:44 p.m. CNA #1 said when she was providing care for Resident #50, she put on gloves and a gown. She said if she was going to assist the resident transfers, using the bathroom or helping the nurse with wound care, she would put on a gown and gloves to ensure the resident would not get an infection. RN #2 was interviewed on 4/16/25 at 3:00 p.m. RN #2 said Resident #50 was on EBP. She said the staff should wear gloves and a gown when providing wound care or when providing any close contact activities to protect the resident from getting an infection. RN #2 said she forgot to put on a gown today when she was changing his abdominal wound dressing. RN #2 said staff should put on gloves and gowns before going into Resident #104's room because he had an infectious bacteria in his wound. She said wearing a gown and gloves helped prevent the resident's infection from transferring to staff or residents. The director of nursing (DON) was interviewed on 4/16/25 at 4:33 p.m. The DON said if a resident was on precautions, the facility's procedure was to ensure there was a sign on the door to inform the staff the precautions that needed to be followed. She said if the resident was on precautions, a cart with PPE was stored outside of the resident's room. She said the nursing staff was provided education so they knew how to correctly care for the residents and prevent the transmission of bacteria or cause an infection. The DON said it was the responsibility of the nursing staff to update the care plan so all of the staff knew how to address the care needs for the individual residents. The DON said the staff should put on gloves and a gown before entering Resident #104 room and remove the gloves and gown before exiting the room. The DON said staff should put on gloves and gown with any high contact care for Resident #50 such as wound care, bathing, dressing, transfers and assisting the resident to the bathroom. The infection preventionist (IP) was interviewed on 4/16/25 at 4:55 p.m. The IP said staff should put on gloves and a gown when providing wound care for Resident #50 to ensure the wound does not get infected. The IP said she did not think the staff had to wear a gown when transferring a resident that was on EBP. The IP said Resident #50 had physician's orders that indicated he was on EBP. The IP said she was responsible for training the nursing, dietary and rehabilitation staff regarding EBP and contact precautions procedure. She said she would conduct surveillance and audits in addition to giving all staff re-education on the different precaution procedures. The IP said if the nurses and the CNA's did not read the care plan, that could have been the reason precaution procedures were not followed.

Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care was provided such care, consistent with professional standards of practice for one (#1) of two residents reviewed for the use of supplemental oxygen of 27 sample residents. Specifically, the facility failed to ensure Resident #1's oxygen was consistently administered according to physician's orders. Findings include: I. Facility policy and procedure The Oxygen Administration policy, revised April 2024, was provided by the nursing home administrator (NHA) on 4/17/2025 at 3:03 p.m. It read in pertinent part, The nurse should monitor oxygen administration and record the resident's response to oxygen therapy in the medical record. Verify that there is a physician's order for the procedure. Review the healthcare provider's orders or community protocol for oxygen administration. II. Resident #1 A. Resident status Resident #1, age 65, was admitted on [DATE]. According to the April 2025 computerized physicians orders (CPO), diagnoses included chronic respiratory failure with hypercapnia and hypoxia (a condition where there is an excess of carbon dioxide in the blood and low levels of oxygen in body tissue), chronic obstructive pulmonary disease (COPD), muscle weakness, cognitive communication deficit, phocomelia of the limbs (a rare congenital anomaly with the proximal aspect of an extremity is absent with the hand or foot) anxiety disorder, altered mental status and pneumonitis due to inhalation of food and vomit. The 1/14/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The assessment indicated the resident did not have any behaviors or rejections of care during the assessment period. She was dependent on staff due to upper and lower impairment on both sides and required extensive to maximum assistance with care. The MDS assessment indicated the resident required continuous oxygen. B. Record review The oxygen care plan, initiated 1/14/25, revealed Resident #1 received oxygen therapy related to COPD, chronic respiratory failure. Pertinent interventions included providing oxygen via nasal canal between two to four liters per minute (LPM) during the day at a continuous flow per physician's orders. The April 2025 CPO included: -Oxygen at two to four LPM continuously via nasal cannula, ordered 4/7/25. C. Observations and interviews On 4/15/25 at 10:45 a.m. Resident #1 was in her room. There was an oxygen concentrator in her room, but the nasal canula was not in place via nasal canula. There was a portable oxygen tank on the back of the resident's wheelchair. However, the portable oxygen concentrator was empty. The personal care provider alerted the facility staff about the resident's oxygen tank being empty. Certified nursing assistant (CNA) #5 said the oxygen tank was empty. The resident was having difficulty understanding her personal care provider, who was visiting her. On 4/16/25 at 2:45 p.m., Resident #1 was in her room. She was talking on the phone. The resident repeatedly asked the individual she was speaking to on the phone if she was coming to get her. Resident #1 asked licensed practical nurse (LPN) #1 if her oxygen tank was working. The LPN checked the resident's portable oxygen tank and said she was replacing it for the resident. LPN #1 took the portable tank with her, leaving the resident with no oxygen for approximately two minutes. She returned with a full tank for the resident. D. Staff interviews Certified nursing aide (CNA) #5 was interviewed on 4/16/25 at 4:05 p.m. CNA #5 said Resident #1's portable oxygen tank was refilled by the night shift and the CNA's ensured that the resident had her oxygen on at all times. CNA #5 said the resident was receptive to having staff assist her with wearing her nasal cannula and would not resist or decline the oxygen use. CNA #5 said Resident #1 would get short of breath and display other medical complications if she was not receiving continuous oxygen. CNA #5 said she tried to keep an eye on all the portable oxygen tanks but sometimes they ran out without her noticing CNA #5 said Resident #1's portable oxygen tank was usually set between 2 to 4 LPM. Licensed practical nurse (LPN) #1 was interviewed on 4/16/25 at 4:25 p.m. LPN #1 said Resident #1 had a physician's order for 2 to 4 liters of continuous oxygen (LPM). She said all staff nursing members were responsible to check the portable tanks to ensure they were not empty. LPN #1 said oxygen was considered a medication and a physician's order for a resident to receive oxygen should be followed accordingly. She said the resident could suffer medical complications such as shortness of breath. The director of nursing (DON) was interviewed on 4/16/25 at 4:56 p.m. The DON said it was important for physician's orders to be followed. She said all of the CNA's and nurses were responsible for monitoring the portable oxygen tanks to ensure they were not empty. The DON said if Resident #1 was having difficulty and appeared agitated, the staff should have checked her oxygen tank. She said the nursing staff should have ensured that Resident #1 received continuous oxygen as prescribed by the physician. The DON said she had updated the medication administration record (MAR) for the nursing staff to check all portable tanks more frequently. She said she would immediately provide education to the nursing staff about the importance of oxygen administration and the proper monitoring of oxygen use.

Based on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychosocial well-being for two (#29 and 42) of three residents reviewed for dementia care out of 27 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #29 and Resident #42 to provide the resident with their highest practicable quality of life and care. Findings include: I. Facility policy and procedure The Dementia Care policy and procedure, revised February 2022, was received from the nursing home administrator (NHA) on 4/16/25 at 10:39 a.m It read in pertinent part, Residents who have been diagnosed as having dementia should have a resident-centered care plan to maximize remaining abilities and quality of life. II. Resident #29 A. Resident status Resident #29, age 83, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included dementia, type 2 diabetes mellitus with other diabetic neurological diabetic neurological complications, scrotal varices (enlarged veins in the scrotum that can cause pain), urinary tract infections and hearing loss. The 1/10/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. He required total assistance with toileting, showering, personal hygiene and dressing and moderate assistance with oral hygiene. The assessment revealed the resident did not reject care and did not exhibit physical or verbal behaviors or wander. B. Resident #29 interview and observations Resident #29 was interviewed on 4/15/25 at 10:45 a.m. The resident was in his wheelchair on the left side of his bed in his room. He said help me and said he wanted to go to bed. At 10:59 a.m. certified nurse aide (CNA) #7 went into the resident's room. The resident said he wanted to go to bed. The CNA said it was almost time for lunch and assisted the resident to the dining area. At 11:20 a.m. Resident #29 was in his room. He said help, help. CNA #6 went into his room. Resident #29 said he wanted to be in bed. CNA #6 said it was almost time for lunch and he could not go to bed. At 11:23 p.m. CNA #6 assisted Resident #29 out of the resident's room. At 11:26 a.m. Resident #29 went back in his room. He was on the left side of his bed, rolling back and forth in a repetitive motion. At 11:28 a.m. Resident #29 initiated his call light indicating he needed assistance. At 11:29 a.m. CNA #8 went into the resident's room. CNA #8 did not provide the resident with any care and left the room within the minute. At 11:30 a.m. Resident #29 initiated his call light. CNA #7 and CNA #8 went into Resident #29's room. Resident #29 said he wanted to go to bed. CNA #7 and CNA #8 said it was lunchtime and assisted the resident to the dining area. Between 11:30 a.m. and 11:35 a.m. Resident #29 assisted himself back to his room. At 11:35 a.m. Resident #29 was back in his room. An unidentified CNA was assisting another resident when they walked past Resident #29's room, Resident #29 was sitting in his doorway and attempted to reach for the unidentified CNA. -However, the staff did not offer any person-centered care when the resident requested to go to bed multiple times. During a continuous observation on 4/16/25, beginning at 11:12 a.m. and ending at 12:54 p.m., the following was observed: At 11:12 a.m. Resident #29 was in his wheelchair in his room on the left side of his bed with his head down. At 11:16 a.m.,Resident #29 left his room and looked at the newspaper that was on the counter in the common area. At 11:19 a.m. Resident #29 self-propelled back to his room and was on the left side of his bed. At 11:25 a.m. Resident #29 left his room, turned off his bedroom light and went back to the dining room. At 11:27 a.m. an unidentified CNA walked passed Resident #29, he said help and she said one second. The unidentified CNA left the common area. Resident #29 went to his room, turned on his bedroom light and went to the left side of his bed. From 11:30 a.m. to 11:32 a.m. Resident #29 left his room, turned his bedroom light off and went to the farthest dining table from his room. He was sitting in his wheelchair in front of the dining table with no activities in front of him. At 11:38 a.m. Resident #29 returned to his room. He turned his bedroom light on. He went to the left side of his bed. He turned around and he was at his doorway and said help nurse help. He turned off his bedroom light and went back to the dining table closest to his room. At 11:43 a.m. Resident #29 returned to his room, turned on his light, went to the left side of his bed and began rolling back and forth in a repetitive motion in his wheelchair. At 11:46 a.m. Resident #29 left his room, turned his bedroom light off and went to the dining table closest to his room. At 11:48 a.m. Resident #29 returned to his room, turned on his light, went to the left side of his bed and began rolling back and forth in a repetitive motion in his wheelchair. At 11:53 a.m. Resident #29 left his room, turned off his bedroom light, went to the dining table closest to his room and then self-propelled himself around the dining area. From 11:58 a.m. until 12:04 p.m. Resident #29 returned to his room, turned on his light, went to the left side of his bed and began rolling back and forth in a repetitive motion. At 12:05 p.m. Resident #29 was sitting in his doorway. He raised his hand when licensed practical nurse (LPN) #3 walked by. She told him he was first on the list for the scenic drive outing at 2:30 p.m. He looked at his watch and went to the dining table closest to his room. At 12:13 p.m. Resident #29 went to the dining table closest to his room. At 12:15 p.m. Resident #29 returned to his room, turned on his light, went to the left side of his bed and began rolling back and forth in a relative motion. At 12:26 p.m. Resident #29 left his room and went to the dining table farthest away from his room. At 12:33 p.m. an unidentified CNA walked by Resident #29. He told the CNA he had terrific pain in his scrotal area and needed a pain pill. The CNA said she would tell the nurse. At 12:35 p.m. Resident #29 went to his room and the CNA went to the nurse's station. At 12:37 p.m. LPN #3 went to Resident #29's room. At 12:42 p.m. Resident #29 left his room and went to the dining table farthest away from his room. At 12:46 p.m,. LPN #3 was with Resident #29 at the dining table farthest away from the resident's room. Resident #29 said his testicle hurt. LPN #3 offered incontinence care and Resident #29 declined. -During the observation, the staff failed to address the resident's request for help and provided person-centered interventions for the residents' behaviors. C. Record review Review of Resident #29's dementia care plan, initiated on 2/4/23 and revised on 3/15/23, revealed the resident had impaired cognitive function or impaired thought processes. Interventions included communicating with the resident, family and caregivers regarding the resident's capabilities and needs, encouraging the resident to take medications offered and asking yes or no questions to determine the resident's needs. -The care plan failed to include the resident's repetitive behavior of rolling back and forth, requests to go to bed before, asking for help or person-centered interventions to address the resident's behaviors. Review of Resident #29's activities care plan, revised on 9/22/24, revealed the resident benefited from associate support for resident programs. Interventions included establishing and recording the resident's prior level of activity involvement and interest with the resident, caregiver, and family on admission and as necessary, inviting the resident to programs of interest, preferred activities were reading the newspaper ,and family visiting. An additional intervention initiated on 4/17/25 (during the survey) included for the staff to assist the resident to bed per his preference when requested. -The care plan failed to include the request for a bed before the start of the survey (see staff interview below). III. Resident #42 A. Resident status Resident #42, age 85, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included dementia, Parkinson's disease (disease that causes tremors), hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction (stroke) affecting the right dominant side, insomnia (difficulty sleeping) and depression, The 3/4/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. He required moderate assistance with oral hygiene, showering and moderate assistance He required substantial assistance with toileting. The assessment revealed the resident did not reject care, did not exhibit physical or verbal behaviors or wander. B. Additional resident interviews Resident #153 was interviewed on 4/15/25 at 11:10 a.m. He said Resident #42 wandered into his room once since he was admitted to the facility. He said he did not know what the facility was doing to prevent him from coming into his room. Resident #38 was interviewed on 4/15/25 at 3:07 p.m. She said Resident #42 sometimes would wander into her room in the evening. She said did not know what the facility was doing to prevent him from coming into her room. She was frustrated he wandered into her room because it took time away from the staff to redirect the resident out of her room. C. Observations During a continuous observation on 4/16/25, beginning at 11:12 a.m. and ending at 12:54 p.m., the following was observed: Resident #42 was observed in his bed lying on his right side with his eyes closed. D. Record review Review of Resident #42's wandering care plan, revised 3/23/25, revealed the resident was at risk for elopement and the resident wandered aimlessly. Interventions included discussing the risks, discussing safe discharge with the resident and responsible party, distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, identifying patterns of wandering and intervening as appropriate, monitoring location throughout the shift and documenting wandering behaviors and attempting diversional interventions. The care plan documented the resident prefers: (blank). -However, the care plan failed to identify the resident wandered into other resident's rooms, interventions to prevent wandering into other resident's rooms and did not specify the resident's preferences. The 3/5/25 nurse progress note revealed the resident made many attempts to wander into other resident's rooms. He was not easily redirected. The staff had to sit with the resident one-on-one at times to keep him from entering others' rooms. The 3/6/25 nurse progress note revealed the resident continued to wander around and sometimes in other resident's rooms. The 4/14/25 nurse progress note revealed the resident often exhibited increased wandering and agitation at this time of day due to disease process. The 4/16/25 nurse progress note revealed the resident was confused and wandered around the common area and attempted to go into another resident's room. He was not easily redirected. He was provided with snacks and games. -Review of the Resident #42's progress notes revealed there was not consistent documentation regarding what interventions were used and which interventions were effective when the resident's wandering was observed. The behavior monitoring and intervention task record was reviewed from 3/19/25 to 4/17/25. It revealed Resident #42 was known to have wandering on 3/22/25, 3/23/25, 3/28/25, 3/30/25, 4/4/25, 4/6/25, 4/7/25, 4/8/25, 4/11/25 and 4/16/25. -Review of the behavior monitoring and intervention task record revealed there was no documentation regarding what interventions were used and which interventions were effective when the resident's wandering was observed. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 4/15/25 at 8:55 a.m. RN #1 said she was familiar with Resident #42. At the time of the interview, she said he was sitting at a dining table near the kitchenette near his room. She said he often wandered and he moved very quickly. She said she had to keep her eyes on him because he was quick to stand up. During the interview, RN #1 directed CNA #6 to assist the resident as he was trying to stand up. LPN #3 was interviewed on 4/17/25 at 3:44 p.m. LPN #3 said if a resident had dementia and they asked to go to bed, the nursing staff should help the resident go to bed. She said if a resident was consistently doing the same behavior, there should be interventions to redirect the resident. She said she needed to document behaviors she observed during her shift. She said she needed to do a better job of documenting the behaviors residents exhibited, what interventions she used and if the interventions were effective. LPN #3 said Resident #29 had dementia. LPN #3 said he asked to go to bed, he would go in and out of his room and roll back and forth on the left side of his bed daily. She said she did not know what interventions to redirect the resident to meaningful activities that were person-centered worked for him. She said she knew he liked participating in activities that were outside of the facility. She said Resident #39 went on an outing yesterday (4/16/25). LPN #3 said Resident #42 wandered and had dementia. LPN #3 said he wandered most recently on Friday and Saturday. She said he slept during the day because his sleep schedule was off. LPN #3 said he experienced sundowners (confusion and agitation occurring in the late afternoon or early evening). She said the physician adjusted his medications to try to help with his sleep pattern but she said she has not seen a change in his sleep. She said she needed to be better at documenting when he wandered, what interventions she used and if the interventions were effective. The director of nursing (DON) was interviewed on 4/17/25 at 4:06 p.m. She said if a resident had dementia and they asked to go to bed, the nursing staff should not say it was almost time for lunch. The DON said the nursing staff could do better in offering personalized interventions for dementia residents. She said if the resident was asking for help or the same behavior, there should be personalized interventions in place to help redirect the resident. The DON said she knew Resident #29 asked to go to bed frequently. She said effective interventions to prevent the resident from going to bed before meal time were offering a newspaper or a banana.

Based on observations, record review and interviews, the facility failed to ensure meals were served according to the resident's preferences for one (#103) of three residents out of 27 sample residents. Specifically, the facility failed to ensure Resident #103 received the meal items she ordered. Findings include: I. Resident #103 A. Resident status Resident #103, age greater than 65, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included dementia, depression and Parkinson's disease (a disease that causes tremors). B. Resident interview and observations Resident #103 was interviewed on 4/17/25 at 12:20 p.m. The resident said she had problems with her lunch meal. The resident's meal ticket did not indicate the resident's choice for the lunch meal on 4/17/25 as it was blank. Resident #103 said this happened all the time since she was admitted to the facility. The resident said her son helped her fill out her meal tickets but the meal ticket that was delivered with her lunch tray was blank. She said she did not know what happened to her meal ticket that was completed a few days ago with the help of her son. The resident said she did not order the food on her tray so she did not eat it. C. Observations and resident representative interview During a continuous observation on 4/17/25, beginning at 12:25 p.m. and ending at 12:50 p.m. the following was observed: Resident #103's son arrived at the facility to visit his mother during lunch. The resident's son asked the registered dietitian (RD) the reason his mother's meal ticket was blank. He said he completed the meal ticket with a nurse on the phone and the meal his mother received was not what they had ordered. The (RD said she was not sure why the meal ticket was blank. The resident's son said it had been an issue since the resident was admitted to the facility and that's the reason he called to ensure that the ticket was completed. D. Record review The nutrition care plan, dated 4/10/25, revealed the resident was at nutritional risk as evidenced by her medical diagnosis. Interventions included providing the resident her diet as ordered and monitoring meal intake with each meal. II. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 4/17/25 at 1:05 p.m. CNA #4 said the nursing staff assisted the residents who needed assistance to complete their meal tickets. CNA #4 said Resident #104's son assisted the resident in completing her meal ticket. She said she did not know why her ticket came back blank. The RD was interviewed on 4/17/25 at 12:40 p.m. The RD said Resident #103's son had called her and requested to assist his mother to complete the meal ticket. She said she gave the blank meal tickets to the nursing staff and it was completed on the phone with the resident's son. The RD said she does not know what happened to that meal ticket. The RD said the dietary staff should review and ensure all meal tickets were completed, submitted and notify the nursing staff of any incomplete meal ticket. The RD said she did not know this was happening and she would consult with the dietary department to come up with a plan to prevent this from happening again. The dining service supervisor (DSS) was interviewed on 4/17/25 at 12:55 p.m. The DSS said sometimes the dietary department received blank meal tickets. The DSS said when this happened the dietary staff would serve the main dish for the residents whose meal tickets were not completed. She said the nursing staff were supposed to assist the residents in completing their meal tickets. She said she was not sure if that was happening, as they received several blank meal tickets. She said the dietary staff should be reviewing the meal tickets to ensure they were completed and calling the nursing staff to verify every incomplete ticket. The DSS said if the meal tickets were not reviewed and verified for any inconsistencies, residents would receive meals that they did not order or preferred to eat. The executive chef (EC) was interviewed on 4/17/25 at 1:10 p.m. The EC said the dining service staff should be reviewing the meal tickets and informing the nursing staff of all inconsistencies to ensure residents receive their food preferences. The EC said he would consult with the dietary team to review their meal ticket process and immediately offer education to the staff to prevent the issue from happening again.

Based on observation, record review, and interviews, the facility failed to protect the residents' privacy by using video monitoring for eight (#15, #27, #36, #37, #41, #43, #80 and #203) of eight residents reviewed out of 30 sample residents. Specifically, the facility failed to obtain resident and/or family consent for resident video monitoring, failed to consistently observe the video displays for resident behaviors, failed to protect the video display from others not involved in direct resident care, failed to post signage that indicated video cameras were in use and failed to obtain consent from roommates when cameras were in use. Findings include: I. Facility policy The Electronic Monitoring policy, dated October 2019, was requested and received on 8/30/23 from the nursing home administrator (NHA). The policy included in pertinent part: The facility allows residents and/or their legal representative to monitor their room through the use of electronic monitoring devices subject to the procedures listed below. Policy detail. Permission from the NHA for the use of monitoring equipment must be obtained prior to installation. Covert monitoring is not permitted. Authorization Form to Allow Electronic Monitoring. If a resident and/or legal representative would like to have Authorized Electronic Monitoring take place in his/her room, the resident and/or legal representative should complete the Request for Authorized Electronic Monitoring form, which may be provided by the NHA. Once the form has been completed, a copy of this form should be given to the NHA. The NHA in conjunction with the District Director/Regional [NAME] President of Operations should verify that the individual with appropriate legal authority has completed the form. Obtaining Consent from Roommates. The resident and/or legal representativemust also obtain the consent of any other residents residing in his/her room by using the Consent by Roommate for Authorized Electronic Monitoring form. A copy of this completed form should be given to the NHA and filed in the active portion of both residents' records. Authorized Electronic Monitoring cannot begin until the individual with appropriate legal authority for the roommate completes this form and a copy is given to the NHA. If each resident in a shared room wishes to use their own electronic monitoring then each should sign a consent form to allow permission for the other. NHA Approval of Electronic Monitoring. Once the NHA has reviewed the Request for Authorized Electronic Monitoring Form and Consent by Roommate for Authorized Electronic Monitoring Form, if applicable, and permission has been granted, the NHA will execute the Resident's Request for Authorized Electronic Monitoring Form and place the approved request in the active portion of the resident's record. Device Installation, Cost, and Maintenance. The resident/legal representative who requests the use of an electronic monitor is responsible for the cost, installation, maintenance of the monitoring equipment, internet connection, and removal of equipment, as applicable. The device should be visible and securely mounted in a fixed position that allows for the privacy of any roommate and for residents, staff, and visitors to move safely about the room. Protecting Privacy: a. Resident. The resident/legal representative may place restrictions on the use of the monitoring device, such as turning it off or blocking the device for personal care. This information should be documented on the Request for Authorized Electronic Monitoring Form. b. Roommate. A roommate may require that certain conditions be implemented before signing the Consent by Roommate for Authorized Electronic Monitoring Form. The roommate will be responsible for assuring these conditions are met and may include: -Pointing the camera away from the roommate, when the proposed electronic monitoring is a video surveillance camera; and/or -Limiting or prohibiting the audio component of a device unless the resident is using it to communicate; - Posting Sign Outside Resident Room. A sign should be posted at the entrance to the room of a resident who has installed an electronic monitoring system notifying those who enter the room that they may be monitored. This sign may not be removed while the room is subject to Electronic Monitoring; -When Electronic Monitoring May Begin. Once the forms have been completely filled out by the appropriate parties and approved by the ED and signs have been posted at the entrance to the resident's room, the Authorized Electronic Monitoring can begin. II. Resident status and record review A. Resident #15, over age 65, was admitted on [DATE]. The 8/12/23 minimum data set (MDS) revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score 3 of 15. The August 2023 computerized physician orders (CPO) included the diagnoses of Alzheimer's disease, dementia, anxiety and depression. The resident's care plan was reviewed and the care plan failed to include the use of video monitoring equipment. B. Resident #27, age 89, was admitted on [DATE]. The 2/6/23 MDS revealed the resident had a moderate cognitive impairment with a BIMS score of 12 out of 15. The August 2023 CPO included the diagnoses of dementia, depression and osteoporosis. The resident's care plan was reviewed and the care plan failed to include the use of video monitoring equipment. C. Resident #36, age 80, was admitted on [DATE]. The 3/30/23 MDS revealed the resident had a severe cognitive impairment with a BIMS score 0 of 15. The August 2023 CPO included the diagnoses of dementia. The resident's care plan was reviewed and the care plan failed to include the use of video monitoring equipment. D. Resident #37, age 76, was admitted on [DATE]. The 6/2/23 MDS revealed the resident had severe cognitive impairment with a BIMS score of 3 out of 15. The August 2023 CPO included the diagnoses of dementia, Parkinson's disease, anxiety and depression. The resident's care plan was reviewed and the care plan failed to include the use of video monitoring equipment. E. Resident #41, age 71, was admitted on [DATE]. The 2/18/23 MDS revealed the resident had a moderate cognitive impairment with a BIMS score 8 of 15. The August 2023 CPO included the diagnoses of stroke and paralysis. The resident's care plan was reviewed and the care plan failed to include the use of video monitoring equipment. F. Resident #43, over age 65, was admitted on [DATE]. The 8/7/23 MDS revealed the resident had intact cognition with a BIMS score of 13 out of 15. The August 2023 CPO included diagnoses of seizure disorder and anxiety. The resident's care plan revealed the facility identified a treatment focus to prevent falls. A fall prevention intervention included using a camera for monitoring. The care plan failed to describe the type of monitoring that would be provided and how the resident's privacy would be protected while the camera was operating. G. Resident #80, over age 65, was admitted on [DATE], discharged on [DATE] and readmitted on [DATE]. Record review revealed the new MDS was in progress. The August CPO diagnoses included risk for falls and knee joint infection. The resident's care plan revealed the facility identified a focus treatment to prevent falls due to poor safety awareness. An intervention listed for fall prevention was to have a camera in the room for supervision. The care plan did not specify camera type, monitoring or recording, times when the camera would be on and off and who would be monitoring the display. H. Resident #203, over the age of 65, was admitted on [DATE]. The 2/28/23 MDS revealed the resident had a moderate cognitive impairment with a BIMS score of 11 out of 15. The August CPO included the diagnoses of dementia and depression. The resident's care plan was reviewed and the care plan failed to include the use of video monitoring equipment. III. Documentation request The NHA reviews and approvals for video monitoring and consents were requested on 8/31/23 and not received. The NHA said that consents were not required and the nurse documented in the resident record when resident and family consent was obtained. IV. Observations and resident interviews On 8/28/23 at 9:25 a.m., Resident #36 was observed in her bed, awake and watching television. There was a camera placed on the resident's dresser, beneath and in front of her television. She was interviewed and said she did not know why there was a camera in her room. She said she thought it was something for her television. The resident was unable to say why a camera was pointed at her while she was in bed. The resident's roommate was interviewed on 8/28/23 at 9:32. The roommate said she was unaware there was video monitoring in her room and said she hoped the camera was not pointed at her. On 8/28/23 and 8/31/23 eight video display screens were observed on the 3rd, 4th and 5th floor nurses' desks. The display screens were on and residents were viewed while they were in their beds. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/30/23 at 1:18 p.m. She said the facility used video cameras on residents that had a high risk of falling. The CNA said the camera was never turned off during personal care. She said she had not received training specific to the use of video cameras and was unaware of a facility policy for monitoring. The 5th floor licensed practical nurse (LPN) #1 was interviewed on 8/31/23 at 9:47 a.m. She said one resident on the 5th floor had a video camera in her room to help monitor the resident for falls. She said the facility did not have a policy for video monitoring and if the nurse identified a resident as high risk for falling, a camera could be placed in a resident's room for monitoring. She said cameras were never turned off during personal care.The LPN said the video equipment also monitored audio and the audio function was also helpful because the nurse could speak to the resident through the monitor and remind the resident to wait for assistance. She said the video display was on the nurse's desk next to the nurse's computer monitor so that when the nurse sat at the desk, the nurse could also monitor the resident's behavior. She said if the nurse was in the common area for an extended period of time, the nurse was able to place the video display on the medication cart, near the nurse's computer display. The LPN said the video display was not turned off when unattended and that it was possible that anyone nearby could view the display. The 4th floor registered nurse (RN) #2 was interviewed on 8/31/23 at 10:08 a.m. She said six residents had cameras set up in their rooms for monitoring. She said cameras were used for monitoring residents when a resident had poor safety awareness or had a high risk for falling. The RN said the facility did not have a policy to use video cameras and the consents were not required. The RN said the use of a camera was an intervention and did not require a physician's order or review by the multidisciplinary team. The RN said video monitoring was helpful because staff could not watch everyone, especially when the unit had three staff members and eighteen residents. She said the video monitoring helped to prevent falls; and an example was if a resident was observed on the camera to self transfer, staff could respond quickly and provide assistance. The RN said the cameras were never turned off. The 3rd floor LPN #3 was interviewed on 8/31/23 at 10:21 a.m. She said one resident on the 3rd floor had a camera set up for video monitoring. The LPN stated she was unaware if the facility had a policy for the use of video monitoring. The LPN said the monitoring was helpful for staff when the resident had a high risk for falling. The LPN said she did not know if cameras were turned off when staff provided personal care for the resident. The director of nursing (DON) was interviewed on 8/31/23 at 12:35 p.m. She said the facility did not have a policy for video monitoring and the nursing staff initiated the use of cameras when a resident had a high risk for falls. The DON said the use of cameras did not require consent but the nurse documented in the resident's record when verbal permission was obtained from the resident or resident family. The DON said the nurse was responsible for observing the resident on the video display. She said resident privacy was maintained because the video display did not contain the resident name. The DON said the use of cameras or video monitoring should be included on resident care plans. The DON said the staff member writing the care plans was behind and she would eventually add the information to the care plans. The NHA and regional director of clinical operations (RDCO) were interviewed together on 8/31/23 at 1:30 p.m. The NHA said the nurse could initiate video monitoring to help staff closely monitor the resident for safety. She said sometimes families requested video monitoring and provided the monitoring equipment. The NHA said the resident's right to privacy was maintained because the video displays did not include the resident name or room number. She said privacy was maintained because the cameras were pointed only at the upper portion of each resident and when staff performed personal hygiene care, they stood between the camera and the resident. The RDCO said the use of video monitoring did not violate the resident's privacy because the monitoring was necessary for resident safety. She said privacy was maintained because the video display was set up on the nurse's work desk and not placed in public view. She said video monitoring was helpful to prevent falls because staff were able to respond quickly when resident behavior was observed on the video display. The NHA said they did not have a policy for video monitoring. The DON said the use of video monitoring was authorized and implemented as a nursing intervention. As a nursing intervention, a consent was not required but the nurse documented that video monitoring was discussed with the resident and/or family. The NHA said that she would locate the documentation regarding the resident/family conversations in the medication records. The NHA located one nurse progress note, which documented only the camera was to be used, but did not indicate what the monitoring would be used for or when, or to allow for resident privacy during personal care. VI. Facility follow up On 9/1/23 at 2:48 p.m. the NHA provided via email an admission note, dated 7/16/23, for Resident #42. The nurse's note revealed the resident was agitated during the admission process and the medical power of attorney agreed to the camera in the room for safety.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles and hand rails); and -Ensure surface disinfectant times were followed. Findings include: I. Professional references A. Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review, The Journal of Hospital Infection, 2021 Jul;113:104-114 retrieved on 9/5/23 revealed in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. B. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 9/5/23 read in pertinent part: High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. II. Facility policy and procedure The Housekeeping Services policy and procedure dated 2023 was provided by the nursing home administrator (NHA) on 9/6/23 at 11:14 a.m. It read in pertinent part: Resident Room Cleaning-Standard Process. Honor privacy, knock, greet and enter. Wash hands, wear gloves and change gloves before cleaning each room to avoid cross-contamination. Secure cleaning cart; leave the housekeeping cart in the hallway, ensuring that it is locked and all chemicals are secured. Set up safety sign and spray & disinfect the bathroom. Place wet floor sign. Spray toilets (handle), sinks (faucets), showers, bath/spa, handrails, walls, area around toilet. Allow chemical to set per manufacturer instructions before wiping. Clear clutter; resident personal items, dishes, flatware (return to owners). Straighten pillows, cushions, throws. Wipe hard surfaces; spray disinfectant multi surface cleaner on a microfiber cloth for horizontal hard surfaces. Disinfect equipment; when present in room: wet cloth with disinfectant multi surface cleaner to wipe down poles, enteral pumps, special chairs, wheelchairs, walkers bedside commode, oxygen concentrators,etc. Clean bathroom; wipe down all areas previously sprayed and dust mop floor. Place microfiber cloth in designated bag on the cart to be laundered. Restock consumable supplies (toilet paper, etc.), collect trash, empty trash, replace liner. Wet mop bathroom floor and ensure wet floor sign is placed. Always use a fresh microfiber pad, mop kitchen area first, and bathroom last. Discard pad for washing after bathroom mopping. Vacuum when carpet is present. -The daily resident room cleaning policy did not address disinfecting high frequency touch areas. -The daily resident room cleaning policy did not address manufacturer's recommendations related to disinfectant application and dwell times when disinfecting hard surfaces and high frequency touch areas. III. Manufacturer recommendations The disinfectants in the facility were identified as: A. Super Sani Cloth Wipes The product label was reviewed which read in pertinent part, Super Sani-Cloth Germicidal Disposable Wipe is a premoistened nonwoven durable wipe containing a quaternary ammonium chloride/alcohol based solution. Recommended for use in hospitals and other critical care areas where the control of the hazards of cross-contamination between treated surfaces is required. Designed to be compatible with hard nonporous surfaces and equipment made of plastic, Formica laminate, glass and more. Some organisms are removed from the surface by thoroughly wiping the surface with the wipe. Most remaining organisms are killed within two (2) minutes by exposure to the liquid in the wipe. B. Ecolab Peroxide Multi Surface Cleaner and Disinfectant The product label was reviewed which read in pertinent part, For use as a Multi-Surface Cleaner/Disinfectant or Restroom Cleaner/Disinfectant: Dilute according to use directions. Pre-clean heavily soiled areas. Apply Use Solution by coarse trigger sprayer to hard, non-porous surfaces. Spray 6-8 inches from the surface; making sure to wet surfaces thoroughly. All surfaces must remain wet for 3 minutes. Wipe surfaces or allow to air dry. Rinsing is not necessary on non-food contact surfaces. Do not use this product to clean or disinfect glassware, dishes, or silverware. Rinse food contact surfaces with a potable water rinse prior to reuse. C. Ecolab 66-Heavy Duty Alkaline Bathroom The product label was reviewed which read in pertinent part, one-step daily cleaning and disinfection spray application: Add 8-12 fl. oz. of product per 1 gallon of solution. Apply to hard non-porous, non-food contact surfaces by spray application. Spray 6-8 inches from the surface. Allow for a 5-minute contact time and then remove solution and entrapped soil with a clean wet mop, cloth, sponge, vacuum pickup or rinse to drain. IV. Observations On 8/29/23 registered nurse (RN) #1 was continuously observed from 9:05 a.m. to 11:00 a.m. RN #1 took residents' vitals in rooms #400, #405, #406 and #410. RN #1 did not disinfect the vitals machine between each resident. RN #1 disinfected the machine after the last set of vitals were taken. RN #1 did not adhere to the dwell time listed for the disinfectant wipes. RN #1 wiped the blood pressure cuff, pulse oximeter and stethoscope for approximately 15 seconds per surface and the surface was no longer wet within 20 seconds. On 8/30/23 housekeeper (HSKP) #1 was continuously observed cleaning rooms #307, #404, #405, #407, #408, #409, and #410 from 10:57 a.m. to 1:00 p.m. HSKP #1 wiped the surfaces (bedside table, dresser, chest and tv table) in each room with a cloth that she sprayed with the cleaning product for approximately five seconds per surface. The surface disinfectant time was not followed in each resident room and therefore all surfaces in each room were not disinfected. The call lights, light switches, door handles, handrails and bathroom call lights in each room were not disinfected (see above per CDC guidelines). V. Interviews RN #1 was interviewed on 8/29/23 at 11:05 a.m. RN#1 said she tried her best to clean the vitals machine but it was hard to do when the unit was busy. She said she did not disinfect the vitals machine between residents and she did not know the dwell time of the disinfectant wipes. HSKP #1 was interviewed on 8/30/23 at 1:05 p.m. HSKP #1 said she was primarily the only housekeeper available throughout the week and she did not disinfect any areas in the room because she did not follow the dwell time because she assumed the peroxide disinfectant product did not have a dwell time. HSKP #1 said she did not clean or disinfect any high touch areas in any rooms because she did not know what high touch areas were. The director of housekeeping (DOH) was interviewed on 8/30/23 at 1:18 p.m. The DOH said rooms should be cleaned top down, dirtiest to cleanest. All high frequency touch areas in the room should be disinfected daily. The DOH said surface disinfectant times should be adhered to ensure surfaces were properly disinfected and based on the deficient practice identified she needed to provide training to all housekeeping staff that covered correct resident room cleaning procedures, surface disinfectant times and high frequency touch areas. The infection preventionist (IP) was interviewed on 8/30/23 at 1:36 p.m. The IP said surface disinfectant times should be adhered to be effective in killing germs, viruses and bacteria. The IP said if the surface disinfectant time was not adhered to then a surface would not be clean or disinfected, which could lead to potential infection. High frequency touch areas should be disinfected because those areas are more prone to contain higher amounts of pathogens and cross contamination. All shared medical equipment should be disinfected after each resident use according to the dwell time listed on the product and surfaces should remain wet for the duration of the dwell time specified.

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Include the email address of the State Survey Agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents. Findings include: I. Resident group interview The group interview was conducted on 8/30/23 at 10:35 a.m. with five residents (#4, #5, #13 and #45) identified by assessment and the facility as interviewable. All four residents said they did not know they could file a complaint with the State Agency and they did not know where the facility posted information in regard to pertinent State Agencies' contact information and it was not reviewed in the resident council meeting. II. Observations and staff interviews On 8/28/23 at 10:46 a.m. observation of the mandatory posting for the State Agency was made on the fourth floor prior to entering the unit. An eight inch by 11 inch paper was stapled to a bulletin board. The posting was hung approximately six feet up from the floor. The bulletin board contained a paper with the names, addresses and phone numbers of State Agencies. The contact information was approximately font size 11 but it would be hard to read with a visual impairment. The complaint intake email address was not included for the State Survey Agency on the posting. The posting was not accessible at wheelchair height so a resident could not read the sign without assistance. The posting was in an area that was not easily accessible to residents who were not mobile. On 8/28/23 at 10:58 a.m. observation of the mandatory posting for the State Agency was made on the third floor prior to entering the unit. An eight inch by 11 inch paper was stapled to a bulletin board.The posting was hung approximately seven feet up from the floor. The bulletin board contained a paper with the names, addresses and phone numbers of State Agencies. The contact information was approximately font size 11 but it would be hard to read with a visual impairment. The complaint intake email address was not included for the State Survey Agency on the posting. The posting was not accessible at wheelchair height so a resident could not read the sign without assistance. The posting was in an area that was not easily accessible to residents who were not mobile. On 8/28/23 at 11:05 a.m. observation of the mandatory posting for the State Agency was made on the fifth floor prior to entering the unit. An eight inch by 11 inch paper was stapled to a bulletin board.The posting was hung approximately six feet up from the floor. The bulletin board contained a paper with the names, addresses and phone numbers of State Agencies. The contact information was approximately font size 11 but it would be hard to read with a visual impairment. The complaint intake email address was not included for the State Survey Agency on the posting. The posting was not accessible at wheelchair height so a resident could not read the sign without assistance. The posting was in an area that was not easily accessible to residents who were not mobile. Registered nurse (RN) #1 was interviewed on 8/28/23 at 11:11 a.m. She said she was uncertain where the State Agencies' contact information was located. Certified nurse aide (CNA) #1 was interviewed on 8/28/23 at 11:35 a.m. She said she did not know where the State Agencies' contact information was located. The nursing home administrator (NHA) was interviewed on 8/28/23 at 11:45 p.m. She said the State Agencies' contact information posting did not include the state agency email address on three out of three units. The director of nursing (DON) was interviewed on 8/30/23 at 1:15 p.m. She said the State Agencies' contact information posting was corrected during the survey process to include the state agency email, however, the posting was still inaccessible and the bulletin boards should be lowered across all 3 units.

Based on observations, record review, and interviews, the facility failed to ensure two (#16 and #34) of four out of 30 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to: -Ensure Resident #16 was wearing her geri gloves (to help her skin from bruising and skin tears) at all times when out of bed; and, -Ensure Resident #34 was wearing her prevalon boots (which help reduce the risk of pressure injuries to the heel/foot). Findings include: I. Resident #16 A. Resident status Resident #16, age above 80, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included rheumatoid arthritis, protein-calorie malnutrition, and unspecified dementia. The 6/3/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of three out of 15. She had no behaviors and did not reject care. She required total dependence with all her ADLs. She had impairment to both sides of her upper and lower extremities. She used a wheelchair. She was always incontinent of bowel and bladder. She was on a nutrition or hydration intervention to manage skin problems. B. Record review The skin integrity care plan, revised 1/10/23, revealed the resident had a potential for impairment of skin integrity related to decreased mobility, physical behaviors towards staff, and incontinence. The interventions included: -air mattress for wound prevention; -apply barrier creams as ordered; -assist with turning and repositioning; -avoid scratching and keep hands and body parts from excessive moisture; -keep fingernails short; -float heels while in bed to prevent pressure injuries; and, -the resident needs assistance, supervision, and a reminder to apply protective garments (geri gloves). The August medication/treatment administration record included: -Ger-sleeves to be worn to protect forearms and hands while out of bed daily in the morning. It documented that Resident #16 had her geri-gloves in place every morning. C. Observations The resident was observed on 8/28/23, 8/29/23, 8/30/23, and 8/31/23 eating lunch in the dining room. She did not have her geri gloves in place. D. Staff interviews Resident #16's private caregiver was interviewed on 8/29/23 at 11:38 a.m. She said she had never seen Resident #16 wear geri gloves. Certified nurse aide (CNA) #1 was interviewed on 8/30/23 at 9:21 a.m. She said Resident #16 did not wear geri gloves. She said if the resident had an order for geri gloves, the CNA was responsible for putting them in place. Licensed practical nurse (LPN) #1 was interviewed on 8/30/23 at 9:43 a.m. She said Resident #16 was supposed to wear geri gloves when she was up in her chair to protect her skin. She said the CNA was responsible for placing the geri gloves on the resident. The director of nursing (DON) was interviewed on 8/30/23 at 10:34 a.m. She said Resident #16 should have been wearing her geri gloves when out of bed to prevent wounds and/or skin injuries. She said she was not able to find the geri gloves in her room and would make sure she had new ones in place. II. Resident #34 A. Resident status Resident #34, age above 80, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included senile degeneration of the brain, age related osteoporosis (weak and brittle bones), essential hypertension (high blood pressure), cognitive communication deficit, and encounter for palliative care. The 7/10/23 MDS assessment revealed the resident was unable to complete a BIMS assessment. She had no behaviors and did not reject care. She required extensive assistance with all her activities of daily living (ADLS). She was at risk for developing pressure injuries. B. Record review The skin integrity care plan, revised 8/9/23, revealed the resident had potential/actual impairment to skin integrity. She had a deep tissue injury (DTI) to her right lateral foot. The interventions included: -Air mattress to bed to assist in offloading pressure. Assist with turning and reposition as needed. Reduce friction and shearing with use of lift/transfer sheets; -Right lateral foot wound; cleanse with NS, pat dry, apply skin prep and cover with dressing; report any s/s of infection or complications to the provider. Staff to make sure wheelchair pedals are off prior to transferring the resident. Prevalon boots on bilateral feet at all times while in bed. A physician's order, dated 2/23/23, documented prevalon boots on bilateral feet at all times while in bed every shift for skin protection. The August 2023 medication/treatment administration record documented Resident #34 had her prevalon boots in place when in bed. C. Observations The resident was observed on 8/30/23 at 2:02 p.m. laying in bed. She did not have her prevalon boots on nor were her heels floated. D. Staff interviews CNA #1 was interviewed on 8/30/23 at 10:30 a.m. She said Resident #34 should have been wearing her prevalon boots while in bed. She said she did not put them on the resident, because the resident was only going to lie down for an hour. The DON was interviewed on 8/30/23 at 10:34 a.m. She said Resident #34 should have had her prevalon boots in place while in bed unless she refused. She said the boots should be in place no matter how long she was in bed. The DON removed the prevalon boots from the dresser and placed them on the resident's feet. She said it was important to have the boots in place to protect the heels from new pressure injuries or worsening pressure injuries.

Based on observation, record review, and interviews, the facility failed to provide care and treatment for the resident's hearing aid that was required to maintain hearing ability for one (#21) of one resident out of 30 sample residents. Specifically, the facility failed to develop a resident centered care plan for the care and treatment to maintain ability to hear, failed to ensure the resident's hearing aid was maintained in working condition, failed to identify communication needs and preferences for the resident with hearing impairment when the device did not work, and failed to ensure hearing impairment was included as a current diagnosis for treatment. Findings include: I. Facility policy The Care of Hearing Impaired Resident policy, dated October 2016, was requested and received on 8/30/23 from the nursing home administrator (NHA). The policy documented in pertinent part: Associates will receive guidelines for providing care to a resident with a hearing impairment. Policy detail -Review the resident's care plan to identify any special needs of the resident. General guidelines -Administer or arrange for a hearing test, as ordered; -Arrange for consultation with otolaryngologist and/or audiologist if needed; -Directly face resident when speaking to him/her so he/she can lip read; -Allow resident to see facial expression; -Enunciate clearly, slowly, and in a normal tone. Do not shout. Give the resident time to grasp what you have said; -Provide pencil and paper or communication board to communicate in writing, if the resident is able; -If the resident has trouble understanding procedures and treatments because of hearing loss, provide written materials or a sign-language translator; -Address the resident's questions, encourage him/her to discuss his concerns about hearing loss, and offer reassurance when appropriate; -Allow the resident more time to answer your questions; -Use gestures and objects to help with verbal communication; -Determine residents awareness of hearing loss; -Evaluate residents ability to determine different sounds; -Engage resident in social conversation and give your undivided attention; -Motivate resident to adjust to the different sounds of a hearing aid; -Evaluate residents progress and adjustment at regular intervals; -Assist residents with arranging transportation or other requirements for hearing care. II. Resident interview Resident #21 was interviewed on 8/28/23 at 9:37 a.m. The resident had a hearing aid in her right ear and requested the surveyor to speak directly into her ear. She said that she had been waiting for someone to take care of her hearing problems. She said she was frustrated from the wait to have help with her ability to hear. The resident said she did not know who she needed to see but had been waiting a long time. III. Resident status Resident #21, over the age of 65, was admitted on [DATE]. A review of the August 2023 computerized physician orders (CPO) revealed the diagnoses included unsteadiness on feet, need for assistance with personal care, repeated falls and failed to include hearing loss. The 4/5/23 minimum data set (MDS) documented the resident had mild cognitive impairment as evidenced by a brief interview for mental status (BIMS) with a score of 13 out of 15. She required assistance for all activities of daily living (ADL). Extensive, two-person assistance was required for bed mobility and transfers, extensive, one-person assistance was required for dressing, toilet use, and personal hygiene. The resident required supervision from one staff member and walking and locomotion had not occurred. Section B of the 4/5/23 MDS documented the resident had adequate ability to hear and that she used a hearing aid. On 6/16/23 a change of condition MDS was completed and section B documented the resident was highly impaired in her ability to hear with a hearing aid. IV. Record review The resident's care plan initiated on 4/18/23 and was not revised on 6/16/23, failed to include specific care needs for communication with hearing loss and hearing aids and failed to direct staff to ensure the hearing aids functioned properly after the change in condition. On 6/16/23 the resident was evaluated by an ancillary services provider for a hearing aid check. The resident reported she had difficulty with placement and removal of the hearing aid, turning the hearing aid on and off, and the sound quality of the hearing aid. The ancillary provider documented the hearing aid was cleaned and placed a wax guard. Adjustments were made for better understanding with the hearing aid. During the appointment the resident reported she could hear better at a soft conversation level. Recommendations by the provider were for daily use of the hearing aid and to follow up as needed. V. Interviews Certified nurse aide (CNA) #1 was interviewed on 8/30/23 at 1:18 p.m. She said knew the resident well and she helped the resident replace the hearing aid batteries when the resident asked for help or if the resident had placed the hearing aid on the bedside table she placed it in a storage box. The CNA said she would also help the resident insert or remove the hearing aid. The CNA said the care she provided was not an assigned task and she just knew what help to provide. Licensed practical nurse (LPN) #1 was interviewed on 8/31/23 at 9:47 a.m. She said she was unaware the resident had a change in her hearing ability. She said the resident continued to watch TV and participated in activities and felt the care provided met the need for the resident. When the surveyor notified the LPN the resident reported she had difficulty hearing the LPN said she would follow up with the resident. The director of nursing (DON) was interviewed on 8/31/23 at 12:35 p.m. She said she was unaware the resident had a change in her ability to hear. The DON was unable to locate specific communication needs or preferences for the resident in the resident's care plan. The DON said when a resident needed assistance with communication the facility should complete an assessment to determine what the resident required for communication and if assistive devices were required the facility should provide required assistance. The social services director (SSD) was interviewed on 8/31/23 at 12:52 p.m. She said the resident had her hearing aid checked in June 2023 by the audiologist. The social worker was unaware the resident had difficulty hearing and she said would add the resident to the next audiology day, sometime in September 2023.

Based on observations, record review, and interviews, the facility failed to ensure one (#7) of three residents who required respiratory care received the care consistent with professional standards of practice, out of 30 sample residents. Specifically, for Resident #7 the facility failed to: -Ensure a physician's order was in place to include the appropriate care of a continuous positive airway pressure (CPAP) machine; -Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #7's CPAP; -Accurately complete section O in the comprehensive minimum data set (MDS) assessment under respiratory treatments; -Ensure a care plan was in place to include settings, cleaning, disinfecting, and storage of the CPAP; -Ensure a physician's order was in place for oxygen therapy for Resident #7; and -Ensure a care plan was in place to include oxygen route, frequency, and liters required. Findings include: I. CPAP A. Facility policies and procedures The CPAP/BiPAP policy, last revised September 2017, was provided by the nursing home administrator (NHA) on 8/29/23 at 2:39 p.m. The policy revealed in pertinent part: To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. To improve arterial oxygenation (Pa02) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. Review and follow health care provider's orders and manufacturer's instructions for CPAP/BiPAP support, machine setup and oxygen delivery. -Notify the health care provider if the resident experiences any adverse consequences, including (but not limited to) respiratory distress and marked change in vital signs; -Documentation should include the resident's response to oxygen therapy, as well as notification to the health care provider; and, -Use distilled water for the humidification chamber, interior filter, tubing, and mask cushion. Filtered or tap water should not be used. Storage and Cleaning: -Make sure the machine and parts are kept out of direct sunlight; and, -Use mild detergent and a damp cloth to wipe the surface of the machine, then dry it thoroughly with a lint-free towel. Never submerge the machine in water. CPAP/BiPAP mask interface and frame: -Wash mask daily in mild, fragrance-free soap and warm water, then rinse well in warm water and air dry; -Soak mask weekly in 1 part vinegar to 3 parts water for 20 minutes, followed by a rinse in distilled water; and, -Frame of the mask (the sturdy plastic or soft fabric part) should be cleaned weekly in warm soapy water. CPAP/BiPAP humidifier: -Use distilled water only, empty and refill daily; -Wash the humidification chamber, using mild soap and warm water daily, then air dry; and, -Soak weekly for 20 minutes in a vinegar-water solution (1 part vinegar: 3 parts water). CPAP/BiPAP tubing: -Use vinegar water solution, mild soap and warm water to clean the tubing twice a week and as needed. Hang it to dry for best results; and, -Replace tubing annually. B. Resident #7 status Resident #7, age above 80, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included chronic respiratory failure with hypoxia (lack of oxygen), sleep apnea, morbid obesity, hypertension (high blood pressure) and dependence on oxygen. The 6/24/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She had no behaviors and did not reject care. She required limited assistance with personal hygiene. All other activities did not occur. She used oxygen. -The use of the CPAP was not triggered/coded on the MDS assessment under section O. C. Resident interview Resident #7 was interviewed on 8/28/23 at 1:00 p.m. She said she did not know when the CPAP tubing was cleaned or changed and did not know when the mask was last cleaned. D. Observations The CPAP was observed on 8/28/23, 8/29/23, 8/30/23, and 8/31/23 on the resident's night stand next to her bed. The CPAP mask was attached to the tubing and placed in the top drawer of the night stand. The top drawer was not empty nor clean and had wound care items in it. The drawer had debris, a small pair of used scissors, a small bottle of opened normal saline, gauze in the package, and a roll of used tape. E. Record review The medical record was reviewed on 8/28/23 and did not reveal an order for the CPAP, the settings, care for the CPAP mask, whether the CPAP should be initiated with or without oxygen, or a care plan addressing the CPAP. F. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/30/23 at 9:21 a.m. She said she did not know how often the CPAP mask or tubing should be cleaned or stored. She said the nurse was responsible for the care. Licensed practical nurse (LPN) #1 was interviewed on 8/30/23 at 9:43 a.m. She said she was not sure how often the CPAP mask, tubing, and machine should be clean or with what cleaner. She said the mask should be stored in a plastic bag when not in use. She said there should be a care plan and physicians order in place for the use of the CPAP. The director of nursing was interviewed on 8/30/23 at 1:30 p.m. She said a physician's order was required for the use of the CPAP and a care plan should have been initiated. She said she received a physician's order for the CPAP on 8/29/23 and initiated a care plan. II. Oxygen A. Facility policies and procedures The Oxygen Management policy, last revised November 2017, was provided by the NHA on 9/1/23 at 1:31 p.m. The policy revealed in pertinent part: Verify that there was a physician's order for the procedure. Review the healthcare provider's orders for oxygen administration. Review the resident's care plan to evaluate for any special needs of the resident. Physician's orders for oxygen therapy to include: -Amount of oxygen to be delivered per minute; -Device through which oxygen is to be delivered (mask or cannula); -Frequency of oxygen use (Routinely vs. PRN); -If PRN, circumstances under which oxygen should be used; -Avoid the use of electrical equipment near the oxygen; -Avoid the use of oil or any other petroleum jelly on the face or around the cannula; -Provide for routine care of the resident and equipment while oxygen is in use: o Inspect skin for signs of irritation from the cannula / mask. o No smoking / oxygen in use signs posted. o Date and change the tubing per orders. o Cover mask or cannula when not in use. B. Resident interview and records 1. Resident interview Resident #7 was interviewed on 8/28/23 at 1:00 p.m. She said she did not know when her oxygen tubing had last been changed. 2. Record review The impaired airway clearance care plan was initiated on 5/14/23 and revealed the resident's goal was to have an oxygen saturation greater than 92% through the review date. The interventions did not include oxygen. The medical record was reviewed on 8/28/23 and did not reveal an order for the use of her oxygen and was not addressed in her care plan. C. Observations Resident #7 was observed on 8/28/23, 8/29/23, 8/30/23, and 8/31/23. Her oxygen concentrator was set for 3 liters via a nasal cannula. D. Staff interviews CNA #2 was interviewed on 8/31/23 at 12:30 p.m. She said she would ask the nurse how many liters of oxygen a resident should be on. She said the nurse would look at the resident's order to clarify the liters to be used. LPN #1 was interviewed on 8/31/23 at 12:35 p.m. She said she would look at the resident's order to see how many liters they should be using. She looked at Resident #7's medical record and acknowledged there was no physician's order for the use of her oxygen. She said there should have been a physician's order to include the liters, the route, and the frequency. She said the oxygen should have been addressed in her care plan. She said Resident #7 was on 2 liters, because that is what she was admitted on . The DON was interviewed on 8/31/23 at 12:40 p.m. and said all residents using oxygen should have an order including the liters, the route, and the frequency. She said it should have been addressed in her care plan. She said she would immediately get a physician's order and address the oxygen use in the care plan.

Based on observations, record review and interviews, the facility failed to maintain emergency response carts and equipment in safe operating condition for two of three emergency carts. Specifically, the facility failed to ensure emergency oxygen canisters on the emergency response carts were maintained and ready for use. Findings include: I. Facility policy The Emergency Cart and Checklist policy, dated July 2015, for maintaining patient care equipment was provided by the nursing home administrator (NHA) on 8/30/23 and documented in pertinent part: The emergency medical cart is readily accessible in the event of an emergency. -The emergency cart will be checked daily by the nursing associates; -Equipment will be be checked to verify proper functioning and availability; -The emergency cart will also be checked and restocked accordingly after every use. II. Observations and interviews On 7/26/23 at 3:15 p.m. the fifth floor emergency response cart was observed with licensed practical nurse (LPN) #1. Observations revealed the oxygen canister designated for the emergency response cart did not have an oxygen key available. Subsequently, the oxygen canister could not be opened and tested to verify the level of available oxygen. The LPN did not know where the key was located and said a key might be available in the oxygen supply room, which was on another floor. On 7/26/23 at 3:15 p.m. the fourth floor emergency response cart was observed with registered nurse (RN) #2. Observations revealed the oxygen canister designated for the emergency response cart registered in the red area marked refill when the canister was opened and tested . After the flow regulator was adjusted and checked, a flow liter per minute still did not register above the refill marking and the dial remained in the read area. The registered nurse said the tank needed to be replaced and a tank was available in the oxygen supply room. III. Facility administration interview The director of nurses (DON) was interviewed on 7/26/23 at 3:15 p.m. The DON said the oxygen canisters with the emergency response carts were checked every day by the night shift nurse. She said a key to open the canister should be attached to the canister or on the emergency cart where it would be ready for use. The DON said when the oxygen canisters were empty any nursing staff member could obtain a replacement canister from the oxygen supply room. IV. Facility follow-up On 7/27/23 an email message was received from the NHA. She reported the fifth floor oxygen canister was in working condition and had a level of one-half full.

Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of eight sampled residents received adequate assistance and supervision to prevent an accident while toileting. Record review and interview revealed Resident #1 had multiple risk factors for falls, including impulsivity, lack of coordinator, impaired balance, and unassisted transfers, among others, and fell without injury on 4/14/23 when he attempted a transfer from his wheelchair to bed without assistance. His care plan read not to leave the resident alone in the restroom. However, on 4/22/23, the certified nurse aide (CNA) left the resident unattended on the toilet to get a clean gown. When the CNA returned, the resident was lifting himself up in front of the toilet. The CNA did not report the incident and the resident was not assessed for injuries until several days later when he complained of back pain. X-rays revealed 7th and 10th right rib fractures. Findings include: I. Resident #1 A. Resident status Resident #1, age 81, was admitted to the facility on [DATE]. According to the May 2023 computerized physician orders (CPO), diagnoses included spastic cerebral palsy, chronic respiratory failure with hypoxia, schizoaffective, anxiety, and insomnia. According to the 3/26/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required extensive assistance for bed mobility, transfers, grooming, and toilet use. The MDS assessment revealed no falls. The resident's care plan, initiated on 6/21/18 and revised on 3/29/23, identified the resident was at risk for falls related to lack of coordination, abnormal gait and mobility, impaired balance, weakness, and history of falls with fracture. It further read the resident can be impulsive due to cognition and a determination to be independent. He also was at risk due to a diagnosis of cerebral palsy. Further, he did not use the call light and he attempts to transfer self-unassisted. Interventions included: a high-low bed and encouraging the resident to have a bed the same height as a wheelchair when transferring himself. The resident was not to be left alone in the restroom (revised 9/8/18). The resident needed prompt responses to all requests for assistance. B. Record review 1. 4/14/23 A nurse's note, dated 4/14/23 at 3:32 p.m., documented in part, CNA alerted the nurse that the resident was on the floor next to his bed with his wheelchair in close proximity. Alerted registered nurse (RN) of the fall. The resident received assistance two times to get the resident on the bed; the resident stated he did not have any pain or discomfort due to the fall. Notified provider - no recommendations at this time; notified power of attorney (POA); will continue to monitor and provide care. Record review revealed a fall investigation worksheet on the 4/14/23 fall that identified the resident fell during a transfer of himself to bed. There were no progress notes on the fall or the resident's condition in the days that followed until 4/24/23. 2. 4/24/23 - 4/26/23 On 4/24/23 a CNA observed a bruise on Resident #1 during the bedtime routine. On 4/25/23, Resident #1 complained of back pain and stayed in bed and rested during the shift. Scheduled Tylenol was administered. On 4/26/23, the resident again complained of back pain, and the staff administered medication. The nurse practitioner ordered X-rays. The x-rays revealed a fracture to the 7th and 10th ribs on the right side. The primary care provider and family were notified. On 4/27/23, the department was notified. II. Facility failures A. The facility failed to ensure Resident #1 received adequate assistance and supervision to prevent an accident while toileting on 4/22/23. Record review revealed the NHA initiated an investigation of the resident's pain and x-ray results on 4/27/23. The investigation revealed CNA #4 left the resident unattended on the toilet, contrary to his care plan, on 4/22/23. The investigation read in part: -Resident #1 was complaining of pain on 4/26/23 at 4:00 p.m. Licensed practical nurse (LPN) administered Tylenol and the nurse practitioner ordered an x-ray. X-ray results revealed a fracture of the 7th and 10th rib on the resident's right side. -Resident interview summary: Resident #1 stated he started hurting the day prior (4/26/23). When asked how the injury happened he stated he attempted to transfer from the toilet and fell over the weekend. The resident stated the CNA assisted him with the toilet transfer. The resident did not have concerns with his care at this time. -Staff interview summary: CNA #4 stated she assisted Resident #1 to the toilet on 4/22/23 at approximately 7:00 p.m. She noticed he needed a clean gown and stepped out of the room to retrieve a gown. When she returned a few seconds later, she observed Resident #1 attempting to transfer himself off the toilet. His back was up against the toilet bowl and he was in a squatting position with his arms still on the rails of the toilet. She assisted him and finished providing him care. He had no complaint of pain that night. CNA #4 noticed Resident #1 was complaining of pain and observed a bruise on 4/26/23 at approximately 6:00 p.m. CNA #2 stated on 5/1/23, that she provided Resident #1 with a shower on 4/23/23 but did not notice bruises or any injury and the resident had no verbal or physical complaint of pain. CNA #5 stated on 5/2/23 at 7:45 p.m. that he noticed a bruise below the shoulder blade while assisting the resident (no date referenced). Resident #1 disclosed that it happened when he was attempting to transfer off the toilet over the weekend. -Conclusion of the investigation: The facility did not substantiate neglect. CNA #4 received counseling and education prior to returning to direct care services. The facility provided in-services to all staff members to ensure they reviewed and followed residents' Kardex and updated care plans to reflect resident needs. The facility would interview staff members to identify other residents that fail to comply with not being left alone in the bathroom. (Although all pertinent information regarding the incident involving Resident #1 was requested at the entrance to the facility on [DATE], the facility did not offer documentation of the steps taken by the facility at the conclusion of the investigation.) B. The facility failed to follow its fall management policy and procedures 1. Facility policy and procedure The nursing home administrator (NHA) provided the fall management policy, revised in April 2023, on 5/25/23 at 1:32 p.m. It read in pertinent part, A witnessed or reported unwitnessed fall with or without injury, is reported in the facility incident reporting system . Residents who sustain a fall should have a post fall evaluation completed to consider-possible interventions to reduce (the) potential for future falls. 2. Record review revealed no documentation of the incident involving Resident #1 on 4/22/23, no documentation the incident was reported, no documentation to show the resident's condition was assessed, and no documentation the resident's care plan was updated with new intervention to prevent additional falls. III. Staff interviews LPN #1 was interviewed on 5/24/23 at 9:34 a.m. She said Resident #1 would have his good and bad days when it came to his behaviors. She said he had fallen in the past and had fractured ribs. She said when any resident falls, whether it was witnessed or unwitnessed, a complete fall assessment should be done by a registered nurse (RN) and reported. CNA #2 was interviewed on 5/24/23 at 9:43 a.m. She said when a resident had a fall she would call for help immediately and request staff get a RN. She said she'd assist with care and follow directions. She said Resident #1 was not comfortable with staff he was not familiar with and would get agitated if he was not familiar with staff providing care. She said when she noticed a bruise she would report it to nursing and they would investigate the cause of the bruise. CNA #3 was interviewed on 5/24/23 at 9:51 a.m. She said if residents had a history of falls, staff were recently re-educated on following care plans and using the Kardex to ensure fall interventions were in place. She said Resident #1 was not supposed to be left in the restroom by himself. The NHA was interviewed on 5/25/23 at 11:58 a.m. She said CNA #4 did not report the incident on 4/22/23 to anyone, as she did not see the incident as a fall. Therefore, there was no investigation or incident report initiated at that time. She said the way CNA #4 described it to her, it could have been classified as a fall. She said they had to go with CNA #4's explanation because the CNA has never had an infraction or other issues on her record. She said they should have trained staff to look at the Kardex to see that Resident #1 should have not been left alone on the toilet. She said all CNAs should have communicated better with nursing to let the facility know Resident #1 did not like having staff in the restroom while he was being toileted. She said, obviously, there was a lack of communication to inform others that Resident #1 did not like anyone in the restroom while he was being toileted. She said technically, the incident on 4/22/23 should have been called a fall and or a near miss. She said staff should have reported the incident so the facility could have gotten ahead of it as it was not reported. She said the incident on 4/22/23 was the only incident that would explain the resident's broken ribs. She said, I don't know if the staff did anything inappropriate and nothing in the process would have changed the outcome. The assistant director of nursing (ADON) and the nurse consultant (NC) were interviewed on 5/25/23 at 1:21 p.m. The ADON said she had been with the facility for two months and she did not have the details of what occurred. The NC said a fall was when there was any change of surface and in this case, there was not a fall because he was lifting himself off the toilet seat. The NC stated the resident was too weak to lift himself up off the floor and the CNA found him lifting himself off the seat. She said it would be no different from anyone lifting himself out of a chair. The NC said this was why it was not reported as a fall. The NC further said the fractured ribs could have happened at another time. However, see above; the resident reported to CNA #5 that he was injured during toileting over the weekend (4/22/23 - 4/23/23) and further said, during the facility investigation, that he attempted to transfer from the toilet and fell over the weekend.

Based on interviews and record review, the facility failed to take the necessary steps to ensure one (#8) of one resident was free from abuse out of 16 sample residents. Resident #8 was admitted to the facility for long term care on 12/18/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was dependent on staff for activities of daily living which included toileting and upper and lower body dressing. The resident had both physical and verbal behavior symptoms directed towards others and had rejections related to care. The facility failed to address the behaviors to ensure resident safety (cross-reference F744 for dementia care). Due to the facility not addressing the verbal and physical behaviors, Resident #8 was involved in an incident involving abuse from a certified nurse aide (CNA). Due to the facility failures, Resident #8 had an altercation with a CNA that resulted in bruising to the right wrist and forearm. Findings include: I. Facility policy The Abuse, Neglect, and Exploitation policy, revised May 2021, was provided by the director of nursing (DON) on 6/15/22 at 11:00 a.m. It read, in pertinent part, The resident has the right to be free from abuse, neglect, mistreatment, misappropriation of resident property, and exploitation. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. II. Altercation on 6/9/22 The DON provided the facility incident investigation on 6/16/22 at 1:18 p.m. The investigation included interviews with the resident, the alleged perpetrator, and staff. The summary of the alleged events indicated the nursing home administrator (NHA) was notified of an incident that involved a resident hitting a CNA on 6/9/22 at 5:00 p.m. CNA #5 indicated that she had changed Resident #8's brief and he complained about the brief poking him. CNA #5 looked at the area Resident #8 was describing and stated that nothing was there. The resident did not agree with CNA #5 and hit her behind the left ear. Resident #8 was interviewed on 6/9/22 as part of the investigation. Resident #8 indicated he attempted to tell CNA #5 the tab on his brief was sticking to him. He indicated he had his hand on the area where he thought the tab was sticking him, in order to show her. He indicated CNA #5 said nothing was there and grabbed his hand and pulled it up. He said this was abuse. He said he hit CNA #5 when she was telling him there was nothing sticking him. CNA #5 was interviewed on 6/9/22 as part of the investigation. She indicated Resident #8 told her the tab on his brief was sticking to him. She said the resident's hand was on the area and she looked and told him nothing was sticking to him. She said the resident became angry and struck her behind her ear. She said she reported this to the nurse. She stated she did not have her hand on his arm at any time during the event. The floor nurse, licensed practical nurse (LPN) #1 was interviewed on 6/9/22 as part of the investigation. She said she did not witness the event but stated CNA #5 reported that Resident #8 struck her. LPN #1 stated the resident was often verbally and physically abusive to staff. There were interviews conducted on 6/9/22 and 6/14/22 with residents on the floor as part of the investigation with no concerns. The summary of the investigation indicated it was substantiated. The investigation indicated the resident had a 6.5 by 2.5 centimeter bruise across his right wrist that followed the fold of his wrist in a long narrow pattern, a 4.5 by 5.5cm bruise on his right forearm that had irregular edges, and three smaller round bruises on his right forearm that were circular. It documented the three smaller bruises could indicate a finger grasp. The investigation indicated that although CNA #5 said she did not touch the resident's arm, the discoloration on the wrist could have been caused by CNA #5 if she did in fact grab his wrist as the resident reported. It indicated the bruise on the forearm looked as though it could have been caused by hitting his arm against his wheelchair. The investigation indicated CNA #5 was suspended. Additional actions taken by the facility included offering alternative choices for briefs so that the tabs would not stick to the resident. CNA #5 no longer worked at the facility. III. Resident #8 A. Resident status Resident #8, age 89, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/18/22 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status score of 14 out of 15. It indicated the resident was dependent on staff for activities of daily living which included toileting and upper and lower body dressing. It indicated the resident had both physical and verbal behavior symptoms directed towards others. It also indicated the resident had rejections related to care. B. Resident interview Resident #8 was interviewed on 6/21/22 at 1:26 p.m. The resident's spouse was present for the interview. Resident #8 said he was pulling at the stickers on his brief when CNA #5 grabbed his arm. He said he pulled his arm back down while she still had a grip on his arm. He said they went back and forth ten times of her pulling his arm up and him pulling his arm back down. He said during this time CNA #5 yelled at him that there was nothing on his brief poking him. He said CNA #5 released his arm and that caused his hand to hit CNA #5. He said he had bruises on his wrist and arm from the event but no pain. He said he was pissed off and annoyed because he could not defend himself. He said no one had spoken to him that way in his life and he wanted respect. He said he was not afraid of any staff and had not seen that CNA since this event. He said he felt safe at the facility. C. Record review The behavior care plan, initiated 7/28/22, indicated Resident #8 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included anticipating the resident's needs, providing choices related to cares and activities, and leaving resident alone when physically or verbally abusive and re-approach later. The mood care plan, initiated 4/13/2020, indicated Resident #8 had an altered mood. Interventions included encouraging the resident to express his feelings and monitoring behavior such as aggressive outbursts. -The care plan was not updated following the 6/9/22 incident. Progress notes from 3/15/22-6/15/22 were reviewed and revealed the following: On 5/21/22 a progress note was completed that indicated Resident #8 kicked and punched a CNA while calling them derogatory names. On 5/23/22 a progress note was completed that indicated Resident #8 was verbally aggressive to a CNA. When the resident was reapproached at a later time, he spit at the CNA. On 6/9/22 a change in condition note was completed. It indicated the resident notified the nurse of purple discolorations on his right wrist, hand, and forearm. The resident stated he hit a CNA and the CNA grabbed his wrist. The NHA was notified. On 6/12/22 a progress note was completed that indicated Resident #8 spoke with a police officer regarding the 6/9/22 incident. It indicated the officer took photos of the resident's bruises. -No other progress notes related to behaviors were documented from 3/15/22-6/15/22. A physician visit occurred on 6/9/22. It indicated Resident #8's bruises were evaluated. The note indicated the resident had fragile skin and if there was contact with another person it could have resulted in the bruising. No medication changes were made related to the bruises. The June 2022 CPO revealed the following: -Monitor purple discolorations on right wrist, hand, and forearm. Notify physician of any changes or worsening. Every shift for discoloration monitoring. Ordered 6/10/22. -No orders for behavior tracking were in place. The task list for CNAs included monitoring for behavior symptoms. The charting from 5/24/22-6/22/22 was reviewed and revealed the following: -On 6/15/22 Resident #8 displayed a behavior of rejection of care. -On 6/16/22 Resident #8 displayed a behavior of abusive language. A skin assessment was completed on 6/12/22. It indicated Resident #8 had discoloration to the right hand, wrist, and forearm. IV. Staff interviews CNA #1 was interviewed on 6/21/22 at 2:14 p.m. She said Resident #8 did not refuse care from her. She said she had seen him refuse care from other CNAs. She said when she first started working at the facility in January 2022, Resident #8 hit her in the face. She said it was best if two caregivers were present for all cares. She said she did not have any additional training on managing Resident #8's behaviors. LPN #1 was interviewed on 6/21/22 at 2:38 p.m. She said she was the nurse working during the 6/9/22 incident. She said CNA #5 informed her that she had been hit by Resident #8. She told CNA #5 to talk to the NHA. LPN #1 went into Resident #8's room and asked if he hit the CNA. She said Resident #8 admitted he hit the CNA. LPN #1 said Resident #8 asked her to look at his hand because the CNA had abused him. She said there was a line on his wrist. She said about 30 minutes later she saw larger bruises on his hand. She said the medical director was notified and was able to see the resident that evening. She said the bruising made sense based off what Resident #8 reported. She said Resident #8 refused care and was more cooperative when his spouse was present. She said Resident #8 could be verbally and physically abusive and was hard to redirect. She said she preferred when two caregivers were present for all care but that was not in the care plan. She said the clinical team had discussed Resident #8's behaviors but there was no formal behavior tracking being completed aside from nursing progress notes. She said CNA #5 was aware of the resident's behaviors and thought it would have been better if another caregiver had been in the room that day. CNA #2 was interviewed on 6/22/22 at 9:50 a.m. She said Resident #8 did not typically have behaviors. She said a lot of his care was provided with two caregivers present since he required a hoyer (mechanical) lift. The social services director (SSD) was interviewed on 6/22/22 at 10:52 a.m. She said she was not thoroughly familiar with the 6/9/22 incident since the NHA completed the report. She said Resident #8 was verbally and physically aggressive to staff and was resistant to care constantly. She said the verbal aggression was associated with brief changes or repositioning. She said the behaviors were tracked on nursing documentation or the CNA task list and discussed during morning meetings with clinical staff. She said there was no additional formal behavior tracking. She said Resident #8 responded best to certain staff members' redirection, his spouse, offering food, or resting. She said Resident #8 had not reported abuse from staff prior to the 6/9/22 incident. She said she did not provide education to staff on his behaviors or dementia care. The DON was interviewed on 6/22/22 at 10:29 a.m. She said Resident #8 had behaviors and was verbally abusive and combative. She said Resident #8 would strike at staff and call staff derogatory names. She said the nurses tracked behaviors as a progress note and CNAs would track behaviors as well. She said CNAs were trained on how to redirect or re-approach at a later time. She said caregivers attempted to provide care two at a time, if possible. She said the facility provided training on how to deal with behaviors but no formal training was provided for his behaviors specifically. She said she was not familiar with the 6/9/22 incident and that the NHA completed the investigation. The NHA was interviewed on 6/22/22 at 11:14 a.m. The NHA said she received a call from LPN #1 stating that Resident #8 hit a CNA. She said CNA #5 reported she attempted to reassure the resident that his briefs were not stuck to him when he hit her behind her ear. She said when she went to speak to the resident he had a bruise on his wrist and arm and said they were from the CNA. The NHA said the bruising appeared to be fresh so she reported the incident as abuse. She said Resident #8 was combative, verbally abusive, and would strike out at staff daily though there was no formal daily behavior tracking. She said he had never had any claims of abuse from staff prior to this incident. She said after the incident the staff had tried different briefs for comfort. She said no additional training was provided to staff after the event.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and adequate supervision was provided to prevent accidents, for two (#14 and #34) for elopement out of 16 sample residents. Specifically the facility: -Failed to complete an elopement assessment at the time of wander guard placement for Resident #14 and #34, and, -Failed to attempt an alternate intervention prior to the implementation of a wander guard for Resident #14. I. Facility policy The Elopement Risk policy, revised October 2020, provided by the nursing home administrator (NHA) on 6/21/22 at 3:16 p.m., included: Skilled nursing elopement: Any incident where a resident leaves the interior of the skilled nursing portion of the community; unescorted or unsupervised, with or without injury, when it has previously been determined that he/she needs supervision. Interventions may include, but are not limited to: -Frequent monitor (Q 15 minute checks) -Activities specific to resident needs -Family/companion services -Electronic Monitoring/Elopement System -Pain Management -Room location -Assess for cause of [CONDITION(S)] -Signage placed to assist resident with directions to room -Knowledge of dominant hand. Completion of Elopement Risk Data sheet with photograph. Interventions will be documented in the Resident's Plan of Care . II. Resident #14 A. Resident status Resident #14, age above 90, was admitted on [DATE] and readmitted on [DATE]. According to the June 2020 computerized physician orders (CPO), diagnoses included [CONDITION(S)], dementia, and rotator cuff tear of both shoulders. The 5/10/22 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. The MDS identified the resident did not display the behavior of wandering. B. Record review The care plan, initiated on 6/16/22, identified the resident was an elopement risk as evidenced by leaving the floor and going on to the elevator unattended. Interventions included: -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers: (incomplete) -Identify pattern of wandering. Intervene as appropriate. -Monitor location throughout the shift. Document wandering behavior and attempted diversional interventions. -Wanderguard to right ankle for safety. Nursing to check placement and function each shift. The June 2022 CPO included: -Wanderguard to right ankle for safety. Check placement and function each shift. Ordered 6/16/22. The facility completed a elopement risk data collection on 6/21/22, five days after the placement of a wander guard. The form documented. Resident recently got lost and was found on the elevator and was unable to state why she went to the elevator. After speaking with direct care staff, the resident is currently at risk for elopement due to confusion and getting lost. C. Observation Resident #14 was at a table in the dining area on 6/21/22 at 9:45 a.m. A new wander guard was on her left ankle. D. Interviews Certified nurse aide (CNA) #3 was interviewed on 6/21/22 at 2:05 p.m. They said Resident #14 did not have a history of wandering. They said they were surprised she had a wander guard on. They said they needed to ask the nurse why the resident had a wander guard placed. They said the resident was dependent on staff for most of her mobility. CNA #4 was interviewed on 6/21/22 at 2:26 p.m.She said she did not recall Resident #14 wandering. They said they were surprised about the wander guard. Licensed practical nurse (LPN) #1 was interviewed on 6/21/22 at 2:09 p.m. She said the resident did not wander very much beyond the dining room table to her room. She said the resident did not have a history of wandering. She said she preferred the resident have the wander guard, because it would be easier to know where she was with the wander guard. She said the facility would revisit the need for the wander guard, and if the team determined she no longer needed it, it would be removed. The director of nursing (DON) was interviewed on 6/22/22 at 11:49 a.m. She said Resident #14 did not have a history of wandering before the most current incident with the resident getting on an elevator and making it from the third floor down to the first floor. She said the resident was happy and laughing when she was found and did not know how she had gotten there. She said there was not an order for frequent checks. She said the interdisciplinary team met the following morning and as a group determined the wander guard placement was an appropriate intervention. III. Resident #34 A. Resident status Resident #34, age 71, was admitted on [DATE]. According to the June 2020 computerized physician orders (CPO), diagnoses included cerebral infarction, cognitive communication deficit, and difficulty walking. The 6/7/22 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. The MDS identified the resident as having wandered between one to three days in the past seven. B. Record review The care plan, initiated on 5/27/22 and revised 6/13/22, identified the resident as an elopement risk as evidenced by wandering into other resident's rooms and attempting to leave the unit. Interventions included: -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers: (incomplete). -Identify pattern of wandering. Intervene as appropriate. -Monitor location throughout the shift. Document wandering behavior and attempted diversional interventions. -Wanderguard to wheelchair. Nurse to check placement and function each shift. The June 2022 CPO included: -Wanderguard to w/c (wheelchair).Check placement and function ordered on 6/14/22. The Elopement risk data collection, completed on 6/21/22, documented, Resident had a history of wanting to leave the facility to go back to Oklahoma. He has a history of [CONDITION(S)] per daughter and has frequent agitation and aggressive behaviors towards staff. At this time he is at risk for elopement. -The elopement risk data collection was completed eight days after placement of the wanderguard. C. Interviews CNA #4 was interviewed on 6/21/22 at 2:26 p.m. CNA #4 said Resident #34 wandered frequently in the unit and sometimes would go into other resident's rooms. She said he was a frequent wanderer. Registered nurse (RN) #1 was interviewed on 6/21/22 at 2:30 p.m. She said the resident had attempted to leave the unit and go to the elevator. She said it would increase his safety if he had a wander guard. The DON was interviewed on 6/22/22 at 11:49 a.m. She said Resident #34 had a history of wandering in the unit to include into other resident's rooms. She said the resident had an elopement assessment upon admission, and was not identified as exit seeking. She said the team had met and had determined a wander guard was the best option for Resident #34. The NHA was interviewed on 6/22/22 at 12:15 p.m. She said all the elopement risk data collection forms were completed the previous day to ensure they were done. She said her expectation was for the elopement risk data collection to be completed at a minimum the day the wander guard was placed. She said staff were re-educated yesterday (6/21/22) on elopement and wander guard usage.

Based on interviews and record review, the facility failed to ensure one (#8) of three residents reviewed for dementia care of 16 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to address Resident #8's behaviors that were directed towards staff and the resident was involved in an altercation with a caregiver. Findings include: I. Facility policy The Dementia Care policy and procedure, revised November 2019, was provided by the nursing home administrator (NHA) on 6/22/22 at 11:34 a.m. It read, in pertinent part: Skilled Nursing residents who have been diagnosed as having dementia and those with otherwise impaired cognition should have a resident-centered care plan to maximize remaining abilities and quality of life. When a resident exhibits behavioral expressions, associates should attempt to discover possible contributing factors. Tools such as the Survey of Discomfort in Dementia (SDD) Analysis form and the Behavioral Review with Divisional Dementia Care Manager Form in PointClick Care (the electronic charting system) may be utilized. The Interdisciplinary Team (IDT) should evaluate residents to help identify symptoms and findings that differentiate dementia from other causes, such as [CONDITION(S)]. II. Incident on 6/9/22 Resident #8 alleged certified nurse aide (CNA) #5 had abused him by grabbing his arm on 6/9/22. The incident was investigated by the facility and was substantiated (cross-reference F600 for abuse). III. Resident #8 A. Resident status Resident #8, age 89, was admitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/18/22 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status score of 14 out of 15. It indicated the resident was dependent on staff for activities of daily living which included toileting and upper and lower body dressing. It indicated the resident had both physical and verbal behavior symptoms directed towards others. It also indicated the resident had rejections related to care. B. Resident interview Resident #8 was interviewed on 6/21/22 at 1:26 p.m. The resident's spouse was present for the interview. Resident #8 said he was pulling at the stickers on his brief when CNA #5 grabbed his arm. He said he pulled his arm back down while she still had a grip on his arm. He said they went back and forth ten times of her pulling his arm up and him pulling his arm back down. He said during this time CNA #5 yelled at him that there was nothing on his brief poking him. He said CNA #5 released his arm and that caused his hand to hit CNA #5. He said he had bruises on his wrist and arm from the event but no pain. He said he was pissed off and annoyed because he could not defend himself. He said no one had spoken to him that way in his life and he wanted respect. He said he was not afraid of any staff and had not seen CNA #5 since this event. He said he felt safe at the facility. C. Record review The behavior care plan, revised 6/16/22, indicated Resident #8 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included anticipating the resident's needs, providing choices related to care and activities, and leaving resident alone when physically or verbally abusive and re approach later. The mood care plan, revised 9/9/2020, indicated Resident #8 had an altered mood. Interventions included encouraging the resident to express his feelings and monitoring behavior such as aggressive outbursts. The activities care plan, revised 4/4/22, indicated Resident #8 would benefit from associate support for resident programs. Interventions included inviting him to scheduled activities and allowing wife to assist with activity functions. The care plan indicated Resident #8's preferred activities were outings, bingo, reading the newspaper, music, and use of personal iPad. -The care plan was not updated with personalized strategies or approaches for the staff with the resident's verbal and aggressive behaviors. The care plan was not updated after the incident that occurred on 6/9/22. There was no interdisciplinary review of Resident #8's ongoing behaviors. Progress notes from 3/15/22-6/15/22 were reviewed and revealed the following: On 5/21/22 a progress note was completed that indicated Resident #8 kicked and punched a CNA while calling them derogatory names. On 5/23/22 a progress note was completed that indicated Resident #8 was verbally aggressive to a CNA. When the resident was reapproached at a later time, he spit at the CNA. On 6/9/22 a change in condition note was completed. It indicated the resident notified the nurse of purple discolorations on right wrist, hand, and forearm. The resident stated he hit a CNA and the CNA grabbed his wrist. The NHA was notified. On 6/12/22 a progress note was completed that indicated Resident #8 spoke with a police officer regarding the 6/9/22 incident. It indicated the officer took photos of the resident's bruises. -No other progress notes related to behaviors were observed from 3/15/22-6/15/22. The staff interviews (see below) revealed the resident had behaviors routinely. The June 2022 CPO were reviewed and revealed the following: -Monitor purple discolorations on right wrist, hand, and forearm. Notify physician of any changes or worsening. Every shift for discoloration monitoring. Ordered 6/10/22. -No orders for behavior tracking were in place. The task list for CNAs included monitoring for behavior symptoms. The charting from 5/24/22-6/22/22 was reviewed and revealed the following: -On 6/15/22 Resident #8 displayed a behavior of rejection of care. -On 6/16/22 Resident #8 displayed a behavior of abusive language. IV. Staff interviews CNA #1 was interviewed on 6/21/22 at 2:14 p.m. She said Resident #8 did not refuse care from her. She said she had seen him refuse care from other CNAs. She said when she first started working at the facility in January 2022, Resident #8 hit her in the face. She said it was best if two caregivers were present for all cares. She said she did not have any additional training on managing Resident #8's behaviors. LPN #1 was interviewed on 6/21/22 at 2:38 p.m. She said she was the nurse working during the 6/9/22 incident. She said CNA #5 informed her that she had been hit by Resident #8. She told CNA #5 to talk to the NHA. LPN #1 went into Resident #8's room and asked if he hit the CNA. She said Resident #8 admitted he hit the CNA. LPN #1 said Resident #8 asked her to look at his hand because the CNA had abused him. She said there was a line on his wrist. She said about 30 minutes later she saw larger bruises on his hand. She said the medical director was notified and was able to see the resident that evening. She said the bruising made sense based off what Resident #8 reported. She said Resident #8 refused care and was more cooperative when his spouse was present. She said Resident #8 could be verbally and physically abusive and was hard to redirect. She said she preferred when two caregivers were present for all care but that was not in the care plan. She said the clinical team had discussed Resident #8's behaviors but there was no formal behavior tracking being completed aside from nursing progress notes. She said CNA #5 was aware of the resident's behaviors and thought it would have been better if another caregiver had been in the room that day. CNA #2 was interviewed on 6/22/22 at 9:50 a.m. She said Resident #8 did not typically have behaviors. She said a lot of his care was provided with two caregivers present since he required a hoyer (mechanical) lift. The social services director (SSD) was interviewed on 6/22/22 at 10:52 a.m. She said she was not thoroughly familiar with the 6/9/22 incident since the NHA completed the report. She said Resident #8 was verbally and physically aggressive to staff and was resistant to care constantly. She said the verbal aggression was associated with brief changes or repositioning. She said the behaviors were tracked on nursing documentation or the CNA task list and discussed during morning meetings with clinical staff. She said there was no additional formal behavior tracking. She said Resident #8 responded best to certain staff members' redirection, his spouse, offering food, or resting. She said Resident #8 had not reported abuse from staff prior to the 6/9/22 incident. She said she did not provide education to staff on his behaviors or dementia care. She said Resident #8 was offered mental health services quarterly but declined those services. The DON was interviewed on 6/22/22 at 10:29 a.m. She said Resident #8 had behaviors and was verbally abusive and combative. She said Resident #8 would strike at staff and call staff derogatory names. She said the nurses tracked behaviors as a progress note and CNAs would track behaviors as well. She said CNAs were trained on how to redirect or re approach at a later time. She said caregivers attempted to provide care two at a time, if possible. She said the facility provided training on how to deal with behaviors but no formal training was provided for his behaviors specifically. She said she was not familiar with the 6/9/22 incident and that the NHA completed the investigation. The NHA was interviewed on 6/22/22 at 11:14 a.m. The NHA said she received a call from LPN #1 stating that Resident #8 hit a CNA. She said CNA #5 reported she attempted to reassure the resident that his briefs were not stuck to him when he hit her behind her ear. She said when she went to speak to the resident he had a bruise on his wrist and arm and said they were from the CNA. The NHA said the bruising appeared to be fresh so she reported the incident as abuse. She said Resident #8 was combative, verbally abusive, and would strike out at staff daily though there was no formal daily behavior tracking. She said he had never had any claims of abuse from staff prior to this incident. She said after the incident the staff had tried different briefs for comfort. She said no additional training was provided to staff after the event. She said the CNA that was involved in the incident had completed training on dementia care. V. Facility follow-up The NHA provided staff training documents on 6/23/22 at 3:00 p.m. The documents included staff onboarding checklist for new hires. The checklist included training and competencies on communicating with residents and behavioral expressions. The training documents also included the facility's 2022 training schedule which included a plan for CNA training on behavior management for those with Alzheimer's and related diseases; in August 2022, CNA training on behavior and activities of daily living for those with Alzheimer's and related diseases in September 2022; and an all staff training on dementia care for November 2022. The NHA provided an updated care plan on 6/23/22 at 3:38 p.m. The behavior care plan, revised on 6/23/22 included description of incidents involving verbally or physical aggression between Resident #8 and staff. An updated intervention was included and involved approaching the resident in a calm manner, offering the resident his iPad or providing a back rub when upset, and explaining bluntly when comments were not appropriate. The NHA also provided activities participation records for Resident #8 on 6/23/22 at 3:38 p.m. The records indicated the resident regularly participated in activities such as fitness groups, scenic rides, and music over the three previous months.

Based on observations, record review and interviews, the facility failed ensure each resident received adequate supervision and assistance devices to prevent accidents for one (#133) of six out of 19 sample residents. Resident #133 admitted to the facility on [DATE] with a known history of falling and weakness before being admitted to the facility. The resident was identified as being high risk based on the facility fall risk assessment. The resident was not assessed for a wheelchair to be utilized for her mobility in the room. A transport chair was in her room for mobility which was utilized at the time of her fall instead of a wheelchair, which caused the resident to fall backwards due to not being able to utilize the brakes on the transport chair. Due to the facility's failure to assess and analyze the hazards/risks of the resident's use of a transport chair in the facility, she sustained a fall with a laceration that required hospital treatment (see record review below). I. Professional reference [NAME], [NAME] (updated [DATE]) Mobility Deck: What Is The Difference Between a Transport Chair and a Wheelchair? Retrieved on [DATE] from: https://mobilitydeck.com/transport-chair-vs-wheelchair/. It read in pertinent part, Lightweight transport chairs are not designed for independent use. They can only be operated if a second, able bodied person pushes the chair forwards. That said, in some circumstances, a transport chair can be used as a makeshift walker if the primary user is able bodied enough to stand behind and push the chair forward. Wheelchairs allow for completely independent use even if an individual is paralyzed from the waist down. If their arms are functional, a person can propel themselves without assistance. This is why wheelchairs are the superior choice in most environments, and for most people. The only time a transport chair is a better option is when navigating a narrow or hard to access area, or if the user has upper body weakness. For example, transport chairs may be a better choice when travelling on things like trains, trams or buses. They can usually be folded, unlike many standard wheelchairs, and made narrower to slip down aisles and over single steps. On the whole, however, a wheelchair is still the superior option for anybody who wants to move around truly independently. II. Facility policies and procedures The Falls Management policy, revised February 2021, was provided by the nursing home administrator (NHA) on [DATE] at 11:58 a.m. The policy revealed residents had the potential to fall and therefore the facility had identified universal fall precautions applicable to residents. -A fall referred to an unintentional coming to rest on the ground, floor, or other lower level either witnessed or unwitnessed, with or without injury. The Head Injury policy, revised February 2021, was provided by the NHA on [DATE] at 11:58 a.m. The policy revealed all residents that sustained a head injury would receive immediate attention for serious injury. The Falling Star Program (FSP) policy, revised [DATE], was provided by the NHA on [DATE] at 11:58 a.m. The policy revealed new admissions to the facility would be reviewed for fall risk by the nursing department and referred to the rehabilitation department as indicated. Residents who had a fall would be discussed by the interdisciplinary team (IDT) and reviewed as needed. -The program was designed to facilitate recognition of residents who were a risk for falls. When residents were determined to be at risk for falls, they would be referred to this program. -A resident who was identified as being at risk for falls (score of 10 or more on the Fall Risk Data Collection form) or who had two or more falls, would be referred to the program. The Quality of Life - Accommodation of Needs policy, effective date of [DATE], was provided by the NHA on [DATE] at 10:50 a.m. The policy revealed the facility's environment and associated behaviors were directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. -The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, should be evaluated upon admission and reviewed on an ongoing basis. III. Resident #133 A. Resident status Resident #133, age 76, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included [CONDITION(S)], chronic combined systolic (congestive) and diastolic (congestive) heart failure, muscle weakness, lack of coordination, abnormalities of gait/mobility, lack of coordination and repeated falls. The [DATE] minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required limited staff assistance for bed mobility, transfers, and toileting. The resident required staff supervision for personal hygiene and dressing. The resident was not steady and was only able to stabilize with staff assistance for surface-to-surface transfer between the bed and a chair or wheelchair. The resident utilized a wheelchair (contrary to record review see below). B. Resident observation and interview The resident was interviewed on [DATE] at 5:15 p.m. She was seated in her recliner with her feet resting on the seat of a wheelchair that was directly in front of the recliner. She said she did remember the fall on [DATE]. She said the wheelchair she had at the time of the fall was red and had small wheels (transport chair). She said the transport chair had been in her room since her admission and she did not know where it came from. She said she had used the transport chair in her room multiple times for ambulation. She said prior to the fall she was seated in the transport chair and the back of the chair faced the television that sat on the dresser against the wall and she faced her recliner. She said she had non-skids socks on at the time of the fall. She said she must have had the brakes on because when she used her feet to push the transport chair back from the recliner (she was not transferring herself at the time), the transport chair tipped backward and she fell to the floor. She hit the back of her head during the process on the dresser. She said she got a small wound to the back of her head. She said she was seated on her bottom on the floor and was unable to reach the call light because it was on the bed near the recliner. She said she started to yell for help and within five minutes the staff were in the room. She said she was assessed by the staff before she was helped back to bed. She said she was sent to the hospital and received a staple to the back of her head. She said she was offered pain medication and she did not want any. She said after the fall she was not dizzy and did not have any other problems from the fall. C. Record review The Hospital History and Physical dated [DATE] at 5:52 p.m., revealed the resident presented with weakness and falls at home. The chief complaint regarded a fall yesterday with swollen feet and being out of breath. The resident's physician orders dated [DATE] did not reveal an order for the use of a transfer wheelchair in the facility. The Nursing Admission Data Collection form dated [DATE] at 4:19 p.m., revealed the resident had a fall risk score of 20, indicating high risk with any score over 10 per facility policy (see above). -History of falls: during the past 90 days the resident had three or more falls. The resident ambulated with problems and with devices (gait was unsteady, slow, lurching). If the resident had a score of 10 or more, initiate the fall risk interventions and document in the interim care plan. The Evaluation Summary note dated [DATE] at 4:19 p.m., by registered nurse (RN) #4 revealed the resident arrived at the facility at 3:35 p.m., by a transportation service in a wheelchair. The resident was assisted by one staff member using a gait belt to the bathroom and her wheelchair. The care plan for the resident being at risk for falls was initiated on [DATE]. Some of the interventions revealed staff were to make sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. Encourage the resident to wear appropriate footwear when ambulating or mobilizing in her wheelchair. The plan did not reveal the resident utilized a transport chair. -The plan did not reveal the resident was on the Falling Star Program as described in the facility policy for a history of three or more falls in the past 90 days. -The interventions initiated on [DATE] (after the survey started) were to replace the transport chair with a wheelchair so the resident was able to reach and self-operate the brakes. The resident would be a falling star program participant. The Physical Therapy Evaluation and Plan of Treatment, signed electronically on [DATE] at 5:46 p.m., by the rehabilitation manager (RM) revealed the resident did not use a wheelchair and/or scooter. The evaluation did not document any assessment for the use of a transport chair. The History and Physical, dated [DATE], signed electronically on [DATE] at 8:40 p.m., by the resident's physician revealed the resident's chief complaint was recurrent [CONDITION(S)] exacerbating her congestive heart failure that required multiple [CONDITION(S)]. The resident was weakened, frail and fatigued. The history and physical did not reveal the resident utilized a transport chair or a wheelchair for ambulation. The comprehensive nursing note dated [DATE] at 7:05 a.m., by RN #1 revealed the resident was up walking in her room to the doorway this morning. This RN assisted the resident to her wheelchair (transport chair) and provided her with the call light. The comprehensive nursing note dated [DATE] at 3:28 a.m., by RN #6 revealed the resident was in her recliner and wheelchair (transport chair) throughout the day. The comprehensive nursing note dated [DATE] at 11:28 a.m., by RN #5 revealed the resident was in her recliner and wheelchair (transport chair) throughout the day. A nursing note dated [DATE] at 6:30 p.m., (late entry date of [DATE] at 8:13 a.m,) by RN #3 revealed the resident was found on the floor in her room in front of the television stand. She was facing the bed. The resident was a poor historian and could not really tell the story of how she ended down on the floor. The certified nurse aide (CNA) staff found the resident during morning rounds while reports were being given. The resident acquired a laceration to the occipital area of her head. The on call provider was notified and since it was an unwitnessed fall, the resident was sent to the hospital for a computerized tomography (CT) scan of her head for further evaluation and possible treatment. The resident had one staple placed on the lacerated skin and was sent back to the facility. No new orders were received. Staff were to continue the neurological assessments and report any significant changes. The resident was reoriented to use the call light for help to avoid another incident like this one and she verbalized understanding. The call light was placed within reach and the room was free from potential safety hazards and clutter. An electronic Interact Situation-Background-Assessment-Recommendation (SBAR) dated [DATE] at 6:30 p.m., by RN #3 revealed the resident had a change of condition and the on call provider recommended to send the resident to the hospital since the resident was on blood thinners and needed a CT scan for her head since the fall was unwitnessed. The comprehensive nursing note dated [DATE] at 7:28 p.m., by RN #3 revealed the resident was sent to the hospital for further status post unwitnessed fall. The resident acquired an abrasion/skin tear to the occipital area. The area was bleeding, pressure was applied and the bleeding stopped within three minutes. The provider was notified and a new order was received to send the resident to the hospital for further evaluation and possible treatment. The Falls Investigation Worksheet dated [DATE] at 8:21 p.m., revealed the resident was in her room and attempted to transfer from her wheelchair (transport chair) to her recliner. The resident had a skin tear and abrasion at the occipital area measuring 1.0 centimeters (cm) by 0.25 cm. An Alert Note dated [DATE] at 8:42 p.m., by RN #3 revealed the resident's provider was contacted. A non-immediate new order was received for the resident to be sent to the hospital for further evaluation and a CT scan of her head status post unwitnessed fall. The resident acquired a skin tear/abrasion at the occipital area. The Hospital CT electronically signed by a physician on [DATE] at 10:03 p.m. revealed the resident fell backwards and hit the back of her head. There was no evidence of acute internal fracture. The comprehensive nursing note dated [DATE] at 11:50 a.m., by RN #7 revealed the resident was confused about her current placement/location today. The resident had an intact staple to the back of her head. The site was free from bleeding. The resident denied any headaches, [CONDITION(S)] (whirling sensation or loss of balance), [CONDITION(S)] (a loss of consciousness due to a decrease in blood pressure) or visual changes or other related complications. The Collaborative Care Review dated [DATE] at 12:28 p.m., revealed the resident had a change of condition for a fall on [DATE]. The resident had a fall risk score of 24 (indicating high risk). The resident sat in a transport chair and attempted to stand but was unable to reach the brakes. The interventions or recommendations were to place the resident on the Falling Star Program and for physical therapy or occupational therapy and neurological assessments. -The further details section revealed the resident had an unwitnessed fall on [DATE] in her room. The resident sat in a transport chair and attempted to stand but was unable to reach the brakes secondary to the brakes were located low on the back wheels. The chair tipped backwards causing the resident to fall back hitting her head on the bedside table. The resident was sent to the emergency room for evaluation and a staple was placed over the laceration. The resident had been on physical therapy, occupational therapy and speech therapy services since her admission to this facility for congestive heart failure, weakness and impaired cognition. The resident currently required on staff member assistance for transfers and ambulation. The recommendations were to replace the transport chair with a wheelchair in which the resident was able to reach and self-operate the brakes, re-educate the resident to use the call light and wait for assistance for all transfers. The comprehensive nursing note dated [DATE] at 11:50 a.m., by RN #1 revealed the resident had a fall over the weekend and hit the back of her head. The resident had a staple to the back of her head with no bleeding noted around the staple. The resident was encouraged to use the call light for staff assistance but she did not usually do so. Therapy provided her with a wheelchair after her fall. The comprehensive nursing note dated [DATE] at 7:50 p.m., by RN #5 revealed the resident had a fall with an injury to the back of her head that required one staple to the occipital side of her head. The Fall Risk Data Collection form dated [DATE] at 2:00 p.m., revealed the resident had a score of 18, indicating high risk. The resident had ,d+[DATE] falls during the last 90 days. The resident ambulated with problems and with devices (gait was unsteady, slow and lurching). The resident was steady and maintained her position as required with balance while standing, sitting and during transitions. -The resident had a fall on [DATE] and the goal was for the resident not to sustain serious injury through the review date. The interventions revealed placing the resident on the Falling Star Program, make sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. The Rehabilitation Screen form, completed by the rehabilitation manager (RM) on [DATE] at 12:48 p.m., revealed the primary reason for the physical therapy screen was the resident had an unwitnessed fall on [DATE] in her room that resulted in a laceration to the back of her head. The resident was seated in a transport chair and attempted to stand but was unable to reach the brakes secondary to the brakes being located low on the back wheels. The transport chair tipped backwards, causing the resident to fall back, hitting her head on the bedside table. The resident was sent to the emergency room for evaluation and placement of a staple over the laceration. The resident had received physical therapy, occupational therapy and speech therapy since her admission. The recommendations were to replace the transport chair with a wheelchair in which the resident was able to reach and self-operate the brakes. The resident was re-educated to use the call light and await assistance prior to all transfers. The comprehensive nursing note dated [DATE] at 11:50 a.m., by RN #1 revealed the resident recently had a fall and required one staple to the back of her head. The staple was intact and the resident denied discomfort to her head. The resident transfers herself from her recliner to the wheelchair frequently. Occupational therapy provided the resident with a different wheelchair and cushion that fitted her better. A nurse practitioner (NP) note dated [DATE] at 7:32 p.m., revealed the resident was seen for recurrent [CONDITION(S)] exacerbating her coronary heart failure requiring multiple [CONDITION(S)]. The resident was weakened and reported today that she was feeling better. The resident's essential hypertension was evaluated today and she had no headache or dizziness. The report did not reveal the resident had a fall with a head injury that required a staple to be placed in the resident's head at the hospital due a unwitnessed fall in her room on [DATE]. Neurological assessments started on [DATE] at 6:30 p.m., and ended on [DATE] at 6:00 a.m. III. Staff Interviews The rehabilitation manager (RM) was interviewed on [DATE] at 3:58 p.m. She said to gather information on the resident's fall and condition, she interviewed the resident, the therapist and nursing staff that were working on the day of the fall. -The RM said the resident told her that she tipped over backwards in her transport chair, hit her head on the night stand and received a wound to her head. She said it would have been difficult for the resident to reach the brakes on the transport chair. -The RM said the transport chair was light weight and was used to transport a resident to a specific place. The transport chair had small wheels and the brakes were located toward the back of the chair. A transport chair was not a wheelchair. -The RM said she was not sure why the resident had a transport chair in her room or how the chair arrived in the resident's room. She said therapy did not use transport chairs. She said on the day of the fall, a transport chair was in the resident's room. She said an assessment with the resident was completed on [DATE] and the transport chair was removed and a wheelchair was provided. -The RM said the resident currently had a wheelchair and she knew how to apply the brakes on and off. She said the resident had the ability to use the wheelchair in her room. The occupational therapist registered (OTR) was interviewed on [DATE] at 4:30 p.m., by a phone conference call. She said she was not in the facility on the date the resident fell . She said she checked in with the nursing staff for any updates on the resident on [DATE], a day after the fall. She was told the resident had an unwitnessed fall on [DATE]. She said the resident was sent to the emergency room and a staple was placed on her head. She was told the resident was seated on a transport chair in her room, it tipped backward and the resident hit her head on the television stand or the night stand. -The OTR said she had not seen the resident use the transport chair. She said therapy did not provide the chair and she had no knowledge where the transport chair came from. RN #3 was interviewed on [DATE] at 4:14 p.m., by a cell phone conference call. She said during the shift change nurse report ([DATE]), a CNA came and reported a resident had fallen. She said the resident's call light was not on. She said she assessed the resident and there was a little blood on her head. It was a small cut to the back of her head that measured 1 cm by 0.25 cm. She put pressure on the cut and the bleeding stopped in two to three minutes. -RN #3 said when she arrived, the resident was seated on her bottom on the floor, she was leaning on the television stand (dresser) and was holding her head. There was a wheelchair (transport chair) in her room that had small wheels. She said this chair (transfer) was the one that had always been in her room. -RN #3 said the resident complained of her head hurting but did not want any pain medications at this time. The resident was worried about the blood on her head and she said she was okay. -RN #3 received orders from the on call physician to send the resident to the emergency room . The neurological assessments were started immediately and the resident did not have abnormal assessments. The resident returned from the emergency room at 8:30 p.m., and the neurological assessments were re-started. -RN #3 said on the day of the fall, the door to the resident's room was half open and the resident was observed by staff approximately ,d+[DATE] minutes prior to the fall. RN #1 was interviewed on [DATE] at 5:00 p.m. She said she first learned about the resident's fall on [DATE] when she received the nurse report on [DATE]. She said she was told the resident fell and hit the back of her head. She said the resident was taken to the hospital for a CT scan and a staple was placed over the injury to the back of her head. -RN #1 said she had seen the resident seated in her recliner with her feet resting on the red transport chair. -RN #1 said the resident now had a wheelchair and it was provided to the resident either on Sunday [DATE] or Monday [DATE], after the fall. -RN #1 said she had not seen the resident use the transport chair and had no knowledge where the transport chair came from. The NHA was interviewed on [DATE] at 9:09 a.m. She said two RNs assessed the resident after the fall because it occurred at shift change. -The NHA said she had no knowledge from where the transport chair came from. She said the facility did not purchase or provide transport chairs to residents and it must have come into the facility from another source. -The NHA said the facility completed a wheelchair audit of the entire facility on [DATE] to make sure there were no other transport chairs in resident rooms. She said the staff received an in-service on the difference between transport chairs and wheelchairs. She said only one resident had a transport chair in their room that was used when the resident went to [CONDITION(S)]. All other times, this resident used a wheelchair. -The NHA provided the in-service staff education documentation form dated [DATE]. The form revealed the in-service education to staff on the difference between a wheelchair and a transport chair. The content revealed that staff were not to ever have a resident or new admitted resident in a transport chair, because this could cause the resident potential harm. The transport chair was not very sturdy, the arms of the transport chair were higher and the brakes were difficult to reach. Attached was an audit of all the residents in the facility and a staff signature page.

Based on observation, record review and staff interview, the facility failed to ensure one (#38) out of 35 sample residents received and the facility provided the necessary care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically: The facility failed to ensure the resident's pain was managed during wound care, and failed to ensure the provider carrying out wound care (Hospice nurse) changed gloves at appropriate intervals and demonstrated hand hygiene between glove changes. The resident was observed in pain during wound care 10/25/12. The findings include: 1. Resident #38, age 83, was admitted to the facility on [DATE]. According to the Face Sheet, printed 9/18/12, [DIAGNOSES REDACTED]. 2. Resident Status According to the 8/28/12 minimum data set (MDS), the resident had severe cognitive impairment. He usually understood the communication of others, and usually was able to make his needs known. He required extensive assistance for most activities of daily living, except eating, which involved supervision only. He was incontinent of bladder, and was frequently incontinent of bowel. The resident received hospice services. Review of the resident's care plan for pain, most recently reviewed in late 8/12, revealed the resident's goal was that he would have pain controlled and maintained at a tolerable level. Approaches included administer [MEDICATION NAME] as ordered, document changes and report significant changes to MD/Hospice, evaluate verbal, non-verbal cues to assess pain, monitor for decrease in function, behavior changes and anxiety. Review of the resident's orders on 10/23/12 included the following medication orders [REDACTED] -A 7/14/12 for APAP (for Tylenol) 325 mg x2 tablets by mouth every 4 hours as needed for a [DIAGNOSES REDACTED]. -A 7/14/12 order for [MEDICATION NAME]-APAP (for [MEDICATION NAME]) 5-325 1 tablet by mouth every 4 hours as needed for pain (moderate); and -A 7/14/12 order for [MEDICATION NAME]-APAP (for [MEDICATION NAME]) 5-325, 2 tablets every 4 hours as needed for pain (severe). Observation on 10/25/12 at 8:30 a.m., at 9:15 a.m., 9:25 a.m. and 9:33 a.m., revealed the resident asleep in his wheelchair in the dining room and then in the television room with his head hanging over his chest. At 9:55 a.m., the standing lift was used to lift the resident from his wheelchair to the bed. He held on to the hand grips on the lift, and did not grimace or call out during this transfer. He lay on his bed, head resting on a pillow, and closed his eyes. He was observed sleeping in bed at 10:05 a.m., 10:30 a.m. and 11:10 a.m. 3. Report of Inadequate Pain Management In an interview on 10/25/12 at 9:15 a.m., the facility Licensed Practical Nurse (FLPN) said she was waiting for call back from Hospice. She reported at 7 a.m., the resident had received two [MEDICATION NAME] (oral narcotic medication for pain relief), given for severe pain. She said the resident was grimacing this morning and hollered out while the staff moved him. She reported when not being moved, the resident fell asleep. She said she wanted the resident to receive routine scheduled narcotic pain medication around the clock for consistent comfort. (See orders above that were in place on 10/25/12; the only routine medication as of this date was Tylenol). She said the resident usually did not experience pain. Observation revealed on 10/25/12 at approximately 10:20 a.m., the FLPN was observed calling the Hospice nurse and discussing the resident's status - his grimacing and hollering out when moved that morning. She told the Hospice nurse the resident had received two [MEDICATION NAME] at 7:00 a.m. that morning. The Hospice nurse said she would be at the facility in about one hour. Subsequent observations at 11:55 a.m., revealed two Hospice nurses in the facility and at 12:00 p.m., the FLPN informing the primary Hospice registered nurse (PHRN) that the resident got routine Tylenol at noon. In interview on 10/25/12 at 1:10 p.m., the FLPN said PHRN had told the FLPN that she would do an evaluation and change the resident's dressings. 4. Observations of Dressing Changes - Failure to Ensure Resident's Pain was Managed On 10/25/12 at 1:20 p.m., the PHRN entered the resident's room to perform dressing changes on the resident's right elbow, bilateral heels, and right foot. -The resident was in bed, head elevated on pillow, mouth breathing. He aroused after repeated verbal and physical contact with his head. The PHRN asked the resident if he had pain. His response was not audible. His face appeared relaxed at the start of the procedure. -The Hospice physician called the PHRN as the nurse was about to begin the dressing change. The nurse took the call prior to starting the wound care. The Hospice physician was given an update on the resident's deteriorating condition, and ordered scheduled narcotic pain medication and other care changes for the resident's comfort. -The PHRN, after completing the call, washed and then dried her hands at the sink. She donned exam gloves. She obtained dressing materials from the resident's closet. -The PHRN removed the dressing on the resident's right elbow, revealing a small skin tear. She wrote the wound measurements on the outside of a gauze wrapper. She cleaned the wound with normal saline on gauze, and then dried the wound. She applied [MEDICATION NAME] (a topical skin healing agent) and a small dressing. She washed her hands at the sink, and donned new gloves. -The PHRN then placed a towel under the resident's right foot. She opened the packets of dressing materials, and opened a fresh normal saline nib as a wound cleanser. Wearing the same gloves worn to open the dressing materials, the PHRN removed the fluffy gauze dressing, then the foam dressing from the right heel wound. Drainage in the foam dressing was scant. She measured the wound using the measuring tape on the outside of a gauze package. She doffed her gloves and wrote the measurements of the right heel wound on a gauze wrapper. She did not wash or in any other way sanitize her hands before donning new exam gloves. -The PHRN, after donning clean exam gloves, moistened gauze with normal saline, and used it to cleanse the right heel wound. The resident grimaced and hollered out when the nurse touched the right heel wound. He continued to grimace as she dried the wound, applied a new foam dressing and fresh fluffy gauze wrap. She set his right lower leg down on a pillow. However, the pillow was thin and the resident's heel did not float, but rested on the mattress. The resident repeatedly lifted the right foot off the mattress, grimacing as he let the right foot rest on the mattress for a few seconds, then lifted it again to reposition the heel to a different position. The nurse asked the resident if he had pain. His response was not verbal. She asked him if he could quantify the pain, but he did not reply. She asked him to say if the pain was medium or severe, and again, he did not reply. He no longer cried out, nor was he crying, but he grimaced as he sought a comfortable position for his right foot. -The PHRN removed her gloves, and washed her hands for 5 seconds, then dried her hands, putting on new exam gloves. She placed a clean towel under his left foot, and opened additional dressings and normal saline nib. She removed the fluffy gauze wrap, and then removed the foam heel dressing, which had some pink drainage. She used 4x4 gauze moistened with normal saline to cleanse the left heel wound. As this occurred, the resident grimaced and hollered, and had tremors in his left leg. Brown eschar (a thick scab-like tissue adhered to the wound bed) caught in the cleansing gauze so when the cleansing gauze was removed from the wound after cleansing, a small piece of the eschar tissue was pulled from the wound. The resident grimaced and hollered during cleansing as well as during application of a fresh foam dressing. He then gritted his teeth. The left foot was wrapped in fluffy gauze to hold the dressing in place. At this point, the PHRN asked the resident if he was okay, and he replied no. The PHRN folded the thin pillow in half, floating the resident's heels above the mattress surface. -The PHRN then went to the FLPN and requested the resident get additional pain medication. On 10/25/12 at 2:30 p.m., the PHRN returned to the resident's room. He was sleeping quietly in bed. The nurse washed and dried her hands, and put on clean exam gloves. She removed the soiled dressing from the resident's right bunion. The drainage was pink serous fluid. Fibers from the dressing matrix were visible in the wound. The resident became slightly restless when the wound was cleansed, but tolerated the third dressing change well. He closed his eyes and slept as the new dressing was placed on the wound. The PHRN changed gloves after cleaning the wound, and before applying the new border dressing, but did not wash or in any other way sanitize her hands before donning clean gloves. 5. New Orders 10/25/12 Review of the 10/25/12 telephone orders, at 1650 (4:50 p.m.), for resident #38 revealed the following new orders: (written by the PHRN from the Hospice physician): -[MEDICATION NAME] 20 mg/ml) give 5 mg orally sublingual (under the tongue) every 4 hours as needed for pain; -Discontinue scheduled Tylenol; -Schedule [MEDICATION NAME] 5/325 (also known as [MEDICATION NAME]) 5/325; 2 tablets three times a day, orally, for pain. 6. Medication Administration Review of the 10/12 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] -Pain assessments were on-going three times a day. -A 10/12 Pain Flow sheet showed a four out of ten (4/10) pain in both heels on 10/4/12 and 10/19/12, and in each case, as-needed Tylenol successfully relieved his pain. -On 10/25/12 at 7:00 a.m., the resident had 8/10 pain in his left hip and leg, and received two tablets of [MEDICATION NAME] 5 mg/325 mg orally to successfully handle this severe pain. The next dose of [MEDICATION NAME] was given on 10/25/12 at 1400 (2:00 p.m.), after the wound care of the right and left heel and skin tear by the PHRN (see above). At this time, the pain was described as 8/10, severe. The next dose of [MEDICATION NAME] was given on 10/25/12 at 1800 (6:00 p.m.) for 6/10 pain with movement. The next dose of narcotic pain medication was administered on 10/25/12 at 1915 (7:15 p.m.) was [MEDICATION NAME] 0.25 cc (5 mg). 7. Staff Interview In interview on 10/25/12 at approximately 2:05 p.m., the PHRN said she did not feel the need to change gloves after removing soiled dressings as she did not get them soiled. In interview on 10/29/12 at 10:15 a.m., the FLPN said the resident was eating better with pain medication being given around the clock. She said he got [MEDICATION NAME] three times a day, and there was as-needed [MEDICATION NAME] as well as [MEDICATION NAME] (strong liquid pain medication ordered by Hospice to control pain) In interview on 10/29/12 at 5:00 p.m., the FLPN again said the scheduled narcotic pain medication was successful in keeping the resident comfortable. In interview on 10/29/12 at 9:40 a.m., the Director of Nursing (DON) said she expected a Hospice provider to handle pain and wound management as well as her own staff. She said she would contact Hospice DON and discuss training needs, pain and wounds/gloves changes before the PHRN could return and provide wound care in the facility. She said it was her expectation the PHRN would have stopped the dressing change after the first heel elicited severe pain so the resident could be given additional pain medication. In interview on 10/30/12 at 9 a.m., the Nursing Home Administrator (NHA) reviewed a written response from the PHRN. -The PHRN confirmed she washed her hands before moving to another wound. -The PHRN wrote the resident had been given scheduled [MEDICATION NAME] prior to the dressing change in question. However, according to the MAR, next dose of [MEDICATION NAME] was given on 10/25/12 at 1400 (2:00 p.m.), after the wound care of the right and left heel and skin tear by the PHRN. Moreover, the scheduled [MEDICATION NAME] the telephone orders were initiated on 10/25/12 at 16:50 (4:50 p.m.) after the dressing change (see above). -The PHRN wrote the resident received as-needed [MEDICATION NAME] on 10/25/12 prior to the change of the third foot wound; however, review of the 10/25/12 MAR indicated [REDACTED]. 8. Expectations a. Hospice Review of the 5/12/12 Hospice contract revealed the following: "4.2.2 Credentials (ii) Qualifications of Personnel. Personnel who provide Hospice Services shall be reasonably acceptable to Facility. Hospice represents and warrants that personnel providing Hospice Services: (i) are duly licensed, credentialed, certified, and/or registered as required under applicable state laws; and (ii) possess the education, skills, training and other qualifications necessary to provide Hospice Services." b. Hand Washing According to the Centers for Disease Control (CDC) website, <http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf>: "1. Indications for hand washing and hand antisepsis (in pertinent part): A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water (IA) (66). G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA) (400). H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II) (25,53). J. Decontaminate hands after removing gloves (IB) (50,58,321)."