Every finding on record at Canyon View Care Center

Based on observations and interviews, the facility failed to maintain the building temperature three out of four units.Specifically, the facility failed to:-Ensure the building was maintained at comfortable temperature; and, -Ensure the walls did not have chipped paint. Findings include: I. Failure to maintain the building at a comfortable temperature A. Facility policy and procedure Maintenance of Building Temperatures/Provisions for Extreme Heat or Cold policy, revised June 2024, was provided by regional clinical resource #2 on 7/9/26 at 3:54 p.m. It read in pertinent part, The facility is equipped with central heating and cooling systems and has established prevention maintenance programs to ensure these systems function properly. The following provisions and plans are outlined to ensure building temperatures are always maintained at a safe and comfortable level in each resident area. The building temperature in all resident areas at the facility will be maintained between seventy-one degrees Fahrenheit and eighty-one degrees Fahrenheit (F). B. Observations On 7/7/26 at 1:00 pm, there on the South hallway the control switch for the coolers had a note under it, it read in pertinent part the temperature in the building is to remain 71 to 81 degrees. On 7/7/26 at 2:00 p.m. the two vents on the south hallway were blowing warm air near room [ROOM NUMBER] and #46. On 7/8/26 at 12:00 p.m. a portable cooler was on South hallway. The portable cooler was in front of the emergency exit. C. Resident interview and observation The resident who resided in room [ROOM NUMBER] was interviewed on 7/6/26 at 3:38 p.m. He said his room was too hot. He said the hallways were also too warm. The resident who resided in room [ROOM NUMBER] was interviewed on 7/7/26 at 2:00 p.m. She said the south hallway was too warm. She said she wished the facility was cooler. The resident who resided in room [ROOM NUMBER] was re-interviewed on 7/7/26 at 3:50 p.m. The resident said within the last month the temperatures had been increasing in her room and now they were too hot. She said the little breeze she got from her window being open helped. She said the overhead coolers in the hallway seemed to do nothing, as they blew hot air. She said when it was this hot, she did not sleep well. She said she did not have a fan in her room. The resident had a thermometer hanging on her wall and it read 82 degrees F. The resident who resided in room [ROOM NUMBER] was interviewed on 7/7/26 at 4:23 p.m. She said it was hot in the facility. During the interview, the resident had beads of sweat on her forehead and was fanning herself with her hand to cool down. During the interview, registered nurse (RN) #2 came into to provide care for Resident #6. Resident #6 told RN #2 that it was hot. RN #2 did not offer any solutions to the heat or offer to let maintenance know. RN #2 was interviewed at this time (see staff interviews) The resident who resided in room [ROOM NUMBER] was interviewed on 7/7/28 at 4:25 p.m. The resident said it was hot in her room all day. She said the coolers in the hallway blew hot air, which did not help cool the facility down. She said the facility provided her with a fan, but it did not help cool her room. The resident who resided in room [ROOM NUMBER] was interviewed on 7/8/26 at 3:48 p.m. The resident said he was happier today as the temperature in the building was cooler than usual. He said the heat was overbearing yesterday (7/7/26). C. Staff interviews and observations RN #2 was interviewed on 7/7/26 at 4:23 p.m. RN #2 said she was newly employed. She said the south hallway had been very hot today. She said usually there were fans in the resident's rooms and in the hallways, but there were not any today. The maintenance director was interviewed on 7/7/26 at 4:34 p.m. The maintenance director said the facility coolers were not adequate to keep the building cool. During the interview, the maintenance director used an infrared thermometer and took the temperature of the ceiling, which measured at 86 degrees F. He said it was important to have the correct temperature in the building for resident safety. The maintenance director said the sun hit the South hallway in the afternoon each day, which made the hallway hotter. He said he could supply fans for the residents. During the interview, the maintenance director tested the room temperature with a digital infrared thermometer in room # 46 and it read 87 degrees F. Regional clinical resource #1 was interviewed on 7/7/26 at 4:45 p.m. Regional clinical resource #1 said the facility was putting out portable coolers at that time. The maintenance director was interviewed a second time on 7/8/26 at 2:43 p.m The maintenance director said he noticed temperatures had been going up in the rooms as the temperatures outside increased. He said last summer it was not this bad and the coolers were replaced in 2024. The maintenance director said portable coolers were installed on 7/7/26. He said they were not in a good location as they were blocking the fire exit. He said he would get them moved immediately. The director of nursing (DON) and the regional clinical resource #3 were interviewed together on 7/9/26 at 2:45 p.m. Regional clinical resource #3 said the facility had determined the facility was hot on 7/7/26 at 3:00 p.m. She said the facility was temporarily using the portable coolers until they fixed the cooling units that were on the roof. Regional clinical resource #3 said the facility fixed the placement of the portable coolers in the South hallway to ensure the fire exit was not blocked. She said the staff were educated to not block the exits. Regional clinical resource #3 said an audit of the facility's coolers on top of the roof was completed by a sister facility on 7/7/26. She said the facility will follow the suggestions of the completed audit. Regional clinical resource #3 said it is important for facility temperatures to be in between 71 degrees F to 81 degrees F for safety of the residents and prevent health issues. Housekeeper (HK) #1 was interviewed on 7/8/26 at 12:08 p.m. HK #1 fanned herself during the interview, she said it was hot. HK #1 said it was usually hottest back on unit #1. HK #1 said she was not sure what else they could do to keep the facility cool because it was so hot outside this time of year. II. Failure to ensure walls were maintained A. Observations On 7/6/26 at 9:12 a.m., the following was observed on unit #2. The door to room [ROOM NUMBER] of unit #2 was observed with a smiley face drawn on the door in permanent marker. The door frames facing the hall to rooms #7, #8, #9 and #10 had an area approximately 18 inches long and two inches wide with multiple layers of missing and chipped paint. The wall of the dining area next to the television was observed with chipped paint and scratched, exposed dry wall measuring approximately 18 inches in length. The same wall had a second area of exposed dry wall measuring approximately 12 inches in length with the metal lath (mesh) and corner bead (metal flashing on the corner of a wall). The wall also had mismatched paint. The wall next to room seven included a trapezoidal wall sconce insect light trap. The insect trap was broken and the box containing the extension cord had a broken latch and would not close. Below the insect trap, a metal bracket for mounting a screen was on the wall with mismatched paint. The bracket no longer held a screen. On 7/6/26 at 11:16 a.m. the doorframe to room [ROOM NUMBER] on unit #3 was observed with numerous areas of chipped and missing paint on the doorframe facing inside the residents' room. On 7/6/26 at 4:34 p.m. the door to the bathroom of room [ROOM NUMBER] on unit #3 was observed with over a dozen scratches across the door facing the bathroom, with scratches at the base of the door and approximately waist height. On 7/8/26 at 8:58 a.m. room [ROOM NUMBER] on unit #1 had missing paint in the shape of a hand sanitizer that used to be on the wall. There was also missing paint in the shape of a hand sanitizer was next to the utility room on unit #1. The doorframe to room [ROOM NUMBER] had chipped paint around the door frame facing the hall. On 7/8/26 12:05 p.m. room [ROOM NUMBER] on unit #3 had chipped paint on the doorframe facing the hallway of room [ROOM NUMBER] at approximately handrail height. room [ROOM NUMBER] on unit #3 had chipped paint on the door frame facing the hall, near the floor. B. Resident interviews Resident #13, who was cognitively intact, was interviewed on 7/6/26 at 4:48 p.m. Resident #13 said she had scuff marks across the door to her bathroom since she moved in. Resident #13 said she thought they were from a wheelchair or walker scraping against the door. Resident #13 there was chipped and missing paint all over the facility. Resident #13 said no staff had offered to repaint her bathroom door. Resident #13 said she did not like the way it looked, but did not ask the maintenance staff because the door still worked and she knew he had a lot of other areas to fix. Resident #55, who was cognitively intact, was interviewed on 7/8/26 at 5:02 p.m. Resident #55 said her room was too hot the past few days and it was not comfortable without the door open. Resident #55 said the chipped paint around her door did not look nice, but she had not asked staff to repaint the doorframe because she knew how busy the staff were and did not think she could ask maintenance to repaint the doorframe. C. Staff interviews Activity assistant (AA) #1 was interviewed on 7/7/26 2:43 p.m. AA #1 said the box was supposed to cover the extension cord and plug for the bug catcher. AA#1 said it has not worked in months. She said when she informed the director or maintenance, he said they did not have any replacement light bulbs. The maintenance director was interviewed on 7/8/26 at 1:02 p.m. during a tour of the facility. The maintenance director said he was aware many walls and doors around the facility needed painting. The maintenance director said he did not have enough time to paint everything himself. The maintenance director said he had to spend most of his time fixing more immediate problems, and the reason so many areas had chipped or scratched pain was because he was the only maintenance worker. He said they tried to organize a group of staff last year to paint various walls, handrails and doorframes around the facility, but they were not able to get to all of the areas he planned to repair dry wall or paint. He said the facility previously had another maintenance employee, and that employee started a log to track what needed painting on each unit, but this employee quit and they have not found a replacement. The maintenance director said he could not recall the last time they repainted unit #2. The maintenance director said he knew the light for the insect trap was broken and they have been looking to order a replacement, but he was not previously aware that the box holding the extension cable was also broken. The housekeeping supervisor was interviewed on 7/8/26 at 1:43 p.m. during a tour of the facility. The housekeeping supervisor said he was aware some of the hand sanitizer stations had fallen off of the wall, but he was not sure how many. He said he helped replace the hand sanitizers when they stopped working or fell down, but he only had one replacement hand sanitizer at the time of the tour. The DON and regional clinical resource #1 was interviewed on 7/9/26 at 3:06 p.m. The DON said he had only worked at the facility for a few months, but he did not know the last time any doors, doorframes, or walls were repainted. The DON said he assumed the maintenance director would have a record of repairs around the facility that could show the last time each unit was repainted. The DON said he was not aware the scratches on the wall of unit #2 were significant enough that the metal under the dry wall was exposed. The DON said he was aware the bug catcher light was broken. He said the facility used to have a contract with a cleaning supply company to supply replacement bulbs, but the contract ended. The DON said they ordered a new bulb and were waiting for the replacement bulb to be delivered.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive and at an appetizing temperature. Specifically, the facility failed to ensure residents were served warm food that was appetizing in taste.Findings include:I. Facility policy and procedure The Food and Nutrition Services policy, revised April 2023, was provided by nursing home administration (NHA) on 7/14/26 at 10:30 a.m. The policy read in pertinent part, The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.II. Resident observations and interviewsResident #18, who was cognitively intact, was interviewed on 7/6/26 at 10:41 a.m. Resident #18 said the food did not look good or taste good. He said there was no flavor and it was bland. He said he left the facility, he purchased his own food. He said that he wanted the food to be hotter when the food was delivered to his room. He said he bought a food thermometer, and he would test his food before he ate it. Resident # 18 said he had roast beef last week. He said this meal was bland and was not flavorful. He said it was bland and most food served here was bland. He said that he wanted fresh vegetables as well, as all the vegetables were served from a can.Resident #3 was interviewed on 7/6/26 at 11:22 a.m. Resident #3 said he did not like the way the food was prepared and it tasted bad. He said the meat was often dry, overcooked, tough to chew and cold in temperature when it was served to him.Resident #14, who was cognitively intact, was interviewed on 7/6/26 at 11:42 a.m. Resident #14 said the meat was dry, tough and hard to cut. She said her toast was often burnt.Resident #10, who was cognitively intact, was interviewed on 7/6/26 at 3:40 p.m. Resident #10 said he did not eat breakfast because the breakfast was often overcooked. He said the food had no taste, and the food was terrible overall. The temperature was okay, but could be better.Resident #13, who was cognitively intact, was interviewed on 7/6/26 at 4:51 p.m. Resident #13 said she frequently waits a long time for food and breakfast was often cold. Resident #13 said she previously attended food committee meetings, but she still had problems with the taste and temperature of the food. Resident #12, who was cognitively intact, was interviewed on 7/7/26 at 9:58 a.m. Resident #12 said the food was not good. He said the meat was tough and the food overall tasted bad. He said he felt the food over the past weekend upset his stomach. Resident #55, who was cognitively intact, was interviewed on 7/8/26 at 5:02 p.m. Resident #55 said she frequently waited a long time, because the facility would put her tray on the cart for room delivery, even when she ate in the dining room. Resident #55 said she was told they place the tray where the resident usually eats when explaining why she had to wait in the dining room. Resident #55 said she did not like the food served for dinner today. Resident #55 said she only took one bite of the meatloaf and stopped because she disliked the taste. She said she did not try the mashed potatoes because they were unappetizing and looked to be the wrong consistency. III. Resident group interviewFour residents (#17, #25, #36 and #57) who were identified as interviewable by the facility and assessment were interviewed on 7/8/26 at 9:30 a.m. Resident #25 and Resident #36 said they had concerns with the facility meals. The residents said they have complained to staff about their food concernsResident #25 said that the food was hit or miss. Resident #25 said sometimes the food was good, and sometimes it was not. Resident #26 said sometimes the food was so cold it seemed almost frozen.IV. Test trayOn 7/8/26 at 1:37 p.m. the lunch test tray was evaluated by four surveyors immediately after the last room tray was delivered. At 1:27 p.m. the temperature and taste of the tray, consisting of regular meatloaf, baked zucchini, mashed potatoes, cheesecake and chicken noodle soup was evaluated by four surveyors. The following was observed:Each of the food items was placed all on one plate and covered. -The internal temperature of the regular textured mashed potato registered at 110.3 degrees Fahrenheit (F) and felt lukewarm and tasted dry.-The internal temperature of the regular textured zucchini registered at 111.2 degrees F, felt lukewarm and tasted overcooked, mushy and bland.-The internal temperature of the regular textured meat loaf registered at 110.7 degrees F and felt lukewarm. -The internal temperature of the chicken noodle soup registered at 115.9 degrees F and felt lukewarm. II. Record reviewThe April 2026, May 2026 and June 2026 food committee minutes were provided by the director of nursing (DON) on 7/6/26 at 3:54 p.m. The May 2026 food committee minutes documented some of the residents in the food committee felt the food needed in improvement. The minutes did not identify what improvement was needed. According to the minutes, the residents were told about the plate warming system. The June 206 food committee minutes documented some residents reported not liking some of the food and the food was always cold. V. Staff interviewsThe dietary manager (DM) was interviewed on 7/9/26 at 11:53 a.m. The DM said he often tasted the food prepared for residents to check palatability but he did not taste the lunch meal on 7/8/26. The DM said he was aware of food concerns in the past, but the facility recently bought and was currently using a new steam table which should have helped maintain the temperature of the food. He said the plates were warmed by and plate warmer, covers and pellets were used to help maintain the warm temperature of the food. He said the nursing staff were reminded to close the food cart doors when they delivered the room trays. He said he did not know why the temperatures of the food cool when served from the food cart. The DM said he would look at food temperatures and taste and provide additional training with his staff.

Based on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure staff followed appropriate hand hygiene practices during the meal service.Findings include:I. Professional referenceAccording to the Colorado Retail Food Regulations (3/16/24), retrieved on 7/13/26, Food employees shall clean their hands and exposed portions of their arms immediately as specified under S 2-301.12 before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (Chapter 2-301.14)II. Facility policy and procedureThe Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions policy, revised January 2024, was provided by the nursing home administration (NHA) on 7/14/26 at 10:30 a.m. The policy read in pertinent part, Store, prepare, distribute, and serve food under sanitary conditions. Food is handled properly with frequent handwashing and proper sanitation guidelines per local, state and federal guidelines and codes. III. Observations 1. Kitchen meal serviceDuring a continuous observation of the lunch meal service in the kitchen on 7/8/26, beginning at 11:25 p.m. and ending at 1:10 p.m., the following was observed:At 11:32 a.m. dietary aide #1 washed his hands and dried his hands with a paper towel. Dietary aide #1 dropped the paper towel on the floor, picked it up off the floor and threw it away. He picked up a pan of rolls and placed the pan on a rack. -Dietary aide #1 did not perform hand hygiene after he picked up the paper towel off of the floor. At 12:09 a.m. dietary aide #1 placed gloves on his hands. Dietary aide #1 used his gloved hands to separate each roll from each other.-Dietary aide #1 did not wash hands before donning his gloves. At 12:17 p.m. dietary aide #1 touched his hair and his left ear in an attempt to bat a fly away from him. Dietary aide #1 proceeded to touch the handles of the plate covers with his hands.-Dietary aide #1 did not wash his hands after touching his body.At 12:18 p.m. dietary aide #1 retrieved a new pair of gloves from the glove box and placed the gloves on the counter. At 12:19 p.m. the dietary manager (DM) washed his hands and picked up the gloves up that were set on the counter by dietary aide #1. The DM placed the gloves on his hands and separated multiple cheese slices from their wrapper with his gloved hands. He removed his gloves and washed his hands. At 12:21 p.m. dietary aide #1 scratched the back of his neck with his hand and placed his hands on the kitchen counter. At 12:26 p.m. without performing hand hygiene, dietary aide #1 used a marker to mark items off of the production guide, set the plate covers back on the rack and entered the kitchen office, touching the computer mouse. At 12:45 p.m. cook #1 left the steam table to retrieve a bowl of salad from the refrigerator, touching the door handle with his hand. He carried the salad back to the steam table with his thumb inside the eating surface of the bowl. He placed the salad on a tray for resident delivery and continued plating residents' meals. At 12:48 p.m. cook #1 left the steam table a second time and retrieved another salad from the refrigerator, touching the door handle and returning to plate residents' meals.-Cook #1 did not wash his hands after touching the refrigerator door handle and before plating residents' meals.At 12:52 p.m. aide #1 left the kitchen office and without performing hand hygiene pulled a pan cheesecake out of the refrigerator. His thumb touched inside the eating surface of the bowl when he retrieved a stack of bowls for the cheesecake.At 12:55 p.m. dietary aide #1 retrieved cottage cheese from the refrigerator, taking the refrigerator handle. He placed a scoop of cottage cheese into a bowl and handed it to a staff member for a resident.-Dietary aide #1 did not wash his hands after touching his neck, a computer mouse, a marker, a refrigerator door handle and returning from the kitchen office. At 12:57 p.m. Dietary aide #1 washed his hands.2. Resident rooms delivery and dining room serviceDuring a continuous observation of lunch on 7/6/26, beginning at 11:47 a.m. and ending at 1:10 p.m., following was observed:At 12:22 p.m. the staff began delivering meals to the residents in the dining room. Most of the residents were served a lunch that included a sandwich. The residents were observed picking up their sandwich with their hands. -The residents were not offered, assisted or encouraged to use hand hygiene prior to receiving their meals. At 12:46 p.m. certified nurse aide (CNA) #2 sat between Resident #61 and Resident #47. CNA #2 assisted Resident #61 with a sip of his beverage, touching his cup, his face and repositioning the spoon in his hand. CNA #2 turned to Resident #47, pick up Resident #47's utensil and proceeded to place bites of food into Resident #47's mouth with the same hand. Between 12:50 p.m. and 1:03 p.m. CNA #2 continued to assist Resident #61 and Resident #47 with their food and beverages. -CNA #2 did not perform hand hygiene between assisting Resident #61 and Resident #47.During a continuous observation of room tray delivery on 7/6/26, beginning at 1:18 p.m. and ending at 2:00 p.m.At 1:00 p.m., the food cart arrived for the South hallway. The staff retrieved meals from the cart and delivered the trays to room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. The staff members did not offer or encourage hand hygiene to the residents. During a continuous observation of room tray delivery on 7/6/26, beginning at 12:57 p.m. and ending at 1:10 p.m., residents received their lunch delivered to them in their rooms in the North hallway.At 12:57 p.m. the food cart arrived for the North hallway. The staff retrieved meals from the cart and delivered the trays to room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. The staff members did not offer or encourage hand hygiene to the residents.V. Staff interviewsCNA #2 was interviewed on 7/8/26 at 10:32 a.m. CNA #2 said she conducted hand hygiene every time she entered and exited a resident's room, before serving meals tray to each resident and before assisting residents with their meal. She said when she had to help two residents with their meals at the same time, she would need to do hand hygiene between each resident.The dietary manager (DM) was interviewed on 7/9/26 at 11:53 a.m. The DM said hand hygiene should be conducted anytime the hands could be potentially contaminated and before donning gloves. He said he reminded his staff of hand hygiene protocols and the start of the week of survey but has not had a recent hand hygiene inservice. The DM said the cook should stay at the steam line when they were plating food or wash their hands again before continuing to plate food. He said he observed [NAME] #1 open the refrigerator and return to the steam table without performing hand hygiene. The director of nursing (DON) and regional clinical resource #3 were interviewed together on 7/9/26 at 2:12 p.m. The DON said hand hygiene prevents the spread of potential pathogens from person to person. The DON said staff should conduct hand hygiene between each meal tray and between each resident. The DON said residents should be offered and encouraged to have hand hygiene prior to eating. Regional clinical resource #3 said the facility was in the process of educating staff following the above meal observations.IV. Facility follow upThe 7/9/26 (during the survey) hand hygiene and glove use in-service education was provided by the NHA on 7/14/26 at 10:30 a.m. The education identified hand hygiene helped prevent and protect residents from cross-contamination by practicing proper hand hygiene and glove use.The education staff directed staff to wash their hands before they put their on gloves and immediately after removing them; wash their hands between every task and anytime contamination may have occurred; and, change their gloves between raw and ready-to-eat foods, after cleaning, after touching contaminated surfaces, after handling trash, after leaving your workstation, when torn, and at least every 4 hours during continual use. The education directed staff to never touch phones, door handles, carts, or your face with food-service gloves and continue food preparation. The education identified the proper sequence of glove use. The staff should wash their hands, place clean gloves on, perform the task, remove the gloves, and wash their hands.According to the education, every resident deserved safe food prepared with clean hands. Hand hygiene was everyone's responsibility and it was required for every meal service.

Based on observations, record review and interviews the facility failed to ensure the self-administration of medications was clinically appropriate for one (#13) of three residents reviewed out of 39 sample residents.Specifically, the facility failed to obtain an order from the provider and complete assessment for unsupervised self administration of Resident #13's albuterol inhaler.Findings include:I. Facility policy and procedure The Medication administration policy, revised August 2025, was provided by regional clinical resource #2 on 7/9/26 at 4:40 p.m. It revealed in pertinent part, Residents are allowed to self administer medications when specifically authorized by the attending physician and in accordance with the guidelines for self administration of medication.II. Resident #13A. Resident statusResident #13, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included sciatica, chronic obstructive pulmonary disease (COPD), diabetes, atrial fibrillation, chronic pain, presence of cardiac implant, depression and generalized anxiety disorder.The 6/12/26 minimum data set (MDS) assessment documented Resident #13 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out 15. The MDS assessment revealed Resident #13 required moderate assistance with toileting and set up assistance with bathing. The MDS assessment revealed Resident #13 ambulated independently with a walker.B. Resident observation and interviewResident #13 was interviewed on 7/7/26 at 2:08 p.m. Resident #13 was observed with two albuterol inhalers in the top drawer of her night stand. One of the inhalers was unopened with a facility pharmacy label dated as dispensed from the pharmacy 4/13/26. Resident #13 said she did not remember which nurse, but a nurse gave her two inhalers a few months ago. Resident #13 said even a small trip to the bathroom in her room could leave her coughing and short of breath sometimes. Resident #13 said it was probably a good idea to have the medication in reach in case she needed them quickly. Resident #13 said she used the medication a couple of times. Resident #13 said the nurse did not assess to make sure the resident was safe to administer the inhaler unsupervised when they gave them to her, and she had never had an assessment from staff to make sure she was using the inhaler safe and effectively.C. Record reviewReview of Resident #13's CPO revealed the following physician order:Albuterol sulfate hydrofluoroalkane Inhalation aerosol solution 108 micrograms (mcg)/actuation; inhale 2 puffs orally as needed for shortness of breath or wheezing, every 6 hours. The order indicated the medication was to be administered by a clinician. Ordered 12/15/25 at 6:52 p.m. -However, review of the CPO revealed no physician's order for Resident #13 to self-administer the medication.Review of Resident #13's assessments and progress notes revealed no documented assessment for Resident #13 to safely administer the albuterol inhaler unsupervised. III. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 7/9/26 at 1:40 p.m. LPN #2 said if he found medication at a resident's bedside, he would check the physician's orders to confirm the resident had correct orders and had completed a self administration assessment. LPN #2 said if they could not find the assessment, they would complete an assessment with the assessment and contact the provider to update the order. LPN #2 said he frequently found medications in resident's rooms that were not ordered for self administration. LPN #2 said a store selling over the counter medications was within walking distance and residents frequently bought their own medication without telling staff. LPN #2 said he was not aware Resident #13 had two albuterol inhalers in her room, and it was unusual for her to have a pharmacy dispensed medication in her room. LPN #2 said he planned to meet with Resident #13 after the interview to complete an assessment for unsupervised medication administration, then contact the provider.The director of nursing (DON) was interviewed with regional clinical resource #1 on 7/9/26 at 3:09 p.m. The DON said residents should not have medications at their bedside without an order or a way to safely store them. The DON said any floor nurse was trained on how to complete an assessment for unsupervised self administration of a medication when appropriate. The DON said the purpose of completing the assessment and obtaining a physician's order was to ensure the resident knew when and how to administer the medication, to report administration to staff and how to safely store the medication out of reach of other residents.

Based on record review and interviews, the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property for one (#63) of six residents out of 39 sample residents.Specifically, the facility failed to report bruising of unknown origin on Resident #63 to the State Agency.Findings include:I. Facility policy and procedureThe Abuse reporting and Investigating policy, revised February 2023, was provided by regional corporate resource #2 on 7/9/26 at 4:40 p.m. It revealed in pertinent part, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting can be completed verbally or in writing. If any type of abuse, neglect, or misappropriation of property is confirmed the NHA (nursing home administrator) will be responsible to notify the Health Department Occurrence Reporting website within two hours from the time the incident occurred.II. Resident #63A. Resident statusResident #63, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), ischemic cardiomyopathy, vascular dementia with mood disturbance, depression, acquired absence of the right great toe and right other toe. The 6/17/26 minimum data set (MDS) assessment documented Resident #63 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out 15. The MDS assessment indicated the resident had impaired long term and short term memory per staff assessment. The MDS assessment revealed Resident #63 supervision or touching assistance with ambulation and used a walker or wheelchair for mobility. Resident #63 required moderate assistance for dressing, footwear and hygiene. Resident #63 was dependent on staff for toileting and bathing.B. Record reviewThe weekly nursing assessment, dated 6/18/26, documented Resident #63 was lowered to the floor earlier in the week after losing his balance in the hallway but had no injuries. The assessment documented no bruising was found during the assessment. The weekly nursing assessment, dated 6/25/26, documented Resident #63's skin was intact with no bruising or injuries. The progress note, dated 7/6/26 at 3:59 p.m., documented Resident #63 had three small bruises on the right side of his back that were slightly yellow. The progress note documented the bruising had an unknown origin. The progress note documented Resident #63 did not report pain at the time the bruising was found. A request for documentation indicating the bruising of unknown origin was reported to the State Agency on 7/8/26 at 11:00 a.m. -However, the director of nursing (DON) and the NHA said the bruise was not reported. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 7/8/26 10:31 a.m. CNA #1 said she was aware Resident #63 had superficial injuries after a fall occurring during the night shift of 7/6/26 at approximately 8:00 p.m., but she was not aware if Resident #63 had bruises before the fall. CNA #1 said Resident #63 had poor balance and would attempt to ambulate without assistance. CNA #1 said anytime she found any new injuries on a resident that she was not previously aware of, she reported the injury to the floor nurse in order for the floor nurse to complete an assessment. CNA #1 said she had not reported bruises of unknown origin to an on-call manager before, because when she reported the skin change to the floor nurse, the floor nurse might already know about the bruising or find the cause in the chart. Registered nurse (RN) #1 was interviewed on 7/8/26 at 10:44 a.m. RN #1 said she was not aware of any bruising found on Resident #63 prior to the fall on the night shift of 7/6/26. RN #1 said nurses typically gave updates on any new skin conditions or injuries from their CNAs or during a report at change of shift, but she did not remember hearing about any bruising found on Resident #63's back. RN #1 said any injuries with no known origin should be reported to the manager on call, the director of nursing (DON) or the NHA immediately. RN #1 said she was not sure if the bruises documented in the progress notes for Resident #63 were reported to management. The NHA was interviewed on 7/8/26 at 11:00 a.m. The NHA said she was not working on 7/6/26, and she needed to contact the DON, the assigned manager on-call, to see if the event was reported to him on 7/6/26. The NHA said she planned to contact the nurse who wrote the progress note to find out if the bruising truly had no known origin. The NHA said if they could not readily find the origin of the bruising, they would report to the State Agency and investigate further. The NHA said even if they could not conclude whether or not the injury was caused by abuse, they would still investigate to try to find the root cause for the bruising. The NHA and the DON were interviewed together on 7/8/26 at 12:40 p.m. The DON said he spoke with RN #2, the nurse who wrote the progress note for Resident #63's bruises. The DON said RN #2 did not report the bruising to the DON because she thought management was already aware of the bruising, since it appeared yellow, indicating the bruise was healing. The DON said RN #2 told him she wrote the bruising was of unknown origin, because the origin was unknown to the nurse. The NHA said they provided education to the nurse to clarify their documentation to include if the injury was reported and who they reported it to. The NHA said they also provided education to always contact the on-call manager if the nurse was not sure if the injury was already reported. The DON said he reviewed Resident #63's progress notes, skin assessments, and incident reports, but he could not find any documentation of Resident #63's bruising prior to the progress note on 7/6/26. The DON said they thought the bruising occurred when the resident lost his balance, causing Resident #63 to lean into a wall before he was assisted to the floor by a CNA on 6/15/26. The DON said the bruising was likely still there because Resident #63 was also taking a blood thinner. The NHA said she had not reported the incident because they felt the incident that occurred on 6/15/26 was the likely cause of Resident #63's bruising.-However, review of the incident investigation on 6/15/26 revealed no injuries were found on assessment immediately after the event. Review of progress notes and skin assessments also revealed no documentation of bruising prior to the progress note on 7/6/26.

Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for one (#63) of six residents out of 39 sample residents.Specifically, the facility failed to maintain documentation to show a thorough investigation of bruising of unknown origin on Resident #63.Findings include:I. Facility policy and procedureThe Abuse reporting and Investigating policy, revised February 2023, was provided by regional clinical resource #2 on 7/9/26 at 4:40 p.m. It revealed in pertinent part, All allegations of abuse or occurrences will be thoroughly investigated. The administrator/designee initiates the investigations. The administrator/designee provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. The administrator/designee is responsible for keeping the resident and his/her responsible party informed of the progress of the investigation. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. The abuse or occurrence investigation will be completed using the abuse packets. The individual conducting the investigation will: review the documentation and evidence; review the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; observe the alleged victim, including his or her interactions with staff and other residents; interview the person(s) reporting the incident; interview the alleged victim or the resident's representative - if the resident is not interviewable, Non-Interviewable Resident Observations form will be completed to determine whether there has been a change to the person's baseline. Interview any witnesses to the incident; interview the alleged assailant or the resident's representative; interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; interviews other residents to whom the accused employee provides care or services; interview other residents who witnessed the alleged event to determine whether they had any concerns; reviews all events leading up to the alleged incident; and m. Documents the investigation completely and thoroughly. Witness statements are obtained in writing, signed and dated. The witness may write his/her statement, or the investigator may obtain a statement. The investigator consults daily with the administrator concerning the progress/findings of the investigation. Upon conclusion of the investigation, the resident's care plans will be updated with any change to the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. The investigator will record the findings of the investigation and provide the completed documentation to the administrator.II. Resident #63A. Resident statusResident #63, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), ischemic cardiomyopathy, vascular dementia with mood disturbance, depression, acquired absence of the right great toe and right other toe. The 6/17/26 minimum data set (MDS) assessment documented Resident #63 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out 15. The MDS assessment documented the resident had impaired long term and short term memory per staff assessment. The MDS assessment revealed Resident #63 supervision or touching assistance with ambulation and used a walker or wheelchair for mobility. Resident #63 required moderate assistance for dressing, footwear and hygiene. Resident #63 was dependent on staff for toileting and bathing.B. Record reviewWeekly nursing assessments, dated 6/18/26 and 6/25/26, documented Resident #63's skin was intact with no injuries or bruising before the progress note dated 7/6/26 (see progress note below).The progress note, dated 7/6/26 at 3:59 p.m., documented Resident #63 had three small bruises on the right side of his back that were slightly yellow. The progress note documented the bruising had an unknown origin. The progress note documented Resident #63 did not report pain at the time the bruising was found. C. Facility investigationThe facility incident investigation note, dated 7/8/26 (during the survey), documented Resident #63 had three small bruises on the right side of his back that were slightly yellow. The investigation documented the bruising was of unknown origin. The investigation documented Resident #63 had no complaints of pain or discomfort at this time. The investigation documented staff were interviewed and the staff suspected Resident #63 may have bumped into something as he was laying or sitting down. The investigation documented Resident #63 was on a blood thinner that increased his risk for bruising. The investigation documented when Resident #63 was asked about how he acquired the bruises on his back, Resident #63 did not know. The investigation documented the nursing home administrator (NHA) and the director of nursing (DON) interviewed registered nurse (RN) #2, the nurse who documented the bruising as well as the certified nurse aides (CNA) who were working on the unit on 7/8/26. The investigation documented that RN #2 documented the bruising as an unknown origin because it was unknown to her. The investigation documented RN #2 did not contact nurse management because the CNAs were aware of how the bruising occurred and there were no signs of potential abuse. The investigation documented the CNAs said they were aware of the bruising because Resident #63 frequently sat down hard in chairs, leaning to his right side and often bumping or rubbing his right lower side or right arm against the chair. The investigation documented observations of the resident and additional staff interviews confirmed the potential for injury related to the way Resident #63 transferred. -However, there was no documentation provided by the facility regarding what specific staff members were interviewed or the questions asked during the staff interviews or documentation of observations of other residents on the unit. -Additionally, there was no documentation provided by the facility asking why the bruising was not previously found and reported on weekly skin assessments.III. Staff interviewsThe NHA and the DON were interviewed together on 7/8/26 at 12:40 p.m. The NHA said she and the DON contacted RN #2 regarding her progress note from 7/6/26. The NHA said she asked her what she meant when she documented Resident #63 had bruises with unknown origin. The DON said RN #2 told him she did not report the bruising on 7/6/26, because she thought management was already aware of the bruising. The DON said RN #2 told him she documented the bruising as of unknown origin because the bruises were unknown to her until the CNA told her on 7/6/26. The NHA said she provided education to RN #2 to report any injury if RN #2 was unsure how the injury occurred, and overreporting was safer than not reporting. The NHA said based on the initial investigation she and the DON completed, they did not think anything potentially abusive occurred.Cross reference F609 for failure to report an injury of unknown origin. The DON was interviewed again with regional clinical resource #1 on 7/9/26 at 3:09 p.m. The DON said he interviewed RN #2 and the two CNAs working on the unit on 7/8/26. The DON said he had not interviewed additional staff at the time of the interview. The DON said it was possible another nurse found the bruising before 7/6/26 and failed to document the skin alteration. The DON said RN #2 should have confirmed whether or not the bruising was unknown with management and investigated more when she initially found the bruising. The DON said he thought he would have also noticed the progress note and started an investigation when he completed monthly chart audits of each resident on the unit. The DON said he reviewed all of Resident #63's documentation and could not find any previous documen

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of four medication storage carts. Specifically, the facility failed to:-Properly date a resident's insulin pen with the date it was opened;-Properly date a residents injectable lidocaine bottle (pain medication) with the date it was opened and,-Discard a resident's medication in a timely manner.Findings include:I. Professional referenceAccording to the manufacturer, Sanofi-Aventis, Prescribing and Safety information, September 2025, retrieved on 7/13/26 from https://www.novolog.com/taking-novolog.html, Store unused NovoLog pens, PenFill cartridges, and vials at room temperature up to 86 degrees Fahrenheit (F) for up to 28 days. Store unused NovoLog pens and vials in the refrigerator at 36 degrees F to 46 degrees F until expiration. Storage after use: keep at room temperature (below 86 degrees F) or refrigerate for up to 28 days; keep away from direct heat and light. Dispose after 28 days, even if there is insulin left in the pen or vial.According to the center for disease control (CDC), Preventing Unsafe Injection Practices, March 2024, retrieved on 7/13/26 from https://www.cdc.gov/injection-safety/hcp/clinical-safety/index.html#cdc_clinical_safety_best_practices_recomm-recommendations, Once a multi-dose vial is opened ( needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer states another date for that opened vial. The beyond-use-date should never exceed the manufacturer's original expiration date.II. Facility policy and procedureThe Medication administration policy, revised August 2025, was provided by regional clinical resource #2 on 7/9/26 at 4:40 p.m. It revealed in pertinent part, Follow the medication/pharmacy guidelines for storage.III. Observations and interviewsOn 7/9/26 at 9:03 a.m., the medication administration cart #2 was observed with licensed practical nurse (LPN) #1. The following medications were found:-An opened Novolog 100 units per milliliter (ml) injectable insulin pen for Resident #56, which had smeared marker on the pen. The opened date on the pen was no longer legible.-An opened multi dose vial of Lidocaine 200 milligrams (mg)/20 ml for Resident #69, which had no open date.-An opened bottle of Latanoprost ophthalmic solution 0.0005% 2.5 ml, which had a pharmacy use by date of 11/20/25.LPN #1 was interviewed on 7/9/26 at 10:08 a.m. LPN #1 said she had not seen the incorrectly labeled or expired medications in her cart, because she normally worked on a different unit. She said the medication administration cart #2 was not her usual medication administration cart. LPN #1 said she thought the night shift nurse for each unit should have completed an audit of their medication cart each shift. LPN #1 said each of the medications found should be removed from the medication cart because she cannot confirm when the medication was first opened or if the medication was safe to use. IV. Additional staff interviewThe director of nursing (DON) was interviewed on 7/9/26 at 11:30 a.m. The DON said LPN #1 gave him all of the medications in order to remove them for circulation. The DON said the date on the insulin pen appeared to be written in a marker that then smeared off over time. The DON said the medication should have been checked for the open date prior to administration, and removed from the medication cart when the administering nurse was not able to confirm if the medication was opened in the last 28 days. The DON said the multi-dose lidocaine solution was delivered by the pharmacy to reconstitute a dose of Rocephin (an antibiotic). The DON said he was not sure the exact date the injection was administered, but all multi use medications needed open dates to ensure the medication was still safe to administer. The DON said the box the latanoprost ophthalmic solution was was dated as dispensed by the pharmacy at the end of 2024 and the bottle itself was not expired. The DON said he could not be certain, but he thinks a nurse placed a new bottle in the old box, causing the mislabeled medication. The DON said all nurses receive education to check all medications prior to administration in order to ensure they were safe for use. The DON said in addition, night shift were supposed to complete an audit of their cart each shift to check for expired medications. The DON said he also completed monthly audits of medication carts.

Based on observations, record review and interviews the facility failed to ensure accurate medical records were kept for one (#52) of four residents out of 39 sample residents reviewed. Specifically, the facility failed to update the resident's allergies in the electronic medical record (EMR) when Resident #42 experienced an adverse reaction to a medication.Findings include:I. Professional referenceAccording to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 366 Documentation is an important professional responsibility. To limit liability, your documentation needs to follow organizational standards, which include a clear description of individualized and goal-directed nursing care you provide based on your nursing assessment. Always document patient care in a timely manner following agency standards. Documenting all aspects of the nursing process is a critical nursing responsibility that limits nursing liability by providing evidence that you maintained or exceeded practice standards while taking care of patients. Mistakes in documentation that can result in malpractice include the following examples: failing to record pertinent health or drug information, failing to record nursing actions, failing to record medication administration, failing to record drug reactions or changes in patients' conditions, incomplete or illegible records, and failing to document discontinued medications.II. Facility policy and procedureThe Charting and Documentation policy, revised July 2017, was provided by regional clinical resource #2 on 7/9/26 at 4:40 p.m. It revealed in pertinent part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.III. Resident #52A. Resident StatusResident #52, age less than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included dementia, symptomatic epilepsy and intracranial injury with loss of consciousness.The 6/12/26 minimum data set (MDS) assessment documented Resident #52 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out 15. The MDS assessment had impaired long term and short term memory. The MDS assessment revealed Resident #52 had impaired communication and was rarely understood by others. Resident #52 was dependent on staff for toileting, personal hygiene, footwear and oral hygiene. Resident #52 required substantial assistance with bathing and moderate assistance with dressingB. Record reviewThe progress note, dated 6/6/26 at 6:46 p.m., documented Resident #52 experience a fall with injury. The progress note documented the floor nurse entered the room to find Resident #52 on the floor. The progress note documented Resident #52 had a new deep open laceration to their left fifth toe. The progress note documented Resident #52 was sent to the local emergency room.The progress note, dated 6/7/26 at 12:28 a.m., documented Resident #52 returned to the facility with sutures to the left fifth toe. The progress note also documented physician's orders to start. Cephalexin (antibiotic) 500 milligram (mg) oral tablet, give one tablet three times a day for seven days. The progress note, dated 6/11/26 at 4:03 p.m. documented Resident #52 had new symptoms during the morning medication administration. The progress note documented at approximately 9:00 a.m., Resident #52 had significantly more edema in his left leg compared to his right leg. The progress note documented Resident #52's left leg was warm to the touch and appeared with redness extending up to the mid calf. The progress note documented the nurse outlined the red area with a marker. The progress note documented when the floor nurse saw Resident #52 at approximately 1:30 p.m., Resident #52 began convulsing. The progress note documented Resident #52 had seizure activity lasting less than one minute before snoring. The progress note documented the nurse placed Resident #52 on their side for safety, and noticed the area of redness marked in the morning had spread approximately one inch further than the line drawn at 9:00 a.m. The progress note documented the floor nurse contacted the provider to notify. The provider placed orders to discontinue to Cephalexin and start the following doxycycline (antibiotic)100 mg oral tablet, give one table by mouth twice a day. The provider note, dated 6/30/26, documented the facility nurse practitioner reviewed the resident's condition and medications. The provider documented Resident #52 experienced an allergic reaction due to an anti-infective agent. The provider note documented review of the nurse progress notes indicated Resident #52 had red patches and increased itching since the start of the cephalexin for the infection in his left toe. The provider note documented Resident #52's cephalexin was discontinued due to an allergic reaction. -However, review of the resident records revealed the resident EMR was not updated to reflect the new allergy. IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 7/9/26 at 10:53 a.m. RN #1 said she was the nurse on duty the day Resident #52 began to have redness and swelling on his left leg. RN #1 said she was not aware the provider documented the reaction as an allergy, and she did not think it was an allergic reaction based on her observations on 6/11/26. RN #1 said any floor nurse was able to update the resident's EMR to reflect a new allergy or adverse reaction. RN #1 called the provider during the interview. RN #1 said the provider responded that she would like Resident #52's chart updated to reflect cephalexin as an adverse reaction in the EMR. RN #1 said it was important to make sure the resident's allergies were up to date in the EMR to inform staff in the future when providing care. The director of nursing (DON) was interviewed with regional consultant #3 on 7/9/26 at 3:42 p.m. The DON said he would need to look at Resident #52's EMR to confirm which antibiotics, but he was aware Resident #52 was taking one antibiotic, then had a reaction to the antibiotic and was started on a new antibiotic. The DON said he was not aware Resident #52's allergies were not updated in the EMR after the reaction occurred. The DON said all floor nurses receive training to update the resident's allergies any time a reaction occurred and had the ability to update Resident #52's medical record. The DON said needed to be accurate to prevent Resident #52 from having another adverse reaction if he were prescribed the same type of medication again.

Based on observations, record review and interviews, the facility failed to implement policies and procedures to ensure that annual influenza vaccination for one (#1) resident of six residents reviewed out of 39 sample residents.Specifically, the facility failed to:-Ensure Resident #1's representative was provided education regarding the benefits and potential side effects of influenza immunization; and,-Ensure Resident #1 was offered the influenza immunization.Findings include:I. Facility policy and procedure The Immunizations policy, revised September 2025, was provided by regional corporate resource #2 on 7/9/26 at 4:40 p.m. It revealed in pertinent part, Before administering the influenza, pneumococcal, or COVID-19 immunization on an ongoing basis, each resident, or the resident's legal representative, will receive the Up-to- Date CDC (Centers for disease control) Vaccine Information Sheet (VIS) regarding the benefits and potential side effects of the immunizations. Each resident will be offered an influenza immunization from October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this period.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE] and passed away at the facility on 4/18/26. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic kidney disease, atrial fibrillation, heart disease, pulmonary embolism, stroke, dementia, dysphagia, left sided hemiplegia and hemiparesis (loss of function to one side of the body). The 3/16/26 minimum data set (MDS) assessment documented Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out 15. The MDS assessment revealed Resident #1 did not receive the influenza vaccine and documented the vaccine was offered and declined. -However, there was no documentation indicating the resident refused the vaccine (see record review below).B. Resident representative interviewResident #1's representative was interviewed on 7/9/26 at 11:05 a.m. Resident #1's representative said Resident #1 was confused and was not able to make medical decisions. Resident #1's representative said the only call he received from the facility during the fall of last year was regarding Resident #1 having a fall at the facility. Resident #1's representative said nobody called him to provide education or offer the annual influenza vaccination to Resident #1. Resident #1's representative said if they had called, he would have wanted the facility to attempt to administer the vaccination and let him know when in case he needed to be at the facility. C. Record reviewReview of Resident #1's immunization records revealed an influenza declination form, dated 9/24/25. The declination form included a signature from a facility nurse, and the comment that the vaccine was refused twice.-However, the form did not include the signature of Resident #1's representative or the signature of Resident #1. The line for the resident representative to sign indicating they received explanation of the benefits and potential side effects of influenza immunization was blank.Review of Resident #1's progress notes revealed no documentation of staff attempting to contact Resident #1's representative to offer education and obtain consent or refusal for influenza immunization. The progress note, dated 4/10/26 at 7:37 p.m., document Resident #1 tested positive for Influenza A.III. Staff interviewsThe infection preventionist (IP) was interviewed with regional corporate resource #2 on 7/9/26 at 1:56 p.m. The IP said when a resident was assessed and found to have severe cognitive impairment, the nurse obtaining consent for immunizations and providing education should contact the resident's representative. The IP said she did not complete the vaccine declination forms for Resident #1, so she could not say for certain who refused the vaccination as noted on the document. The IP said she had a spreadsheet to track the dates for all resident vaccinations, but she did not have a way to track staff attempts to contact resident representatives regarding immunizations for residents with cognitive impairment. The IP said she would assume the nurse who signed the declination form attempted to contact Resident #1's representative, but she does not have any evidence to show he was provided education. The director of nursing (DON) was interviewed with regional clinical resource #1 on 7/9/26 at 3:09 p.m. The DON said a resident found to have severe cognitive impairment when assessed cannot understand the risks or benefits of immunization. The DON said the nurse providing education and obtaining consents should have contacted Resident #1's representative instead and should have provided clearer documentation of who refused the vaccination on the declination form.

Based on observations, record review and interviews, the facility failed to implement policies and procedures to ensure that annual Covid-19 vaccination for two (#1 and #55) residents of six residents reviewed out of 39 sample residents.Specifically, the facility failed to:-Ensure Resident #55 and Resident #1's representatives were provided education regarding the benefits and potential side effects of COVID-19 immunization annually; and,-Ensure Resident #55 and Resident #1 was offered the COVID-19 vaccine.Findings include:I. Facility policy and procedure The Immunizations policy, revised September 2025, was provided by regional clinical resource #2 on 7/9/26 at 4:40 p.m. It revealed in pertinent part, Before administering the influenza, pneumococcal, or COVID-19 immunization on an ongoing basis, each resident, or the resident's legal representative, will receive the Up-to- Date CDC Vaccine Information Sheet (VIS) regarding the benefits and potential side effects of the immunizations. Each resident will be offered the COVID-19 immunization annually, unlessimmunization is medically contraindicated or they are up to date with the currentvaccine.II. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE] and passed away at the facility on 4/18/26. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic kidney disease, atrial fibrillation, heart disease, pulmonary embolism, stroke, dementia, dysphagia, left sided hemiplegia and hemiparesis (loss of function to one side of the body). The 3/16/26 minimum data set (MDS) assessment documented Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out 15. The MDS assessment revealed Resident #1 was not up to date on his COVID-19 vaccination.B. Resident representative interviewResident #1's representative was interviewed on 7/9/26 at 11:05 a.m. Resident #1's representative said Resident #1 was confused and was not able to make medical decisions. Resident #1's representative said the only call he received from the facility during the fall of last year was regarding Resident #1 having a fall at the facility. Resident #1's representative said nobody called him to provide education or offer the COVID-19 booster vaccination to Resident #1. Resident #1's representative said if they had called, he would have wanted the facility to attempt to administer the vaccination and let him know when in case he needed to be at the facility.C. Record reviewReview of Resident #1's immunization records revealed a COVID-19 immunization declination form, dated 9/24/25. The declination form o included a signature from a facility nurse, and the comment that the immunization was refused twice.-However, the form did not include the signature of Resident #1's representative or the signature of Resident #1. The line for the resident representative to sign indicating they received explanation of the benefits and potential side effects of COVID-19 immunization was also blank.Review of Resident #1's progress notes revealed no documentation of staff attempting to contact Resident #1's representative to offer education and obtain consent or refusal for COVID-19 immunization. III. Resident #55A. Resident statusResident #55, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included hypertension, ocular hypertension, dry eye syndrome, diabetes, hypothyroidism, generalized anxiety disorder, depression and diabetic neuropathy. The 6/19/26 MDS assessment documented Resident #55 was cognitively intact with a BIMS score of 14 out 15. The MDS assessment documented Resident #55 was not up to date on her COVID-19 vaccination.B. Resident interviewResident #55 was interviewed on 7/8/26 at 5:02 p.m. Resident #55 said she did not remember the facility offering her a COVID-19 vaccination when she admitted to the facility in December 2025. Resident #55 said she did not sign a refusal for or receive an educational hand out. She said she tested positive for COVID-19 in January 2026, and she had to be under isolation. Resident #55 said she was not sure if she would have wanted the COVID-19 booster vaccination when she arrived at the facility, because she already had the initial two vaccines and did not know enough about the COVID-19 booster. C. Record reviewThe physician's note, dated 12/12/25, revealed the physician documented the resident appeared coughing and hoarse voice for the last three to four days. The physician note documented the resident was negative when assessed for COVID-19 on 12/10/26. The physician note documented the resident was not able to receive the covid vaccine at the time of the visit because of her respiratory symptoms, but the resident was interested in receiving the vaccine when available. -However, review of Resident #1's immunization records revealed no documentation the COVID-19 vaccine was offered or administered to the resident. oThe progress note, dated 1/13/26 at 1:41 p.m. revealed Resident #1 tested positive for COVID-19 and placed placed under isolation. IV. Staff interviewsThe infection preventionist (IP) was interviewed with regional corporate resource #2 on 7/9/26 at 1:56 p.m. The IP said her tracking documented said Resident #55 was offered the Covid-19 vaccine and declined on 10/24/25; but the date might have been historical from her previous assisted living facility. The IP said Resident #55's medical record should have a signed copy of her declination, but she could not find it during the interview. The IP said when a resident was assessed and found to have severe cognitive impairment, the nurse obtaining consent for immunizations and providing education should contact the resident's representative. The IP said she did not complete the vaccine declination forms for Resident #1, so she could not say for certain who refused the vaccination as noted on the document. The IP said she had a spreadsheet to track the dates for all resident vaccinations, but she did not have a way to track staff attempts to contact resident representatives regarding immunizations for residents with cognitive impairment. The IP said she would assume the nurse who signed the declination form attempted to contact Resident #1's representative, but she does not have any evidence to show he was provided education. The director of nursing (DON) was interviewed with regional clinical resource #1 on 7/9/26 at 3:09 p.m. The DON said a resident found to have severe cognitive impairment when assessed cannot understand the risks or benefits of immunization. The DON said the nurse providing education and obtaining consents should have contacted Resident #1's representative instead and should have provided clearer documentation of who refused the vaccination on the declination form.

Based on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent the occurrence or recurrence of pressure injuries for one (#12) of three residents reviewed out of 24 sample residents.Specifically, the facility failed to:-Ensure complete and thorough documentation of weekly wound assessments to track the progression of a chronic pressure injury for Resident #12; and,-Ensure recommendations provided by the outpatient wound clinic provider were followed for the chronic pressure injury for Resident #12. Findings include: I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 2/6/26 from https://www.internatinoalguidline.com/2019 Pressure ulcer classification is as follows:Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk).Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.Unstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed.Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Pressure injury assessment includes an evaluation of the pressure injury size and physical characteristics Assess and document physical characteristics of the pressure injury, including: Anatomical location, category/stage, size and surface area, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining and tunneling, exudate and odorII. Facility policy and procedureThe Pressure Injury Prevention and Management policy, revised February 2024, was provided by the nursing home administrator (NHA) on 2/5/26 at 11:09 a.m. It revealed in pertinent part, Weekly documentation of the pressure injury should include at least the following: Locations and stage of the pressure injury, size (perpendicular measurements of the greatest extent of length and width of the ulcerations), depth; and presence, location and extent of any undermining or tunneling/sinus tract. Please note the length assessment is always measured head to toe. Exudate, if present: type (such as purulent/serous), color, odor and approximate amount. Pain, if present: nature and frequency (e.g., whether episodic or continuous). Wound bed: Color and type of tissue/ character including evidence of healing ( e.g., granulation tissue), or necrosis (slough or eschar). Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) as appropriate. Pressure reducing surfaces. Any changes in pressure injury condition should be reported to the physician. III. Resident #12A. Resident statusResident #12, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included paraplegia (paralysis from the waist down) pressure ulcer of the sacral region, stage four, pressure ulcer of the left buttock stage four, pressure ulcer of the left ankle stage four, pressure ulcer of the right ankle stage four, non-pressure chronic ulcer of other part of the right foot with fat layer exposed, osteomyelitis of the vertebra, sacrum and sacrococcygeal region, chronic peripheral venous insufficiency, methicillin resistant staphylococcus aureus (MRSA) infection as the cause of diseases classified elsewhere.The 1/9/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #12 was independent with eating, upper body dressing and oral hygiene. Resident #12 required set up assistance with bathing. Resident #12 was dependent on staff for toileting, lower body dressing, footwear and personal hygiene. B. Record reviewResident #12's care plan, initiated 8/29/17 and revised 11/25/25, documented Resident #12 had multiple chronic wounds including a right lateral foot wound with a history of recurrent MRSA infections to multiple wounds. Interventions included assessing, recording, observing the wound healing weekly; measuring the length, width and depth where possible; assessing and documenting the status of the wound perimeter, wound bed and healing progress; and reporting improvements and declines to the provider.A review of Resident #12's February 2026 CPOs revealed the following physician's orders to Resident #12's right lateral foot wound: -Cleanse with wound cleanser, apply cavilon skin prep to peri wound tissue and apply a foam border dressing three times a week and as needed (PRN). -Monitor for signs and symptoms of infection. Observe for abnormalities to the wound bed, surrounding skin, or pain associated with the wound, document any abnormalities in the nursing progress notes. Ordered 7/30/25The nursing progress note, dated 1/20/2026 at 7:18 a.m., revealed the outpatient wound clinic nurse practitioner recommended to cleanse the right lateral foot wound with wound cleanser, apply calcium alginate and dry dressing, change daily and as needed if dislodged, saturated, or soiled. The nursing progress note, dated 1/27/2026 at 2:42 p.m., revealed the outpatient wound clinic nurse practitioner recommended to cleanse the right lateral foot wound with wound cleanser, apply calcium alginate and dry dressing, change daily and as needed if dislodged, saturated, or soiled.-Review of Resident #12's January and February Treatment administration record revealed the facility failed to update the frequency of the wound care orders to daily instead of three times per week in accordance with the outpatient wound clinic nurse practitioner's recommendations. A review of Resident #12's electronic medical record (EMR) revealed missing weekly wound assessment forms for the following weeks: 10/5/25, 10/26/25, 11/2/25, 11/16/25, 11/23/25, 11/30/25, 12/21/25 and 12/28/25.IV. Staff interviewsThe director of nursing (DON), regional consultant and NHA were interviewed together on 2/5/26 at 11:09 a.m. The regional consultant said the facility underwent an internal survey on 1/12/26. The regional consultant said inconsistent wound assessment documentation was identified during the internal survey and a plan of correction was started. The DON said she completed wound care assessments including measurements each week, but did not complete assessments in the EMR because the resident also had wound care clinic appointments some weeks and she thought the outpatient provider notes were sufficient. The DON said she kept a log of each of Resident #12's wounds in a spreadsheet including measurements to monitor the progress of each wound. The regional consultant said she provided education to the DON to complete assessments in the EMR each week. The regional consultant said the facility also started an audit of all residents with wounds in the facility to find missing weekly wound assessment forms. The NHA said they asked the outpatient wound care clinic to no longer send the nurse practitioner who completed the wound care assessments in January because her measurements of multiple residents' wounds were not accurate. The DON said she reviewed the outpatient wound clinic documentation from the nurse practitioner, but she was not sure if the nurse practitioner recommended any changes to Resident #12's wound care orders. -However, a review of the plan of correction provided by the NHA on 2/5/26 at 11:09 a.m. revealed the DON did not receive verbal education on the requirement to complete weekly wound care notes until 2/4/26 (after the start of the survey). A review of the wound tracking logs provided by the DON revealed missing weekly wound assessment documentation without a corresponding outpatient wound clinic progress note for the weeks of 10/5/25 and 12/21/25. The wound tracking log provided by the DON included only measurements with no documentation of descriptions of the wound bed, periwound tissue or exudate from the wound for the weeks of 11/21/25 and 12/18/25.

Based on interviews, record review and observations, the facility failed to ensure residents were free from accidents or hazards for one (#14) of three residents reviewed for accident hazards out of 24 sample residents. Specifically, the facility failed to prevent the elopement of Resident #14. Findings include:I. Facility policy and procedureThe Elopement and Wandering policy, initiated 2/29/24, was provided by the nursing home administrator (NHA) on 2/5/26 at 2:41 p.m. It read in pertinent part, To ensure the safety and well being of all residents with potential elopement risk. It is a goal of the facility to provide a safe environment using the least restrictive measure available in caring for residents who are exhibiting elopement behavior. Implementing and care planning interventions to address safety and decrease risk of elopement.II. Facility investigationThe facility investigation was provided by the NHA on 2/4/26 at 9:36 a.m. The facility investigation documented Resident #14 was in a locked courtyard on 11/30/25 and was last seen at 8:30 a.m. by a nurse. Resident #14 was believed to climb the metal railing over the fence and leave the facility grounds. The resident encountered a police officer at approximately 9:10 a.m. Resident #14 asked the officer to take him closer to his house. The police officer proceeded to drop off the resident at the gas station six miles away from the facility in the neighboring town. According to the investigation, on 11/30/25 at 9:15 a.m. the staff completed the breakfast meal service with the other residents on the secured unit and went outside into the courtyard to notify Resident #14 that his breakfast was ready. At that time, the staff determined the resident was not in the courtyard and initiated a full facility and perimeter search. The police were notified of the missing resident at 9:39 a.m. The police picked the resident up at the gas station and returned him to the facility at 10:14 a.m. without injury.The facility investigation documented the review of the courtyard identified there were no other access points other than proximity of a metal railing near fence that could have contributed to Resident #14's elopement. The facility removed a portion of the metal railing that was believed to have allowed access over the fence and placed the resident on one-to-one supervision while in the secured unit courtyard. III. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included unspecified dementia, mild with mood disturbance, major depressive disorder, recurrent, and personal history of Hodgkin's lymphoma.The 12/1/25 minimum data set (MDS) assessment revealed Resident #14 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. He was independent with his mobility and required limited to no assistance with most of his activities of daily living. According to the MDS assessment, Resident #14 had wandering behaviors. IV. Resident interviewResident #14 was interviewed on 2/4/26 at 3:05 p.m. Resident #14 said he was very frustrated and wanted to go home. He said when he first arrived at the first he was very confused as a result of his treatment for his disease (lymphoma). He said he knew he had memory issues from his treatment but did not feel belonged at the facility and wanted to go home. He said he had left the facility before by climbing over two fences outside. V. Observation and interviewsThe facility's two facility courtyards were observed with the maintenance director (MTD) on 2/4/26 at 4:00 p.m. Review of the secured unit courtyard identified a portion of the metal pathway railing was removed and discarded in the second courtyard (smoking courtyard). The wooden fence that Resident #14 was believed to have climbed by use of the metal railing was approximately six feet high. The fence was shared with the smoking courtyard. The gate to the fence was secured with a keypad attached to an alarm which entered into the smoking courtyard. The review of the smoking courtyard identified a chain link fence surrounding the perimeter of the courtyard. In the back of the courtyard was wired fencing between the [NAME]. The top of the wired fencing was slightly bent down. The MTD said he did not know how long the wired fencing had been bent. VI. Record reviewThe elopement care plan, revised 12/5/25, identified Resident #14 was an elopement risk related to his dementia. According to the care plan, Resident #14's triggering words for wandering/eloping were the use of the words guardian and conservator. The care plan interventions directed staff to identify a pattern of his wandering and intervene as appropriate (revised 12/5/25); providing structured activities of toileting, walking inside the facility and outside, and use of reorientation strategies (revised 2/4/26); providing a staff member with Resident #14 at all times when he was outside in the courtyard due to his risk of jumping the fence (initiated 12/5/25); distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, chocolate and juice (revised 2/4/26); and, providing the resident with de-escation behavioral strategies of redirection, moving to a quiet place, providing one-to-ones and going outside in the courtyard with staff (2/4/26).The 5/22/25 weekly nursing note documented Resident #14 frequently talked about leaving the facility and told the activities staff that he wanted to jump the fence and run. The 7/13/25 behavior note documented Resident #14 had been perseverating about his property. According to the note, he said he wanted to jump the fence and return to his property.The 11/9/25 behavior note, documented Resident #14 offered to help an activity staff member take the breakfast cart back to the kitchen off of the secured memory unit. According to the note, when the activity staff member was not looking, he quickly went to the front door and shoved and kicked it hard in an attempt to open it. The 11/26/25 nursing note documented Resident #14 was observed standing on the metal railing in the backyard (courtyard) and looking over the wooden fence into the smoker's courtyard. According to the note, the resident got down from the railing without assistance and was encouraged to not stand on the railing. The 11/28/25 behavior note documented Resident #14 was yelling that his property was stolen and said he wanted to take a bus or hitchhike home. According to the note, the staff advised the resident that the police would bring him back to the facility if he left. The 11/29/25 behavior note Resident #14 spent most of the day outside, away from other residents. According to the note, Resident #14 offered to pay a nurse $3000.00 to take him home. He told the nurse that he had to get out of the facility and go home by walking or hitchhiking. The 11/30/25 nursing progress note documented Resident #14 went over the back fence and was returned to the facility by the police. VII. Staff interviewsActivity assistant (AA) #1 was interviewed on 2/4/26 at 2:35 p.m. AA #1 said Resident #14 was upset about the loss of his property prior to his elopement. She said she tried to help the resident's mood with activities of interest. The NHA was interviewed on 2/4/26 at 4:12 p.m. The NHA said on 11/30/25, Resident #14 was picked up by a police officer approximately five blocks from the facility after he eloped and dropped off at a gas station in the neighboring town and then brought back to the facility. She said the secured unit courtyard was assessed and it was determined that the only way Resident #14 could have eloped was for him to go over the fence. She said the resident was asked about his elopement and he pointed to the fence that he went over. The NHA said there were no reports to her of him wanting to leave or attempting to leave, prior to his elopement. She said the facility was looking into trialing a room for him off of the unit, prior to his elopement. She said he had periods of calm behaviors and other times he would tell staff he wanted to go to his property. The NHA said no one reported to her that Resident #14 was standing on the metal railing a few days prior to his elopement. She said that should have been reported to her. She said if she had been made aware, then the resident would have been placed on one-to-one supervision in the courtyard and not just frequent checks when he was outside. The NHA said on the morning of 11/30/25, Resident #14 was agitated and went outside to the secured unit courtyard to de-escalate. She said he went outside alone at approximately 8:05 a.m. or 8:10 a.m. The NHA said the staff usually would check on the resident every five to 15 minutes by glancing outside. She said the secured unit staff did not check on him that morning as frequently as they normally would because they were serving the other resident's breakfast at the time. The NHA said at 8:30 a.m., a nurse saw Resident #14 in the smoker's courtyard but the nurse was new to the facility and was not aware that he was a secured unit resident and should not be in the general population/smoker's courtyard. The NHA said since the elopement, the resident was now required to have one-to-one supervision when in the courtyard and no longer just on frequent checks. She said Resident #14 could no longer sit outside alone. The MTD was interviewed on 2/4/26 at 3:50 p.m. The MTD he was made aware of the elopement of Resident #14 and removed a section of mental pathway railing alongside of the fence in the secure unit courtyard. The MTD said no other modifications were made to the courtyard. He said the secure unit courtyard was secured at the gate by a key pad and weekly he checked the alarm of the gate to ensure it was in good working order. He said he was not asked to remove or modify the metal railing prior to the resident's elopement. The MTD said Resident #14 went over two fences to leave the property (see observation above). The NHA was interviewed on 2/5/26 at 12:18 p.m. The NHA said there was no staff education implemented after the elopement. She said she did not feel additional education was needed. She said the staff followed his care plan to allow him to cool off outside and followed the elopement policy. The NHA said Resident #14 expressing desire to leave was a pattern of his. The secured unit manager was interviewed on 2/5/26 at 1:54 p.m. The unit manager said prior to Resident #14's elopement, staff would check on him every 10 to 15 minutes when he was in the secured unit courtyard. She said there was no formal schedule to check him before he eloped. She said the staff just knew to check on him. The unit manager said the resident never indicated that he wanted to leave. She said she was not aware that the resident was observed standing on metaling railing near the fence prior to his elopement. The unit manager said the secured unit courtyard had two areas. The first area was just outside the dining room where staff could look out the window or the door and see Resident #14. She said the second area of the secured unit courtyard was along the side of the facility which could have hindered the visibility of the resident from staff. Registered nurse (RN) #1 was interviewed on 2/5/26 at 2:02 p.m. RN #1 said Resident #14 was usually in line-of-sight in the courtyard and staff would check on him every 10 to 15 minutes. She said she was working on the day he was observed standing on the metal railing by the fence (11/26/25). She said she was told he was talking to another resident on the other side of the fence and shaking someone's hand. She said she documented the incident and reported it to the next shift nurse. The NHA was interviewed again on 2/5/26 at 2:11 p.m. The NHA said the facility was discussed Resident #14 moving off the secured unit and into a less restricting environment in July 2025 and again in August 2025. She said Resident #14 decided he did not want to move off of the secured unit. The NHA said it was normal for him to say he did want to remain at the facility and he would become agitated. She said staff would allow him to cool off outside in the secured unit courtyard. She said staff would just get a quick visual confirmation when he was outside because sometimes he was not accepting of the staff to stay or sit with him prior to the elopement. The NHA said she reviewed her investigation and was reminded that it was about 40 minutes from the time the secured unit staff saw the resident and the time they discovered he was unaccounted for. She said his nurse saw him at 8:30 a.m. The NHA said the new nurse on the general population side saw him at approximately 8:45 a.m. in the smoker's courtyard. AA #2 was interviewed on 2/5/26 at 4:38 p.m. AA #2 said activity staff tried to keep an eye on all the residents during activities. He said if Resident #14 wanted to go outside into the courtyard, prior to his elopement, they would let go outside. He said every 10 minutes the staff would peek outside to check on him. AA #2 said he was the one who witnessed Resident #14 standing on the metal railing a few days before his elopement. AA #2 said he thought the resident might have been trying to say hello to another resident because he had his hand over the fence. He said the resident was talking but he was not sure if he was talking to someone on the other side of the fence. AA #2 said he walked up Resident #14 while he was standing on the railing and the Resident #14 got down.

Based on record review and interviews, the facility failed to ensure two (#2 and #3) of three residents reviewed for abuse out of three sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #2 and Resident #3 from physical abuse by Resident #1. Findings include:I. Facility policy and procedureThe Abuse policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 8/14/25 at 10:29 a.m. It read in pertinent part, Residents have the right to be free from abuse. This includes but is not limited to freedom from physical abuse. Providing a safe environment for the residents is one of the most basic and essential duties of our facility. Employees have a unique position of trust with vulnerable residents. This facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including but not limited to other residents. Identification of abuse shall be the responsibility of every employee.II. Physical abuse by Resident #1 towards Resident #3 on 5/28/25A. Facility investigationThe 5/28/25 facility abuse investigation documented that at 10:00 a.m. two female residents (Resident #1 and Resident #3) were in the hallway in the secured dementia unit. The nursing staff were providing medications and care to other residents when the staff heard someone yell, Hey! The staff immediately checked and saw that one female resident (Resident #1) was reaching toward and hitting another female resident (Resident #3) in the chest. The staff immediately separated both residents. The investigation documented Resident #3 had two superficial abrasions on her chest with slight redness. Resident #3 was unable to recall the incident. The investigation documented Resident #1 said Resident #3 was after her. Both residents were placed on increased supervision and were in line of sight when they left their rooms. The investigation documented a summary of the staff interviews revealed Resident #3 was agitated prior to the incident and she was unhappy she had to wait for the nurse as the nurse was passing medications. The staff were uncertain if Resident #1 was standing in her doorway or if she was exiting her room, but the incident occurred in the doorway to Resident #1's bedroom. Both residents indicated the other resident attacked them, however, Resident #3 was the only resident with injuries. After the incident Resident #1 calmed down and Resident #3 required one-on-one supervision to calm down. Resident #1 was placed on 15-minute checks for 72 hours. An intervention of line of sight supervision was put into place to prevent a recurrence of the situation.-The facility investigation documented the abuse was substantiated.III. Physical abuse by Resident #1 towards Resident #2 on 6/13/25A. Facility investigationThe 6/13/25 facility investigation documented a female resident (Resident #1) was sitting in the dining room chair watching television. Another female resident (Resident #2) was standing behind her chair next to a certified nurse aide (CNA). Resident #2 put her hand on the back of Resident #1's chair. Resident #1 reached up and said Do not touch me! Resident #1 then grabbed Resident #2's arm using her fingernails, which resulted in three red areas and one superficial open area on Resident #2's right forearm. The investigation documented the CNA stepped between the residents in order to separate them. Resident #1 attempted to hit Resident #2, but the staff prevented the resident from making contact. Resident #1 was asked to go to her room until she was able to calm down, which she agreed to do. The investigation documented a summary of the staff interviews revealed Resident #1 was seated at a table in the main dining room and a CNA was on the right side of Resident #2 as she guided her through the dining room. Resident #2 reached for the back of the chair Resident #1 was sitting in. Resident #2 made contact with the back of Resident #1's chair. Resident #1 did not like being touched and perceived the contact as being hit, as she stated She hit me. Resident #1 reacted with a retaliatory behavior by grabbing Resident #2's forearm, resulting in skin tears and redness. The investigation documented Resident #2 walked independently but needed staff guidance. The investigation indicated the dining room was a little congested with other residents sitting and walkers and chairs. The congestion made Resident #2 navigate around obstacles which resulted in Resident #2 needing to use a chair for either comfort or to steady herself while ambulating. Both residents were placed on 15-minute checks for 72 hours. -The interventions to prevent a recurrence of the situation section of the investigation was not filled out.-The facility investigation documented the abuse was substantiated.IV. Resident #1 (assailant) A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and passed away on 6/20/25. According to the June 2025 computerized physician order (CPO), diagnoses included Alzheimer's disease, paranoid schizophrenia (mental illness) and dementia with psychotic disturbances.According to the 5/1/25 minimum data set (MDS) assessment Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The MDS assessment documented the resident rejected care at times. B. Record reviewResident #1's behavior care plan, revised on 6/30/25, documented the resident had physical aggression, paranoid delusions, dementia and poor impulse control. Pertinent interventions included performing 15-minute checks for 72 hours (initiated 8/29/24), removing or redirecting Resident #1 away from other residents when she was agitated (initiated 9/10/24), conducting medication administration as ordered (initiated 8/6/24) assessing and anticipating the resident's needs (initiated 8/6/24), providing physical and verbal cues to alleviate Resident #1's frustrations (initiated 8/26/24), encouraging Resident #1 to sit with her male friends for meals because she preferred male companionship while eating (initiated 8/30/24), monitoring for any signs of Resident #1 posing danger to herself and others (initiated 8/6/24) and intervening before Resident #1 became agitated and guiding the resident away from sources of distress (initiated 8/6/24).-Review of the resident's care plan did not reveal new interventions were implemented after the resident was involved in two physical abuse altercations.-Review of Resident #1's electronic medical record (EMR) did not include documentation regarding the physical abuse incidents on 5/28/25 or 6/13/25.V. Resident #3 (victim)A. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, Resident #3 had a diagnosis of dementia with severe anxiety.The 7/17/25 MDS assessment revealed Resident #3 had severe cognitive impairment per staff interview. The assessment indicated Resident #3 had physical behavioral symptoms directed towards others and verbal behavioral symptoms directed towards others.B. Record review-Review of Resident #3's comprehensive care plan did not reveal documentation indicating the resident received received physical aggression from Resident #1. -Review of Resident #3's EMR did not reveal documentation regarding the physical abuse incident on 5/28/25.VI. Resident #2 (victim)A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included Alzheimer's disease with late onset and dementia.According to the 5/29/25 MDS assessment Resident #2 had a severe cognitive impairment per staff assessment. The assessment documented Resident #2 did not have any behaviors.B. Record reviewResident #2's comprehensive care plan, revised 6/2/25, documented she received physical aggression from another resident. Interventions included assessing and addressing for contributing sensory deficits (initiated 6/2/25), assessing and addressing for contributing sensory deficits (initiated 6/2/25), sitting with the resident and taking her for a walk outside as needed (initiated 6/2/25) and monitoring for any signs of other residents posing danger to the resident (initiated 6/2/25).A progress note, dated 6/13/25, documented a resident (Resident #1) was sitting in the dining room chair as she watched television. Resident #2 stood behind the resident's chair and next to a CNA. Resident #2 placed her hand on the back of the resident's chair. The resident (Resident #1) reached up and said Do not touch me! Resident #1 grabbed Resident #2 by the arm with her fingernails, which resulted in three red areas and one superficial open area on Resident #2's right forearm. The CNA stepped between the residents and separated them. The resident attempted to hit Resident #2 again, but the staff prevented her from making contact. Resident #1 was asked to go to her room until she was calm.VII. Staff interviewsThe memory care director was interviewed on 8/13/25 at 11:20 a.m. The memory care director said the staff on the dementia unit prevented resident-to-resident altercations and behaviors with snacks and a lot of redirection. The memory care director said all staff received dementia training once a year. She said Resident #1 was sometimes volatile but had recently calmed down. She said Resident #1 was good at leaving the area if she was anxious, but often tried hitting others who invaded her personal space. The NHA was interviewed on 8/13/25 at 11:35 a.m. The NHA said it was important to update care plans with new interventions because whatever was previously in place obviously did not work. She said it was important to prevent resident-to-resident abuse to prevent fear or injuries. The NHA said she felt Resident #1 did not instigate the altercations for either incident. The NHA said the root cause of the incident on 6/13/25 appeared to be the dining room was cluttered and Resident #2 got in Resident #1's personal space. The NHA said Resident #3 was the one who was agitated and near Resident #1's doorway on 5/28/25. She said both incidents of abuse were substantiated.

Based on observations, record review and interviews, the facility failed to maintain an effective pest control program so the environment was free of pests. Specifically, the facility failed to prevent and take adequate measures to eliminate mice within the facility. Findings include: I. Professional references According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (revised 3/16/24) retrieved on 5/1/25, read in pertinent part, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: -Routinely inspecting incoming shipments of food and supplies -Routinely inspecting the premises for evidence of pests -Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and -Eliminating harborage conditions. (Chapter 6) II. Facility policy and procedure The Pest Control policy and procedure, revised May 2008, was provided by the corporate consultant (CC) on 4/29/25 at 10:12 a.m. The policy read in pertinent part, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. The Pest Control policy and procedure for dietary services, revised October 2022, was provided by the director of nursing (DON) 4/29/25 at 12:45 p.m. The policy read in pertinent part, A program will be established for the control of insects and rodents for the dining services department. The dining service director coordinates with the director of maintenance to arrange pest control services on a monthly basis, or as needed. All food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin. The (facility) staff will be notified immediately of any concerns. When applicable, bulk foods will be removed from their original packaging and stored in containers with tight fitted lids. III. Observations On 4/28/25 at 3:31 p.m. two closed container mouse traps were identified on the floor in the kitchen. One trap was located under the dish washing station and the other trap was in the dry storage room under a dry food storage shelf. The floor of the kitchen and dry storage room had visible food remnants and other indistinguishable surface debris throughout the kitchen floor egress, under storage shelves, under the food prep station, under the stove and behind the waste bin. At 4:29 p.m. the kitchen floor was observed by the dietary consultant (DC) who identified mouse feces on the floor in the dry food storage room. IV. Resident interviews Resident #6 and Resident #7 were interviewed together on 4/28/25 at 4:55 p.m. The residents shared the same room. Resident #6 said she saw a mouse in their room last night (4/27/25). Resident #7 said mouse droppings/feces were found under her bed by her family member on 4/28/25. Resident #7 said there was mouse droppings in her dresser drawer a few days ago. She said she notified staff and they cleaned the dresser drawer. Resident #7 said she kept her snacks in her dresser drawer. Resident #6 said it bothered her to see mice in her room because she did not like mice. Resident #8 was interviewed on 4/28/25 at 5:03 p.m. She said a few weeks ago she had a mouse run out from under her reclining chair as she sat in it. She said it really startled her. Resident #9 was interviewed on 4/28/25 at 5:11 p.m. He said two mice jumped out of his desk drawer and ran across his bedroom floor a month ago. He said he kept candy bars in his desk drawer. V. Record review The March 2025 resident council minutes, dated 3/25/25, were provided by the DON on 4/28/25 at 3:45 p.m. The minutes identified the facility had a plan of correction related to mice and their pest control vendor had come out to the facility three times in March 2025. According to the minutes, food had been a big issue so the facility was spring cleaning to help with mice entering the facility. A pest control plan of correction binder was provided by the maintenance director (MTD) on 4/28/25 at 3:50 p.m. The plan of correction contained a summary timeline and monitoring goals, photos of interventions such as potential mouse entry holes filled with mouse foam sealant, new door sweeps, contract pest control service invoices and recommendations, identification of findings and audits of room cleanliness. The plan of correction summary of action documented on 2/25/25, the nursing home administrator (NHA) and the MTD were notified of mice sightings in the facility and contacted a pest control vendor. The pest control vendor sprayed a chemical pest control barrier around the outside of the facility. The plan of correction indicated the pest control vendor returned to the facility on [DATE], after additional mouse sightings and dropping were reported on 3/10/25. The pest control vendor removed three mice from the facility, placed glue boards in the mouse traps and recommended the facility complete exclusion work (fix potential mouse entry ports) in several locations around the kitchen. According to the plan of correction, more mice sightings were reported to the NHA on 3/11/25. The MTD sealed all possible entrances with a mouse shield foam spray patched damaged wall surfaces. The plan of correction indicated the NHA conducted education on 3/12/25 with staff regarding facility cleanliness to prevent the drawing in of mice into the facility. The plan of correction identified all residents had the potential to be affected by pests/mice in the facility and monitoring was put in place. The plan of correction documented the MTD would interview staff five days a week on each hallway to determine if there were new mouse sightings or dropping found and notify the NHA if there were concerns. The housekeeping director (HKD) or designee would complete visual checks five days a week of cleanliness of all resident rooms. The dietary director (DM) would complete an inspection of the kitchen area for cleanliness, mice and mice droppings, notify the NHA if concerns were identified and maintain a kitchen deep cleaning log. A maintenance audit identified maintenance conducted floor observations and questionnaires for mice sightings in resident areas between 3/10/25 and 4/27/25. A housekeeping audit identified a daily floor visual cleanliness assessment was conducted on 3/10/25 through 4/21/25. The 3/10/25 pest control vendor service report identified the mice were breeding in the walls and entering near the exposures of plumbing pipes that required exclusion work. The service report documented the mice breeding inside the walls, indicating the mice were finding adequate amounts of food, water and shelter resources to reproduce. The service report recommended the facility reduce the mice resources to reduce the number of mice. The 4/14/25 pest control vendor service report identified a large quantity of drain flies were found in the kitchen and six mice in the kitchen mouse traps. The service report recommended the facility to leave the traps in place and not to bait the mice with human food. The report also recommended two holes under the sink in the kitchen, a hole in the wall in the memory care unit, and broken/damaged/clogged drains be repaired. -The plan of correction did not include the identification and prevention of food sources such as the back door of the kitchen routinely left open on warm weather days and residents'snacks in resident room drawers (see interviews below). -The plan of correction did not identify how long the plan of correction audits should be maintained/conducted. A kitchen audit was provided by the DC on 4/28/25 at 4:25 p.m. The kitchen indicated a daily visual cleanliness and storage check for mice and mice droppings audit was conducted on 3/15/25 through 4/8/25. According to the audit, the floors and counters were clean, all food was sealed and there were no mice or mice droppings found. -The review of the kitchen audit documented the review of kitchen cleanliness for mouse prevention and observation was completed for three weeks, even though the facility continued to have reports of mice (see staff and resident interviews). VI. Staff interviews Dietary aide (DA) #1 was interviewed on 4/28/25 at 3:40 p.m. DA #1 said he had seen mice and mice droppings in the kitchen but the sightings had been less in the last few weeks. He said the pest control vendor installed mouse traps in the kitchen. The MTD was interviewed on 4/28/25 at 3:50 p.m. The MTD said the facility had a contract with a pest control vendor beginning in 2024. He said the pest control vendor routinely came every month to the facility. The MTD said recently, the facility had to use their services more often. He said the pest control vendor used a barrier spray around the facility and placed mouse traps in various areas around the building. He said over the couple of months, there had been quite a few mouse sightings in the facility. He said mice had been found in five known resident rooms and in the kitchen. He said the most recent incident was on 4/27/25. He said a mouse was found in a resident's dresser drawer. The drawer contained food and candy. He said he was conducting mice sighting audits in resident rooms and the kitchen staff were conducting their own audits. Cook (#1) was interviewed on 4/28/25 at 4:25 p.m. [NAME] #1 identified himself as the acting supervisor while the DM was on leave. He said he had not seen any mice or evidence of mice in the kitchen in the last two to three weeks. [NAME] #1 said seven mouse traps were outside the back door of the kitchen so they could be checked for mice. He said after every meal, the staff should sweep and mop the floors and after every shift they should do a deep cleaning of the kitchen. [NAME] #1 said he reviewed the kitchen audit for mouse prevention and said he did not know why the audit was not conducted after 4/8/25. He said the DM was responsible for the audit. [NAME] #1 said he just made sure the staff were keeping things clean. [NAME] #1 said the DM did not delegate the continuation of the audit to him while the DM was gone. [NAME] #1 did not know if the audits were delegated to someone else and did not know if the audits should have been continued past 4/8/25. The DC was interviewed on 4/28/25 at 4:29 p.m. after the above observations in the kitchen. She said she would ensure the kitchen cleanliness would be addressed and corrected on the evening of 4/28/25. Certified nurse aide (CNA) #1 was interviewed on 4/29/25 at 11:49 a.m. CNA #1 said she had not seen any mice or had been instructed on how to help prevent mice in the facility. CNA #2 was interviewed on 4/29/25 at 11:57 a.m. CNA #2 said she heard mouse traps were set up in the facility but she has not seen any mice or evidence of mice or other mouse prevention. She said residents kept snacks in their room. CNA #2 said there was no set location on where the snacks were stored in the residents' room. She said the location of the snacks in a resident's room was the resident's choice. The DC was interviewed on 4/29/25 at 12:05 p.m. She said on 4/28/25 (during the survey), the dietary staff pulled all the equipment from the walls and center console and cleaned the floors underneath. The DC said the dietary staff pulled everything off the shelves and inspected all the boxes for damage and feces. She said the only thing they found was an open container of pudding. She said the refrigerators were cleaned and all surfaces in the kitchen were wiped down. The DC said the dietary staff needed to make sure every crumb on the floor was addressed quickly. She said the facility was prone for pests. She said the kitchen staff have been told to move everything when they sweep and mop and make sure any mess they made was cleaned up right away to prevent mice. The DC said removing food debris on the floor was a preventative measure in pest control so mice do not consume the food and breed. The DC said she contacted the DM and he said the NHA told him he no longer had to continue the kitchen audit logs for cleanliness and mouse prevention. She said the kitchen had other cleaning logs but they were more directed at basic cleaning. The DC said she would do an education with the dietary staff scheduled today (4/29/25) on sanitation and continue the education for the remainder of the dietary staff. The DON was interviewed on 4/29/25 at 12:47 p.m. She said there were mouse sightings at the facility and pest control was contacted. She said audits were conducted and the staff was educated to remind residents not to keep food in their room. She said she was not aware of any new reports of mice. The MTD was interviewed on 4/29/25 at 1:27 p.m. The MTD said the pest control vendor came out the morning of 4/29/25 and found a couple more holes in the kitchen's dish room that needed a foam seal. The MTD said the mice could come into the facility through the kitchen's back door. He said the dietary staff leave the kitchen back door open even though he has put up signs to remind the staff to keep the door closed so mice do not enter. He said he has also had to remind the staff to not remove the traps from the kitchen. A staff member who wished to remain anonymous was interviewed on 4/29/25 at 1:35 p.m. The staff member said mouse droppings have been seen in the kitchen and the mouse traps were not routinely cleaned causing an odor. The staff member said the mouse traps were not helping get rid of the problem. The staff member said the dietary staff left the back door of the kitchen open to help with the warm temperatures in the kitchen. The staff member said the staff had not been told to put food away and where it belonged to help prevent the mice. The staff member said the mice infestation was really bad in March 2025 and they had not seen much of an improvement in April 2025. The HKD was interviewed on 4/29/25 at 2:55 p.m. He said he has seen mouse urine or droppings in a few resident rooms but not in the last couple of weeks until today (4/29/25). He said a resident room was reported to have a mouse sighting. He said the room was cluttered per the resident's choice. He said the room was deep cleaned and a trap was placed in the room. The HKD said residents with food in their rooms had been the common pattern of evidence of mice in a resident's room and almost always found in dresser drawers. He said on the back side of most of the residents' dressers with predrilled holes. He said the holes make it easy for the mice to get into the dressers and assess resident's stored snacks. The HKD said he was still auditing the rooms after 4/21/25 but did not have the audit logs at the facility (see audits above). The DON was interviewed on 4/29/25 at 3:05 p.m. The DON said the facility would start a full facility cleaning of all rooms and look at food storage. She said the dietary staff would be educated on keeping the kitchen back door closed and the facility will look at ways to reduce the heat in the kitchen without the reliance of an open door for air flow. The DON said she would implement more monitoring in the kitchen for mouse prevention interventions such as closing the back door. VI. Facility follow up A 4/29/25 dietary department education was provided by the DON on 4/29/25 at 12:45 p.m. The education reviewed the dietary pest control policy and cleaning and sanitizing procedures with three dietary staff. The education included an accompanied quiz that highlighted the education materials. According to the cleaning and sanitizing procedures, resident safety in a health care environment was a top priority. Cleaning and sanitizing properly was one of the most important things staff for staff to continually do in a kitchen to prevent harm.

Based on observations, record review, and interviews, the facility failed to ensure that one (#1) of three out of six sample residents was kept safe and free from elopement. Resident #1 was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (a chronic, progressive neurological condition) with dyskinesia (involuntary movements). A wander/elopement risk evaluation, completed upon the resident's admission on 8/31/24, revealed Resident #1 had no previous elopement attempts and was not at risk for eloping or wandering. Resident #1's record review revealed the following attempted and successful elopements after admission: On 9/4/24, a progress note revealed Resident #1 left the facility through the South Short Hall emergency exit and was verbally redirected inside. On 9/5/24, Resident #1 was agitated, packed his suitcase, and dragged it to the front door of the facility with his walker. The front door keypad was not armed and Resident #1 exited the facility, fell outside in the grass, and got himself up. He became aggressive when staff attempted to help him up or offered stand-by assistance. After 45 minutes, the resident agreed to sit in a wheelchair and staff transported him back inside the facility. On 9/10/24, Resident #1 displayed restlessness as he paced from one side of the building to the other for over an hour. The resident stated he was bored but refused activities the staff offered. Resident #1 went to the front of the facility and said he was waiting for the bus but it was unclear where he wanted to go. Resident #1 attempted to go out the front door but the keypad was armed which locked the door without the code. The resident walked toward another hallway, saw the emergency exit in the North Hall, exited the facility, and walked toward a bus parked outside the front of the building. The nursing home administrator (NHA) attempted to redirect the resident verbally but he was agitated and got on the bus. The facility called emergency medical services (EMS) for support. EMS arrived and after 20 minutes, Resident #1 agreed to get off the bus and into a wheelchair and was transported inside the facility. -Despite Resident #1's exit-seeking behaviors and successful elopements from the facility within 11 days of his admission on 9/4/24, 9/5/24, and 9/10/24, the facility failed to reassess the resident's elopement risk and implement interventions to prevent the resident from again eloping from the facility. On 9/11/24, Resident #1 exited the facility through the emergency exit on the South Long Hall. The door alarm on the emergency exit was not turned on and staff were informed by a resident of Resident #1's elopement. A conflicting report among staff members revealed the resident was missing for five to 30 minutes before facility staff began to search for the resident. Resident #1 was missing from the facility for 42 hours before he was found by the local search and rescue team and taken to the hospital where he was diagnosed with dehydration, three sunburns, and a deep, concerning stage 3 pressure injury which was not present at the time the resident eloped from the facility on 9/11/24. On 9/23/24, Resident #1 returned to the facility from the hospital but was hospitalized again on 10/4/24, and his pressure injury was diagnosed as a progressive stage 4. The hospital recommended surgical repair which the resident and the family declined. Resident #1 was sent to a hospice center where he passed away. The facility's failure to reassess Resident #1 as an elopement risk after his first three elopement attempts, failure to implement interventions to decrease Resident #1's risk of elopement, and failure to arm emergency exits properly, contributed to the resident's successful elopement attempt on 9/11/24. According to the NHA, the facility created an action plan and performance improvement plan to check the alarms on the emergency exit alarm at shift change, twice a day after Resident #1's elopement from the facility. She said the residents were all assessed for elopement risk and staff were provided education on the emergency exits. However, on 11/13/24, during the survey, the emergency exits on the South Hall Short and the South Hall Long were tested and the alarms were not armed and alarms did not sound when the exit doors were opened. The emergency exit in the North Hall was tested . Although the door was armed, staff failed to respond to the sound of the alarm. The facility's failure to prevent elopement, which resulted in serious harm to Resident #1, and failure to ensure a systemic, effective, and sustainable approach to prevent further elopements, created a situation of immediate jeopardy for serious harm. Finding include: I. Immediate jeopardy A. Situation of immediate jeopardy Resident #1, who was diagnosed with Parkinson's disease with dyskinesia had three successful elopements from the facility, on 9/4/24, 9/5/24, and 9/10/24 before he went missing. On 9/11/24, Resident #1 eloped from the facility when the emergency exit alarms were not activated. The lack of the door alarms functioning appropriately contributed to the facility's failure to ensure the resident's safety. Additionally, on 11/13/24, during the survey, the emergency exits in the South Hall Short and the South Hall Long were tested and the alarms were not armed, which caused the alarms not to sound. The emergency exit in the North Hall was tested and, although the door was armed, staff failed to respond to the sound of the alarm. The facility had not implemented a systemic, effective, and sustainable process to ensure the alarms on the emergency exit doors were functioning properly and that staff responded timely if an exit door alarm sounded to prevent additional resident elopements. These failures created a situation of immediate jeopardy for serious harm. B. Imposition of immediate jeopardy On 11/14/24 at 2:05 p.m., the NHA was notified of the immediate jeopardy situation created by the facility's failure to prevent Resident #1's elopement, which resulted in serious harm and the facility's failure to ensure a systemic, effective, and sustainable process to prevent further elopements. C. Facility plan to remove immediate jeopardy On 11/15/24 at 1:00 p.m., the facility submitted a plan to remove immediate jeopardy. The plan read: Identified concern: Resident #1 eloped the evening of 9/11/24. Upon quality assurance (QA) review of the incident, several opportunities were identified to decrease the risk of similar elopement risks. Identified the alarm at the west end of South Hall was turned off at the time of the elopement. Resident #1 had two attempts of exiting the community prior to this incident, no re-assessment was completed and no update to the care plan. Action plan: -The director of nursing (DON) or designee to complete the elopement assessment review of all residents by 9/13/24; -The DON or designee to implement or update plan of care with each resident identified at risk; -The NHA or designee will review the elopement binders and ensure that all high-risk residents are placed in the binder at each nurses' station; -The staff development coordinator (SDC) or designee will initiate a full house education on 9/12/24 regarding the elopement policy and procedures to include elopement binder, ensuring all exit alarms are on and functioning, appropriate redirection and diversional activities and how to respond to an elopement; -The director of maintenance (DOM) or designee will ensure that all door alarms are functioning on 9/12/24; -The DOM or designee to monitor and check door alarm function twice daily for seven days; -The DON or designee to review all completed elopement assessments daily Monday through Friday to ensure appropriate person-centered interventions are in place and that the elopement binder is current and updated; -The DON or designee will review all changes of condition and notes related to increased wandering or exit seeking to ensure a new elopement assessment is completed and will update the plan of care with new person-centered interventions daily as needed; and, -The action plan to be reviewed at the next quality assurance and performance improvement (QAPI) meeting and revised as needed. The plan was updated on 11/14/24 after the door alarms were not armed and immediate jeopardy was called. -The NHA or designee will review the elopement binders and ensure that all high-risk residents are placed in the binder at each nurses' station (ongoing); -All staff re-educated in elopement policy, alarm check procedures and staff response expectations. All staff were educated on the new alarm system process which was provided by the NHA and SDC. -On 11/13/24, the DOM installed new emergency push bars with alarms to emergency exit doors. The push bar requires a key to arm or disarm the alarm; -On 11/13/24, the door alarm checks were increased to hourly by floor staff and two times a shift by the NHA or designee; and; -On 11/14/24, the DOM removed the keypad alarm system. D. Removal of the immediate jeopardy The immediate jeopardy situation was removed on 11/15/24 at 1:00 p.m., based on the implementation of the above plan to prevent elopements and to maintain resident safety. However, the deficient practice remained at a G level, isolated, actual harm. II. Facility policy The Elopement and Wandering policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 11/14/24 at 11:05 a.m. It read in pertinent: It is a goal of the facility to provide a safe environment using the least restrictive measure available in care for residents who are exhibiting elopement behavior. 'Elopers' are defined as residents who make an overt or purposeful attempt to leave the facility and do not have the ability to identify safety risks. A wander/elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the interdisciplinary team (IDT) during the initial care conference. The elopement risk is assessed quarterly or as needed with change of condition. If the resident is identified as an elopement risk, the following will be maintained: Elopement Resident Identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder; and, implementing and care planning interventions to address safety and decrease risk of elopement. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted to the facility on [DATE] and discharged to the hospital on 10/4/24. According to the October 2024 computerized physician orders (CPO), diagnoses included nontraumatic subarachnoid hemorrhage (bleeding in the brain), cognitive-communication deficit, Parkinson's disease with dyskinesia, muscle weakness, unsteadiness on feet, and lack of coordination. The 10/4/24 minimum data set (MDS) assessment revealed Resident #1 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. Resident #1 was documented to use a walker and did not have a physical restraint for elopement. Resident #1 was dependent on staff to put on his footwear and required maximal assistance for toileting hygiene, showering, and upper and lower body dressing. B. Family interview Resident #1's representative was interviewed on 11/14/24 at 10:49 a.m. The representative said the resident was admitted to the facility for rehabilitation for a brain bleed on 8/31/24. She said on 9/11/24 she was informed a resident wanted to look outside the emergency exit on the South Hall Long and the staff disabled the alarm so the resident was able to open the door. She said the staff failed to turn the alarm back on and Resident #1 was able to leave the facility without the staff knowing. She said she was told the resident was missing at least 15 minutes before the staff realized he was gone and began looking for him. The representative said Resident #1 appeared to have slipped down a hill and laid stuck in that spot for 42 hours. She said when search and rescue found the resident, he had a large pressure sore on his left buttocks that he did not have before he eloped from the facility. The representative said Resident #1 was admitted to the hospital for treatment for about 10 days. She said the resident returned to the facility on [DATE] and was no longer able to walk independently. The representative said she was frustrated that the staff turned off the alarm so no one knew exactly when the resident went missing. The representative said she informed the facility that Resident #1 had a history of leaving his assisted living facility and she was unsure what the facility implemented to prevent elopement at the facility. C. Record review - repeated elopement attempts - failure of the facility to respond. A wander/elopement risk evaluation, completed on 8/31/24, revealed Resident #1 had no previous elopement attempts and was not a risk for eloping or wandering. On 9/4/24, a behavior note documented in Resident #1's electronic medical record (EMR) revealed the resident attempted to leave the facility through an emergency exit door at the end of the South Short Hall at 1:30 p.m. The staff were able to notify the resident's representative and the management team. -The facility failed to complete a wander/elopement risk evaluation and an elopement care plan was not started. On 9/5/24, a behavior note documented in Resident #1's EMR revealed the resident was agitated at the nurses' station which caused a significant gait imbalance and the resident was at a higher risk of falling. Resident #1 became more agitated when staff encouraged him to use his walker or his wheelchair. The director of rehabilitation (DOR) provided therapeutic encouragement and the resident agreed to use his walker and go into his room. Resident #1 gathered and packed his belongings in his suitcase. Resident #1 attempted to drag his suitcase and walker which caused him to be even more off balance. The staff attempted to stand close to the resident in case he fell which caused the resident to escalate more. The resident then attempted to drag a therapy machine backwards but the machine was unable to be moved by the resident. Resident #1 pushed on the front door and went outside because the keypad on the door was not armed and the door was not locked. The DOR and additional staff followed close by for his safety. Once outside, Resident #1 became unsteady on the sidewalk. He went into the grass and fell , landing on his knees. The resident got himself up and was combative with staff. Resident #1 began walking in the middle of the street and attempted to drag his walker in an unsafe manner. Staff redirected the resident to the grass for his safety. The DOR and the NHA provided hands-on assistance to the resident which increased the resident's aggression toward staff. Resident #1 was tired and sat in a wheelchair provided by the staff and was transported to the empty activity room. -The facility again failed to complete a wander/elopement risk evaluation and an elopement care plan was not started. On 9/6/24, a skilled nursing note revealed Resident #1 had increased agitation and exit-seeking behaviors. On 9/10/24, the physician documented a visit and revealed Resident #1 was seen to follow up on his recent admission, behaviors, and exit seeking. The physician recommended re-evaluating the resident's antipsychotic medications and doses and looking into an as needed (PRN) medication for his behaviors in the early afternoon. The physician documented the resident was exit-seeking in the afternoon because he was bored. On 9/10/24, a behavior note revealed Resident #1 was showing signs of restlessness and he paced across the facility for over an hour. One staff member engaged the resident to ensure he was not overstimulated. The speech therapist provided a friendly conversation and attempted to redirect the resident with momentary success for approximately 15 minutes. Resident #1 said he was bored and the staff offered him different activities. Resident #1 said he liked to read and the nurse encouraged the resident to pick out several books but the resident was disinterested. The NHA provided the resident with magazine options and Resident #1 picked out two magazines but placed the magazines in the basket of his walker and continued to pace. Resident #1 told staff he was waiting for the bus but was unable to tell anyone where he was going. Resident #1 then saw a small transport bus in front of the facility. He attempted to go out the front door but the keypad was armed and the door was locked. The resident continued walking with his walker down the hallway, observed an emergency exit at the end of the North Hall, and walked toward the door. Resident #1 was able to get outside and climbed onto the bus. The bus driver attempted to redirect the resident off the bus and said the bus was not a public transportation bus. Resident #1 began escalating and refused to allow staff near him. The resident was escalating. The bus driver and the NHA disengaged with the resident and EMS was called for assistance. EMS spent approximately 20 minutes encouraging Resident #1 to get off the bus. The resident began to get fatigued and agreed to sit in the wheelchair. Resident #1 returned to his room and laid down for a nap. -The facility failed, yet again, to complete a wander/elopement risk evaluation, and start an elopement care plan. On 9/11/24, a behavior note revealed the director of nursing (DON) purchased a building activity to assist the resident with not being bored in the afternoon. On 9/11/24, a skilled nursing note revealed Resident #1 had agitation toward staff in the afternoon. On 9/11//24, an investigation was started after Resident #1 eloped. According to the investigation report: The certified nurse aide (CNA) was assisting another resident to bed while the nurse was completing a medication pass. Resident #1 was seen at 7:03 p.m. The resident was calmly sitting at the nurses' station. The staff noticed Resident #1 was no longer at the nurses' station at 7:08 p.m. The CNA thought the resident had gone to his room until another resident said a resident with a walker left out of the emergency exit on the South Hall Long. The search for the resident began and, after 30 minutes with no success, the police were called for assistance. The resident was documented as being missing for 42 hours and when the resident was found, he was assessed by emergency medical services (EMS) and transported to the hospital via ambulance. The resident was stable with no broken bones but had some scratches and bruises and a possible wound on the coccyx or lower back per the family report. Resident #1 was admitted to the facility on [DATE] with no signs of exit-seeking but was documented as having two exit-seeking attempts with a noted change in behavior and cognition with one to two hours of significantly increased pacing and agitation noted by staff with redirection provided to the resident. No other residents were documented as affected by the incident. The investigation concluded the cause for the alarm on the emergency door not alarming at the end of the South Hall Long was that staff had turned off the alarm for another resident and failed to arm the door afterward. On 9/12/24, an order administration note revealed Resident #1 was [NAME] (missing in action) from the facility. The facility and the grounds were searched and all staff were interviewed regarding the resident's history of exit seeking. A wander/elopement risk evaluation, completed on 9/12/24, revealed Resident #1 had attempted to elope from the facility and revealed the resident had one or more risk factors that indicated he was at high risk for elopement. Resident #1's elopement care plan, which was not initiated until 9/12/24, revealed the resident was at risk for eloping and wandering. Interventions included: the resident's current information was to stay in the elopement binder; when the resident was showing signs of agitation, staff were not to physically redirect or tell the resident he was not able to do something; monitor the resident if he went outside to ensure he was not putting item by the fence to climb over; redirect the resident by offering help, pleasant diversions, structured activities, food, conversation, television, books, and walks; provide structured activities like toileting, walking inside and outside and using reorientation strategies which included signs, pictures and memory boxes; and assess the resident for the risk of falling. On 9/17/24 an elopement note for Resident #1 revealed the resident went missing on 9/12/24 for 42 hours. The resident was located by the local search and rescue team and sent to the emergency room where he was admitted with a wound to his left buttocks, and scrotal area, abrasions on his shins, three sunburns, and dehydration. The investigation revealed the resident exited out of the emergency exit on the South Hall Long. The alarm on the door did not sound because the staff disabled the alarm and did not turn the alarm back on. The resident's exit-seeking behaviors were documented for two attempts when the resident was unable to be redirected when inside the facility which required the staff to provide Resident #1 with assistance and supervision outside until the resident became tired and agreed to return inside. D. Record review - Resident status and facility interventions on readmission. On 9/23/24 a nursing progress note revealed Resident #1 was admitted back to the facility at 3:04 p.m. The resident had returned to the facility with healing sunburns, abrasions on both of his shins and a large open wound that covered almost the entire area of his left buttocks and contained a black center. Resident #1 was bed and wheelchair-bound due to his pressure wound and was admitted to the secure unit due to eloping. -Resident #1 had a BIMS score of 11 out of 15 on 9/6/24 and a BIMS score of seven out of 15 when he returned on 9/23/24. A wander/elopement risk evaluation, completed on 9/24/24, revealed Resident #1 had attempted to elope the facility and had one or more risk factors that indicated he was at high risk for eloping when he was ambulatory. Resident #1's elopement care plan (see above), revised on 9/24/24, revealed new interventions were not implemented after he eloped again. On 9/25/24 a skilled nursing note revealed Resident #1 had pressure wounds to his sacrum and scrotal area. On 10/4/24 an alert note revealed Resident #1 had wet himself and the dressing on his wound at 12:40 a.m. The resident's pressure ulcer appeared significantly deeper than the previous day with an odor and a lot of light yellow and brown drainage. Resident #1 reported excessive pain at the wound site and was unable to receive additional pain medication for several hours. Resident #1 said he wanted to be sent to the emergency room for pain control and further evaluation. The nurse attempted to clean the wound with gauze sponges and normal saline but the pain was too much for Resident #1 to tolerate. Non-emergency transportation was arranged for the resident and he was admitted to the hospital, where his pressure sore was diagnosed as a progressive stage 4. The hospital recommended surgical repair which would leave the resident with a colostomy bag and months of healing. The resident and the family declined. Resident #1 was sent to a hospice center where he passed away. E. Observations of the emergency exit alarms On 11/13/24 at 9:15 a.m., the emergency exit on the South Hall Short and the South Hall Long were tested and the alarms were not armed which caused the alarms not to sound. On 11/13/24 at 9:21 a.m., the emergency exit on the North Hall was tested and, although the door was armed, staff failed to respond to the sound of the alarm. IV. Staff interviews The NHA, corporate consultant (CC) #1 and CC #2 were interviewed on 11/13/24 at 11:39 a.m. The NHA said the facility implemented a plan of correction, provided staff education, completed elopement risk evaluations on all of the residents and emergency exit alarm checks occurred twice a day at shift change by the floor staff and documented on logs. The NHA said she was aware the door alarms had not been armed during the observations on the morning of 11/13/24. The NHA said she spoke to the CNA who completed the checks and the CNA said the alarms beeped and indicated the alarms were on when they had been checked earlier in the day. The NHA said the facility planned to monitor the emergency exits once an hour by floor staff for the following 24-48 hours. The NHA said she checked the door alarms and the alarms were on at 11:30 a.m. She said Resident #1 did not have a pressure sore before he eloped from the facility and when the resident was admitted back on 9/23/24, he was admitted to the secured unit and not ambulatory. CC#2 said the facility did not have any current residents who were high-risk exit seekers. A person who wished to remain anonymous was interviewed on 11/14/24 at 11:30 a.m. The person said the door alarm was not on so it did not trigger when the resident exited the building. The person said the staff propped multiple doors open with rocks to make it easier to go outside to smoke or take the trash out and Resident #1 was missing almost an hour before the staff who were working realized he was missing. CNA #1 was interviewed on 11/14/24 at 12:15 p.m. CNA #1 said the facility installed new alarms on the emergency exits (on 11/13/24) but the floor staff checked that the keypad and key alarms worked. She said the staff entered the code to disable the alarm and then entered the code again and when it beeped it meant the alarm was activated. CNA #1 said she did not open the door first to ensure the alarm had not malfunctioned and was not sure why the staff did not check the actual alarm first. CNA #2 was interviewed on 11/14/24 at 12:18 p.m. CNA #2 said the facility installed new alarms on the emergency exits (on 11/13/24) but the floor staff checked that the keypad and key alarms worked. She said the staff entered the code to disable the alarm and then entered the code again and when it beeped, it meant the alarm was activated. CNA #2 said she did not open the door first to ensure the alarm had not malfunctioned and was not sure why the staff did not check the actual alarm first. CNA #3 was interviewed on 11/14/24 at 12:21 p.m. CNA #3 said the facility installed new alarms on the emergency exits (on 11/13/24) but the floor staff checked that the keypad and key alarms worked. She said the staff entered the code to disable the alarm and then entered the code again and when it beeped, it meant the alarm was activated. CNA #3 said she did not open the door first to ensure the alarm had not malfunctioned and was not sure why the staff did not check the actual alarm first. Licensed practical nurse (LPN) #1 was interviewed on 11/14/24 at 12:25 p.m. LPN #1 said she was not the staff who checked the door alarms, usually it was the CNAs but she knew how to check the alarms. LPN #1 said Resident #1 did not have the pressure sore before he eloped. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 11/14/24 at 3:29 p.m. -The DON said the resident went missing and returned to the facility with a pressure wound. -The ADON said she and the DON were the wound nurses and completed the wound care according to the hospital's wound care discharge plan. The ADON said the wound care ordered by the hospital was not a good treatment plan because the hospital ordered a cream to be placed on an opened wound instead of a regimen that included some form of medihoney with gauze and bandages. -The DON said Resident #1 was sent back to the hospital on 10/4/24 because he experienced a lot of pain from the wound and the facility was unable to treat the wound accurately. A frequent visitor (FV) to the facility was interviewed on 11/14/24 at 5:10 p.m. -The FV said a staff member first informed her Resident #1 was missing 30 to 60 minutes before the staff realized he was gone, but the facility was not really sure how long the resident was missing initially. She said another staff member told her it was about 15 minutes before the staff realized Resident #1 was missing. -The FV said the NHA told her the resident was only missing for five minutes and that the facility waited to call the police until after 11:00 p.m. She said she was not sure why the facility delayed calling the police for help. She said the residents had complained about the staff turning off the door alarms or propping the doors open all of the time since the beginning of 2024 and it was not addressed by the facility. The NHA was interviewed a second time on 11/15/24 at 11:33 a.m. The NHA said Resident #1 was not an elopement risk when he was first admitted to the facility and should have been assessed again after each elopement attempt. She said the resident's elopements were reviewed as behaviors and not the resident wanting to elope from the facility. She said the resident's care plan should have been updated after the first elopement attempt. She said elopement interventions needed to be updated after each incident, not just adding a revision date change. She said the facility had room for improvement in many areas and that was why the plan of correction was started after Resident #1 eloped.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Implement an effective water management plan; and, -Ensure housekeeping staff properly sanitized resident rooms. Findings include: I. Failure to have an effective water management plan A. Professional reference According to The Center for Disease Control (CDC) Legionella (Legionnaires Disease and Pontiac fever) (3/25/21), retrieved on 7/10/24 from https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: -Establish a water management program team -Describe the building water systems using text and flow diagrams -Identify areas where Legionella could grow and spread -Decide where control measures should be applied and how to monitor them -Establish ways to intervene when control limits are not met -Make sure the program is running as designed (verification) and is effective (validation) -Document and communicate all the activities. Principles: In general, the principles of effective water management include:maintaining water temperatures outside the ideal range for Legionella growth; preventing water stagnation;ensuring adequate disinfection; and,maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs. According to the CDC's Controlling Legionella in Potable Water Systems, (2/3/21), retrieved on 7/10/24 from https://www.cdc.gov/control-legionella/media/pdfs/Control-Toolkit-Potable-Water.pdf, Store hot water at temperatures above 140 degrees fahrenheit (F) and ensure hot water in circulation does not fall below 120 degrees F. Recirculate hot water continuously, if possible. Store and circulate cold water at temperatures below the favorable range for Legionella (77 degrees F to 113 degrees F). Legionella may grow at temperatures as low as 68 degrees F. B. Facility policy and procedure The Legionella Water Management Program policy, revised September 2022, was obtained from the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. The water management team consists of at least the following personnel: the infection preventionist, the administrator, the medical director, the director of maintenance, and the director of environmental services. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE (The American Society of Heating, Refrigeration, and Air Conditioning Engineers) recommendations for developing a Legionella water management program. The water management program includes the following elements: -An interdisciplinary water management team, a detailed description and diagram of the water system in the facility, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, the identification of situations that can lead to Legionella growth and specific measures used to control the introduction and/or spread of Legionella. B. Record review The facility's water management plan was provided by the director of maintenance services (DMS) on 7/23/24 at 11:01 a.m. The documentation included a copy of the CDC's recommendations for developing a Legionella water management program and a diagram of the building, without identifying water systems. -The facility failed to describe the building water systems using text and flow diagrams. -The facility failed to document when the water management program was initiated. -The facility failed to identify areas where Legionella could grow and spread. -The facility failed to decide where control measures should be applied and how to monitor them. -The facility failed to establish ways to intervene when control limits were not met. -The facility failed to make sure the program was running as designed and was effective. -The facility failed to document and communicate all the activities of the water management program. C. Staff interviews The DMS was interviewed on 7/23/24 at 1:24 p.m. The DMS said he checked some of the water systems regularly in the building but did not keep documentation of water system maintenance. He said he was not sure if he knew where all the water lines in the building were. The DMS said he was unsure if the facility had a diagram of all of the water lines in the building. He said he did not know if the facility had identified a method for ensuring the water management program was effective. The DMS said he had not read the water management program documentation that he had provided during the survey on 7/23/24 at 11:01 a.m. The NHA and the DON were interviewed together on 7/23/24 at 4:53 p.m. The NHA and the DON said they were unaware the facility did not have a water management program. The NHA was interviewed again on 7/23/24 at 7:33 p.m. The NHA said she was not familiar with the details of what needed to be done concerning Legionella and Legionella prevention. II. Housekeeping failures A. Professional reference The CDC Environment Cleaning Procedures, (3/19/24) was retrieved on 7/25/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-c.html. It 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: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. 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 and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Observations On 7/22/24 at 1:04 p.m. housekeeper (HSKP) #1 was observed cleaning room [ROOM NUMBER]. -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. On 7/23/24 at 10:36 a.m. HSKP #2 was observed cleaning room [ROOM NUMBER]. -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. C. Record review Housekeeping in-service documentation, not dated, was obtained from corporate consultant (CC) #4 on 7/23/24 at 5:15 p.m. It documented the five step daily patient room cleaning procedure included emptying trash, disinfecting horizontal surfaces, spot cleaning walls, dust mopping the floor, and damp mopping the floor. It documented the seven-step washroom cleaning process included checking supplies, emptying trash, dust mopping the floor, cleaning and sanitizing the sink and tub, cleaning and sanitizing the toilet, spot cleaning walls and/or partitions, and damp mopping the floor. -The in-service documentation did not indicate who attended the training or when the training was held. -The documentation failed to identify when housekeepers should clean resident call light cords. D. Staff interviews HSKP #1 was interviewed on 7/22/24 at 1:29 p.m. HSKP #1 said she did not clean the resident call lights when she cleaned room [ROOM NUMBER]. HSKP #1 said resident call light cords should be cleaned but did not have to be cleaned every day. HSKP #2 was interviewed on 7/23/24 at 10:56 a.m. HSKP #2 said she did not clean the resident call lights in room [ROOM NUMBER]. HSKP #2 said that housekeepers did clean resident call lights but not every day. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 7/23/24 at 1:58 p.m. The IP said the resident call lights should be cleaned because they were considered high touch surfaces that could transmit infections. The IP said resident call light cords should be cleaned every day. The IP said she had not provided the housekeeping staff with room cleaning education. The DON said the housekeeping staff were contracted outside of the facility. 40467

Based on observations, record review and interviews, the facility failed to maintain an environment for residents, staff and the public that is safe, functional, sanitary and comfortable. Specifically, the facility failed to ensure appropriate communication occurred regarding the facility's [AGE] year old hot water heater. The facility's failure to address the concerns timely resulted in the hot water heater failing and the facility was without hot water to provide a comfortable bathing experience for residents during a three week time period. Finding include: I. Facility policy and procedure The Promoting/Maintaining Resident Dignity policy, dated 1/1/23, was obtained from the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The resident's former lifestyle and personal choices will be considered when providing care and services to meet the resident's needs and preferences. II. Group resident interview Four residents (#16, #49, #59 and #65), who were identified as interviewable by the facility and assessment, were interviewed on 7/22/24 at 9:30 a.m. The following comments were made regarding the lack of hot water: -A resident said the facility had a hard time the first couple of days without hot water. The staff was not sure how to meet all the hot water needs when the hot water heater went down. The facility purchased basins to help with bathing. The staff would fill the basins with hot and cold water. -A resident said she normally had two showers a week. She said it would have been nice to have a shower but gave herself a sponge bath. She said it was hard to scrub her own back. She said the staff would offer to give her a bed bath at times. -A resident said she was worried that the lack of hot water would affect her personal hygiene and health. She said her skin had itched because she had not felt clean. -A resident said the staff would offer bed baths sometimes during the time the hot water heater was out and he would wash himself in the private areas but it was difficult. He said he felt the facility could have done more to make sure there was hot water for the showers. He said he was used to two showers a week and did not feel completely clean when he could not shower. III. Additional resident interviews Resident #16 was interviewed on 7/18/24 at 10:31 a.m. Resident #16 said the hot water went out for three or four weeks. Resident #16 said she was not able to shower during that time, and her wound care had to be provided differently than normal. Resident #16 said the lack of hot water made her feel like she wasn't getting cleaned as well or as often. Resident #16 said most residents hated the bed bath alternative that was offered during the three week period, but she said the only other choice was a cold shower. Resident #16 said she had not felt comfortable without hot water since that was a basic necessity of everyday life. Resident #65 was interviewed on 7/18/24 at 2:39 p.m. Resident #65 said he did not like either of the alternative bathing options presented so he chose to shower in cold water when the facility did not have hot water. Resident #65 said that showering with cold water day after day was an aggravating experience for him. Resident #59 was interviewed on 7/18/24 at 2:50 p.m. Resident #59 said when the hot water went out, many residents were not offered showers as often as they preferred. Resident #59 said she was offered alternative shower options but only once per week. Resident #59 said she preferred to shower three times per week. Resident #59 said she felt dirty and upset when the hot water was out and the bathing experience offered was uncomfortable for her. Resident #59 said she felt she had no other choice. Resident #10 was interviewed on 7/23/24 at 2:54 p.m. Resident #10 said the hot water was out for about three or four weeks in the facility and no one could take a hot shower. Resident #10 said she was not offered showers per her normal preference without the hot water. Resident #10 said she hated the bed bath option with water heated from the kitchen, but she would have tried that if she had ever been offered that option from staff. Resident #10 said she felt like any facility should have hot water and not being able to access warm water when she needed to had been very frustrating. Resident #40 was interviewed on 7/23/24 at 3:12 p.m. Resident #40 said she was never offered a bath in the period when the facility was without hot water. Resident #40 said she had wanted a normal hot shower like any facility should have and she just didn't want to take a cold shower. Resident #40 said she felt the bed bath option was demeaning for residents who normally showered themselves. IV. A frequent visitor (FV) was interviewed on 7/17/24 at 9:16 a.m. The FV said there was no hot water in the facility for resident showers for over three weeks between May 2024 and June 2024. She said there was a significant odor in the facility during that period of time. V. Resident council minutes The 5/28/24 resident council minutes documented the NHA said she would contact the facility's corporation on the afternoon of 5/28/24 to discuss the water heater and then would inform the residents on the water status when she knew more. The 6/24/24 resident council minutes documented the hot water heater has been fixed. VI. Record Review A 5/13/24 impromptu QAPI meeting agenda/summary form was provided by CC #4 on 7/18/24 at 5:30 p.m. The summary form read the form was to be used between meetings to address an opportunity for improvement which required immediate response. According to the summary, the opportunity for improvement was a malfunction of the singular hot water heater that provided hot water to the entire building. The form identified the facility's response/plan: -The HVAC vendor attempted to repair the hot water heater on 5/12/24. It was determined to be nonrepairable. -Ensure adequate paper products for the meals. -Ensure adequate bath packets for all residents three times a week for three weeks. -Notify residents and their families. -5/12/24 notification of the company and landlord. -Completion of a provided proposal for replacement on 5/13/24. -Educate staff on hand hygiene, bed baths and temperature safety. -Kitchen hot water and sanitation education. -Kitchen hot water and sanitation log. The 5/10/24 HVAC vendor invoice was provided by the DMS on 7/22/24 at 1:40 p.m. The invoice identified the water heater was inspected, repairs were made and the counter steamer transformer was replaced. The invoice read the water heater was not firing and water was leaking from the heat exchanger tubes, which was a sign that the water heater was going bad. The 5/12/24 HVAC vendor invoice was provided by the DMS on 7/22/24 at 1:40 p.m. The invoice read the water heater was not lighting. According to the invoice, the vendor was contacted on 5/12/24 due to the water heater not operating. The vendor arrived at the facility and observed water from the water heater was leaking onto the burners and water was leaking from the tubes of the heat exchanger. After multiple attempts to light and repair the hot water heater it was determined it was no longer safe for use and needed to be replaced. An undated HVAC vendor invoice was provided by the DMS on 7/22/24 at 1:40 p.m. The invoice read the vendor received a monetary deposit on 5/30/24 and ordered the water heaters on 5/30/24. The water heaters would be delivered from two separate supply distributors. The estimated arrival delivery date of the water heaters was on 6/4/24. The demolition of the old water heater system was started on 6/4/24. The first water heater arrived on 6/4/24 and was installed and identified as in normal operation condition. According to the invoice, the original freight company that was scheduled to deliver the remaining water heaters was not available to deliver as scheduled. The HVAC vendor company offered to pick up the water heaters and deliver them to the facility on [DATE]. Installation was started and completed between 6/7/24 and 6/10/24. The invoice read, on 6/10/24, all three water heaters were in normal operating condition. A 5/31/24 mandatory manual wash in-service was provided by CC #4 on 7/18/24 at 5:30 p.m. The attendance for the in-service was signed by 12 staff members between 5/31/24 and 6/7/24. The inservice reviewed the policy and procedure to manually wash and sanitize all cookware, silverware and serviceware that was not processed through the dish machine. The 6/10/24 HVAC vendor service receipt was provided by the DMS on 7/22/24 at 1:40 p.m. The receipt read the failure of one water heater should no longer affect the hot water supply to the facility. The June 2024 quality assurance and performance improvement (QAPI) meeting minutes were provided by the NHA on 7/23/24 at approximately 9:15 a.m. The QAPI minutes documented the following in pertinent part: Hot water heater stopped working on 5/12/24. Final repairs completed on. -The QAPI minutes did not include the date the final repairs were completed. -The QAPI minutes did not include additional review of the lack of hot water facility response or revisions made to the facility ' s emergency plan. VII. Staff interviews The director of maintenance services (DMS) was interviewed on 7/18/24 at 1:52 p.m. The DMS said on 5/12/24 the hot water heater broke. He said he contacted the NHA and the regional consultant. He said he contacted a heating, ventilation and air conditioning (HVAC) service vendor and attempts were made to repair the hot water heater but it was determined the hot water heater was not repairable. He said he and the NHA started a plan of correction. He said the facility started boiling water from the kitchen, bed bath kits were ordered and hot water was collected from the hot and cold water drink dispensing towers. He said the kitchen started using paper products for meals. The DMS said the facility corporation was contacted and told it was an emergency. The corporation requested bids for a new water heater and repairs. The DMS said the facility's landlord and stakeholder had to also approve of the process. The DMS said, overall, the whole process went well and the residents seemed accepting of the changes and complained very little. The DMS said he did not believe the facility had a hot water heater policy to outline the procedures of what to do if the facility did not have hot water readily available. He said before the hot water heater broke, the facility did not have a back up plan. The DMS said the facility now had a three water heater system so if one went out, the other water heaters would still be able to provide the facility with hot water. He said each of the new hot water heaters were 100 gallons each. The DMS said the prior water heater was over [AGE] years old and was leaking before it stopped working. He said the HVAC vendor came out to service the heater and recommended the facility get a new water heater. The DMS said he informed the NHA and his regional consultant of the recommendations but he was not sure exactly when he informed them. He said he was told to do the best he could as long as the hot water heater was still working. The DMS said there were no follow up meetings after the new hot water heaters were installed. He said the facility did not review the event after the incident to put new procedures in place. He said the facility was still pulling everything together. Certified nurse aide (CNA) #7 was interviewed on 7/18/24 at 1:55 p.m. CNA #7 said the hot water was out for about almost a month in the facility in May 2024. CNA #7 said the facility had offered residents bed baths with water warmed from the kitchen, or prepackaged bathing cloths during that time period. CNA #7 said most residents did not like either alternative bathing option. CNA #7 said a lot of residents in the facility refused baths while the hot water was out. CNA #8 was interviewed on 7/18/24 at 2:01 p.m. CNA #8 said the facility did not have hot water for three or four weeks in May 2024. CNA #8 said the facility had offered residents prepackaged bathing cloths or bed baths during that time period. CNA #8 said many residents refused both alternative bathing options while the hot water was out. Licensed practical nurse (LPN) #1 was interviewed on 7/18/24 at 2:10 p.m. LPN #1 said the facility had offered residents prepackaged bathing cloths or a warm water basin bath as alternative bathing options while the hot water was out. LPN #1 said the residents who showered themselves independently were the most upset when the facility was without hot water. The director of nursing (DON) was interviewed on 7/18/24 at 2:29 p.m. The DON said when the hot water heater broke, her main focus was the residents' personal hygiene and sanitary conditions for preparation and service. She said wound care was not impacted by the lack of hot water. The DON said more disposable paper products were ordered for meal services. She said the facility ordered shower caps, more bed bath kits and water basins. The DON said the staff tried to offer bed baths on the same days the residents were usually scheduled for their showers. She said the residents were told they could also ask for bed baths and/or wipes if they felt they needed additional bathing opportunities. She said some residents were able to bathe at their family's homes. The DON said bathing wipes were warmed to help the residents feel more comfortable. She said the temperature of the hot water from the hot water drinking dispensers was taken and used for personal washing. She said the facility verbally informed the residents about the limited hot water and families were informed by letters. She said the lack of hot water from the hot water heater lasted for about three weeks, from May 2024 to June 2024. She said the facility now had three hot water heaters so if one water heater went down the facility would still have two working hot water heaters. The DON said staff expressed some frustration during the event. She said the bed baths took more staff time and there were more resident refusals than expected. The DON said many of the residents expressed understanding of the situation. She said once the hot water heaters were replaced, all residents were back to having their regular showers scheduled. She said everything was now back to normal. The NHA was interviewed on 7/18/24 at 2:50 p.m. The NHA said when the DMS informed her of the broken hot water heater, she informed her corporate consultants and regional operation managers of the situation and started to put interventions in place. The NHA said on 5/13/24 she created a plan to review and identify needed supplies such as paper products, and bathing kits. She said she notified the residents of the situation and sent letters out by email to families. The NHA said she put together a three week plan because the HVAC vendor estimated it would take two to three weeks to have the water heater ordered and replaced. She said she discussed the costs with the corporation after getting quotes. The NHA said the facility had to decide on whether to have the hot water heater replaced quickly or take a little longer and get a better system that would include three water heaters so if one went down there would be a backup. She said by the end of the week of 5/13/24, the facility had decided to go with the three tank system. She said the hot water heaters needed to be ordered and transported from several miles away because there was nothing compatible in the area. The NHA said the HVAC vendor informed her that he would be able to do the labor within 24 to 48 hours of the delivery of the tanks. She said most of the delay for getting the hot water heater tank replaced was related to the release of the funds to the HVAC vendor so the tanks could be ordered. She said when the HVAC vendor received payment he ordered the tanks but the transportation company to deliver the tanks could only do part of the trip. She said the HVAC vendor had to find another company to transport the tanks the remainder of the way. The NHA said the tanks were delivered and installed on 6/4/24 and by 5:30 p.m. that day, the facility had running hot water throughout the facility with one domestic tank/heater operational. She said by 6/7/24, the other two tanks were installed and running. The NHA said the event was discussed in the June 2024 quality assurance and performance improvement (QAPI) meeting with the interdisciplinary team (IDT) (see record review above). Corporate consultant (CC) #4 was interviewed on 7/18/24 at 4:52 p.m. CC #4 said the facility did not have a lack of hot water policy and procedure. She said the closest the facility had was the plan created on 5/13/24, after it was determined the facility would be without hot water until the parts and repairs were in place. The DMS was interviewed again on 7/22/24 at 1:40 p.m. The DMS said he did not document his observations of the leaks with the hot water heater or communication of the leaks or invoices from the HVAC vendor when they came out to look at the leaks prior to May 2024. The HVAC service vendor was interviewed via telephone on 7/22/24 at 2:10 p.m. He said he was called out to the facility on [DATE] because the hot water heater was not firing up. He said the water was leaking from the heat exchanger tubes. He said he recommended replacing the water heater. The HVAC vendor said he replaced the burner assembly unit and transformer on 5/10/24. The HVAC vendor said he came out again on 5/12/24 when the hot water heater was not working again. He said water was leaking onto the burners and water was leaking from the heat exchanger. He said the water heater was shut off on 5/12/24 because it was no longer safe to run it. The HVAC vendor said he was at the facility in January 2024 or February 2024. He said the expansion unit on the hot water heater had a hole in the unit, but the unit was not leaking at that time. He said, due to the price, the facility did not proceed with replacing the expansion tank. He said without a working expansion unit, he was not able to determine if there were additional problems with the system. The HVAC vendor said the facility had a separate tank that was working for domestic water. He said he did not have access to the invoices from January 2024 or February 2024 to determine the date when he came out to the facility because he was no longer working for that company. The HVAC vendor said he asked the facility if they had a policy for the hot water heater and he asked for one but never got an answer or the policy. The NHA and the DMS were interviewed together on 7/23/24 at approximately 9:15 a.m. The DMS said the facility did not have a safety meeting but plant operations were reviewed in QAPI. He said the review was mainly regarding fire drills or tabletop reviews of a potential emergency. He said the facility did not identify the lack of hot water if the hot water heater went out as a potential facility emergency, however he was concerned the hot water heater would go out in the middle of the night. He said the hot water heater was over [AGE] years old and there was some leaking and some corrosion on the old pipes. He said the system would shut itself off if there was a problem for safety. The DMS said, on 5/10/24, the hot water heater system would not light. The NHA was informed of the above interview with the hot water heater service vendor. The DMS said he also saw some leaking in April 2024 and had the vendor look at it, however, he said he had not informed the NHA that the hot water heater was leaking at that time. He said part of the system related to the copper coils boiler was disconnected to stop the leak. He said the facility had been operating with the one [AGE] year old hot water heater tank since April 2024. He said the one tank was due to be replaced. He said he did not think the corporation was aware that the facility had only one tank available that was [AGE] years old. The DMS said he did not record or document the past repairs, recommendations or observations to reference but he should have. The NHA said she was not aware that a new expansion tank was recommended by the vendor in January 2024 or February 2024. The NHA said during the hot water heater event, the residents were not in danger and basic needs were accommodated for. She said after the hot water heater event she learned that the facility needed to be more prepared with needed supplies, such as disposable paper products for food. She said the facility needed to make sure they had at least three days worth of supplies on site. She said the facility needed to have more bathing kits available in case of an emergency. She said the water heater event was an emergency. The NHA said, in retrospect, the facility could have benefited from an extra certified nursing assistant (CNA) on some of the busier days. She said staff did not complain a lot but she felt some of the staff needed more training on how to manage the situation with less frustration versus increasing the number of staff. She said she would like to have the staff go through additional training on crisis management. The NHA said nothing had been scheduled yet for the training and she needed to look at the training schedule to determine when it could be set up. She said she would reach out to CC #4 and other sister facilities to see if there were training materials available. The NHA said to directly prevent the lack of hot water available, the new hot water system was purchased. The NHA said she did not have documentation that a post review of the hot water event was conducted or actions moving forward to prevent similar situations other than a reference in QAPI. She said she and the dietary manager verbally talked about the needed kitchen supplies and steps to take during the water heater event, but a procedure was not created and put in place after the water heater event to help mitigate future emergencies that involved the kitchen. The NHA said she would like to have three weeks for some supplies in the event of an emergency but had to see where there was enough space to stock the supplies. The NHA said reviewing the event following the incident on what the facility learned and what the next steps were to put in motion to help with future emergencies could use improvement. The NHA said the facility did not have a specific lack of hot water plan but it would be appropriate to have a policy in place. She said she would reach out to her corporate resources on how to create the policy and procedures. She said the policy would be implemented and added to the facility's emergency plan. The NHA said if the facility had a policy and procedure available, she would have added it with her plan as part of the facility's response and use it as additional guidance. 50314

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive and at the appropriate temperature. Specifically, the facility failed to ensure food was palatable and attractive when delivered to residents. Findings include: I. Resident interviews Resident #65 was interviewed on 7/17/24 at 11:54 a.m. Resident #65 said when he received his breakfast in his room it was always served cold and under seasoned. Resident #49 was interviewed on 7/18/24 at 8:40 a.m. Resident #49 said the food was bland and had no taste. He said he received cold food. Resident #13 was interviewed on 7/18/24 at 10:34 a.m. Resident #13 said breakfast was always served cold. She said she was the last resident to get her tray. Resident #28 was interviewed on 7/18/24 at 11:56 a.m. Resident #28 said the food tasted awful and the meals were frequently served cold. Resident #28 said he had received undercooked chicken so he ordered something different if chicken was being served. II. Resident group interview Four residents (#65, #16, #59 and #49), who were identified as interviewable by the facility and assessment, were interviewed on 7/22/24 at 9:30 a.m. Residents made the following comments: -The vegetables were soggy or uncooked; -The meals were served cold; -Food items were switched out (received chips instead of french fries); -Food items were served burnt; and, -The meat was undercooked. III. Test tray A test tray was evaluated by three surveyors on 7/22/24 at 12:29 p.m. The test tray consisted of cheesy ham and macaroni casserole, sauteed garlic and spinach, pineapple tidbits and a dinner roll. -The cheesy ham and macaroni casserole was dry, bland and did not have a cheese sauce mixed through it. - The spinach tasted plain and did not have garlic seasoning. IV. Food committee notes The food committee notes were provided by the nursing home administrator (NHA) on 7/22/24 at 4:00 p.m. The food committee notes from 5/7/24 revealed the kitchen was still working on proper food temperatures and appealing plating. The food committee notes from 6/4/24 revealed the kitchen was still working on proper food temperatures and appealing plating. The food committee notes from 7/16/24 revealed the kitchen was working on ensuring food was properly cooked before it was served and getting the meals out on time and promptly. V. Staff interviews The cook (CK) was interviewed on 7/22/24 at 11:30 a.m. The CK said he seasoned the meals based on what the recipe indicated. The dietary manager (DM) and the dietary consultant (DC) were interviewed together on 7/23/24 at 10:15 a.m. The DM said she and the DC were worried about the pineapple not being on ice during the meal service and had placed the last tray of pineapple in the refrigerator to try to cool it down before the last half of the residents were served. The DC said the CK was supposed to put poultry gravy over the top of the casserole for all residents who were on a dysphagia altered diet. The DC said the cheesy ham casserole was dry and bland because the CK was adding poultry gravy to the casserole for the residents but failed to add it to the test tray. She said the CK was worried about how the gravy tasted on top of macaroni and cheese and omitted it from the test tray. The DC said she was going to review the recipes. She said she would let the kitchen staff know if the recipe indicated to provide a sauce, it needed to match the menu item and not just a form of gravy. She said the CK should have provided a cheese sauce to the residents on a dysphagia diet and the test tray, instead of gravy, since it was a macaroni and cheese type of casserole. The DM said she tried to follow-up on the residents' concerns in food committee meetings but she had a budget she had to stay under and she tried her best to please the residents while not going over the budget. The DC said the DM needed to make sure the residents were happy and not focus on the budget as much. The DC said she was going to work with the DM to fix the concerns in the kitchen.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two of two kitchenettes. Specifically, the facility failed to: -Ensure residents were offered and provided hand hygiene before meals; -Ensure the kitchen staff appropriately cleaned thermometers before temperatures were obtained from ready-to-eat foods; and, -Ensure cold foods were held at 41 degrees Fahrenheit (F) or below before serving residents. Findings include: I. Resident hand hygiene A. Facility policy and procedure The Handwashing and Hand Hygiene policy, revised August 2019, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Wash hands with soap and water when hands are visibly soiled. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: before and after direct contact with residents, and before and after eating or handling food. B. Observations On 7/17/24 during a continuous observation, beginning at 11:49 a.m. and ending at 12:58 p.m., the following was observed in the main dining room: At 11:55 a.m. Resident #5 was observed self-propelling herself in the dining room. The resident shook the hands of Resident #27 and Resident #70. After shaking hands, Resident #5 then self-propelled herself to a dining table. At 12:08 p.m., Resident #5 was served her lunch plate by staff, which included peas, a dinner roll, meatloaf, mashed potatoes and an ice cream cup. -The resident was not offered hand hygiene by staff members. At 12:10 p.m., Resident #5 began eating her lunch plate. Resident #5 used her fingers to scoop the ice cream out of the ice cream cup and then eat the ice cream. The resident frequently licked her fingers between bites of the ice cream she was scooping out with her fingers. After finishing her ice cream with her hands, she began picking up pieces of meatloaf, peas and mashed potatoes with her hands. The resident continued to lick her fingers between small scooping bites which she ate with her fingers. The resident had been provided with tableware but did not attempt to use it. At 12:15 p.m., Resident #70 began eating his dinner roll with his hands. -Resident #70 had not been offered hand hygiene after he shook hands with Resident #5. At 12:19 p.m., Resident #27 began eating his dinner roll with his hands. -Resident #27 had not been offered hand hygiene after he shook hands with Resident #5. At 12:36, Resident #5 finished eating. After licking her fingers, she self propelled herself in her wheelchair and shook hands with Resident #27. After shaking hands with Resident #27, Resident #5 self-propelled herself out of the dining room. -The facility failed to offer hand hygiene to Resident #5 before or after meals. -The facility failed to offer hand hygiene to Resident #27 or Resident #70 when their hands became contaminated. C. Resident interviews Resident #16 was interviewed on 7/18/24 at 10:31 a.m. Resident #16 said the facility did not offer hand hygiene before or after meals in the main dining room. Resident #16 said the facility used to have hand sanitizer on dining room tables but one resident ate the hand sanitizer and there had not been hand sanitizer available in the dining room for residents since that incident. Resident #27 was interviewed on 7/18/24 at 11:13 a.m. Resident #27 said the facility sometimes offered hand hygiene before meals but it was not done consistently. Resident #27 said he would like to be able to clean his own hands when he wanted to during meals but he said he would have to either leave his table or bother the busy staff to do so. D. Staff interviews The dietary manager (DM) was interviewed on 7/23/24 at 10:15 a.m. The DM said it was the nursing staff's responsibility to provide the residents with hand hygiene at meals. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 7/23/24 at 1:58 p.m. The IP said all residents should be offered hand hygiene before and after all meals. The IP said the dining room staff should offer hand hygiene to residents that were eating with their hands. The DON said she was not aware of any concerns with hand hygiene of residents in the dining room. II. Improper cleaning of food thermometer A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 7/28/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, revealed in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. Utensils shall be cleaned before using or storing food temperature measuring devices. B. Lunch observations on 7/22/24 at 11:30 a.m. The cook (CK) grabbed five thermometers to obtain the temperatures of lunch before service began. The CK uncovered one thermometer and immediately placed it in the pureed spinach. The CK uncovered the second thermometer and immediately placed it in the pureed cheesy ham and macaroni casserole. The CK uncovered the third thermometer and immediately placed it in the dinner rolls. The CK uncovered the fourth thermometer and immediately placed it in the vegetable soup. The CK uncovered the fifth thermometer and immediately placed it in the mashed potatoes. -The CK did not sanitize any of the thermometers prior to putting them into the food to obtain the temperatures. C. Staff interviews The CK was interviewed on 7/22/24 at 11:45 a.m. CK said he assumed the thermometers were disinfected from the last time the thermometers were used. The CK said the thermometers appeared clean. The DM and the dietary consultant (DC) were interviewed together on 7/23/24 at 10:15 a.m. The DM said the staff were to gather the thermometers, temperature recording log and alcohol wipes. She said the staff needed to use an alcohol wipe to clean the thermometer when the cover was removed because staff should not assume the thermometers were clean. The DM said she disinfected the thermometers after the CK took the initial temperatures but failed to see he did not disinfect the thermometers prior to use. The DC said the CK should have sanitized each thermometer before he placed the thermometers in the food and it was unacceptable to assume the thermometers were already sanitized. III. Correct cold food holding temperatures A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 7/28/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/views, read in pertinent part, Except during preparation, cooking, or cooling, or when time is used as the public health control time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. The FDA (Food and Drug Administration) food code (3/27/23) was retrieved on 7/28/24 from https://www.fda.gov/food/fda-food-code/food-code-2022. It read in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long. B. Observations On 7/22/24 at 11:30 a.m., the CK obtained the temperature of the two trays of individually portioned pineapple sitting on the counter near the serving line. He said one tray was 45 degrees F and the other tray was 42 degrees F. C. Test tray A test tray was evaluated by three surveyors on 7/22/24 at 12:29 p.m. The test tray consisted of cheesy ham and macaroni casserole, sauteed garlic and spinach, pineapple tidbits and a dinner roll. -The temperature of the pineapple was 47.5 degrees F. D. Staff interviews The CK was interviewed on 7/22/24 at 11:30 a.m. The CK said he preferred the temperature of cold items to be below 39 degrees F but the pineapple was okay to be served at the temperatures he got. The DM and the DC were interviewed together on 7/23/24 at 10:15 a.m. The DM said she was concerned about the pineapple not being on ice while lunch was served. The DC said she moved the last tray of pineapple to the refrigerator until it was needed for lunch. The DC said she hoped it would keep the pineapple cold and at the proper temperature. The DC said the trays the pineapple was on should have had ice under them to keep the pineapple at the correct temperature.

Based on record review and interviews, the facility failed to ensure the money from personal funds accounts was managed adequately for two (#7 and #13) of five residents reviewed for personal funds out of 41 sample residents. Specifically, the facility failed to notify Resident #7 and Resident #13, who were Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person. Findings include: I. Facility policy and procedure The Management of Residents' Personal Funds policy, revised March 2021, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, The facility manages the residents' funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident. No service charge is levied against the resident for the management of personal funds. II. Record Review A. Resident #7 A review of the facility's current trust account balance on 7/18/24 revealed Resident #7 had $2,083.69 in her account, which was $83.69 over the allotted $2000.00 eligibility limit for Medicaid funded residents. -There was no documentation to indicate the facility had notified Resident #7 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. B. Resident #13 A review of the facility's current trust account on 7/18/24 revealed Resident #13 had $1,876.24 in her account. -There was no documentation to indicate the facility had notified Resident #13 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. III. Staff interviews The business office manager (BOM) was interviewed on 7/22/24 at 3:04 p.m. The BOM said she had not provided letters to Resident #7 and Resident #13 stating they were within $200 of the Medicaid spending limit. The BOM said she was trained by the regional personnel at the same time as a few other BOM's at other health care facilities. She said she was concerned that some business office education may have been lost in the training process. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 7/23/24 at 4:53 p.m. The NHA said she was not aware that Medicaid letters had not been sent when residents were within $200 of the spending limit. The DON said Medicaid spending limit letters should be provided to residents.

Based on record review and interviews, the facility failed to manage severe intractable pain for one (#3) of 16 sample residents. Resident #3 was admitted to the facility from the hospital on [DATE] with severe pain from cancer that had metastasized to her bones. Resident #3's goal was rehabilitation therapy and strengthening so she could be discharged home with family. Resident #3 had severe pain and physician orders for regularly scheduled and as-needed (PRN) pain medications. However, the resident was only given one dose of PRN pain medication, her daily ordered pain patch was never administered during her stay at the facility, and Resident #3 continued to suffer excruciating pain rated at severe levels, of 8, 9, and 10 out of 10 on ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. Her physician was not notified at any time about her severe intractable pain. On [DATE], she was readmitted to the hospital and did not return to the facility. Findings include: I. Facility policy The Pain Management policy, dated [DATE], provided by the regional director of operations (RDO) on [DATE] at 3:00 p.m., included in pertinent part: Pain is subjective and is what the resident says it is, existing when and where the resident says it does. Purpose: To accurately assess and achieve pain control. This does not necessarily mean the resident is pain free. Acceptable (tolerable) pain control is defined by the resident. Procedure: The pain evaluation includes the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness. All subsequent pain evaluations will be documented on the Pain Evaluation in PCC (point click care, the electronic medical records system) and/or the MAR (medication administration record) as applicable, to include location, intensity rating and response to pain management interventions. Document your findings on the Pain Evaluation in PCC and/or MAR as applicable. Considerations: Around the clock (ATC) dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management. Intermittent pain can be managed with intermittent (PRN) analgesic administration. (Every shift pain checks on the MAR should be completed after the resident receives the routine medication.) Titration is the manipulation of dose (up or down) to attain the greatest pain control with the least amount of side effects. Rescue doses (bolus) may be prescribed for periodic breakthrough or incident pain related to activity, treatment and/or diagnostic procedures. Residents are started on an appropriate bowel program whenever analgesic medications are prescribed. Associated symptoms are evaluated and aggressively treated. Nausea, vomiting, itching, somnolence, anxiety, depression, fear of addiction, fatigue and insomnia are amenable to simple remedies. Left untreated they can have a profoundly negative effect on the resident's morale and pain perception. Success rate is increased utilizing a multi-disciplinary, multi-treatment modality approach and using a combination of analgesic and adjuvant drugs and therapies. Do not forget the non-pharmacological interventions such as repositioning, relaxation, aromatherapy, visualization, desensitization, massage and humor therapy. Non-pharmacological interventions should be documented in progress notes and included on the individual resident care plan. II. Resident status Resident #3, age 81, was admitted on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of vulva and breasts; secondary malignant neoplasm of bone; right lower quadrant and abdominal pain; pain, unspecified; intra-abdominal and pelvic swelling, mass and lump and Crohn's (inflammatory bowel) disease. A minimum data set (MDS) assessment was not completed due to Resident #3's recent admission. According to the [DATE] nursing admission assessment, Resident #3 was alert and oriented to person, place, time, and situation. She needed extensive assistance for transfers, bed mobility, eating, and drinking; was totally dependent for dressing and incontinence care, had generalized weakness and used a wheelchair for ambulation. She had generalized, severe pain at 9 out of 10 on a scale of 1 to 10 and was unable to state her acceptable level of pain. She exhibited grimacing, clenched jaw, frowning, tearfulness/crying, a furrowed brow, moaning, grunting and was frightened. Her pain was relieved by medication and cold (ice packs). Her pain management medications were morphine sulfate twice daily and oxycodone 10 mg every four hours PRN (as needed). The admission nurse documented Resident #3 was in constant pain. -Resident #3's pain patch (see order below) was not documented in the assessment as a pain relief measure. III. Record review - failure to manage Resident #3's severe intractable pain as expected per facility policy, as care planned, and as ordered. A. Care plan Resident #3's care plan, initiated on [DATE] and not revised, identified pain related to bone cancer with the goal for inadequate pain relief to be minimized. Interventions included: administer analgesia (pain medication) as per orders; evaluate the effectiveness of pain intervention; review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; monitor/document for probable cause of each pain episode, remove/limit causes where possible; monitor/document for side effects of pain medication; observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls; report occurrences to the physician; notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain; offer non-pharmacological interventions for pain prior to administering medication and PRN. -Non-pharmacological interventions for Resident #3 were not specified or person-centered. The facility failed to administer analgesia per orders, evaluate the effectiveness of pain interventions to alleviate symptoms and resident satisfaction with the results, and failed to notify the physician when Resident #3's pain was not relieved, or timely when she experienced side effects including nausea/vomiting and constipation (see nurse's note prior to hospital discharge below). B. Orders The CPO documented the following pertinent orders: -Monitor pain every shift using ,d+[DATE] pain scale; -Acetaminophen 8 hour oral tablet extended release 650 mg, every eight hours as needed for pain; -Lidocaine external patch 5%, apply to right inner thigh topically one time a day for pain, remove in 12 hours; -Morphine Sulfate ER oral tablet extended release 30 mg, three times a day for pain; and -Oxycodone HCI oral tablet 10 mg, every four hours as needed for pain. C. Nursing progress notes, therapy notes, medication administration record, and vital signs/pain level documentation during Resident #3's stay (in pertinent part) On [DATE] at 5:02 p.m., order notes documented the Acetaminophen order was outside of the recommended dose or frequency, because the daily dose of 650 mg is below the usual dose of 1,300 to 3,900 mg. -There was no evidence the physician was called for order clarification. On [DATE] at 5:10 p.m., an administration note documented, Resident arrived and is having severe pain, Oxycodone (10 mg) pulled from STAT (emergency) safe. -The medication administration record (MAR) documented 10 mg Oxycodone was given on [DATE] at 5:10 p.m., and documented as ineffective. However, there was no evidence the physician was notified of the resident's severe pain and that the pain medication was ineffective. -Further, there was no evidence of non-pharmacological interventions, where the pain was or a description of the pain, and no evidence nursing staff assessed the effectiveness of the medication until six hours after the Oxycodone was administered (see below). The physical therapy (PT) evaluation and plan of treatment documented on [DATE] read in pertinent part, the reason for referral was medical history of breast and vulva cancer with bone metastasis, osteoarthritis, Crohn's disease, status post left knee surgery, failed chemotherapy and radiation in past. The resident Had onset of severe pain R (right) inguinal (groin) area approximately 5 (five) weeks ago, has not been ambulatory x (for) ,d+[DATE] weeks d/t (due to) pain. Pt (patient/resident) underwent recent resection (surgical removal) of mass right groin with biopsy positive for reoccurrence of vulva CA (cancer). Precautions: full code, intractable pain - must have medications prior to treatment, bone metastases. Patient has pain levels at ,d+[DATE]. A and O x 4 (alert and oriented to person, time, place, situation), tearful, moaning secondary to pain. Pt undecided vs possible hospice? Severe pain, surgical site, right groin, lower extremities. On [DATE] at 8:00 p.m., scheduled morphine was documented as given. -There was no evidence the effectiveness of the morphine was assessed. At 11:15 p.m., six hours after the PRN Oxycodone administration (and more than three hours after morphine administration), it was documented in nursing progress notes as Ineffective and the resident's follow-up pain scale was 10 out of 10. -There was no documentation of what was done to relieve Resident #3's severe 10 out of 10 pain, which per pain scale assessment is defined as excruciating, even though the resident's pain was documented as severe when the Oxycodone was given. There was no documentation that the physician was notified. The ordered Lidocaine patch was not added to the MAR and was never documented as administered. On [DATE], scheduled morphine was documented as given at 8:00 a.m. and 2:00 p.m. However, at 9:37 a.m. Resident #3's pain level was 10 according to vital signs/pain level documentation. -No PRN pain medication was given and the physician was not notified. On [DATE], no time documented, a PT treatment encounter note documented in pertinent part, Intractable pain - must have meds prior to treatment, bone metastasis, severe pain. Educated pt about pressure sores and continuing to move LEs (lower extremities) and rest in neutral. Pt reports she is unable to do this because of pain levels. Spoke w/ nursing about pain management. Pt participates in therapy today but is extremely limited d/t levels of pain. Son is present with her today and reports that she needs to be doing therapy. Spoke with nursing regarding pain management. Response to session interventions: Patient not finding relief from pain meds provided by nursing, very tearful and sobbing, moaning and holding self, not allowing or participating in motion. Goals for therapy include going home and not long term functional status. Goal is independence with personal care to allow son to care for resident at home. On [DATE] at 8:00 p.m., scheduled morphine was given per the MAR. At 8:25 p.m., Resident #3's pain level was documented as 8 out of 10 on the vital signs/pain level sheet. -No PRN pain medication was given and the physician was not notified of Resident #3's unrelieved pain. On [DATE] at 8:00 a.m., scheduled morphine was given. At 8:16 a.m., Resident #3's pain level was 9 out of 10 per the vitals/pain level sheet. -There was no documentation the nurse re-assessed the effectiveness of the morphine. On [DATE] at 2:00 p.m., scheduled morphine was given. -There was no documentation of effectiveness and no pain level was documented. On [DATE] at 8:00 p.m., scheduled morphine was given. On [DATE] at 8:40 p.m., Resident #3's pain level remained severe at 8 out of 10 per the vitals/pain level sheet. -There were no further pain level assessments on [DATE]. No PRN pain medications were given. The physician was not notified of the resident's severe pain. On [DATE] at 8:00 a.m., scheduled morphine was given. On [DATE] at 8:58 a.m., Resident #3's pain level remained severe at 8 out of 10 per the vitals/pain level sheet. -There was no documentation the physician was notified or that PRN pain medication was offered. PT treatment encounter note on [DATE], no time noted, documented in pertinent part, (The resident had) Intractable pain - must have meds prior to treatment, bone metastasis, no BM (bowel movement) x 10 days, abdominal distension. Pt with abdominal distension, bloating and gas, pt had suppository placed with no results. Pt seen for abdominal massage to facilitate movement of fecal matter. Performed gentle knee to chest x 5 (five) held each x 1 (one) minute, fb (followed by) 10 minutes of stroke from pelvis to ribs, fb effleurage tracing the colon moving clockwise .able to palpate several hard lumps in transverse colon which moved during course of treatment from R upper to L (left) upper segment. Performed kneading to L upper abdomen fb umbilical region and finally gentle vibration to abdomen to help facilitate passing of gas. As treatment was concluding paramedics entered the room to transport patient for disimpaction as she was unable to pass any gas or fecal matter. On [DATE] at 1:00 p.m., a change of condition note, and a 1:59 p.m. nurse's note documented Resident #3's vitals were taken at 9:34 a.m. Resident #3 was documented as alert and oriented to herself with confusion noted to place, time and situation. She used pads/briefs due to incontinence; her urine was slightly red in color. The date of her last BM was blank. Her abdomen was distended and hard. N/v (nausea/vomiting) noted. Resident stated that when she vomited she had dark red spots in the vomit. Nurse noted that resident does have a dx (diagnosis) of malignant neoplasms throughout body. Resident has not had a BM since admission here. No bowel sounds noted. Abdomen is distended and board like. Breath sounds were diminished with shortness of breath upon exertion. Heart sounds, radial pulses and pedal pulses were normal. Resident verbalizes presence of pain. Resident stated that her lower abd (abdomen) and pelvic area with her right leg hurt at a level 8 on the pain scale. The physician was notified and he stated to send her to the ER (emergency room ) for bowel intervention. Suppository ordered. Medication side effects: no. Notes on medications/treatments: no . Resident is receiving PT (physical therapy) and OT (occupational therapy) services. Resident requires 2 staff member extensive assist with ADLs (activities of daily living) and bed mobility. She has been bed bound since admit d/t (due to) extreme pain and inability to move r/t (related to) cancer. The [DATE] PT discharge summary documented in pertinent part, Direct, hands-on care with patient this reporting period focused on the following skilled interventions: bed mobility, positioning, therapeutic abdominal massage and discussion with PTA (physical therapy assistant) re([NAME]) plan of care, caregiver and patient education and training, equipment assessment. Poor response d/t severe intractable pain, distension of abdomen and dx (diagnosis) of bone metastasis. Correspondence with primary caregivers to facilitate development and follow-through of patient's plan of treatment. Functional skills reviewed with team members, reviewed patient's plan of treatment and treatment services with interdisciplinary team members and treatment results communicated to interdisciplinary team. E. Summary of Resident #3's pain management Resident #3 was discharged to the hospital on [DATE]. During her stay at the facility, Resident #3 had received scheduled morphine three times per day and PRN Oxycodone one time on the evening of [DATE]. She did not receive and there was no evidence she was offered PRN Oxycodone on ,d+[DATE], ,d+[DATE], or [DATE]. She never received the ordered Lidocaine patch or PRN Acetaminophen for pain. Her pain level was always documented as severe at 8, 9, or 10 out of 10; however, nursing staff failed to notify the physician of her severe intractable pain. IV. Staff interviews Licensed practical nurse (LPN) #3, the nurse who admitted Resident #3 on [DATE], was interviewed on [DATE] at 5:45 p.m. She said she recalled Resident #3 required total care and was in a lot of pain. She was in bad shape; it was so sad. She said just touching the resident's arm or moving her leg caused her severe pain. Repositioning her in bed was extremely painful. LPN #3 said the nurses gave Resident #3 what they could for pain but nothing touched her pain. She said she did not call the doctor to report Resident #3's severe pain. The doctor knew. She came from the hospital. The assistant director of nursing (ADON) was interviewed on [DATE] at 6:00 p.m. She said the evening Resident #3 was admitted she gave her the PRN Oxycodone from the emergency kit and she was gone for the weekend after that and did not see Resident #3 again. Certified nurse aide (CNA) #1 was interviewed on [DATE] at 7:15 p.m. She said she only worked with Resident #3 the one Sunday night she was in the facility ([DATE]). She was in a lot of pain. She said Resident #3 was having leg pain and they applied ice through the night. The resident ended up vomiting a bit. She said she reported the resident's pain and vomiting to the nurse but she did not recall if the nurse went in to see the resident. She (Resident #3) didn't want to take the Oxy (Oxycodone); she was worried about her bowels. The CNA said Resident #3 ended up going to the hospital after that. -The resident's vomiting was not documented in nursing notes on [DATE], nor was it documented in nursing notes that ice was ever applied, or that Resident #3 did not want to take Oxycodone because of constipation side effects. LPN #2 was interviewed on [DATE] at 9:00 a.m. She said she was not Resident #3's direct care nurse, but assisted with transfers and compassionate care as part of a nursing team effort. She recalled Resident #3's stay in the facility as a sad situation, cancer with mets (metastasis) to the bones; she needed medication management. She said to her understanding PT had gone in to address Resident #3's issues the day she was admitted . The LPN became tearful as she talked about Resident #3's pain. I don't think you can touch that (type of pain). She said Resident #3 was sent to the emergency room to alleviate her pain. The director of rehabilitation (DOR), a physical therapist, was interviewed on [DATE] at 10:52 a.m. with the regional therapy mentor (RTM) present. The DOR said the nursing staff asked her to see Resident #3 after she was admitted to the facility on [DATE]. She said she moved in on Friday afternoon and left Monday morning. The DOR said she was concerned about working with Resident #3 aggressively because she was in so much pain. She did a PT assessment and it took almost two hours to get her relaxed and comfortable enough to get situated in bed. She complained about her pain. The nurses were very concerned about how to position her because she was so uncomfortable when she arrived. She wasn't tolerating any of it so they got me in right away. She said she and Resident #3 discussed bed mobility and she spent almost the entire therapy session time trying to find a comfortable position for her. She said the ADON spent quite a bit of time working on trying to get her comfortable. She said they were able to pull the resident up in the bed and get her into a supine position as opposed to on her side. She was still hurting. It did look like ,d+[DATE] pain - it said so in the chart so I knew what to expect. She was nonverbal for the first half hour and then was able to agree to let us move her, give us some information, and was able to be more verbal so the pain medication must have helped. -However, that one dose of PRN Oxycodone was the only one Resident #3 was documented to have received during her stay in the facility. The NHA, DON, and RDO were interviewed on [DATE] at 3:48 p.m. regarding pain management for residents with intractable pain. The DON said they could only provide what the hospital sends. The RDO said she would expect nursing staff to offer PRN pain medications and document if a resident declined the medications. The RDO said she would notify the physician or send the resident out to the hospital if there were concerns about her symptoms. I understand there were some constipation concerns. I'd want it clearly documented so we knew the story. She acknowledged the nursing notes did not give a good picture of what was provided for Resident #3 regarding pain and symptom management. She said in Resident #3's case she would expect the nurses to notify the physician. The RDO said she had conducted nurse training regarding pain management expectations (see below), which had been provided to all the nurses currently on duty in the facility. V. Facility follow-up (during survey) A Pain Management Education document, dated [DATE], was provided by the RDO on the morning of [DATE]. Seven nurses signed to verify they had received the training on [DATE] per the education sign-in sheet. The training included the following: All residents need to be assessed for pain every shift. Document all non-pharmaceutical interventions provided to relieve pain. Offer PRN pain medications as appropriate and document effectiveness. Administer all routine medications per provider order. If non-pharmaceutical and pharmaceutical pain management interventions are ineffective you must notify the provider. If interventions are ineffective, you must document additional interventions offered and implemented. Document the outcome of all interventions both pharmaceutical and non-pharmaceutical. When interventions are ineffective you must document other interventions attempted. Tell the story. Take credit for the care you provide. The RDO said in an interview at 5:15 p.m. on [DATE], that each nursing staff would receive the training prior to working their next shift. VI. Family interview Resident #3's son was interviewed by phone on [DATE] at 11:04 a.m. He said, Mom had bone cancer with horrible pain. He said he arrived at the facility about two or three hours after she was admitted . When I get there she's kind of curled up in a ball. She said they hadn't given her anything for pain. He went to the nurse's station and asked what they were doing for the resident's pain and they said they could probably find some Oxycodone or something for her. They found Mom one pill after I went there and expressed my concern about the pain she was in. At that point, I just wanted to get my mom the help she needed. The pill didn't even touch the pain, the bone cancer was so severe. He said when he left the faciity on [DATE] it was evening and the sun was starting to set. Mom was absolutely still in pain. She was still crying, literally crying, and she was a tough woman. To see her cry from pain I knew something was extremely serious and bad. He said nobody ever showed him or Resident #3 the physician's orders so he would know what she was supposed to have for pain. He said Resident #3 asked several times for pain meds and they said they had to check and see what her next scheduled medication was, then they would return and say she had to wait another half hour or whatever. The resident's son said he did not know there were any as-needed pain medications available for Resident #3 until she was later admitted to the hospice inpatient facility. I'm angry that she suffered because nobody told me she had as-needed pain medications. They made no attempt to manage the pain. They just left her in the corner of that room . Too many people to care for and they just didn't have time for her. The resident's son said Resident #3 was admitted to the hospital from the facility. He refused to allow the hospital to return her to the facility and ensured she went home with him from the hospital. From there she was admitted to the hospice inpatient facility where he said they managed her pain and treated her with dignity until her death on [DATE].

Based on record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for seven (#32, #40, #49, #56, #57, #71 and #226) of nine residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to ensure Resident #32 was free from physical harm and mental anguish. Resident #32 was hit repeatedly in the face by Resident #56 on 12/18/22, resulting in facial lacerations, swelling, and feelings of fearfulness and anxiety. Resident #56 continued to exhibit intimidating behaviors towards that resident in the days following the 12/18/22 altercation. In addition, the facility failed to ensure Resident #40, Resident #49, Resident #57, Resident #71 and Resident #226 on the secured/memory care unit were free from resident-to-resident altercations. Findings include: I. Facility policy The Elder Justice Act and Reporting Suspected Crimes Against Residents policy and procedure, dated 2017, was provided by the facility on 1/26/23. The policy read its purpose was: To facilitate efforts to prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation and to protect elders with diminished capacity while maximizing their autonomy and their right to be free of abuse, neglect, and exploitation. II. Incident #1 A. Resident status 1. Resident #32, age 95, was readmitted on [DATE]. He resided in the secured/memory care unit. According to the January 2023 computerized physician orders (CPO), diagnoses included delirium due to known physiological condition, and unspecified dementia with unspecified severity without behavioral disturbance. The 12/13/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident exhibited inattention, disorganized thinking and an altered level of consciousness. The resident did not exhibit behaviors of concern during the seven day assessment period. The review of the January 2023 care plan did not identify the resident was at risk for abuse or the resident had an actual resident to resident altercation. 2. Resident #56, age 83, was admitted on [DATE]. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease; major depression; and, unspecified dementia with unspecified severity without behavioral disturbance. The 11/10/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of one out of 15. The resident exhibited disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. The behavior care plan, initiated 1/21/23, identified Resident #56 had the potential to be physically aggressive towards others related to his dementia. B. Record review An investigation of alleged physical abuse was initiated on 12/18/22. According to the investigative record, Resident #32 was in bed when his roommate (Resident #56)was documented to trip over Resident #32's walker and hit Resident #32 in the face on 12/18/22 at 6:30 p.m. The report read Resident #32 had a small superficial laceration on the bridge of his nose and upper lip. The report identified the staff controlled his bleeding and cleaned his wounds. The report indicated the police was contacted, Resident #32 and Resident #56 were separated in two different rooms, and were put on one-to-one monitoring until they fell asleep. The investigation report's conclusion read the facility was unable to substantiate physical abuse at this time because there was no injury. The facility was unable to determine intent, due to the assailant's (Resident #56) cognitive status at time of the incident. Under the investigation's conclusion was a handwritten note that read Asked to change to substantiate. Upon clarification, the interim nursing home administrator/director of operations (INHA/DO) reviewed the investigation and requested the nursing home administrator (NHA) to substantiate the abuse findings, as identified in a 1/25/23 interview below. The 12/18/23 change of condition nursing note/situation-background-assessment-recommendations form (SBAR) read Resident #56 started talking fast and oddly, stating Everyone wants to kill me. According to the note, Resident #56 standing over Resident #32, punching Resident #32 in the face. The 12/19/22 at 2:18 a.m. nursing note read Resident #32 appeared to still be a little anxious due to an altercation with his roommate. The 12/19/22 at 12:44 p.m. nursing note read Resident #32 was sent to the hospital per his family's request, post assault by his roommate. The note identified the resident had been punched in the face and received a split lip, bruise under his left eye, and swollen nose with a laceration to the bridge of the nose. The 12/19/22 emergency department (ED) report read Resident #32 suffered facial injuries from unspecified assault, likely being punched in the face. Resident #32 had swelling and contusions to his face and nose. The ER report read emergency medical services (EMS) reported Resident #32 was assaulted on 12/18/22. According to the report, the resident was hit five times in the face. Resident #32 was provided pain medication, ice, and discharged back to the facility's memory care unit. The 12/20/22 nursing note read Resident #32 was up all night due to fear of being assaulted again. The resident was provided with one-to-one attention. According to the note, Resident #56 continued to pace near Resident #32 for about three hours. The 12/20/22 administration note, documented in the medical record of Resident #56, read Resident #56 was pacing and staring down another resident. The resident was placed on one-to-one monitoring and implemented a medication change to help with his agitation. The 12/24/22 nursing note read Resident #32 did not want to remain at the facility. According to the note, Resident #32 was afraid and not sleeping well after being hit. The note read the staff assured him that he was safe now that he was close to the nursing office and his roommate was in another room. The 12/27/22 nursing note read Resident #32 still spoke about feeling fearful after being punched. III. Incident #2 and #3 with Resident #57 and Resident #226 A. Resident status 1. Resident #57, age 71, was admitted on [DATE]. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Wernicke's encephalopathy (a brain disorder causing confusion), anxiety disorder, and delusional disorders. The 12/19/22 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The resident exhibited disorganized thinking and inattention. According to MDS assessment, the resident exhibited physical and verbal behaviors directed towards others. The behavior care plan, initiated on 1/24/23, read the resident had the potential to become verbally or physically aggressive towards other residents. Her care plan goal was to not harm or be harmed by others. 2. Resident #226, age 62, was admitted on [DATE]. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease, early onset, bipolar disorder, and unspecified dementia with unspecified severity with agitation. The 12/22/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident exhibited disorganized thinking and inattention. The resident exhibited physical and verbal behaviors directed towards others, impacting their care and social interactions. According to the MDS assessment, Resident #226 put others at significant risk for injury. The behavior care plan, initiated on 12/27/22, read the resident had potential for physical and verbal outbursts related to her dementia, bipolar disorder, and poor impulse control. B. Record review 1. Incident on 12/11/22 between Resident #226 and Resident #57 The 12/11/22 at 4:00 p.m. behavior note documented in the medical record of Resident #226 read Resident #226 was very anxious, and briskly pacing in and out of rooms, and up and down the hall. According to the note, a resident (Resident #57) started to yell at her. Resident #226 proceeded to throw juice at Resident #57. The 12/11/22 at 4:02 p.m behavior note documented in the medical record of Resident #57 read Resident #57 was yelling at a newly admitted resident to the facility. A resident (Resident #226) proceeded to throw juice at Resident #57, making contact with Resident #57's chest. According to the note, Resident #57 felt frustrated and needed to be cleaned up. An investigation of a resident to resident altercation was initiated on 12/11/22, however, according to the investigative record, the event was incorrectly documented on 9/23/22 at 4:00 a.m. between Resident #226 and #57. The investigation documented the yelling and juice incident and identified all residents (on the memory care/secured unit) were placed on observation for any changes in behavior due to the incident. As a result of the incident, the facility was to create a non-pharmacological plan to assist with the behaviors of Resident #226. The 12/12/22 at 4:57 a.m. behavior note identified the resident had an increase in behaviors following the incident. The behavior note read Resident #57 got out of bed several times throughout the shift, wandering the hallway and exit seeking. According to the note, the resident would be verbally abrasive and shoot the finger several times when the staff guided her back to her room. 2. Incident on 12/24/22 between Resident #226 and Resident #57 The 12/24/22 change of condition/SBAR note documented in the medical chart of Resident #226 read Resident #226 was leaving an activity when another resident (Resident #57) said a few grumpy things to Resident #227. Resident #226 lightly slapped Resident #57's face and walked away. The 12/24/22 change of condition/SBAR note documented in the medical chart of Resident #57 read another resident (Resident #226) was restless and walked near Resident #57 and her friend. Resident #57 told the resident in a gruff voice not to come near her. Resident #226 lightly slapped Resident #57. According to the note, a light pink mark appeared (on her face) lasting a few minutes. There was no broken skin or bruising. The residents were separated. An investigation of alleged physical abuse was initiated on 12/25/22. The review of the physical abuse report, identified the physical altercation was reported to the State Agency on 12/25/22 at 9:17 a.m. almost 24 hours after the incident occurred. According to the investigative record, on 12/24/22 at approximately 11:55 a.m. Resident #57 was participating in an activity. When the activity ended, Resident #226 approached another resident Resident #57. Resident #226 entered Resident #57's personal space, slapping Resident #57 on the cheek with her hand. The incident was witnessed by a certified nursing aide (CNA). The police were called, the residents were separated, and monitored. The 12/25/22 nursing note documented in the medical chart of Resident #226 read police were notified related to the incident. No additional details were included in the progress note. IV. Incident #4 A. Resident status 1. Resident #71, age 81, was admitted on [DATE]. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 12/30/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a BIMS) score of 2 out of 15. The resident exhibited inattention and disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. The physical aggression care plan, initiated 1/20/23, read Resident #71 received physical aggression from another resident. 2. Resident #40, age 73, was admitted on [DATE]. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included neurocognitive disorder with [NAME] bodies and anxiety disorder. The 11/10/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of 1 out of 15. The resident did not exhibit inattention or disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. The physical aggression care plan, initiated 1/21/23, read Resident #40 had the potential to exhibit physical aggression towards staff and other residents. The care plan read the resident would quickly pace when agitated and could be difficult to be redirect. The review of the care plan did not identify the resident had an actual physical altercation with another resident. B. Record review An investigation of alleged physical abuse was initiated on 1/10/23. According to the investigative record, Resident #40 was witnessed to be agitated and pacing the halls when he saw Resident #71 and struck her on the back on 1/10/23 at 6:15 p.m The investigation report indicated that police were called and residents were separated and monitored. The report read Resident #71 said she was not afraid following the incident. She said she was surprised and thought she might have gotten in his way. There was no identified injury to Resident #71. The 1/10/22 SBAR communication assessment for Resident #40 read Resident has been sundowning more often and becoming combative with other residents and staff. IV. Staff interview Registered nurse (RN) #3 was interviewed on 1/19/23 at 4:40 p.m. RN #3 identified a resident who was physically injured during a resident to resident altercation in the secured/memory care unit. The RN said Resident #32 was punched in the face by Resident #56 resulting in wounds to his face and an evaluation at the hospital. The intertrim nursing home administrator/corporate director of operations (INHA/DO) was interviewed on 1/25/23 at 5:34 p.m. The INHA/DO said there were multiple factors to determine abuse including injury, intent, resident reaction, she said even threatening could be considered abuse. She said the investigation determined if the alleged abuse occurred. She said the former nursing home administrator (NHA) reported an the allegation of physical abuse between Resident #32 and Resident #56. She said the former NHA conducted the investigation and reported the allegation of abuse was unsubstantiated related to Resident #56's cognitive ability and unknown intent. The INHA/DO said she reviewed the former NHA's report and educated the NHA what factors needed to be considered to determine if the abuse was substantiated. The INHA/DO said Resident #32 was physically injured. She acknowledged the resident was documented to be afraid after the incident which impacted his sleep. The INHA/DO requested the former NHA to substantiate the physical abuse based on intent and injury. The incidents and intentions between Resident #56 and #71 and Resident #57 and #226 were reviewed with the INHA/DO. She said incidents were not identified as accidents. The residents were either agitated or prompted prior to the incidents. The INHA/DO said she was concerned about the handling of the abuse process with the former NHA. She said she would weekly reviews with the former NHA and provide education but the former NHA would not follow the education. She said she also requested the former NHA to send her all the allegations of abuse for her own review but the former NHA would frequently not send them to her. The INHA/DO said the facility self identified they had a breakdown in the system. She said she created a plan of correction because they know there were issues. The INHA/DO said the former NHA was relieved of her duties on 1/18/23 and the facility proceeded to conduct abuse documentation audits and conduct staff in-services on 1/18/22 and 1/19/23 (first day of survey.) The INHA/DO was interviewed again on 1/26/23 at 6:54 p.m. The INHA/DO said she was not initially aware of the extent of the 12/18/22 incident between Resident #32 and #56, as reported to her by the former NHA. She said she was told that Resident #56 did not intentionally hit Resident #32. She said after further review and after the final report was submitted, the INHA/DO determined the physical altercation was intentional. The INHA/DO said during her continued review of the abuse process and prevention, she had determined interventions to prevent future abuse needed to be more centered, and investigations needed to follow the procedure steps to ensure all information was gathered. The INHA/DO said education was also conducted on 12/19/22 for abuse prevention. The INHA/DO said the education conducted on 1/18/22 and 1/19/23 were focused on staff and their response to resident to resident altercations. She said the education included what the staff could do to minimize the risk of abuse, how to de-escalate abuse, and how to engage and redirect the residents. V. Additional information provided by the facility The following documents were provided by the facility on 1/26/23: -A information form addressed to the secured/memory care staff. The form read the listed residents had been involved in verbal and physical altercations with other residents. The list of residents included Resident #40, Resident #56, and Resident #57. Resident specific interventions were identified. The form requested staff to attempt to utilize the interventions to prevent altercations from occurring. -Staff and interviews on knowledge of resident abuse and if residents felt safe. The interviews were conducted on 1/19/23 and 1/20/23. -Facility audits of abuse management and interventions conducted on 1/19/23. -The abuse staff in-service conducted on 1/18/23 and 1/19/22 included types of abuse and steps to take if staff witnessed abuse or knew of an instance or allegation of abuse and a review of the abuse policy. According to the in-service any negative interactions involving residents could potentially be abused and the administrator must be notified. 12905 VII. Resident #49-incidents of verbal and physical abuse directed toward other residents A. Resident status 1. Resident #49 Resident #49, age 64, was admitted on [DATE]. According to the January 2023 CPO, diagnoses included alcohol-induced persisting dementia, Wernicke's encephalopathy and generalized anxiety disorder. The 1/2/23 MDS assessment documented Resident #49 was cognitively intact with a BIMS score of 15 out of 15, and had psychosis indicators or hallucinations and delusions. No behavioral symptoms or rejection of care were documented. He needed supervision, oversight, cueing and encouragement for all activities of daily living. 2. Resident #59 Resident #59, under age 50, was admitted on [DATE]. According to the 10/14/22 MDS assessment, he was admitted for rehabilitation after a fracture. He had moderate cognitive impairment with a BIMS score of nine out of 15. No behavioral symptoms were documented. He used a wheelchair and needed limited assistance with most ADLs. 3. See above for status of Residents #40 and #56. No information was available regarding the former/discharged resident. B. Record review Resident #49's behavioral care plan, initiated 8/9/21 and revised 1/20/23, identified a behavior problem related to anxiety disorder and dementia, with increased agitation when other residents entered his room and may be verbally loud with them. The goal was for fewer episodes of anxiety. The interventions were: administer medications as ordered, allow choices within decision-making abilities, anticipate and meet resident needs, assist to develop more appropriate methods of coping and interacting, provide opportunity for positive interactions, engage in television football games when on, provide jobs around the facility such as sweeping floors in the Willow (secure) unit, discuss the resident's behavior and explain why behavior is inappropriate or unacceptable, intervene as necessary to protect the rights and safety of other residents, approach in a calm manner, divert attention, remove from situation and take to alternate location as needed, keep stop sign across his door to deter other residents entering his room, offer craft kits, Lego sets and painting as resident enjoyed taking things apart and putting them back together. The resident benefits from a private room was added as an intervention on 1/20/23 (during the survey). The wandering care plan, initiated 3/12/21 and revised 1/20/23, documented Resident #49 had a history of wandering, and no longer met the criteria to reside on the secure unit and had not wandered since moving off the unit. He is alert and oriented and knows location in the building. Staff were to frequently orient and monitor Resident #49 for new behavior of wandering (added 1/20/23 during the survey). The care plan for potentially aggressive behavior related to poor impulse control was initiated on 1/24/23 (during the survey), and identified Resident #49 had a history of pulling wheelchairs out from under other residents, causing them to fall. The goal was for the resident to demonstrate effective coping skills. Interventions included: the resident's triggers for physical aggression are residents wandering into his room; analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and anticipate needs; if resident is pushing another resident in a wheelchair or attempting to help them, thank him for his offer but inform him that staff are there to take care of other residents; the resident prefers to be alone in his room with the door closed; resident will come out of his room for food and drinks; staff to offer observation when resident is out due to history of altercations with others; resident prefers a private room. C. Abuse incidents Review of facility investigative reports revealed Resident #49 was the assailant in four incidents between 11/10/22 and 11/30/22. Three incidents occurred while Resident #49 resided in the Willow secure neighborhood, and one incident occurred after he was moved in with a roommate on the North hall. 1. 11/10/22 abuse incident against Resident #40 At 8:30 p.m. on 11/10/22, Resident #40 was checking door knobs and before staff could get to him, opened Resident #49's door and walked into the room. Resident #49 then punched Resident #40 in the face, leaving a red mark above Resident #40's right eyebrow. Resident #49 was put on 15-minute checks and the police were notified. Resident #49 had earlier, at 4:23 p.m., been documented having multiple yelling and outbursts this afternoon inside and outside of his room. Redirecting several times unsuccessfully. Will continue to monitor. 2. 11/16/22 verbal abuse incident against Resident #56 Resident #49 threatened Resident #56 for assisting another male resident who was in a wheelchair. Resident #49 told a staff person that Resident #56 was trying to move his dad, and was yelling at Resident #56, Do you want to fight? and the other resident put up his fists. Staff had to intervene and sent Resident #49 to his room to cool down. The nurse documented that Resident #49's Seroquel had just been increased on 11/16/22 after another previous altercation. 3. 11/27/22 verbal and physical abuse incident against a former resident/roommate Resident #49 yelled profanities at his roommate and slung a pair of jeans at him, hitting him in the face, no apparent injuries were noted. The residents were separated and monitored, and police were called. Resident #49 kept referring to the victim as his dad, and said he was trying to get his dad to behave because his restlessness was keeping him awake. The victim did not demonstrate increased tearfulness or self-isolation, and there were no signs of fear or feeling unsafe. No changes were made to the treatment plan other than to increase monitoring. Resident #49 was noted to become easily agitated. Review of nursing notes revealed Resident #49 moved on 11/28/22 from the Willow secure neighborhood to a room on the North hall because secure unit placement not needed. 4. 11/30/22 verbal and physical abuse incident against Resident #59, a former roommate On 11/30/22, a CNA witnessed Resident #49 pulled his roommate's wheelchair out from under him while he was trying to sit in it, causing his roommate to fall. There were no apparent injuries. Resident #49 was heard saying to Resident #59 that he was going to kill him. Resident #49 was placed on one-to-one monitoring and Resident #59 was moved to a different room. Resident #59 later did not remember exactly what happened but was glad not to be with that roommate. All staff members interviewed concurred that Resident #49 needs a private room. -No further abuse incidents were documented involving Resident #49 after 11/30/22. D. Observations Resident #49 was observed throughout the survey on 1/19, 1/22, 1/23, 1/24, 1/25 and 1/26/23 spending most of his time in his room on the South hall, with his door closed, leaving only briefly to get drinks, snacks and food. He was independent with ambulation, and spoke quietly. He resided on the opposite side of the facility from the Willow and North neighborhoods. E. Staff interview The INHA/DO was interviewed on 1/23/23 at 4:00 p.m. She said Resident #49 was territorial and did not like other residents in his room. He was not appropriate for the Willow secure unit, and had an altercation with his roommate after he was moved from Willow. She said that since he has had a private room, he had done well, kept to himself, and only left his room to get something to eat or drink. The INHA/DO said she had to piece together the report documents (above) regarding the abuse incidents because she was unable to find all of the former NHA's investigative documentation. -The facility failed to keep residents free and safe from verbal and physical abuse by Resident #49.

Based on observations, interviews and record review, the facility failed to provide adequate nutrition and hydration to one (#43) of eight residents reviewed out of 41 sample residents. Resident #43 received hospice services and was documented to have unavoidable weight loss. However, the facility failed to assess Resident #43's dietary and drink preferences, assess and implement dietary interventions, provide fortified foods as recommended by the registered dietitian, and provide food and drink access to ensure the resident received the assistance needed for his comfort, enjoyment and dignity, and to ensure he did not go hungry and thirsty. These failures contributed to Resident #43 experiencing severe weight loss within the previous month, and within the previous five months after his admission to the facility. Findings include: I. Facility policies A. The Weight policy, revised May 2021, provided by the interim nursing home administrator/director of operations (INHA/DO) on the evening of 1/26/23, documented in part: Weights will be regularly monitored to assure the identification, evaluation and initiation of care planning for residents who have experienced actual weight loss or weight gain. Significant weight changes include: 5% loss/gain in weight in a month, 7.5% loss/gain in three months, 10% loss/gain in weight in six months. The dietitian and the IDT (interdisciplinary team) will review residents with significant weight changes and develop a care plan accordingly. Individualized interventions will be recommended and initiated to meet weight goals as clinically possible depending on the resident's weight status. B. The Hydration policy, dated 2021, provided by the INHA/DO on the evening of 1/26/23, documented in part: The facility offers each resident sufficient fluid, including water and other fluids, consistent with resident needs and preferences to maintain proper hydration and health. The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care. Interventions will be individualized to address the specific needs of the resident. Offer the resident a variety of fluids during and between meals. Provide assistance with drinking. Ensure beverages are available and within reach. II. Resident status Resident #43, age 74, was admitted on [DATE]. According to the January 2023 computerized physician orders, diagnoses included neurocognitive disorder with Lewy bodies (progressive dementia leading to declines in thinking, reasoning and independent function), chronic kidney disease stage 3, chronic congestive heart failure, and chronic obstructive pulmonary disease. According to the 10/2/22 admission minimum data set (MDS) assessment, Resident #43 had severe cognitive impairment with no brief interview for mental status (BIMS) score, and delirium indicators of inattention. He had mood indicators of trouble sleeping or sleeping too much, feeling tired, and little interest or pleasure in doing things. No behavioral symptoms or care rejection were documented. He needed limited assistance with transfers and walking; encouragement/supervision/set-up with eating; and extensive assistance with toilet use, dressing and personal hygiene. He was unsteady during transfers and used a walker and wheelchair. There were no range of motion limitations. He received hospice services. There were no choking or swallowing problems. Weight loss/gain was unknown. He was 67 inches tall and weighed 194 pounds. He took antipsychotic and antianxiety medications. III. Observations and family interview Observations of Resident #43 during the survey on 1/19, 1/22, 1/23, 1/24, 1/25 and 1/26/23 revealed he spent most of his time in bed on his back. His over-bed table with water pitcher or covered food plate was against his privacy curtain and out of his reach. During observations on 1/19/23, the resident's lips and mouth were dry, and he appeared thin, frail and weak. During subsequent observations, his over-bed table and water pitcher were out of his reach. On 1/24/23 at 3:15 p.m., Resident #43's wife was observed in the hallway walking toward Resident #43's room with a hospice nurse. As she approached Resident #43's room, she said she visited him almost every day, and added, This is what they do, leave his lunch across the room and don't help him, and he's sound asleep, and his food is getting cold. She said this happened day after day and he had lost a lot of weight. The resident was sleeping on his back, and his over-bed table with his lunch tray was out of his reach. Resident #43's wife was interviewed on 1/24/23 at 4:30 p.m. She said she had been told by staff that they had 35 patients on his hall and couldn't just cater to (Resident #43) all day. She said sometimes when she entered his room and saw his water and food out of his reach, I think about all the times that he has to go without. She said he had lost so much weight he looked like bone with skin wrapped around it. He lays in that bed with food all over him, and his sheets. She said when he was too weak to feed himself, she scooped up the food for him bite by bite, hand over hand, and helped him get it to his mouth. She said she tried to visit him at lunch or dinner so she could go to the dining room and eat with him, and she sometimes brought him a little Jell-O pudding or yogurt, bananas and oranges, because he never gets fresh fruit. The food looks like it's been sitting out, it's not even edible, it tastes like (expletive), and it smells bad. The other night when I was here with (Resident #43) they had a big pile of goulash. I tried it and (Resident #43) drew my hand away and said 'No.' He would eat the carrots they served and said 'It's cold,' and the carrots were cold. (Cross-reference F804, palatable foods.) Breakfast observations on 1/25/23 revealed: -At 8:30 a.m., Resident #43's tray was delivered and placed on his over-bed table out of his reach. He reached out for it several times and indicated he wanted it moved closer to him. -Licensed practical nurse (LPN) #3 entered his room to check on him at 8:50 a.m. When he indicated to her that he wanted his breakfast moved closer to him, she asked him to wait until certified nurse aide (CNA) #6 came in to assist him so he did not choke. He motioned again for his breakfast to be moved toward him. -At 8:59 a.m., CNA #6 knocked and entered his room, asking if he was ready to eat. She wheeled his over-bed table in front of him, uncovered his plate of biscuits and gravy, and Resident #43 started eating immediately. He fed himself well and drank from his water pitcher with a straw, holding the water pitcher in both hands. He had not been served coffee or juice, and when asked why, CNA #6 asked him if he wanted those. Resident #46 responded that he wanted apple juice. CNA #6 said she would be right back, as she had to find juice. While CNA #6 was gone, he finished his meal and drank more water from his pitcher. -At 9:05 a.m., LPN #3 checked on Resident #43 and asked if he was finished. He reiterated he wanted juice, but no more food. At 9:07 a.m., CNA #3 brought him a glass of apple juice and an orange juice, which he drank well. CNA #3 stayed with him as he drank his juice. -At 9:34 a.m., Resident #43 was sleeping on his back. His over-bed table had been moved out of his reach again; his plate and cups were gone and his water pitcher remained. On the afternoon of 1/25/23, Resident #43's wife visited and brought him a coffee drink and a piece of iced lemon cake, which he drank and ate. On 1/25/23 at 6:06 p.m., Resident #43 was observed in bed with his dinner tray in front of him. He had finished his fluids and fruit cocktail dessert, but his plate of lasagna, vegetable and dinner roll were untouched. No staff were in sight to assist, encourage, or offer him an alternate meal. -Observations and interviews with the resident's family and staff revealed he enjoyed eating and drinking the foods and fluids of his choice, and needed encouragement, supervision and cueing, and assistance at times. IV. Record review The care plan, initiated 9/20/22, identified a nutritional problem related to his diagnoses, a lacto-ovo (dairy and eggs) vegetarian diet, and receiving hospice services with expected unavoidable weight loss related to terminal processes. The goal was food and fluids as desired for comfort. Interventions were: assist the resident with developing a support system to aid in weight loss efforts, including friends, family, other residents, volunteers; invite the resident to food related activities; observe any signs/symptoms of dysphagia (swallowing difficulty); ensure twice daily (currently on hold, revised 12/8/22) fortified foods; provide and serve supplements as ordered; lacto-ovo vegetarian diet/regular texture/thin liquids; and registered dietitian (RD) to evaluate and make diet change recommendations as needed. -The nutrition care plan was not updated to include actual severe weight loss, preferred foods other than a vegetarian diet, and did not accurately document the resident's dietary supplements or types of liquids. The hospice care plan, initiated 9/27/22 and revised 1/24/23 (during the survey), identified end- stage diagnoses of chronic kidney disease stage 3 and Lewy body disease. Interventions included: provide with food and fluids as desired for physical and emotional comfort. Resident #43's dietary card identified a lacto-ovo vegetarian (vegetarianism that includes consumption of eggs and dairy) dysphagia diet with nectar thickened liquids. His Thursday 1/26/23 lunch menu included a ground barbecue veggie chicken patty, barbecue sauce, roasted green beans, cheesy mashed potatoes, a dinner roll with margarine, banana pudding, and nectar-thickened coffee or hot tea. -No other food preferences were identified in the resident's medical record. The Weights and Vitals Summary revealed the following documented weights for Resident #43: 9/19/22 (admission) - 199.2 pounds 10/2/22 - 194.2 pounds 11/1/22 - 191.8 pounds 12/4/22 - 177.6 pounds 1/3/23 - 171.6 pounds -He had experienced severe weight loss at 14.2 pounds, 7.4%, within one month from 11/1/22 to 12/4/22; and 27.6 pounds, 13.86%, since his admission five months before. The 9/19/22 Nursing Admit Assessment documented Resident #43 weighed 199.2 pounds and was 67 inches tall. He was reported to spend most of his time asleep, and was on hospice. The 9/20/22 admission Nutrition Evaluation documented a weight of 199.2 pounds. Usual body weight was unknown. Weight trends were unavailable. The resident was noted with a history of not eating for a few days and then binging. His fluid intakes were good. His calorie needs were 1825-2190 kcals (calories) and fluid needs were 1825-2190 milliliters (ml). His diet was lacto-ovo vegetarian/regular texture/thin liquids. No issues with chewing or swallowing were documented. His typical intake was about 50 to 100%. His relevant medications were Zofran/bowel movement meds, Lorazepam (antianxiety) and Risperidone (antipsychotic). No edema was present. The recommendation was to add Ensure twice daily between meals to aid in weight maintenance and consume foods and fluids as desired for comfort. Meal intake records for November 2022 revealed the resident ate 76-100% of his meals 15 times, 51-75% of his meals 16 times, 26-50% of his meals three times, and 0-25% of his meals nine times. There was no documented meal intake 11/1-11/10/22, on 11/12/22 or on 11/20/22 (12 out of 30 days). The 11/15/22 Nutrition Evaluation documented Resident #43 had a steady decline since admission of 7.4 lb loss x 2 months, 2.4 lb loss x 1 mo, weight losses unintentional and unfavorable, but anticipated, as resident was admitted to hospice on 10/19/22 (although the resident had been on hospice since admission). Goal for comfort measures now. The evaluation further documented in pertinent part, In interview was unable to give good usable information. Resident appears moderately nourished, consuming about 50% of meals. On Ensure BID (twice daily) to provide those extra calories and protein to help maintain weights. -There was no evidence of an interview with the resident's wife, who could have shared Resident #43's food preferences, assistance needs, and further nutritional history. The 12/7/22 Nutrition Evaluation documented the resident's most recent weight was 177.6 pounds on 12/4/22. His usual body weight was 190 to 200 pounds. His weight trends were loss. The resident triggered for significant weight loss of 7.4% x30 days, 10.8% x 90 days. Weight loss unintentional and unfavorable but expected (due to) recent move to hospice and goal for comfort measures. His estimated nutrition needs were 2421 kcals/day and hydration needs were 2421 ml/day. No chewing or swallowing issues were noted. He needed supervision and setup help with meals and ate in his room. No edema was noted. No nausea/vomiting/diarrhea were noted although there was some constipation. An interdisciplinary team progress note dated 12/15/22 documented in part, Res(ident) is showing noted weight loss of 14 pounds in 1 month, current weight of 177.6 pounds. Will resume Ensure BID, res is a hospice patient. (Former) DON (director of nursing) will request order for unavoidable weight loss. Meal intake records for December 2022 revealed the resident ate 76-100% of his meals 20 times, 51-75% of his meals 25 times, 26-50% of his meals five times, and 0-25% of his meals nine times. There was no documented meal intake on 12/4, 12/10, 12/11, 12/17, or 12/24/22 (five days). Meal intake records for January 2023 (1/1 through 1/26/23) revealed he ate 76-100% of his meals 16 times, 51-75% of his meals 25 times, 26-50% of his meals eight times, and 0-25% of his meals six times. There was no documented meal intake on 1/7, 1/14, or 1/21/23 (three days). Review of Resident #43's fluid intake records from 11/1/22 through 1/26/23 revealed he consumed less than half his assessed fluid needs. An IDT note on 1/18/23 at 1:55 p.m. documented, Supervised in dining room and he allows to go. The January 2023 medication administration record (MAR) documented an order for Ensure/Boost for weight maintenance, ordered 9/20/22, which was held from 1/1 to 1/6/23 and discontinued on 1/25/23. Resident #23 consumed 100 percent of this supplement 10 times between 1/18 and 1/25/23. V. Staff interviews CNA #3 was interviewed on 1/25/23 at 3:40 p.m. She said Resident #43 was changed to thickened liquids about three weeks ago, and does better on the thickened liquids. She said they tried to keep his over-bed table away because he tries to crawl out of bed and trips. She said she checked on him every two hours, although sometimes it was closer to every three hours, to see if he was sleeping, needed to be changed or wanted to get up. The only times he ever gets up is when he has in his mind he wants to get up to the bathroom. She said she tried to offer and assist him with fluids every time she checked on him, when he was awake, and he always drank well. She said usually when she set him up for breakfast he ate well. She said it was difficult to assist all the residents who needed help with eating and drinking in a timely manner, due to short staffing. (Cross-reference F725, sufficient nursing staffing.) LPN #3 was interviewed on 1/25/23 at 4:45 p.m. She said since Resident #43 was on thickened liquids and an aspiration risk, they wanted a staff person to be with him for safety when he ate in case he choked. She said it was best if they delivered a resident's tray and set them up to eat immediately. She said Resident #43 could feed himself but did better with thickened liquids because he had a tendency to gulp, and actually vomited as a result the other day. The registered dietitian (RD) and corporate RD were interviewed by phone on 1/26/23 at 3:30 p.m. They said they added Resident #43 to fortified foods because his wife asked to have him removed from liquid supplements. (No documentation of this could be found in progress notes.) They said per his medical record, he had an unavoidable weight loss and was on a general decline. As of 1/3/23, he had a six-pound weight loss from the beginning of December 2022 to January 2023, which was anticipated with his overall disease progression. He still has some variable meal intakes for sure. Overall he ate about 51-100% on those meals and a few do dip down below at 0-25%. The RD said that added cueing and help with his meals could help Resident #43, but she did not specifically care plan for that, and she had not observed him eating. They said they needed to work with the CNAs and nurses on Resident #43's hall to ensure he received the assistance he needed, and they could double check with the kitchen regarding fortified foods. They said they would educate the staff to make sure they were providing all the help Resident #43 could get, and make sure the nurses were putting his food and fluids in front of him as well. They said they could not give him supplements because of his gastrointestinal issues, but fortified foods might help. They acknowledged they did not have a preferences list for him, usually the food service manager should visit with the resident upon admission, but they would talk to the family and get those preferences. They knew only that he was lacto-ovo vegetarian and disliked pork. They said they could also recommend adding snacks. They acknowledged his documented fluid intakes were not good, and said they could add extra fluids throughout the day for hydration purposes as well. They said his antipsychotic medications could be affecting his appetite as well, blunting the appetite, making him sleepier and a little more out of it. They said they discussed Resident #43 at the last IDT meeting on 1/18/23 but recommended nothing more than what they had just mentioned, and to encourage him to go to the dining room if he would allow. They acknowledged that would be his choice and he should receive the assistance he needed in his room. (See IDT progress note above, which was very brief and did not document that an RD was present.) The dietary manager was interviewed on 1/26/23 at 7:12 p.m. He said Resident #43 was not on fortified foods, for example, added protein. He said he tried to fortify all the foods he served to the residents by adding cream, milk and butter.

Based on record review and interviews, the facility failed to provide the highest practicable quality of care for two (#4 and #5) of 12 sample residents after they sustained falls with injuries. Specifically, Resident #4 was found on the floor in her room on the morning of 10/15/19. Nursing staff failed to thoroughly assess the resident and ensure she received timely emergency care. Although the resident had leg pain when she was found on the floor, staff did not call 911, and instead transferred her from the floor into her wheelchair. The resident's treatment was delayed while nursing staff called and awaited a physician order [REDACTED]. The resident was diagnosed in the ER with a fractured femur. The facility failures contributed to Resident #4 experiencing delayed treatment for [REDACTED]. Cross-reference F689, failure to provide supervision to prevent accidents because Resident #5 suffered a fall with injuries on 11/9/19. Nursing staff further failed to conduct and document timely and thorough skin assessments to determine and monitor the extent of Resident #5's injuries and skin conditions after a fall on 11/9/19. Findings include: I. Resident #4 [NAME] Resident status Resident #4, age 80, was admitted on [DATE] and discharged on [DATE]. According to the face sheet, pertinent [DIAGNOSES REDACTED]. No minimum data set (MDS) assessment was documented due to the resident's short stay in the facility. The Admission Functional Performance assessment, dated 10/13/19 at 1:40 p.m., documented the resident was dependent for bathing, dressing, transfers, using the toilet, personal hygiene, eating and ambulation with a manual wheelchair. The resident was alert and oriented to person (not place or time), and had short term and long term memory problems. She demonstrated disorganized thinking, flat affect, and was socially inappropriate and withdrawn. Her most recent pain level was 10. She was non-weight bearing, balance and gait were impaired, and she had bilateral lower extremity weakness. She required daily skilled nursing related to altered mental status, pain and medication management, and altered mental status. She needed to be fed by staff. B. Family interview The resident's daughter/power of attorney (POA) was interviewed on 11/20/19 at 12:05 p.m. She said she had reviewed EMS records, which documented the resident was found on the floor at 6:00 a.m. but EMS was not called until 7:19 a.m. They got her up off the floor and put her in a wheelchair and had her by the nurses' station. The EMS team had to get additional pain meds from (another local) EMS. C. Staff interviews Registered nurse (RN) #1 was interviewed on 11/20/19 at 11:45 a.m., and on 11/20/19 at 12:54 p.m. RN #1 said she found Resident #4 on the floor as she was doing her first morning rounds, after getting report from the off-going nurse. She said she could not remember time frames, and had no way of knowing how long the resident had been on the floor. She could've been there an hour and a half by the time I found her. She did feel like she was cold. I got a blanket immediately, covered her up and started vital signs. She said after she assessed the resident, It took a while to get the doctor's permission, so we did get her up into a wheelchair eventually. She said the resident was confused and her oxygen saturation level was low so we got 02 (oxygen) on her. I wanted her to go (to the ER) but I couldn't get an order. We're supposed to call the nurse manager on call and we have to call and get the doctor's permission. When I said she was confused and her 02 was low they said go ahead and send her. She said the resident was unable to communicate with her, and was confused, so she had to go by visual. She appeared to be uncomfortable. We put her up by the nurses' station and she sat there, curled up and started shaking. At that hour, it's hard to get calls back - we called on-call. She sat there 30 to 45 minutes . I couldn't make sense of what she was saying and the more we waited the more pain I could see coming . Sometimes it takes forever for the doctors to call back . She didn't appear to be in excruciating pain but as she sat there and began to shake . I can't imagine the pain she was in. Bone pain is supposed to be the worst. The DON and ADON were interviewed on 11/20/19 at 1:26 p.m. The ADON said they had reviewed the resident's chart and determined that when the resident was found on floor on 10/15/19, her pulse ox was 81% compared to her baseline of 93-95%. She had no supplemental oxygen and was taking Eliquis, an anticoagulant. The ADON said, Given the nurse assessment (hip pain, difficult to move) I probably wouldn't have gotten her off the floor and would have called 911 right away. There is nothing in our policy that says nurses can't call 911. There are certain things we like them to call the on-call nurse about, but a fall with pain isn't one of those things. D. Record review 1. Facility documentation Review of nurses' notes revealed two narrative notes on 10/15/19: -On 10/15/19 at 8:11 a.m., sent to (local hospital) for fall. -On 10/15/19 at 11:54 a.m., Pt very confused, not able to comprehend to use call light, self-transferred out of bed, able to ambulate a few steps toward roommate bed, fell on to right side. Vital signs recorded at 6:29 a.m. documented the resident's temperature was 99.1, oxygen saturation level was 81% at 6:32 a.m., and blood pressure at 6:40 a.m. was 151/74. The 10/15/19 SBAR (situation, background, assessment, request) Communication Form and Progress Note by RN #1 at 11:54 a.m. documented the resident was found on the floor laying on her right side in the middle of the room. Movement made the resident's condition worse. The time of the fall was not documented. Vital signs were documented at 6:29 a.m., 6:32 a.m. and 6:40 a.m. The physician and family were notified at 7:28 a.m. The 10/16/19 Interdisciplinary Post Fall Review by the DON at 3:53 p.m. documented Doing post report rounds, found pt (patient) laying on floor, in middle of room about 7-8 feet from her bed, laying on right side. VSS, no open wounds, pain expressed at right hip/pelvic area. Bed in low position and call light in reach. Fall mat in place. Resident has poor safety awareness, did not call for assist . Res sent out to hospital for evaluation, X rays . Notification of the family and physician was documented as 7:00 a.m. Facility documentation did not show that the resident was transferred from the floor to a wheelchair before the physician or EMS were called. According to facility documentation, the time of the fall was 6:30 a.m. but vital signs were initiated at 6:29 a.m. The notification times for the physician were documented at two different times, 7:00 a.m. and 7:28 a.m. 2. EMS prehospital care report The EMS Prehospital Care Report, dated 10/15/19, documented dispatch was notified at 7:19 a.m. and arrived at the facility at 7:27 a.m. Staff reported that at 0600 (6 a.m.) they found pt on the floor of pt room, unknown amount of down time. Staff report that the pt is new to the facility and they know very little about pt history. Staff report that pt has significant pain to pt right side and that pt was found on her right side . During transfer from wheelchair to EMS cot pt exclaimed 'no, no, please don't' and cried out in pain. During transport pt verbalized to EMS that she was in a lot of pain, unable to gain 1-10 pain scale. During transport to hospital pt repeated exclaimed in pain and repeatedly stated that she was in pain, unable to specify where pain was. During transport pt grabbed right side of neck yelling in pain. Unable to obtain if pt had any chest pain, shortness of breathing, nausea or vomiting due to mentation. Upon arrival found . (resident) sitting in a wheelchair at the nurses' desk . Pt responded with pain to palpation of right upper rib pain. Pt was hesitant to move her right leg with the assistance of EMS . During transport observed pt grabbing right side of neck. Upon palpation of right side and c-spine pt exclaimed in pain. Requested rendezvous with (local) rescue to help with pain management due to pt's expressive pain during transport, grabbing her neck complaining of pain, palpated and pt had painful response . Pt did respond minimally to palpation of right hip. 3. Hospital ER report When assessed in theER on [DATE] at 8:36 a.m. (arrival time), the resident was Reluctant to move right leg actively. RT hip pain (faces scale) with flexion or extension of the hip or knee, also pain with palpation of the hip. Right knee without pain to palpation. Moves other extremities actively without complaints of pain. The hip/pelvis X-ray revealed an acute right femoral neck fracture with impaction and slight varus deformity. (A varus deformity is an excessive inward angulation of the distal segment of a bone or joint.) E. Facility follow-up In an email dated 11/21/19 at 5:25 p.m., after the survey was completed, the NHA wrote that staff were encumbered to call '911' when clinically indicated based on the RN assessment. The internal investigation reflects that the RNs involved with this fall acted according to standard of care. Additionally, the actions by the staff in no way delayed treatment to the resident, nor negatively affected the course of care provided to the resident when she was transferred to the acute care provider. The facility's Timeline for Transfer to Hospital for Resident #4 on 10/15/19 documented the resident was observed in her bed at 6:20 a.m. by night shift and day CNAs during walking rounds. RN #1 found Resident #4 on the floor at 6:45 a.m., assessed her and called for assistance from another nurse. At 6:47 a.m. RN #2 arrived to assist RN #1. Both nurses assessed the resident but could not find conclusive evidence of fracture but because of complaints of pain determined to send her to the hospital. At 7 a.m., RN #1 called the physician and spoke to the answering service. At 7:15 a.m., RN #1 spoke with the physician assistant for an order to transport, and at 7:19 a.m. called EMS. The NHA spoke with the facility medical director to discuss if he thought it was appropriate for an RN to transfer a resident without a physician order. He said he would not support that practice and believed that it would lead to residents being sent to the hospital when it is not in their best interest. The NHA wrote, Based on this investigation it is the position of (the facility) that the center was compliant with regulatory requirements, specifically Quality of Care. However, none of the above facility follow-up was documented in the resident's medical record. The timing listed above was inconsistent with record review and staff interviews conducted during the survey. Findings revealed the resident was moved from the floor into a wheelchair although she expressed pain, remained sitting up in her wheelchair -- possibly for more than an hour -- until EMS arrived, and was diagnosed at the ER later that morning with a femur fracture. II. Resident #5 [NAME] Resident status Resident #5, age 90, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 10/25/19 MDS, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. She required extensive two-plus person assistance for transfers, dressing, toilet use and personal hygiene. She had experienced falls since her prior assessment and one fall without injury. B. Observation Resident #5 was observed on 11/19/19 at approximately 12:00 p.m. She was lying in her bed, with a large, fading, brownish-green-yellow bruise to her right eye extending to her right temple. C. Record review 1. Care plans The resident's care plan for behavioral symptoms, initiated 8/9/16 and revised 9/27/19, identified that she picked at her skin causing sores. The care plan for skin integrity, initiated 2/14/18 and revised 9/27/19, instructed staff to encourage lotion after bathing and as needed, skin checks weekly per facility protocol, and document findings. 2. Nurses' notes Nurses' notes revealed the resident fell on [DATE], and suffered bruising to her face, an abrasion to her back, and had scabs on her shoulder and face: -On 11/9/19 at 9:54 p.m., Resident in sitting position on floor in her bathroom . No injuries noted at this time . -On 11/10/19 at 10:08 a.m., f/u (follow-up) with injury to the right eye, appears black and blue bruising . -On 11/10/19 at 2:33 p.m., right eye with purple/blue bruising noted, abrasion noted to the middle right side back . -On 11/16/19 at 7:47 p.m., Resident refused skin assessment. Does have 5 scabs on right shoulder, 7 scabs on lower jaw, and 2 scabs on left shoulder. -On 11/17/19 at 1:23 p.m. and 11/18/19 at 5:26 p.m., healing scabs on face. 3. Photographs Review on 11/19/19 of photographs taken 11/15/19 by the resident's family member revealed bruising to the resident's eye and temple; scattered and inflamed open areas to her shoulder; and bruising and scabbing on her breast. 4. Skin assessments Review on 11/19/19 of skin assessments revealed: -A skin assessment was not documented on 11/9/19 after the resident fell . A skin assessment was not documented on 11/10/19 after facial bruising appeared. -A skin assessment dated [DATE], four days after the resident's fall, revealed she refused a skin assessment by the male registered nurse on duty. -The next skin assessment, dated 11/17/19, documented existing bruises, existing abrasions and several small abrasions to back, upper shoulders and neck and face. Right eye has healing bruise. The further description documented, Resident has 4 abrasions to facial area all scabbed, 4 abrasions across upper back on shoulder and neck area, 2 are scabbed, 2 are open with pink wound bed. No s/s (signs/symptoms) of infection noted. Bruise to R eye appears to be healing without problems. On 11/20/19, the DON provided a skin assessment based on a skin check performed by the DON and ADON on 11/19/19, which documented the current condition of the resident's skin including, per the body map and narrative: fading bruise (to right eye) from fall, bruise and abrasion (to middle right side of back) from fall, 16-18 1 cm open areas non pressure various stages of healing (to the right shoulder, upper arm, neck and face). D. Staff interview The DON and ADON were interviewed on 11/20/19 at 10:00 a.m. They provided the skin assessment they had conducted on 11/19/19 (above). They acknowledged the resident's skin assessments were not conducted in a timely or thorough manner after her 11/9/19 fall.

Based on record review and interviews, the facility failed to provide supervision to prevent falls, one resulting in serious injury, for one (#4) of 12 sample residents. The facility was aware upon Resident #4's [DATE] admission of her history of falls and risk for further falls due to the resident's new environment, dementia and inability to use the call light. However, the facility failed to assess, communicate and implement effective fall prevention measures to prevent two falls within two days. The resident fell in her room on [DATE] at 1:20 a.m. when she got out of bed unassisted. She was wearing regular socks, not gripper socks, and was found on the floor after her roommate called for assistance. The facility failed to update the care plan, implement neurological assessments, or implement frequent, documented visual checks and supervision to ensure the resident was safe. The resident fell again on [DATE], and was found on the floor during morning rounds. The resident sustained [REDACTED]. The resident's death certificate documented the cause of death was fall from a standing height resulting in fractured femur. The facility's failures contributed to the resident suffering a fall resulting in a [MEDICAL CONDITION], and contributed to her death. Findings include: I. Facility policy and procedures The Fall Management policy, revised (MONTH) (YEAR) and provided by the nursing home administrator (NHA) on [DATE] at 4:05 p.m., required adequate supervision to minimize the risk for falls. The interdisciplinary team (IDT) was to evaluate each resident's fall risks, and ensure a care plan was developed and implemented based on this evaluation, with ongoing review. The policy further documented: -A proactive approach will be taken for newly admitted residents with regard to fall risk. -Upon admission, the admitting nurse will complete the Fall Risk User Defined Assessment, the Nursing Initial Plan of Care, address risk factors related to the resident in the plan of care, and implement appropriate interventions as identified. -When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring. -When a fall occurs, the nurse will discuss recommended interventions to reduce the potential for additional falls . and document in the care plan and progress notes. -The IDT designee will discuss recommended significant changes to the care plan to minimize repeat falls. -The DON or designee will ensure communication to staff members regarding changes to interventions related to fall risk is completed. II. Resident status Resident #4, age 80, was admitted on [DATE] and discharged on [DATE]. According to the face sheet, pertinent [DIAGNOSES REDACTED]. No minimum data set assessment was documented. Handwritten nursing admission notes, undated, documented that per the discharging hospital nurse-to-nurse report, the resident had altered mental status and history of falls, required one- to two-person assisted transfers, and used a walker. The Admission Functional Performance assessment, dated [DATE] at 1:40 p.m., documented the resident was dependent for bathing, dressing, transfers, using the toilet, personal hygiene, eating and ambulation with a manual wheelchair. The resident was alert and oriented to person (not place or time), and had short term and long term memory problems. She demonstrated disorganized thinking, flat affect, and was socially inappropriate and withdrawn. Her most recent pain level was 10. She was non-weight bearing, balance and gait were impaired, and she had bilateral lower extremity weakness. She required daily skilled nursing related to altered mental status, pain and medication management, and altered mental status. She needed to be fed by staff. III. Family interview The resident's daughter/power of attorney (POA) was interviewed on [DATE] at 12:05 p.m. She said if the facility had provided the care her mother required, she would not have fallen once, let alone twice, the second fall would not have broken her hip, and surgical hip replacement would not have been needed. She said, They had to know the severity of her dementia. She was unable to use the call light. I told the nurse or CNA at shift change the first night upon move-in, 'She will not use this call light.' She said when she helped Resident #4 to bed the first night at the facility, she noticed her bed was too high so she lowered it, and noticed the bed had no fall mat, and with the wheelchair positioned by the bed so her mother could reach it, it was difficult for her to maneuver next to her bed. Two mornings later, on [DATE] at 5:44 a.m., she received a voicemail informing her the resident had fallen and her roommate had pressed the call button to summon the nursing staff. She began to look for a new facility for her mother. The following morning, on [DATE] at 7:44 a.m., she received a phone call from the facility to inform her the resident had fallen again. She learned that her mom was found on the opposite side of the room from her bed, and that an ambulance had just departed to take the resident to the local hospital. She said the resident's roommate called for help the night of the resident's first fall, but during the second fall she was alone, as her roommate had moved to a different room. She arrived at the hospital, found that the resident had a broken femur, and surgery would alleviate long-term pain but involved risk. She opted for surgery which was performed on [DATE]. The resident suffered complications from the surgery and died on the night of [DATE]. The resident's daughter said, She was declining, but this didn't have to go the way it did. She was still a joy to be around. IV. Record review [NAME] Preadmission hospital documentation The resident's hospital record, dated [DATE], included in the resident's medical record, documented the resident took the following medications: [REDACTED]. The resident's prognosis was documented as poor due to dementia and that severe dementia has progressed rapidly. The [DATE] hospital discharge summary included in the medical record revealed the resident had received treatment for [REDACTED]. Diff [MEDICAL CONDITION], A-fibrillation, [MEDICAL CONDITION] and chronic dementia. Other pertinent notes included: Family (POA) wishes not to proceed with anticoagulation previously secondary to increased risk of bleeding with her increased risk of falls. Risk and benefits discussed . pt (patient) reportedly has had falls out pt . Continue [MEDICAL CONDITION] precautions. Room close to nurse station and bed alarm. Daughter reports pt has a tendency to wander unsupervised and to not call for assist when getting OOB (out of bed) but has rapidly declined within the past week and requires multiple person assist. B. Care plan The resident's care plan, undated, identified concerns with limited physical mobility related to bilateral lower extremity weakness, altered mental status, dementia, communication problems, high fall risk, anticoagulant therapy, chronic left shoulder and side pain, and suprapubic catheter. Pertinent interventions included: -Encourage the resident to use call bell for assistance. -Remind me of where my room is located. -Anticipate and meet needs. -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. -Ensure proper footwear (not personalized or specified) when ambulating or mobilizing in wheelchair. -Fall mat and low bed and soft call light in place for safety. -Staff to do frequent checks when walking by the room for resident safety. -The resident needs a safe environment with (not personalized or specified). The care plan did not include the resident's first actual fall and the circumstances involved, did not document how frequently staff were to check on the resident or how to anticipate her needs, and did not document the resident's poor safety awareness and history of falls, or that the resident was cognitively unable to use her call light. C. Therapy notes Physical and occupational therapy (PT/OT) assessments and notes, dated ,[DATE] and [DATE], documented the resident had severe dementia, difficulty following simple commands, poor safety awareness and risk for falls. OT notes dated [DATE] revealed the resident had a history of [REDACTED]. Dementia resulting in confusion and poor safety awareness, fall risk D. Fall risk assessments Fall risk assessments documented by two different nurses revealed inaccurate information. The resident's first fall risk assessment, dated [DATE] at 1:58 p.m., inaccurately documented that she was at low risk for falls with a score of seven. The licensed practical nurse (LPN) inaccurately documented the resident had no falls within the past three months, no gait/balance issues, no recent medication changes, and no predisposing conditions. The resident's second fall risk assessment by a registered nurse (RN), dated [DATE] at 1:50 a.m., after her first fall, documented she was at high fall risk with a score of 10. However, the assessment inaccurately documented no falls within the past three months, vision was noted as poor instead of adequate per the previous assessment, and gait/balance was not applicable as the resident was unable to perform the function. The other questions were answered the same as the first assessment. E. Nursing and IDT notes According to the resident's Discharge Planning Review, dated [DATE], the resident's treatment and care needs were pain and medication management, safety monitoring, history of urinary tract infection, [MEDICAL CONDITION] and falls. Pertinent nursing/IDT notes revealed the following: -On [DATE] at 3:43 p.m. the resident arrived today (although the admitted was documented as [DATE]) and was settled in by family and placed in bed. Pt fell asleep quickly. -On [DATE] at 2:14 p.m. the nurse documented the resident was found on floor (on [DATE] at 1:20 a.m., see below) after roommate called staff, stating that she 'heard a crash.' Bed in low position, Foley catheter still hooked to bedframe, head toward roommate's bed, regular socks on feet that were changed to non-skid socks by CNAs immediately following assessment. VS (vital signs) stable, no injuries noted at this time. The registered nurse (RN) documented the resident was in a new environment, POA and physician were notified. The care plan was not updated. The pain assessment on [DATE] at 1:56 a.m. documented the resident was unable to verbalize/describe pain presence and fell asleep after repositioning and assessment. -The IDT post fall review, [DATE] at 2:03 p.m., documented the date/time of the fall was [DATE] at 1:20 a.m. The fall was documented as witnessed although the resident was found on floor after the roommate called staff. It was unknown what the resident was doing prior to the fall. Predisposing conditions were dementia, UTI, unsteady gait, history of falls, cognitive deficits, vision deficits, admitted in last 30 days, and new admit, hx (history) of falls, has severe dementia. She was unable to demonstrate use of the call light in her room or bathroom. Intervention recommendations were: Resident is new to the facility. She has a history of falls prior to admission. Has very poor safety awareness. Fall precautions in place: fall mat, soft call light, low bed, PT and OT are in place. Care plan revision and footwear/assistive devices were left blank as intervention recommendations. IDT referrals were checked off for PT and OT. The form was signed by the DON on [DATE] (the date survey was initiated). -[DATE] at 10:09 a.m. (eight hours later - no narrative nursing notes in between), the resident continued on antibiotic therapy and needed assistance from two staff for transfers, toileting and activities of daily living. She complained of pain when being repositioned or transferred to her left side and left shoulder. The POA indicated she was concerned that the [MEDICAL CONDITION] embolism (PE) may be back; the resident was taking Eliquis 10 mg for PE and sitting calmly by nurses' station. -Nursing Daily Skilled Charting documentation, dated [DATE] at 10:10 a.m., revealed the resident's most recent pain level was eight. -[DATE] at 8:11 a.m. (22 hours later - no narrative nursing notes in between), the resident was sent to the local hospital for fall. -A summary note by the RN, dated [DATE] at 11:54 a.m., documented the resident's current VS at 6:40 a.m. as BP ,[DATE], oxygen 81% on room air. Other VS documented were from ,[DATE] and [DATE]. The RN documented, Pt very confused, not able to comprehend to use call bell, self-transferred out of bed, able to ambulate a few steps toward roommate bed, fell on to right side. -A situation, background, assessment, request (SBAR) progress note by the RN, dated [DATE] at 11:54 a.m., documented in part that the resident was found on the floor lying on her right side in the middle of the room. Things that made the condition or symptom worse were movement. Vital signs were not all current and there was no evidence of neuro checks. The resident was very confused, unable to answer questions. The physician assistant requested monitoring of vital signs and transfer to the local hospital. The PA and POA were notified at 7:28 a.m. although (see below) the resident was found on the floor an hour before at 6:30 a.m. -The IDT post fall review, dated [DATE] at 3:53 p.m., revealed the resident's unwitnessed fall occurred at [DATE] at 6:30 a.m. The resident was transferred to acute care, had complaints of pain, decreased movement rt (right) hip area. Assessment by RN and EMS called to transport. VS documented between 6:29 and 6:42 a.m. were: temperature 99.1, pulse 78, respiration 20, blood pressure ,[DATE]. The RN documented: Doing post report rounds, found pt lying on floor in middle of room about ,[DATE] feet from her bed, lying on right side. VSS, no open wounds, pain expressed at right hip/pelvic area. Bed in low position and call light in reach. Fall mat in place. Resident has poor safety awareness, did not call for assist. The resident was wearing socks, not specified whether regular or gripper socks. The physician and responsible party were documented as notified on [DATE] at 7:00 a.m. (although noted in the SBAR as notified a half hour later). Resident sent out to hospital for evaluation, xrays. Will have further discussion on return to facility. OT/PT in place. Safety devices in place. Therapy services in place . soft call light, fall mat, low bed. Again, there was no mention of gripper socks or timed, frequent checks to anticipate and meet needs. -On [DATE] at 3:30 p.m., Risk meeting held . Discussed fall with femur fracture, resident is currently hospitalized at (local hospital). Expected to return to facility. No current updates from (hospital) on current status. No changes to plan of care at this time. -On [DATE] at 10:56 a.m., Resident's family/POA came to collect resident's belongings. Explained to this nurse that her mother passed away last night at (local hospital). F. Hospital course notes A [DATE] Brief Hospital Course by Problem note documented: Closed right [MEDICAL CONDITION]. Bilateral [MEDICAL CONDITION] embolism. Death. S/P (status [REDACTED]. Was being treated for [REDACTED]. Ortho consulted. Recommended surgical repair with hemiarthroplasty. Discussed with MDPOA (medical durable power of attorney) and opted for surgical repair for pain control. Held Eliquis (anticoagulant) and treated with [MEDICATION NAME] (anticoagulant) 1 mg/kg BID (twice daily) before surgery. Surgical repair on [DATE]. Surgery complicated by Afib with RVR (rapid ventricular rate) and worsening respiratory status. Respiratory status decline thought from development of additional PE. Post-op required full ventilator support. PT unable to get further imaging to confirm diagnosis. Unable to wean from ventilator support. Discussion with MDPOA, palliative care, and FMTS (unknown acronym) and decision to withdraw support was made. Patient died following extubation and d/c vent on ,[DATE]. G. Death certificate The resident's death certificate, signed by the local county coroner on [DATE], documented the date of death as [DATE]. The causes of death were: a. complications of right femoral neck fracture; b. fall from standing height. Other significant conditions contributing to death but not resulting in the underlying cause were: dementia, hypertension, [MEDICAL CONDITION]. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on [DATE] at 1:15 p.m. He confirmed he had provided care for Resident #4, and knew she was really confused and was unable to use her call light. During a second interview on [DATE] at 3:08 p.m., he said he recalled Resident #4 was a red flag to be checked on often. He said he recalled seeing the resident in bed at 6:10 a.m. on [DATE] when he reported for work on the day shift, the morning of her fall and hospitalization . Then he stopped back by her room after report at about 6:30 a.m. and she was in bed. It was emphasized to check on her because she was really new in the building. He recalled another staff person finding the resident on the floor, but he could not recall what time, and he went in to assist. He said the resident was on the floor, not crying but you could see she was in distress. He said they used a gait belt and three people to get the resident up off the floor. I remember seeing her at the nurses' station but she wasn't in any distress. The paramedics picked her up at the nurses' station, there in the wheelchair covered with a blanket. The paramedics didn't respond very fast. RN #1 was interviewed on [DATE] at 11:45 a.m. and 1:00 p.m. She said she had not worked with the resident before, and found Resident #4 on the floor as she was doing her first morning rounds, after getting report from the off-going night nurse. She said the resident was unable to tell her what happened and did not have a roommate or the roommate would have called for help for the resident. RN #1 said she covered the resident up, got vitals, assessed her and got a physician order [REDACTED]. (Cross-reference F684, quality of care.) CNA #3 was interviewed on [DATE] at 2:40 p.m. She had not worked with Resident #4, but said newly admitted residents should be supervised closely for safety. She said with dementia, it's hard to tell if they can use the call light or not . Sometimes you can tell if they're alert and oriented really quickly but it depends on the level of dementia. You don't know if they're going to just get up and try to be independent on their own, so you do take a little extra care and you're watching them very closely . At night I understand every two hours (checks) is a given, peeking in while going down the hallways . Things can happen in just a matter of seconds . You may not be able to be there at the moment they're up. During change of shift you should do rounds together - that's the purpose - then you have help if you find someone on the floor. My first question even though I wasn't here was: were the CNAs doing 15-minute checks? Was there a sheet from the first fall - was it needed? There's a sheet for that. That's assigned by the nurses. RN #2 was interviewed on [DATE] at 3:55 p.m. He said he saw Resident #4 several times, assisted with her initial assessment when she admitted , and recalled her daughter's concerns about her fall risk being quite significant. I do remember some of the nurses and staff notifying the manager we needed either a sitter or someone to come in and provide additional assistance because she wasn't appropriate for our facility. Unfortunately that wasn't done, but I think they didn't understand just how bad a fall risk she was. Unfortunately, this isn't the first time I've seen that, where we have a resident whom we just don't have the staff to manage the situation, because we don't know what the situation is until they arrive. It took a while to get her a fall mat, and the initial nurses there for weekend staff should have seen she was lucid at times, but often not cognizant about her actions or reactions to situations. She was very demented, more lucid when her daughter was there. Outside of that she had huge trouble trying to make decisions. That's why she ended up breaking her leg. -There are a few nurses who could do better with fall assessments and prevention. I know with some of the nursing staff at night there have been some questions or concerns about attentiveness and I think it's definitely worth a conversation for safety's sake. I feel we could use more monitoring, rounding and training for night staff. The NHA, director of nursing (DON), assistant director of nursing (ADON) and administrator in training/acting social services director were interviewed on [DATE] at 2:45 p.m. and [DATE] at 10:30 a.m. They said Resident #4 was admitted due to a history of falls. They knew she was a fall risk so she had a room close to the nurses' station for better monitoring and visibility, and therapy assessed her right away. Their policy was usually to conduct every-two-hour rounds on all residents. Staff should be up and down the hall all night, answering lights, and they should look into each room as walked by. They said they determined in their quality assurance process improvement (QAPI) review that they could have done several things better for Resident #4, including better staff awareness, being more analytical and defining frequent checks better. They can do more than instruct staff to watch out closer, really script it out, involve CNAs more in that systemic remedy, why and how falls occur, what equipment/preventions are needed, providing more information pre-admission, utilizing the staff at the bedside more, performing root cause analyses using the five whys, and focusing on prevention of recurrence. The NHA said they had become much better with post-fall reviews. They had identified problems internally and were at the point of asking what they needed to do post-fall to prevent recurrence. This resident is part of what drove that process. So we learned from it. The DON said she had talked to staff on the floor after falls to get their input. She discovered staff did not really get enough time to give good reports to the day staff, so they were unable to give her further information. She said she had not yet interviewed night shift staff because she planned to do that when Resident #4 came back. Maybe we could have talked about, 'Hey, we need you guys in here more often, maybe at least every 15 minutes, since we knew she was really a fall risk after that first fall. She did not say, nor did the policy include, the process nurses should follow if they found a resident on the floor, such as neurological assessment, pain assessment, assessment for injuries, and implementation of an intervention such as a toileting schedule, snacks, or defined frequent checks. The NHA said that during their upcoming [DATE] QAPI meeting they would discuss these specifics further and bring into their process improvement plan (PIP) the plans that were ongoing, would not isolate day shift and night shift, would focus on prevention of recurrence, and the more people involved in that conversation the better. He said, Looking at the big picture systemically, this is our focus - preventing falls with major injury -- since late October. The NHA said they did not deny the resident's fall contributed to her death.

Based on observation, interviews and record review, the facility failed of ensure two of two sample residents (#53, #32) received treatment and care in accordance with professional standards of practice to manage resident #53's lower extremity wounds and manage the resident's pain, and treatment to manage resident #32's circulatory impairments. Specifically, the facility failed to: For resident #53: -consistently assess, evaluate, monitor and document the condition of the resident #53's wounds. -ensure that a comprehensive care plan was developed and updated to reflect the status of the resident's wounds and included interventions coordinated with hospice to manage the resident's wounds and associated pain for resident #53. -ensure timely intervention by the interdisciplinary team, specifically nutritional intervention, to promote wound healing for resident #53. The facility's failure to adequately manage the resident's wounds and pain contributed to the presence of multiple lower extremity wounds which caused the resident severe pain. For resident #32: -Provide care and services for one (#32) of one resident reviewed with circulatory impairments of 46 sample residents. Specifically, the facilty failed to ensure resident #32 received properly fitted compression socks. The findings included: I. Facility Policy According to the facility policy for [MEDICATION NAME] guidelines related to skin management, a care plan was to be developed upon admission identifying the contributing risk for breakdown including history of skin impairment or the actual impairment. The interventions would include implementation to promote healing and prevent further breakdown. A change of condition would be completed and new physician's orders [REDACTED]. Failure to demonstrate progress in healing within 14 days called for a reassessment regarding the adequacy of the overall treatment plan and the need for modification of the treatment plan. Lower extremity ulcers would be assessed weekly and status/progress documented on the non-pressure skin condition report. II. Resident #53 Resident #53, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the medical record face sheet, the resident's [DIAGNOSES REDACTED]. The medical record included hospice notes that revealed the resident was admitted to hospice care 9/6/16 with a primary [DIAGNOSES REDACTED]. 1. Resident status per minimum data set (MDS) assessments According to the admission MDS dated [DATE], the resident was not at risk for developing pressure ulcers and did not have a pressure ulcer. The resident did not have an infection, open lesion, or a venous/arterial ulcer present. According to the 10/22/16 MDS assessment: -The resident was cognitively intact with a brief interview of mental status score of 15/15. The resident did not have a pressure ulcer. -The resident had two venous/arterial ulcers, and infection of the foot and one open lesion on the foot. There were no abnormal behaviors noted. -The resident's balance during transitions from seated to standing was unsteady and required human assistance to stabilize. The resident required extensive assistance of two persons with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident required limited assistance of one person with bathing. -The resident received a scheduled pain medication regimen, received as needed pain medications and received other interventions for pain. The resident said pain was present over the past five days; the pain was frequently present and pain had caused trouble with sleeping at night. The resident said over the past five days, the pain had limited or prevented normal daily activity, and rated the pain level at 8 out of 10, indicating severe pain. 2. Wound clinic records Review of wound clinic records revealed the development of additional areas of skin breakdown on the resident's feet and leg and described non-pressure and pressure related skin injuries. These records revealed: -9/29/16 wound location bilateral feet with dressing change to be made daily using calcium alginate cover with a foam dressing use Kerlix and or stocking net and to wear Rooke boots at all times except when laundering. -10/19/16 wound care instructions included wound location bilateral feet with dressing change daily and as needed. Use calcium alginate cover with cast padding secure with stockinette. -10/31/16, the wound notes included wound number one on the right foot open wound denuded, red, swollen, yellow slough covered wounds, drainage yellow/green large amount on the right foot. The right medial ankle wound 3.2 cm x 6 cm, lateral fifth measures 1.2 cm x 4cm, his right heel wound measured 1.8 cm x 1.2 cm x 0.4 cm., first toe wound 3 cm x 1.2 cm, second toe wound 3 cm x 2.5 cm, third toe wound 0.5 cm x 0.3 cm, and fourth toe 2 cm x 1.3 cm, [MEDICAL CONDITION] of extremity moderate at 2+ wound drainage large amount serous with musty odor. Left foot description included the left foot is less denuded, swollen and red. The first toe wound measured 0.4 cm x 0.7 cm, between the toes 1 cm x 0.3 cm, second toe 0.9 cm x 0.4 cm drainage moderate serous with musty odor. -11/17/16 wound of the right foot denuded, red, swollen, yellow slough covered wounds with drainage yellow/green large amount the right foot, right medial ankle wound measures 13.5 cm x 8cm, lateral ankle wound measured 8 cm x 6.5 cm, lateral fifth foot wound measured 1.5 cm x 0.6 cm, left heel wound measured 1.5 cm x 1.5 cm x 0.5 cm, right heel wound measured 1.5 cm x 1.5 cm x 0.5 cm, the first toe wound measured 4 cm x 1.2 cm, the second toe wound measured 3.5 cm x 3 cm, third toe wound measured 3.5 cm x 2.5 cm, fourth toe wound measured 1.5 cm x 1 cm. Left foot wounds recorded as macerated, denuded, color light red/pink moderate [MEDICAL CONDITION] at 2/3+ large amount of drainage, serous, with a musty odor. Left foot wound between the first and second toe measured 2cm x 0.6 cm, second toe wound measured 1 cm x 0.6 cm, left heel blister measured 3 cm x 9 cm, left medial malleolus wound measured 1 cm x 2 cm and the wound base had yellow slough and 50% necrotic. -11/25/16 the right foot with wounds appeared denuded, red, swollen, with yellow slough covered wounds draining yellow/green, the right medial ankle wound measured 10 cm x 6 cmx 0.1 cm, the lateral ankle wound measured 5 cm x 4 cm x 0 cm, right lateral foot wound measured 1.8 cm x 3 cm x 0.2 cm, lateral foot wound measured 1.2 cm x 0.4 cm x 0.2 cm, the right lateral mid-foot wound measured 0.8 cm x 0.3 cm x 0.2 cm, the right heel wound measured 1.3 cm x 1 cm x 0.3 cm, right first toe wound measured 3.5 cm x 2 cm x ?cm, right second toe wound measured 4 cm x 2.5 cm x ? cm with the appearance looking slightly purple tinged, right third toe wound measured 2 cm x 0.5 cm x ?cm, right fourth toe wound measured 2cm x 1cm ?cm. -12/1/16 the right foot had opened wounds, the right foot appeared denuded, red, swollen, with yellow slough covering the wounds; the first toe wound measured 4 cm x 2 cm (void of depth), the second toe wound measured 4 cm circumferential around the toe with 1 cm x 0.5 cm exposed white tendon, the third toe wound measured 2.5 cm x circumferential, the fourth toe wound measured 2.5 circumferential the fifth toe wound lateral measured 1 cm x 0.5 cm 0.2 cm, the right lateral mid-foot wound measured 1.5 cm x 1 cm x 0.3 cm, the right dorsal foot wound measured 6.5 cm x 6.0 cm x 0.1 cm, the right heel wound measured 1.25 cm x 2 cm x 0.5 cm, the right half anterior wound measured 2 cm x 1.5 cm, the right calf posterior wound measured 6 cm x 8 cm, medial ankle distal wound measured 7 cm x 6 cm, the right medial ankle proximal wound measured 4 cm x 3.5 cm. -12/1/16 the left foot wounds recorded wound base color with yellow slough aquatic tissue 75% surrounding skin macerated, denuded with extremity [MEDICAL CONDITION] moderate at 2+, the left foot first toe wound measured 0.2 cm round, the second toe wound measured 1.3 cm x 0.7 cm x 0 cm, the note for plan provided instructions: don't wrap the feet with Kerlix. -12/9/16 the right foot had opened wounds, the right foot was denuded, red, swollen yellow slough covered wounds and the right medial ankle and right second toe had one centimeter spots of dark moist eschar, the first toe wound measured 4 cm x 2.5 cm, the second toe wound measured 4 cm in circumferential around the toe with 1 cm x 0.5 cm of exposed white tendon, the third toe wound measured 2 cm x 0.8 cm, fourth toe when measured 2cm x 1 cm, the lateral foot at the fifth toe wound measured 0.8 cm x 0.6 cm x 0.2 cm, the right lateral mid-foot wound measured 0.5 cm x 0.6 cm x 0.2 cm, the right dorsal foot wound measured 7 cm x 4 cm x 0.1 cm, the right heel wound measured 1.2 cm x 1 cm x 0.3 cm, the right calf anterior wound was healed, the right calf posterior wound measured 5.8 cm x 3 cm, right medial ankle distal wound measured 1.0 cm x 3 cm x 0.1 cm, the right medial ankle proximal wound measured 4 cm x1 cm x 0.1 cm. -12/9/16 the left foot wounds revealed yellow slough, macerated skin denuded skin with serous drainage, the left first toe wound measured 0.2 cm round, the left second toe wound measured 1 cm x 0.5 cm x 0 cm. -12/19/16 the right foot had open wounds, the skin was denuded, swollen at 3+, yellow slough covered wounds, the right first toe wound measured 3.5 cm x 2.5 cm, the second toe wound measured 3.5 cm circumferential around the toe, the third toe wound measured 2.3 cm x 1 cm, lateral foot fifth toe wound measured 1.5 cm x 1 cm, the right lateral mid-foot wound measured 0.5 cm x 0.5 cm x 0.3 cm, the right dorsal foot wound measured 5.5 cm x 3 cm x 0.1 cm, the right heel wound measured 1.8 cm x 1.4 cm x 0.5 cm, the right calf posterior wound measured 5 cm x 3 cm, the right medial ankle wound measured 10 cm x 7 cm, the right lateral ankle wound measured 13 cm x 4 cm. -12/19/16 the left foot wounds contained yellow slough, the left second toe wound measured 1.1 cm x 0.6 cm x 0.1 cm, skin condition was macerated and denuded, serous drainage without odor, [MEDICAL CONDITION] moderate at 2+. The wound assessment dated [DATE] was the most current documented wound assessment. B. Observations and Resident Interview On 1/5/17 at approximately 10:00 a.m., the resident was observed sitting in the front lobby area near the nurse's station. He had white cloth foot wraps (Rooke Boots) on each foot. His right foot wrap was yellowish colored with the bottom of the wrap moist/wet. He propelled his own wheelchair with his feet. There were no foot pedals on his wheelchair. On 1/5/17 at 12:45 p.m. the resident was observed sitting on the side of his bed with both feet undressed and resting on a bed pillow on the floor. The soiled foot wraps (Rooke Boots) were on the wheelchair seat next to his bed. -Denuded skin (loss of the epidermis layer of skin) covered most of the resident's right foot. The right foot had three necrotic areas, one on the top middle portion of the foot and one on his great toe and one on his second toe. On the back lower right leg was a large open area. On the right back middle heel was a deep area with slough in the bottom. The skin across all the toes was moist with areas of yellowish slough and pus. -One necrotic area was located on top of the left foot near the base of his second toe. The resident said the wounds were painful and rated his current pain 10/10 (with 10 being the worst pain). See failures in pain management below. C. Failure to adequately manage the resident's wounds 1. Failure to ensure that a comprehensive care plan was developed and updated to reflect the status of the resident's wounds and included interventions coordinated with hospice to manage the resident's wounds and associated pain. The care plan initiated 9/7/16 and revised on 11/3/16 identified a terminal [DIAGNOSES REDACTED]. Interventions included consult with the physician and social services to have hospice care provided for the resident in the facility. Adjust and provide activities of daily living to compensate for the resident's changing abilities. Encourage resident participation to the extent the resident wishes to participate. There was no reference to the venous/arterial ulcers noted on the 10/22/16 MDS and the multiple wounds observed on 1/5/17. However, a care plan initiated several months later on 1/9/17, identified venous/stasis ulcer of the left foot related to disease process. The interventions included wound care by the hospice nurse and observe/document/report as needed for signs and symptoms of infection. The care plan did not reference other steps for facility staff to take to promote healing or to prevent skin injury and did not reference any other skin injuries on the right foot and lower right leg as observed on 1/5/17. Except for the mention of wound care by hospice on the 1/19/17 plan, none of the resident's care plans outlined how the facility and hospice would integrate services to manage the resident's wounds. 2. Failure to assess, evaluate, monitor and document the condition of wounds. Review of facility records and hospice documentation revealed a lack of facility management of the resident's wounds. The documentation revealed no assessment of the resident's wounds by facility staff, no documentation of monitoring and documentation of the on-going status of the wounds by facility staff and finally, evidence indicating the facility was unaware of the resident's wound orders. -Review of the facility medical records revealed the records were void of documentation of the resident's wounds on either the non-pressure skin condition report or pressure injury report. -Review of the facility weekly skin checks from 10/25/16 to 1/4/17 were found void of wound assessments. -According to a hospice note dated 9/14/16 at 12:35 p.m., the hospice nurse conducted a visit with the resident. The resident told the nurse from hospice he had a debridement done on his right heel yesterday. There was no documentation by facility staff regarding the debridement of the resident's heel or the status of this wound following the debridement. -According to a hospice note dated 10/15/16, 9:30 p.m., hospice documented the facility nurse contacted hospice with a concern regarding the resident's bilateral lower extremity wounds. She told the hospice nurse the facility did not have current wound orders and that the resident's feet had draining wounds without dressings. The hospice nurse made a visit at 10:10 p.m. on 10/15/16. The hospice nurse observed the resident sitting in his wheelchair in the rehabilitation room of the facility with his feet being soaked in water. His bilateral feet and lower leg swelling, redness, and sloughing of skin on toes and bottom of the feet were noted, his toes on the right foot noted to have purulent drainage. Both of his lower legs were weeping serosanguineous fluid. The hospice nurse reviewed the medical records and did not find orders in the chart for dressing changes. The hospice nurse contacted the wound clinic and asked that orders be faxed over to the facility. The orders were faxed and had an original order date of 9/29/16 from the doctor at the wound clinic. The supplies that the facility had did not include what the wound clinic doctor had ordered 9/29/16. -According to the hospice note dated 10/22/16 at 2:55 a.m., the hospice nurse was called by the hospital triage nurse who reported the patient was transferred to the hospital emergency department related to chronic leg pain and worsening of his wounds. The hospital nurse said the nursing home facility nurse informed her that when soaking the resident's feet, the feet looked like raw hamburger. The hospital nurse was seeking clarification of the wound orders and goals and said the resident had arrived with a [MEDICATION NAME] and Kerlix dressing to the bilateral lower extremities and that the skin was wet with serosanguineous drainage. The right lower extremity had wounds with light greenish yellow slough to the medial ankle/heel and on his second toe, his left lower extremity had slough to the heel. Both feet had dark [DIAGNOSES REDACTED] across his toes and in patches all across his feet. The hospice documented a call was placed to the nursing home to speak with the nurse. The nurse at the nursing facility reported she was unaware if dressing changes have been occurring as ordered last week. She also was unaware if the resident had followed up with the wound clinic. The hospital nurse placed a call to the wound clinic who faxed over wound clinic instructions from the last visit dated 10/19/16 with orders for daily and as needed dressing changes. The wounds were to be cleaned with care klenz or normal saline, dry, and apply [MEDICATION NAME] (calcium alginate) and cover with cast paddings secured with stockinette. 3. Failure to ensure timely intervention by the interdisciplinary team, specifically nutritional intervention, to promote wound healing. Review of the nutritional progress notes were found void of reassessment of nutritional status after the presence of new wounds and worsening of wounds. According to the nutritional status review notes, the registered dietitian's first assessment was dated 5/18/16 and a nutritional status review was conducted on 8/16/16. The most current nutritional status review was dated 11/23/16, well after the resident had developed additional wounds on his feet, bilaterally (see wound clinic notes above). The registered dietitian documented on 11/23/16 that the resident had vascular sores on his feet and one area of shearing on the buttocks. The resident did not receive a supplement/snack/fortified foods according to the status review dated 11/23/16. Review all of the Medication Administration Record [REDACTED]. 4. Interviews The director of nurses (DON) was interviewed on 1/9/17 at 8:34 a.m. The DON said facility staff do not document a weekly assessment of the resident's wounds; she said the wound clinic did that. She said the hospice nurse changed the dressings and the resident was seen at the wound clinic weekly. She said the resident's wounds were not pressure sores and the wounds had begun as [MEDICAL CONDITION]. The hospice nurse was interviewed on 1/10/17 at 10:45 a.m. She said she had only been working for hospice two weeks and was new to the routine at the facility. She said she has not provided dressing changes for the resident. D. Failure to manage the resident's pain 1. Orders a. Review of the October physician orders [REDACTED]. -Aspirin EC ([MEDICATION NAME] coated) 81 mg by mouth one time per day for prevention of [MEDICAL CONDITION] and stroke dated 5/11/16. The Medication Administration Record [REDACTED] -[MEDICATION NAME] 25 mcg/HR [MEDICATION NAME] every 72 hours dated 9/29/16 and discontinued 10/9/16. [MEDICATION NAME] 50 mcg/HR [MEDICATION NAME] every 72 hours dated 10/9/16 and discontinued on 10/25/16. [MEDICATION NAME] 12 mcg/HR [MEDICATION NAME] every 72 hours dated 10/25/16 and discontinued 10/31/16. [MEDICATION NAME] 50 mcg/HR [MEDICATION NAME] every 72 hours dated 10/25/16 and discontinued on 11/1/16. [MEDICATION NAME] HCL 5 mg tablets every eight hours as needed for pain dated 8/29/16 and discontinued on 10/14/16. [MEDICATION NAME] HCL 5 mg tablets every two hours as needed for pain dated 10/14/16 and discontinued on 10/18/16. [MEDICATION NAME] HCL tablets 10 mg by mouth every two hours as needed for pain management dated 10/18/16 and discontinued on 1/5/17. b. Review of the November and December physician orders [REDACTED]. In addition to the orders for Aspirin EC and [MEDICATION NAME] HCL 10 mg tablets every two hours prn (see October orders above), the November orders included: [MEDICATION NAME] HCL 10 mg tablet by mouth as needed with dressing change, date ordered 11/20/16. [MEDICATION NAME] HCL give 7.5 mg per tablets three times every day for pain, administer at 9:00 a.m., 2:00 p.m., and 9:00 p.m. [MEDICATION NAME] HCL 10 mg tablet by mouth every eight hours for pain management date ordered 11/16/16, administer at 6:00 a.m., 2:00 p.m., and 10:00 p.m. [MEDICATION NAME] HCL 10 mg tablet one time per day pre-medicate 30 minutes prior to wound care by mouth and as needed today at 9:00 a.m. order date 11/19/16 and discontinued on 11/20/16. c. Review of the January 2017 orders through 1/5/17 revealed the order for [MEDICATION NAME] HCL 10 mg tablet by mouth every two hours as needed for pain management dated 10/18/16 was discontinued on 1/5/17. A new order read [MEDICATION NAME] HCL 10 mg tablet by mouth every six hours as needed for pain, scheduled times 1:00 a.m., 7:00 a.m., 1:00 p.m., 7:00 p.m., order date 1/5/17. 2. Care plan The resident's care plan dated 5/12/16 revealed the resident had actual, chronic pain. The goal was that the pain would be alleviated with both pharmacological and non-pharmacological interventions with evidence of pain relief through both verbal and nonverbal indicators such as grimacing, groaning, and crying. Interventions included the staff would observe for signs and symptoms of verbal and nonverbal indicators of pain each medication pass and periodically. The staff would notify the physician of unrelieved pain. The staff would provide diversion activities, such as positioning, music, and television. The staff would provide medications as ordered and document effectiveness results of medication administration. 2. Failure to adequately manage the resident's pain. a. MAR indicated [REDACTED]. During the 31 days for the month of October, the documentation revealed different levels of pain throughout the days with a pain level of 10 of 10 recorded one or more times for 13 days out of 31, 11 days at level 9, one day at level 8, one day without a recorded pain level assessment, and five days recorded at 0 to 7 pain level of 31 days. During the 30 days of November, multiple levels of pain were recorded with the highest level recorded for the day as follows: On ten days out of the 30 days, a pain level of 10 was recorded; on 11 days out of the 30 days, a pain level of 9 was recorded; on two days out of the 30 days, a pain level of 8 was recorded; on six days out of the 30 days, a pain level of 7 was recorded and on one day out of the 30 a pain level below 6 was recorded. During the 31 days of December, multiple levels of pain were recorded with the highest level recorded for the day as follows: On nine days out of the 31 days, a pain level of 10 was recorded; on 20 days out of the 31 days, a level 9 pain rating was recorded; on one day out of 31 days, a pain level of 8 was recorded; and on one day out of the 31 days, a pain level of 7 was recorded. During the 5 days in January 2017, the resident's pain levels were recorded as follows: On one day out of the five days, a pain level of 10 was recorded; on three days out of the five days, a pain level of 8 was recorded, and on one day out of the five days, a pain level of 6 was recorded, indicating high to severe levels of pain continued. a. Failure to reassess the resident's pain and monitor the effectiveness of pain medication Review of the clinical/medical records were found void of documentation related to a team meeting for discussion of pain evaluation or need for changes in the medication regime although the resident had high to severe pain documented most days. Review of the medication administration records (MARs) revealed the facility conducted pain level assessments with as needed pain medication and with routine orders for aspirin. The MARs had an individual line for each pain medication to indicate the pain level. -However, review of the form revealed it was void of an individual line for documentation of pain relief. Some of the nurses documented effective using the letter E to indicate it was effective. At times when the E for effectiveness was documented, the E was placed on the same signature line as the time the medication was given. -Moreover, there was no documentation 30 minutes to one hour later with a follow up on what the resident's pain level was after administration of pain medication in order to evaluate the effectiveness of the ordered intervention. b. Failure to review and revise care plan and coordinate with hospice in addressing the resident's pain. See above care plan. There was no evidence the resident's care plan for pain was revised as the resident continued to experience severe pain. There was no evidence the facility coordinated with hospice about how to effectively address the resident's severe pain in the facility, including consideration of effective, nonpharmacological interventions. 3. Observations confirmed the resident continued to experience severe pain. On 1/5/17 at 12:49 p.m. the resident was in his room waiting for his pain level to decrease so the nurse could provide wound care and dressings to his feet. When asked what his pain level was, the resident said it was 10 or, if possible, more than 10. The resident was observed to grimace and clench his fist, expressing he was having a painful twinge of increased pain. He said his pain was severe; he could hardly stand it. He said he was waiting for some new medication and was told it could take two or three hours and that was not acceptable. He said he should not have to wait that long for pain medications. He said in the past, [MEDICATION NAME] worked for him and that was what he requested. 4. Interview On 1/5/17 at 3:30 p.m. the DON said she said she had called hospice today to see if they could get the physician to change or increase his pain medication because his routine pain medication was not effective. She said it would take the pharmacy two maybe three hours to get to the facility with new medications. At 5:00 p.m. the DON said today they tried to get the resident to go to the emergency room so he could receive IV medications for his pain and the resident had refused. She said the hospice nurse was going to try and get the resident admitted to a hospice bed for pain control but all beds were full. She said the physician had changed some of the resident's medications and increased some dosages. She said the physician did not want to order [MEDICATION NAME] because of the other medications the resident had already been taking. She said the resident's pain level was down to a 6. On 1/10/17 at 10:45 a.m. the hospice nurse, who had been working for hospice for about two weeks, was interviewed. She said whenever she comes in she visits with the resident and they talk about pain and pain control, food and intakes, and end-of-life issues. She said the resident had requested [MEDICATION NAME] for pain control last week but the hospice physician did not want to order that due to the amount of other medications he had already been taking. She said he has his own right mind can make his own choice and decisions. She said the resident was telling her pain is about a level 6 out of 10 and had also been telling her his pain was 35 out of 10. She said normally she sees the resident two times per week and a certified nurse aide from hospice also sees him two times per week. She said this past Thursday and Friday morning she had been working with the doctor getting changes made for his pain medication and thinks this had helped to get his pain under control. But see above; January pain levels remained high. III. Resident #32 Facility Policy The facility policy number SSP 0203.00, entitled Routine Resident Care, originally dated April 2005 and most recently revised September 2011, read in pertinent part, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene .Residents are encouraged or assisted to dress in appropriate clothing and footwear daily . Professional Reference According to Lippincott Manual of Nursing Practice, 10th edition, page 445, it read in pertinent part, Applying Compression Stockings, (i.e., TED hose, Circ-aids): Purpose: to prevent acute [MEDICAL CONDITION] ([MEDICAL CONDITION] or [MEDICAL CONDITION] embolism postoperatively or during periods of immobility. A. Resident Status Resident #32, age 92, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 9/24/16 minimum data set (MDS) assessment, the resident had a brief interview for mental status (BIMS) score of six out of 15, which meant she was severely impaired for daily decision making. The resident resided on the secure unit of the facility. The MDS read that the resident required extensive assistance of one for dressing, which included donning/doffing TED hose or Circ-aids, as the resident did carry a [DIAGNOSES REDACTED]. B. Family Interviews A family interview was conducted on 1/3/17 at 5:12 p.m. The family member said that staff were not assisting the resident with donning her TED hose that had been ordered. An interview was conducted with a second family member on 1/5/17 at 9:05 a.m. She said that the facility lost five pairs of the resident's compression stockings. She said that the facility ordered new ones which were extra-large and did not fit properly. The family member said that she spoke with licensed practical nurse (LPN) #13, who worked on the secure unit who told her that she would try to check with a local medical supply company, as the family was being told by facility administration that the resident's stockings were back ordered and had been for quite some time. The family member said that the resident petite, size 15, toeless compression socks as the resident had athlete's feet and needed the toeless type. Another interview was conducted with the second family member on 1/5/17 at 12:55 p.m. The family member said she had been resistive to the facility using Circ-aids instead of TED hose because the facility had used them on her mother before and that the staff did not know how to appropriately don the Circ-aids because they were two pieces with straps and if the straps were placed incorrectly, they caused additional swelling, which is what she said her mother experienced. She was told that the facility did have the appropriate size of Circ-aids already in-house, which had been ordered for the resident. She said she would be comfortable with trying the Circ-aids as long as the director of nursing (DON) promised to provide proper training to the certified nurse aides (CNAs) who would be putting the stockings on the resident. C. Resident Observations On 1/5/17 at 9:00 a.m., the resident was observed wearing regular socks, fuzzy slippers, a long-sleeved shirt and cape for warmth. On 1/5/17 at 12:23 p.m., the resident was eating her lunch on the secure unit, sitting in a leather recliner with a rolling table holding her meal. She was dressed in a long-sleeved pink shirt and had on white, regular socks with pink, fuzzy slippers. On 1/5/17 at 3:45 p.m., the resident was still wearing regular socks and slippers. On 1/9/17 at 8:00 a.m., the resident was observed eating her breakfast at a rolling table in the

Based on observations, record review and resident, family and staff interviews, the facility failed to have sufficient nursing staff to provide care and services for 21 (#2, #4, #6, #9, #15, #20, #23, #27, #32, #34, #39, #40, #53, #58, #60, #62, #67, #72, #80, #95, #104) of 46 sample residents to attain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual care plans in five of five neighborhoods. Residents experienced delays in call light response, pain medication administration, and bathing, grooming, toilet use and incontinence care assistance. Residents stated that as a result, they experienced incontinence accidents and felt degraded, uncomfortable, angry and embarrassed. The findings included: Cross Reference F241 dignity and respect; F242 choices regarding smoking times; F309 skin condition and pain; F312 activities of daily living; F315 catheter care and F329 unnecessary medications. I. Facility Expectations On 1/11/17, the nursing home administrator (NHA) provided the facility's policy and procedure titled, Nursing Staffing Schedule, release date June 2007, which included in pertinent part: The director of nursing services or their designee is responsible for developing the work schedule taking into account the resident's care needs .Procedure: 1) Determine the average census. 2) Calculate daily labor hours .3) Establish the staffing pattern .4) Schedule employees for appropriate shift positions taking into account any time-off requests . II. Resident Census and Condition Report Review of the facility Resident Census and Condition Report signed by the director of nursing (DON) on 12/3/17, revealed a resident census of 83. The residents' functional, mental, and psychosocial needs were described as follows: -68 residents were occasionally or frequently incontinent of bladder; 46 residents were occasionally or frequently incontinent of bowel; 11 had indwelling or external catheters, and zero residents were on individually written bladder or bowel training programs. -42 residents were in a chair all or most of the time and 14 residents ambulated with assistance or assistive devices. -48 residents had dementia or [MEDICAL CONDITION] and 22 had behavioral healthcare needs; 53 were on psychoactive medication; 36 were on antianxiety medications, 70 were on antidepressant medications; and 13 were on hypnotic medications. -83 residents were receiving preventative skin care and 19 were receiving respiratory treatments III. Observations and interviews were conducted throughout the facility from 1/3/17 through 1/10/17. Residents who were identified by facility and assessment as cognitively independent and interviewable, were asked if the facility had enough staff available to make sure the residents received the care and assistance they needed without having to wait a long time. Administration and nursing staff were asked about the staffing schedules, resident activity, safety and ability to meet the needs as outlined in their individual plans of care. A. Resident Interviews and Observations 1. Resident #53 was interviewed on 1/5/17 at 9 a.m. He said, Staffing is a big problem . Where there's two there should be three . They're all great . but you can only go so fast. You have peoples' lives in your hands. The resident said he sometimes observed pills on the floor, and reported it to nurses. When you have a heavy turnover there's a problem. -The resident said cares were rushed All the time, because of the fact that - and a lot of them are young kids - they feel they have to get as much accomplished as fast as they can so they can move on to the next, as if they have a quota. In healthcare the patient comes first. -Asked about call light response time, he said, I seldom ring it and it takes a long time. When I ring (the call light) they know (I need) something and quickly. -The shifts are 12-hour shifts. I see turnover where people call in sick. (They will call in replacements) but . they're going to be gone the next day because they're [MEDICATION NAME]. The resident said he had seen a lot of turnover since he moved into the facility last spring. -When my roommate needs assistance, he needs assistance. He'll ring the call light and wait 35 minutes. I have been known to just flat [MEDICATION NAME] - I grew up in a farm. I'll say 'hey (my roommate) needs something and now!' That gets a response . I look at the clock and I time them. Because of low staffing my favorite nurse can grab me and put me in my wheelchair. (The resident required two-person assistance for transfers.) He said he had had incontinence due to waiting for staff assistance. One staff person says 'we get to you as soon as we can, but we just don't have enough people,' so I try not to call until it's absolutely necessary. She says if you got to pee and poop just do it in your breeches, and it does save them some time. It used to be embarrassing. I don't want this to be a negative mark against them (staff). -There's no training here whatsoever, because they rush them in and rush them out. That's the problem. They should allocate at least 48 to 72 hours of good training and emphasize that you have to clean up poop. There's a girl here right now who just can't. On 1/5/17 at 1:15 p.m., the resident was calling out for help, requesting pain medication. His call light and his roommate's call lights were observed lying on the floor, without clips attached, and inaccessible. The resident started to [MEDICATION NAME] loudly, and a few minutes later, the medication nurse was observed walking toward his room, followed by the staff development coordinator and the director of nursing. The call light was lit up at the wall but not above the residents' door. The resident said he had been in pain since his dressings were removed before lunch. 2. Resident #15 was interviewed on 1/5/17 at 2:15 p.m. She said, They do need more staff. Sometimes I have to wait about an hour (the resident had a clock on her wall opposite her bed) . Mostly it's the bathroom. When I've got to go, I've got to go now. I'm always incontinent. With my [MEDICAL CONDITIONS], I could cough and it just comes out, but it can make a difference between a little and a lot (if they arrive sooner). I'm thinking hurry!' 3. Resident #9 was interviewed on 1/4/17 at 5:34 p.m. She said, Some days they do (have enough staff), more days they don't. People call off and things don't get done. They can't give baths. When asked if she ever felt her cares were rushed, she said, Kind of, yes. They hurry and push us around and everything, but it's not that they're hurting us. They're just in a hurry. (I'll say) wait a minute - I wanted some ice or something extra, and they're down the hall trying to answer the other five calls. -The resident said call light response was slow sometimes, and some of the staff including nurses would not answer call lights. She said residents were doing without baths because of short staffing. 4. Resident #62 was interviewed on 1/10/17 at 11:16 a.m. She said there were not enough CNAs (certified nurse aides) and call light response was slow. When asked if she had to do without anything due to short staffing, she said, It's not me so much, it's the others . other people just have to wait so long for them to answer . There are a lot of times there is only one CNA for the whole floor. We need two to three girls. At least two. She said when she pushed her call light and there were two CNAs working, It doesn't take much time. But when there is only one, it can take awhile; about 20 minutes. 5. Resident #2 was interviewed on 1/9/17 at 1 p.m. Upon entering the room with the resident after she had left the dining room from lunch, it was observed that the resident's room and bathroom had a strong smell of stale urine. The resident's bed was stripped to the mattress, with her linens rolled up at the head of the bed, and her fall mat on the floor next to the bed. The resident looked dismayed as she entered the room for the interview. -When asked about staffing, she said, They say they'll help me and they don't come back. When asked if her cares were ever rushed, she said, Yes, they don't have enough employees to help you. 6. Resident #58 was interviewed on 1/9/17 at 1:15 p.m. He said call light response time depends on the time of day. I use both a urinal and a bedpan. He said he had been left on the bedpan for half an hour, and that he knew by the clock on the wall in plain view. -He said, There's way too many (residents) in here for the amount of (staff) they have working here. They just can't do it. We've got some serious (care needs) and we've got two nurses and two CNAs . They're supposed to change, get dressed, feed, bathe . The biggest thing I want is I'd like to get a shower on a regular basis. -The resident said he had had incontinence accidents waiting for someone to come and help. Oh, yeah . It's a pain in the neck. It's not that they don't care; it's that they can't deal with what they have to deal with. If they go down the hall to help another incontinent resident, everybody on this ward is that way, if you ask me. I don' t know of anybody who gets up and goes to the bathroom (independently). Everybody wears (incontinence briefs) on a daily basis it smells bad down here. It was observed during the interview that the resident smelled of body odor. 7. Resident #27 was interviewed on 1/4/17 at 10:30 a.m. She said the facility did not have sufficient nursing staffing. She said, When you ring your light sometimes it can take them up to an hour. The same way with getting off the bedpan. With night shift it's harder to get the bedpan, stuff like that. Asked how she knew this, she nodded toward the clock on the wall across from her bed. When asked how she felt about this, the resident said, Degraded. -The resident added, When you ask for a nurse, you usually get a CNA. You tell her (you want a nurse) and then she usually comes in. And sometimes not, because they haven't told them. She said she would prefer a bath two or three times a week, but it's been about once a week. -Review of grievances filed by the resident revealed on 12/3/16, the resident reported a concern to the former NHA and current staff development coordinator. The management staff who completed the form documented: Patient was a little upset today cause she wanted to go on the bedpan and both the nurse and CNAs were with other patients, at the time patient needed to go. Other patients are not able to receive care due to the high volume of care that (resident #27) needs. The CNAs and nurse are doing their best to provide care for all patients. We need to see if we can put the patient on a toileting schedule to enhance the level of care other patients are needing also. The action taken by the SDC was Education of all (CNA) duties for all shifts have been initiated on 12/16/16. There was no documentation of follow-up with the resident. The form was signed by the former NHA on 12/12/16. -A grievance filed by the resident on 12/4/16 with the director of nursing noted that the resident was turned onto her left side by one CNA, although she required two-plus-person assistance with bed mobility. I told him I was going to fall and he said, 'No you're not.' My feet slipped off the side of the bed. I've been nervous about turning since. 8. Resident #72 was interviewed on 1/3/17 at 11 a.m. He said the facility did not have sufficient nursing staff. When you ring the emergency light it takes 20 to 25 minutes. There is no expediency in response. And that's especially bad when you have to go to the bathroom, and they don't come and they don't come and they don't come and you need to have a BM (bowel movement). The resident said he had had incontinence because staff did not respond timely to his call light, and as a result, he felt Angry. He said from his room he could hear other residents calling out Help me, help me, help me, help me and it goes on and on and on. When you call them here for some kind of service they just show up when they want to. The resident said he was lucky to get a bed bath once a week, and would prefer to have a shower three to four times a week. 9. Resident #20 was interviewed on 1/3/17 at 2 p.m. Regarding staffing, she said, When I push the button it takes forever for them to come in. Sometimes I wonder 'what if it was a real emergency?' It just seems like forever a lot of times. She said she was sometimes waiting while sitting in incontinence and it was uncomfortable. The resident said one CNA would tell her, just a minute I need more help, just a minute I need more help. There's only one nurse and one CNA on duty at night. One nurse all day. The resident said sometimes at night she had to wait too long for pain medications. 10. Resident #34 was interviewed on 1/3/17 at 3:30 p.m. He said, . They've got a little girl who helps me get a shower . I haven't had a shower in three weeks. That's what this little lady who sits next to me says . I would prefer a shower every other day. The resident said he preferred one particular CNA to give him showers, and she always shaves me too. The resident's hair was oily and unkempt, he was unshaven with several days' beard growth, he smelled of body odor, and his bed linens were stained and soiled with food and grime. The resident had an automatic room air freshener on his bedside table that sprayed on him once during the interview, and he commented that was not supposed to be there. 11. Resident #6 was interviewed on 1/3/17 at 1:56 p.m., and asked if the facility had enough staff available to make sure the residents received the care and assistance they needed without having to wait a long time. He said he has had to wait, up to 40 minutes to get help off the toilet. He said there have been times when his hall had only one CNA working during the night shift. 12. Resident #67 was interviewed on 1/4/17 at 12:27 p.m., and was asked if the facility had enough staff available to make sure the residents received the care and assistance they needed without having to wait a long time. He said no, and explained that his roommate fell out of bed recently and, The call light rang for 10 minutes so I got up to go help him and the CNA came in mad because I was trying to help because no one else had come in. 13. Resident #95 was interviewed on 1/3/17 at 11:52 a.m., and was asked if the facility had enough staff available to make sure the residents received the care and assistance they needed without having to wait a long time. He said no, and said around Christmas time they were short staffed. He stated, They were left short-handed. I felt sorry for the CNAs and nurses who were here. It was at that time bells were going off all at once and there was only one CNA on. Some of the CNAs pulled a double shift. He said the longest he has had to wait when he pushed the call light was 20 minutes and stated, If there is a CNA who walks by she will say she will be back in two-to-three minutes, but that means 10 minutes and I'm ok with that. But if it is important, like going to the bathroom, I will let her know I need someone right now. 14. Resident #39 was interviewed on 1/4/17 at 12:46 p.m., and was asked if the facility had enough staff available to make sure the residents received the care and assistance they needed without having to wait a long time. He said, It is better during the week. The weekend, they are always under-staffed. He explained that usually they had one nurse and one CNA working on the south hall, from end to end. Sometimes there is a roving CNA who works on the north and south side. On the weekends the care needs definitely don't get met. 15. Resident #23 was interviewed on 1/4/17 at 11:18 a.m., and asked if the facility had enough staff available to make sure the residents received the care and assistance they needed without having to wait a long time. She stated, They need more staff. 16. Resident #4 was interviewed on 1/5/17 at 2:51 p.m., and asked if the facility had enough staff available to make sure the residents received the care and assistance they needed without having to wait a long time. She stated, No. There was only one nurse and one aide night before last. She said her roommate had to push her call light a lot in her room at night before anyone will respond to help her and sometimes she gets up to go to the bathroom on her own. She said her roommate had fallen on 1/2/17. 17. Resident #60 was interviewed on 1/5/17 at 2 p.m. She said she normally did not have any issues with staffing, but that morning, she was scheduled for her shower at 5 a.m. She said she had been waiting in bed, in her pajamas, since early that morning for someone to come down and take her for her shower, but she had not seen CNA #17, who was to provide her shower, yet that day. She asked if someone would go and check and see what the delay was. 18. Resident #104 was interviewed on 1/5/17 at 2:15 p.m. He said that the facility had too many staff on duty just standing around talking to each other or just holding pieces of paper. He said that was why things were not getting done around the facility. 19. Resident #80 was interviewed on 1/5/17 at 3:45 p.m. He said the facility did not have enough nursing staff, that this was a chronic problem, that the staff complained to each other about how hard their work was in front of the residents, and that the facility was inconsistently staffed, especially with qualified staff. He said that an average call light response time was about 15 minutes and the longest he had waited recently for a call light to be answered was an hour. He said that it was upsetting to him to have to listen to staff complain to each other about how short staffed they were and how hard they had to work. B. Family Interviews 1. A family member of resident #32 was interviewed on 1/3/17 at 5:18 p.m. She said the facility was probably short of CNAs because of the current high census in the facility. She said that her mother had been going all day without socks on her feet and that her mother's feet were cold. She said that her mother had a problem with [MEDICAL CONDITION] in her legs that was not being adequately addressed, and she felt it was partially due to insufficient staffing and not following through with requested things. 2. A family member of resident #40 was interviewed on 1/4/17 at 1:44 p.m. She said the facility did not have enough staff. When asked if she thought her family member received the same number of baths or showers in a week based on past preferences she said no. She said the family came to visit and found him dirty. She said he had bad body odor and even his room stunk so bad it made the family feel like throwing up. The facility housekeeper saw the family visiting and came down to clean the room. The mop that she used was dirty and smelled bad. She said there had often been times when family had called to check on the resident and the facility did not answer the phone. She said sometimes the staff had answered the phone, asked her to hold on, then didn't return to answer the phone. She said she would like the facility to follow up on the phone calls or help the resident to make a return phone call. 3. A regular visitor to the facility was interviewed on 1/10/17 at 12:09 p.m. She said last Sunday the facility did not have a manager on duty working. She said the facility was filthy, that many good staff had left the facility, and the new staff don't get the training they need, and don't know how to take care of the residents. C. General Observations On 1/5/17 at 10:45 a.m., resident #34 said he did not receive his morning medications and he thought he was supposed to receive them with breakfast. LPN #17, who was working on the north hall at the medication cart, and going quickly to and from resident rooms, was asked about the resident's medications. She acknowledged the resident's medications were late, and should have been given at breakfast. She said he was four down on the list. The secure unit was observed on 1/9/17 at 3:35 p.m. The resident in room [ROOM NUMBER]A was sitting on the edge of his bed, not wearing pants, reaching out for his wheelchair. No staff were observed nearby. A male resident was walking around in the common/dining area, interacting with other residents, wearing gray sweatpants. He had a large wet spot on the back of his pants from incontinence. The nurse was notified and went to assist both residents. -CNA #33 was the only CNA observed on the unit. She was observed trying to lead an activity with the residents who were unengaged or pacing throughout the common/dining area. She was asking residents if they wanted to do a bean bag toss, or do some coloring, and if they were thirsty. When asked, she said the activities person was gone and she was the only CNA today because the other CNA called off. She said she typically worked as one of the bath aides on the open unit. D. Record Review 1. Resident Council Meeting Minutes The resident council minutes were reviewed from 1/19/16 through 12/15/16. The following was of pertinent note: - 1/19/16: Kitchen, staffing, medications are the most concerns we have right now; talked about what the complaints were and what could be done to try to resolve them. - 5/18/16: Nursing concerns . Staffing: mostly on nights, CNAs and nurses. - 6/15/16: Nursing concerns . Staff challenges still, staff in dining room, during meals. - 8/17/16: Nursing concerns . Short staffed on weekends. - 10/19/16: Addressed staffing issues: sign-on bonuses for new staff, bath aides start Monday, social worker has resigned . Department Concerns: Nursing: Asking for help with brushing teeth. Call light goal is under seven minutes . New staff development manager will be starting .Residents feel the night staff spends too much time chatting . Dietary: The food service director has been cooking as the kitchen is short cooks. - 12/15/16: A new receptionist needs to be hired and the staff is not answering the phone nights and weekends. 2. Daily Staffing Sheets The daily staffing sheets were reviewed from 10/1/16 through 1/7/17 and included the following: November 2016: -CNAs worked less than what was staffed as necessary 27 days out of 30 days total. -Nurses worked less than what was staffed as necessary 19 days out of 30 days total. December 2016: -CNAs worked less than what was staffed as necessary 11 days out of 31 days total. -Nurses worked less than what was staffed as necessary nine days out of 31 days total. January 1-6, 2017: -CNAs worked less than what was staffed as necessary on one out of six days total. The call light logs were requested from the Registered Nurse (RN) corporate consultant on the morning of 1/10/17 for nine specific residents. At 11:43 a.m., he explained that the facility did not routinely monitor call light response times, but instead used an audit system where a staff member would randomly choose five residents and turn the call light and wait to see how long it took for staff to respond to it. -The Call Light Response Audits were reviewed from 11/1/16 through 12/27/16. Each form documented the names and room numbers of five random residents, and the Response Time that was measured for each of the call lights to be answered. The results included 38 days the audits were completed and the longest response time was documented as eight minutes on 11/6/16 for room [ROOM NUMBER]-A. The nursing home administrator (NHA) provided a list of residents in the facility who required transfers with two-person assistance: -Secure unit = three -North hall = nine -South hall = 13 3. Patient Hours per Day (PPD) Reports On 1/10/17 at 5:50 p.m., the Director of Nurses (DON) was asked to provide the patient hours per day (PPD) hours for the past two months. However, as of 1/11/17, they had not yet been provided. -On 1/11/17, after survey exit, an email was sent to the DON and NHA with a second request to provide the PPD hours. Later that day, the NHA provided the PPD from 12/816 through 1/8/17, and explained that she did not have access to the additional four weeks. She said the facility's corporate payroll department was working to pull the additional month, and she said she would provide it the following morning. However, as of 1/24/17, the additional documents had not been provided. The PPDs for 12/8/16 through 1/8/17 were reviewed and documented the following: -Week of 12/8/16 through 12/14/16, the average PPD was 3.166 -Week of 12/15/16 through 12/21/16, the average PPD was 3.150 -Week of 12/22/16 through 12/28/16, the average PPD was 2.831 -Week of 12/29/16 through 1/4/17, the average PPD was 2.934 -Week of 1/5/17 through 1/8/17, the average PPD was 2.802 E. Staff Interviews 1. On 1/4/17 at 9:55 a.m., RN #11 said she did not have time to speak with the surveyor and stated, I don't mean to be rude, but I have a lot to do right now. Right after this I have labs to draw and none of the other nurses draw labs. After this, I go right into blood sugars. She said she would finish what she was doing and then she would be available. At 10:53 a.m., the nurse was still unavailable. 2. CNA #5 was interviewed on 1/9/16 at 3:15 p.m. When asked if there was sufficient nursing staffing, she said, No. If people didn't call off, we'd probably be okay. We're short by one aide on each hall today. I guess they don't have enough staff because they don't have anyone to fill in. -She said as a result, the residents have to wait a little longer to get lights answered, (and don't) have their routine like they're used to . I promote independence for residents who are able to do more for themselves. If I have a resident who asks me to do something, I ask them to at least try first. If they can be independent it gives me more time to be with the ones that can't be. -The CNA said on south hall there were six or seven residents who required two-person assistance, and about the same number on the north hall. -She said she answered call lights as soon as possible, and if I need help I'll say 'give me two minutes' so (residents) know I'll be back in that certain amount of time. We didn't get any baths done today. We're supposed to have a bath aide but I think she's the one who called off . They don't cover (call-offs), that's for sure. I guess the girl who's doing the scheduling tried calling people in and only one person answered. That's typical I guess. The CNA had to cut the interview short so she could go to assist another CNA to transfer a resident. 3. CNA #43 was interviewed on 1/9/17 at 4 p.m. When asked if there was sufficient nursing staff, she said, Definitely not. There are times I get really frustrated because I'm single-staffed on this hall many times. It's really unfair that residents have to wait. They deserve the best care and that's really hard when there's only one person able . Priorities go to changing, repositioning, toileting before and after every meal to prevent falls. I have to admit I can be really forgetful when I'm trying to answer many lights and I'm single-staffed, like a glass of juice, passing ice water, things like that. Those things definitely get pushed aside. Charting, today I haven't had a moment to sit down and chart. -She said residents and families had complained to her of insufficient staffing. She said there were eight residents on north hall who needed two-person assistance. 4. CNA #27 was interviewed on 1/10/17 at 2:35 p.m. and she confirmed that she was routinely responsible for providing assistance to the residents who required supervised smoking. She stated, That's a tough one, and explained that staff were to take turns with the scheduled smoking times. She said the south hall was responsible for the 9:00 a.m. and 4:00 p.m. times, and the north hall was responsible for the 1:00 p.m. and 8:00 p.m. times. She stated, I wish we had a little bit more help with that. I have had to ask activities to help me a little bit. I have to ask to get help. She said sometimes the residents have expressed frustration to her about the long wait times for smoking assistance. 5. CNA #33 was interviewed on 1/9/17 at 1:13 p.m. She stated she had worked at the facility for at least two years and that she floated throughout the units. She said, We go through stages where we are fully staffed and then we are not. She said that she detected a pattern of insufficient staffing, maybe around when school starts. She said that, currently, the facility needed maybe three more CNAs working from 6 a.m. to 10 a.m. to assist with getting all the residents up and ready. She said that residents on the north hall had not been receiving their baths/showers in a timely manner. She said that it would be nice for the facility to have a dedicated bath aide or two to help with timely bathing. She recalled a time in early December 2016 where she was assigned to baths, but then she was pulled to work the floor because the facility was short staffed. She said that it was very difficult trying to catch up on residents' baths on 1/8/17 because she was also assigned to work the floor that day. 6. Restorative aide #34 was interviewed on 1/9/17 at 1:02 p.m. She said she worked day shift and was often assigned to the secure unit. She said the facility did not have enough nursing staff because if they did, I would not be working back on the secure unit; I would be working restorative. She said that the facility received a lot of call-offs and management changes. She said that resident cares, such as passing medications, were often delayed because it took longer to pass medications when the facility was short staffed. She said that the residents on north and south halls were not getting their baths or showers timely, if at all. She said the facility was often out of supplies such as briefs, wipes and latex gloves. She said that for a few months towards the beginning of summer 2016, the restorative program was starting up again, but the restorative staff had since been pulled back to the floor due to short staffing. 7. LPN #13 was interviewed on 1/10/17 at 8:37 a.m. She was asked if any residents or family members had reported feeling that the facility was insufficiently staffed to her. She said, You hear that all the time. She mentioned one particular family member who complained a lot and said she took that family member with a grain of salt. She said that if it was a hectic day on the unit or if the facility had some call offs on any particular day, her priority was to see that medications were passed to all residents and that the residents had what they needed. She said that on those types of days, she may have to put things like documenting on the residents' behavior monitoring sheets on the back burner. She said that out of 19 residents currently residing on the secure unit, approximately four residents required a two-person transfer. She said that if the facility had call-offs, they would rearrange and float staff around. 8. CNA #9 was interviewed on 1/10/17 at 8:51 a.m. She said that the facility went back and forth in relation to maintaining sufficient staffing. She said they would go four to six weeks with sufficient staffing, then they would have some staff turnover, then the facility would struggle with staffing again for the next month. She felt that, at present, staffing on the secure unit had been steady. She felt that activities were very important to the residents and that the staff struggled on the secure unit on Sundays, Mondays and Fridays when they did not have an activity assistant to help. Then staff were expected to provide both activities and ADL (activities of daily living) assistance to the residents. She said that she did have one family member who was frequently complaining to her about insufficient staffing in the facility. She said that four residents and an occasional fifth re

Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible by: -Safely securing medications in one of one medication disposal areas used by the facility; and -Ensuring smoking safety for one (#5) of 21 sample residents. The facility failed to ensure an office, where medications were being stored and destroyed, was kept locked and not left unattended. During a tour of the facility on 10/12/16 at 10:18 a.m., the medical records office door was observed to be shut, but the door was unlocked and the office was unattended. A resident with dementia was observed sitting in his wheelchair in the hallway directly outside the office door. Resident rooms were located immediately adjacent to the office. Inside the office, a bath basin lined with a trash can liner was observed on a desk to the left just inside the doorway. The basin was approximately half-full of various pills and pill fragments that were soaking in vinegar. On the desk were three medication blister pack cards that contained the medication Labetalol (antihypertensive). A clear trash bag was on the floor just inside the room door. The trash bag contained 32 blister pack cards with medications in them, a box full of eight Lovenox (anticoagulant) syringes with needles, 35 inhaler nebulizer solutions, 69 Lidocaine (anesthetic) patches, and four bottles of medicated mouth rinse. Across the room, a white plastic basket sitting directly on the floor contained 35 blister pack cards with medications in them, insulin pens and an inhaler. The room had four windows that looked directly outside onto a resident walkway. The windows were open and only the screen separated the room and the walkway. The room was left unlocked and unattended for an uncertain amount of time, but estimated to be approximately 30-45 minutes, per staff interview (see below). At 10:38 a.m., after 18 minutes of continuous observation, the nursing home administrator (NHA) was informed of the above findings and entered the room. She explained that the office belonged to the director of nurses (DON) and assistant director of nurses (ADON). She said she thought they were in the process of destroying medications, and was unsure where they were. She confirmed that the medications and chemicals should not have been left unattended and the door should have been locked. She left the room at 10:40 a.m., again leaving the room unattended by facility staff, to locate the DON. The facility's failures created a situation for residents of immediate jeopardy with the potential for serious harm. The findings included: I. Failure to safely secure medications A. Imposition of Immediate Jeopardy On 10/12/16 at 1:10 p.m., the NHA and DON were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failures to ensure that prescription medications did not remain unattended during the destruction process, which left the facility residents at risk, created a situation of immediate jeopardy for potential serious harm. Facility Response and removal of the Immediate Jeopardy On 10/12/16 at 4:33 p.m., the abatement plan was submitted by the facility to CDPHE. It read: Residents living in (the facility) have the potential to be affected by this alleged deficient practice. Effective immediately, the DON has ensured that all medications are secured in all storage areas to include medication rooms, offices, and medication carts, ensuring no one except appropriate personnel has access to them. Effective immediately, medications that have expired or been discontinued will be destroyed in the presence of two licensed staff members one of which being an RN (registered nurse) in a secured area. The drug destruction will be completed using the Steri-cycle bins for hazardous, non-hazardous, and aerosols medications. DON/designee is ordering drug disposal bins from Steri-cycle. Discontinued and expired drugs will be secured appropriately until bins arrive in facility and destruction can be completed appropriately. The DON re-educated all licensed nursing staff currently working at (the facility) on 10/12/16 to include but not limited to, securing medications, not leaving medications unattended, and destruction of medications utilizing the appropriate destruction bins. Remaining staff not in-serviced on 10/12/16 will be in-serviced on the same process before they work another shift. The DON/designee will audit medication destruction bins and logs to ensure that drugs are destroyed appropriately, and observe one medication destruction weekly or as drug destructions happen. The DON/designee will track and trend issues identified through audits on medication storage and medication destruction and present monthly to the Quality Assurance and Performance Improvement (QAPI) committee for three months or until substantial compliance is achieved. The DON will be responsible for implementing and sustaining recommendations made by the QAPI committee. On 10/12/16 at 5:10 p.m., the NHA was notified that the above plan was accepted and the immediate jeopardy was abated effective 10/12/16 at 5:00 p.m. However, based on interviews and record review, deficient practice remained at an E level, a pattern with the potential for more than minimal harm. B. Facility Expectations According to the Medication Pass and Medication Storage policy provided by the DON on 10/12/16 at 6:20 p.m., revised in October 2006, Medications and biologicals are accessible only to authorized staff and are locked when not under the direct observation of authorized staff. According to the Disposal/Destruction of Expired or Discontinued Medication policy provided by the NHA on 10/12/16 at 11:34 a.m., revised 5/1/10, Facility staff should destroy and dispose of medications in accordance with facility policy and applicable law . Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction . Facility should destroy non-controlled medications in the presence of a registered nurse and witnessed by one other staff member . C. Observations of unsecured medications On 10/12/16 at 10:18 a.m., an office labeled Medical Records Supervisor was observed at the end of the facility's southeast hallway. It had a window that allowed for clear visibility of the contents of the room, and was observed to have a desk near the door that had a bath basin on top of it, filled with pills and pill fragments. On the floor near the door was a clear trash bag that contained multiple medication blister packs with medications in them, and a second white plastic basket of medications located across the room under the window. The door to the room was unlocked and there were no staff present. The following was observed: 1. Contents of the basin on the desk top The bath basin was located on top of the desk and was lined with a trash can liner. The basin was approximately half-full of pills and pill fragments that were soaking in vinegar. Some of the pill fragments contained the imprint numbers RDY532 and D/04, which were identified as Divalproex (anticonvulsant) <https://www.drugs.com/imprints.php?imprint=RDY+532&color=19&shape=5> and Gabapentin (anticonvulsant) <https://www.drugs.com/imprints/d-04- .html> respectively. (Accessed from the website www.drugs.com <http://www.drugs.com> on 10/13/16.) There were also three medication blister pack cards that contained the medication Labetalol (antihypertensive) on top of the desk, next to the computer screen. 2. Trash bag on the floor A clear trash bag was observed on the floor just inside the room door. It was open and contained 32 blister pack cards with medications in them. The cards had the pharmacy labels attached to them that included the resident's name, prescription name, dose, route and specific instructions related to the medications. The following medication cards were observed: -Coumadin (anticoagulant) x3, Lasix (diuretic) x4, Quetiapine (antipsychotic), Labetalol, Lisinopril (antihypertensive), Prednisone (glucocorticoid) x3, multivitamins, Atorvastatin (antihyperlipidemic), Cimetidine (antiulcer) x2, fluconazole (antifungal), Allopurinol (antigout), Divalproex x2, Bumetanide (diuretic), Metoprolol (antihypertensive), potassium chloride (supplement) x2, Metformin (antidiabetic), Gabapentin, Amlodipine (antihypertensive), Levothyroxine ([DIAGNOSES REDACTED]) x2, Losartan potassium (antihypertensive), and Xifoxan (antibiotic). The trash bag also contained a box full of eight Lovenox (anticoagulant) syringes with needles, 35 inhaler nebulizer solutions, 69 Lidocaine (anesthetic) patches, and four bottles of medicated mouth rinse. 3. White plastic basket A white plastic basket was sitting directly on the floor under an open, screened window. The basket contained 35 blister card packs with medications in them. The cards had the pharmacy labels attached to them that included the resident's name, prescription name, dose, route and specific instructions related to the medications. The following pertinent medication cards were observed: -Fluoxetine (antidepressant), Sertraline (antidepressant) x2, Zofran (antinausea), prednisone, Mirtazapine (antidepressant), and Zyprexa (antipsychotic). Additionally, the plastic basket contained multiple insulin pens and an inhaler. Resident #18 was observed in the hallway outside the medical records office. 4. Medication storage and disposal On 10/12/16 at 4:25 p.m., the DON was asked to show where the pharmaceutical waste bins were located in the facility. She stated, There are no bins. That is the problem. She explained that was why she was going to sit in the medical records office and work on MDSs while the staff development manager sat there at the other desk and destroyed medications. She said, The keys to the room were in my desk drawer. I have already been locked out of the room twice this morning. The DON clarified that she had only worked at the facility for approximately three weeks. She was not sure if the facility had a current contract with a hazardous waste disposal company. She said she was going to ensure that there was a contract in place and go get the bins from them tomorrow. D. Resident Status Resident #18, age 70, lived in the room directly across the hall from the medical records office and was observed propelling himself in his wheelchair near the entrance to the office on 10/12/16 at 10:20 a.m. He appeared to be confused and an interview attempt was unsuccessful. According to the most recent minimum data set (MDS) assessment, he was rarely/never understood. His memory and recall ability was limited to the location of his room and staff names and faces. He was able to move between locations in his room and adjacent corridor with supervision. E. Record Review The DON was asked to provide a list of all residents on the south hallway, to include their BIMS scores, who were able to mobilize independently, whether it was ambulating unassisted or using a cane, walker or wheelchair. On 10/12/16 at 12:19 p.m., the DON provided a map of the residents' rooms on the south hallway that documented their BIMS scores and their mobility, which documented the following: -13 residents were moderately impaired and able to use a walker or wheelchair for mobility; and -Eight residents were severely impaired and able to walk independently or use a wheelchair for mobility. -A total of 24 residents on the south hallway were cognitively impaired and able to ambulate around the facility independently. The pharmacy Product Destructions log, reviewed from 7/1/16 through 10/14/16, included the name of each medication destroyed, the quantity destroyed, and the name of one employee who entered the medication into the log. A total of 257 entries were documented during that time period. F. Staff Interviews On 10/12/16, from 10:18 a.m. through 10:34 a.m., for 16 minutes, observations revealed the medical records office door remained unlocked and unsupervised with the medications in the room. At 10:34 a.m., an attempt was made to locate the NHA, and she arrived at the room at 10:38 a.m. She said it was her understanding that the DON and assistant director of nurses (ADON) had previously been in the room destroying the medications when they were called off for an emergency and then maybe went out to smoke. The NHA confirmed that the medications should not be left in the unlocked room, unattended. She left the room at 10:40 a.m. to locate the DON, but did not ensure that the door was locked or that a facility staff member was present. -The DON arrived at the medical records office at 10:46 a.m., and she confirmed that the staff development manager (SDM) had been destroying medications by himself earlier that morning, and it was his desk that held the basin with medications soaking in vinegar. She said that she was not present during the destruction because she stepped out to do wound rounds with the medical director. She explained that the SDM left the office to use the restroom and she said she asked him to assist her to turn a bariatric resident, and was unaware that he didn't lock the medical records office door behind him. She said the staff development manager had just started to work at the facility within the past few days and he did not have a key to the office. She said the keys were in her desk drawer. -The DON was asked to explain the facility's routine process for medication destruction. She said, Right now: what they are doing. This is old school. She said she would expect the door to the room to be locked when staff were not present and the windows should be closed. She explained that the windows had been opened because the vinegar odor was so strong, and assured they would be closed when the process was completed. -The DON was unsure if the file cabinet that contained the personnel files was locked or not, and she confirmed that the file cabinet should have been locked. The staff development manager returned to the medical records office at 10:57 a.m. He said he had never performed drug destruction before. He said he was given the instructions to dispense the medications into the bucket and put vinegar in it. He confirmed that he had left the room unattended to use the restroom down the hall, and was not told to lock the door; just told to shut the door. He also confirmed that it was his office, but he did not have a key. -The DON said that had been a miscommunication and that the door should have been locked. Pharmacist Interview The pharmacist consultant was interviewed on 10/12/16 at 2:35 p.m. with the NHA present. He explained that he was the interim pharmacist for the facility and had been there in August and September. He said the facility had their own policy for the proper disposal of non-narcotic medications and that they had a contract with a hazardous waste disposal company. He confirmed that the staff were supposed to keep medications in the medication room when they were discontinued, and there was supposed to be a place where they could be locked up inside the medication room. -The pharmacist explained that each medication was supposed to be logged and there were different containers that different medications were supposed to be discarded into. He said he did check on the warfarin (anticoagulant) container and nicotine patches container and confirmed that they were there at the facility and in place. He said he thought there was another container for oxidizers and aerosols and a large yellow one for non-hazardous medications. -He was informed of the observations of the medications being left unattended and unlocked in the medical records office. He stated, Usually we do this in the med (medication) room where it is under lock and there is a security provision. I'm pretty sure it says this in Chapter 5 (State long term care regulations). It should not be a room that is totally open so all residents could walk in. I don't think that is following policies. He said in the future it would be his recommendation to perform the medication destruction in the medication room so that it was in a secure location. -The pharmacist further explained that when medications were discontinued in the medication cart, they were then placed in a safe location for destruction, and the whole process takes place in a safe area and not likely that anybody could get into it. He assured that he would meet with the DON and review the policy and procedures to make sure they didn't have another similar issue in the future. Medical Director Interview The medical director was interviewed on 10/12/16 at 2:57 p.m. She confirmed that medication storage and destruction should be performed behind locked doors and consistently supervised. She clarified that the medications should not have been left unattended in the unlocked room. The facility further failed to ensure the resident environment remained as free of accident hazards as possible by ensuring resident #5 received staff assistance and supervision when she smoked. II. Failure to ensure smoking safety A. Facility Policy On 10/12/16 at 5:34 p.m., the DON provided the facility's policy and procedure titled Safe Smoking Policy, revised June 2015, which included: The interdisciplinary team (IDT) members determine if a resident is a safe or unsafe smoker before the resident exercises the privilege to smoke . An evaluation is conducted for all residents who smoke upon admission, readmission, when there is a significant change of status, quarterly, and annually thereafter on all residents who smoke or who use e-cigarettes, in order to: Assess the resident's cognitive status to determine if the resident is capable of safe smoking; Interview the resident to determine their ability to verbalize and understand the smoking rules; and, Observe the residents' ability to smoke in a safe manner. The resident's care plan reflects . The degree of supervision that is necessary, if any; If the resident is to wear a protective smoking vest/apron .If it is determined that the resident is an unsafe smoker, the resident is required to wear a protective smoking vest/apron and is supervised while smoking .Staff members maintain all smoking materials for unsafe smokers .Staff members distribute smoking materials to residents at smoking times. Safe smokers with lock boxes in their rooms may maintain their own smoking materials .Residents, their families, visitors, and staff are instructed not to share lighted cigarettes or other smoking materials with any resident. B. Resident #5 status Resident #5, age 57, was admitted on [DATE]. According to the medication review report, [DIAGNOSES REDACTED]. According to the 8/26/16 MDS assessment, the resident had a brief interview for mental status (BIMS) score of nine out of 15, which indicated she was moderately impaired. She required supervision for bed mobility, transfers, eating, dressing, toilet use and personal hygiene. It was very important for her to do her favorite activities and rejection of care occurred one to three days. The care plan, initiated 8/22/15 and revised 9/21/16, identified risk for injury related to smoking because she was an unsafe smoker and required constant supervision during smoking. The interventions included a smoking apron was to be used, she was to be informed of the facility's smoking policy and potential consequences of noncompliance, smoking was in designated areas only, and smoking materials were to be maintained by staff. C. Observations and Staff Interviews On 10/11/16 at 12:50 p.m., resident #5 was observed sitting outside in the designated smoking area, holding a lit cigarette in her right hand and smoking it. She was not wearing a smoking apron and there were no staff in the smoking area to supervise her. Resident #13 was seated in a wheelchair directly in front of resident #5, and at 12:55 p.m., he provided her with a second cigarette and helped her light it. -At 1:00 p.m., certified nurse aide (CNA) #14 walked out to the designated smoking area and assisted three other residents to place smoking aprons on and to smoke. At 1:10 p.m., resident #5 continued to smoke a cigarette, but she remained sitting on the other side of the smoking area under a canopy behind a tree, outside of the CNA's line of sight. -At 1:15 p.m., the cigarette resident #5 was holding in her right hand was becoming very short, so resident #13 removed the cigarette from her hand and appeared to put it back in his box. He then placed a new cigarette in his mouth, lit it, and handed it to resident #5, who immediately began to smoke it. -At 1:20 p.m., resident #5 dropped the cigarette from her right hand into her lap and it immediately bounced onto the ground. Resident #13 picked it up, took a drag on it and then gave it back to her. -At 1:21 p.m., CNA #14 left the smoking area with the other three residents who had been supervised during their smoking, and resident #5 and #13 remained alone outside in the designated smoking area. The CNA did not bring the basket full of lighters and cigarette supplies back into the building with him, and they remained unattended in the smoking area. At 1:22 p.m., the CNA returned to the smoking area and retrieved the basket from the smoking area. -At 1:25 p.m., resident #5 dropped the cigarette from her right hand into her lap again, and it bounced onto the ground. Resident #13 picked it up again and placed it in his mouth, took a drag on it and then handed it back to resident #5. -At 1:28 p.m., activities assistant (AA) #6 passed by the chapel and was overheard to say, (Resident #5's) not smoking, is she? That's not her husband. That is (resident #13). At that time, resident #5's husband walked into the chapel and spoke to AA #6. He told her he was okay with (resident #13) helping her smoke, and AA #6 explained to him that they had to get everything in writing before that happened. Resident #5's husband appeared frustrated and walked outside to the designated smoking area and joined resident #5 and #13 while they smoked. -The AA said she was concerned about resident #5 smoking with resident #13 because she was unsafe. She said she was going to talk to resident #5's husband and stated, I'm going to pull him in and talk to him about it. On 10/12/16 at 11:08 a.m., resident #5 was observed sitting outside in the designated smoking area smoking a cigarette. She was alone, unsupervised, and was not wearing a smoking apron. At 11:09 a.m., resident #13 was observed to propel his wheelchair up to her and removed her cigarette from her right hand and began to smoke it. He attempted to hand the cigarette back to her, when AA #6 and AA #10 approached the residents, sat down next to them, and stopped him from providing the cigarette to resident #5. They talked for a few minutes and then the AAs left the smoking area. -AA #6 was interviewed as she was leaving the smoking area and she confirmed that resident #13 was planning to give resident #5 the cigarette. She stated, Just look at the ashes on her sweatshirt and on her clothes. She said she informed resident #13 that he was not allowed to provide other residents with cigarettes, even if her husband said it was okay. She said he agreed to stop doing it and was observed to propel himself away from resident #5 and lit himself a cigarette and smoked it alone, out of courtesy. D. Resident and Family Interview On 10/11/16 at 3:08 p.m., resident #5 and her husband were interviewed and he stated, My concern is her quality of life when I can't take care of her. He said he did not feel the facility had enough staff available and said, They are always short-handed. He said he visited the facility daily for eight to nine hours each day and explained that the lack of staff was a problem for the supervised smoking. He explained that the facility had four smoking periods each day, and each resident was allowed to smoke two cigarettes per period. He stated, I can't be here all the time and when I am here, she actually smokes less. -Resident #5 explained that she was a chain smoker and preferred to have more than two cigarettes at a time. -Resident #5's husband said that from time to time, other residents would take her under their wing and they will give them one of their cigarettes. He did not understand why the facility did not approve of that and said he gives (resident #13) my permission to help her smoke. -Resident #5's husband said that sometimes when he left at night, She will turn right around and go back outside. He said there should be enough staff to have someone walk through the courtyard and make sure no one was lying on the ground or sitting out there. (Cross-Reference F353, sufficient nursing staffing) E. Record Review The Safe Smoking Evaluation, dated 7/18/16, documented that the resident was unable to communicate that she understood the smoking materials were for her own personal use and to be used in the designated smoking area only. She was unable to light and smoke a cigarette while demonstrating safe technique for putting out the matches or lights and disposing of the ash. She needed to use adaptive equipment including a smoking apron and required constant supervision. The evaluation determined she was an unsafe smoker and was not interested in a smoking cessation program. The Safe Smoking Evaluation, dated 10/12/16 (during survey), again documented the resident to be an unsafe smoker and she was not interested in a smoking cessation program. F. Staff Interviews CNA #16 was interviewed on 10/12/16 at 8:30 a.m., and she confirmed that she routinely worked with resident #5. She said she was not allowed to smoke by herself, because she drops it. Her motor skills are lacking. She doesn't properly (dispose of) ash like she should. The social services director was interviewed on 10/12/16 at 12:14 p.m. She said she had had multiple conversations with resident #5's husband about her safety. She stated, He will not follow any rules or regulations and it makes it so challenging. She said they had spoken to him about cigarettes and told him that he can't give other residents cigarettes to give to her, because she wasn't going to be safe.

Based on resident and staff interview, the facility failed to protect the residents' right to file grievances without fear of retaliation for three of 12 sample residents (#6, #7 and #10). The residents expressed during interviews that they had concerns about staff retaliation. Specifically: -Resident #6 said s/he was "scared" of retaliation by staff, and said s/he wanted it "to stop"; -Resident #7 asked if s/he was "in trouble" after being interviewed and while his/her allegations were being investigated; and -Resident #10 said staff were "angry" after hearing what was said about them, stated s/he felt that s/he had to watch what s/he said, and said s/he felt "mistreated" and "beaten down" as a result. The findings included: Cross-Refer to F225, failure to timely and thoroughly investigate allegations and protect residents from verbal abuse, mistreatment and neglect during investigations. 1. Resident #6 (alert and oriented per recent facility assessments) Resident #6, interviewed at 3:30 p.m. on 4/30/14, reported concerns about verbal abuse and mistreatment from certified nurse aide (CNA) #1. S/he said, "After (the director of nursing/DON) talked to (CNA #1, the mistreatment) continued, because she (CNA #1) wasn't in trouble for that ... She (the DON) wrote up a concern form, didn't show it to me, didn't ask me to sign it, didn't check back with me. I want something done about (CNA #1) being so rough." -When asked if s/he had experienced retaliation, the resident said, "Yes, that's what I mean, her being rough and stuff. I don't know if she's just doing it to me or if she's doing it to everyone. But it needs to be investigated." -Resident #6 reported that s/he also had problems with CNA #10 who "works on day shift. I've had problems with him. He was mad after I reported him for not wiping me. That feels like retaliation - when people act like they're mad after reporting problems." The resident added, "I'd like somebody to go into their files, their write-ups. I'd like (facility management) to make sure that they don't take it out on me. ... (CNA #11 who works with CNA #1) is a nice lady but she's a friend of (CNA #1's) so I wish you wouldn't ask her about it." During a follow-up interview at 4:15 p.m. on 5/1/14, resident #6 said, "I want it to stop. I want her (CNA #1) to stop hurting me. And I don't want (CNA #10) to retaliate against me either. I told them (management) I didn't want him in my room today and they disobeyed it. That was at 1:30 today, quarter till 2. He (CNA #10) went home at 2. I told (the nurse consultant) I didn't want him caring for me anymore. With (CNA #1) I don't know. It seems like I've complained about her being too rough before and she never stopped." When asked if she felt safe now (since CNA #10 had left the facility), the resident responded, "No. I'm scared of (CNA #1) retaliating if she gets in trouble. I'm scared of her not answering my call light. I want something done but I'm scared of retaliation." 2. Resident #7 (alert and oriented per recent facility assessments) Resident #7, who requested an interview two or three times before 2 p.m., was interviewed at 2 p.m. on 4/30/14 in a private room with the door closed. Resident #7 reported that s/he felt "belittled" and "neglected" by an occupational therapist (OT #8). A few minutes after the interview began, the DON knocked on the door, entered and asked the resident if s/he still wanted him/her present during the interview. The resident initially said to the DON that s/he could come in during the interview as s/he had "nothing to hide." A few minutes later, the resident said s/he felt comfortable being interviewed in private. The DON asked the resident if s/he was going to discuss what s/he had already discussed with the DON. The resident said yes, and the DON left the room. When asked if s/he was comfortable with the interview process, the resident said s/he was. S/he said his/her ambassador, the maintenance director (MD), had approached him/her earlier and said he (MD) understood "(resident #7) was going to be talking to the state," and asked if s/he wanted a staff member to accompany him/her. The resident added, "He actually was the one who said since (the DON is) your other ambassador she's willing to be here. Either way, I have nothing to hide." At approximately 3:30 p.m. on 4/30/14, the resident, looking serious, called out to the surveyor from the dining room, "Did you get me in trouble?" 3. Resident #10 (alert and oriented per recent facility assessments) Resident #10, interviewed at 1 p.m. on 5/1/14, discussed concerns about CNA #1, CNA #10, and the facility environment as follows: -"We have a CNA (#1) who is a rather forceful person." -"She gets angry ... lets out a heavy sigh like she's perturbed." -"She's harsh but not abusive. ...She kind of holds that line, where she's a little on the rough side but then the next thing she's doing it's not. It varies depending on how she's doing when she comes in. She knows I don't like her. She doesn't like me. ... She has no people skills." -"You say something about her and it gets back to her, and then she gets mad, and that's when she gets a little gruff, rough, doesn't say much at all, just comes in, gets it done, gets out." -"So I'm watching my mouth, which I hate. It's attitude. I think it's just a reaction to what I've said. If I was running the place I wouldn't let people like (CNA #1) work here. Not in my shop. You've got to have good people skills and she doesn't." -"(CNA #10), the big tall guy, he again, I don't know what it is. I have trouble addressing exactly what it is. ... His comments are like, 'Well, I really go for the easy way.' The least amount of work he can get away with that's fine. He brings me down to take a shower. He'll stand somewhere and wait to be told everything rather than take the initiative with helping." -"I sound negative but I'm getting beaten down to the point where I'm tired of it." -"It doesn't look like they care. They're not doing anything to make you think that way. They just don't give a loud crap as to what the residents care about." -When asked how that made him/her feel, s/he said, "Mistreated, and certainly not like it was presented. You read the brochure and it says, 'Nobody is more important to us than our residents.' " -"Things never change unless you're (state surveyors) here. The evening you left (after the federal survey revisit), the next morning they had two people working in the dining room again." -"I would love to see some changes, a few, to show that they're actually doing something on a regular basis besides just to shut people up and then go back to the old way of doing it." -The resident said s/he was seriously considering moving to a different facility. S/he added, "I just get so d ...n mad when it seems like it's not an impossible task. I know you have problems getting people in, but why are you waiting until somebody walks out the door?" Staff Interview: The nursing home administrator (NHA), director of nursing (DON), regional nurse consultant, senior NHA and senior DON consultant were interviewed during the exit conference at approximately 5 p.m. on 5/1/14. -The NHA expressed surprise when the word "retaliation" was mentioned. -The DON apologized for attempting to attend the interview with resident #7. She said the resident had requested that she be present. She stated that she and the maintenance director were co-ambassadors for resident #7. She acknowledged that residents had the right to meet with visitors in private. -The NHA, DON and consultants acknowledged that they needed to listen, investigate, and take action on residents' concerns and prevent retaliation.

Based on resident and staff interview and record review, the facility failed to initiate and thoroughly investigate and take steps to protect two of 12 sample residents (#6 and #7) during investigation of allegations of abuse, neglect, and/or mistreatment. Specifically: -Resident #6 stated certified nurse aide (CNA #1) yelled at her, spoke to him/her disrespectfully, and was rough when providing care. -Resident #7 stated an occupational therapist (OT #8) did not honor his/her request during therapy to be transferred via Hoyer lift by his/her nurse and to have his incontinence brief changed after an incontinence episode. After the OT changed the resident, the OT left him/her "half naked" in the front common area. Both residents stated they had complained before to facility management about CNA #1 and OT #8, but they continued to receive care from them, either because their concerns were not investigated or they had no other choices. As a result, resident #6 said this made him/her feel "small" and "unimportant." Resident #7 said s/he felt "belittled" and "neglected" by OT #8. The findings included: 1. Resident #6 Resident Status: Resident #6, under [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 4/21/14 Minimum Data Set, the resident had a BIMS (cognition) score of 15 indicating cognitive independence, with no mood or behavioral symptoms. S/he needed extensive assistance for activities of daily living except eating, and used a wheelchair pushed by others for ambulation. The resident had three care plans related to behavior symptoms, depression/anxiety/mood and cognitive deficits. Problems, goals and approaches included the following: -On 3/17/14, the following behaviors were identified: "False allegations; crying, tearful; yelling at staff; resists care; verbal outbursts; socially inappropriate/disruptive; attempts to manipulate when wanting to smoke; inappropriate verbalizations, 'rub it harder'; and unrealistic demands" related to "diagnosis" and "ineffective coping skills." -The goal was "inappropriate behavior symptoms will be minimized through interventions." -Approaches included: "Use firm, gentle voice; give simple, clear directions; ignore verbal outbursts; check for discomfort, pain; allow choices if possible; modify environment, situations, and/or treatment to minimize episodes; two people for cares; coping skills, one on one; redirection; reassurance; activities of choice." Resident Interview: Resident #6 was interviewed on 4/30/14 at 3:30 p.m. S/he said s/he had a staff person "yell" at him/her recently. S/he said, "The nurse asked one of the CNAs if she could put me to bed and the aide said, 'No ma'am!' really loud." The resident said a regular visitor to the facility overheard this and talked to the CNA. The resident stated, "She asked (me), 'Why do you want to go to bed?' And I said, 'Because I'm in pain,' and I was almost about to cry, and so (CNA #1) turned me around real fast and slammed me into the room and put me in bed and put me in the Hoyer and put me in bed. She had somebody with her." When asked how s/he felt about this, the resident said, "It made me feel small, unimportant." When asked what was done about it, the resident said the director of nursing (DON) talked to CNA #1 first and "then came and talked to me. She talked to her first. She said she'd talked to her and that she didn't think it would ever happen again. I don't know. I don't think she did enough. I don't think she wrote her up or anything." When asked if CNA #1 had provided care for him/her since then, the resident said, "Yes. She's always really rough with me. She's always like punching me in the stomach when she's rolling me and stuff. She's really rough and I don't like it and I've told her about that before. After (the DON) talked to her it continued ... (The DON) wrote up a concern form, didn't show it to me, didn't ask me to sign it, and didn't check back with me. I want something done about (CNA #1) being so rough." Staff Interview: The licensed practical nurse (LPN) who provided care for resident #6 was interviewed at 4 p.m. on 4/30/14 about the incident described by resident #6. -She said, "(A regular visitor to the facility) came to me and reported it ... (CNA #1) kind of has a loud voice ... I know they counseled her. I spoke to her as well. She said, 'I didn't yell,' but she does have a louder voice. It was the tone of voice and loud. I didn't hear it (what was said). It was some comment but I just can't tell you. (The regular visitor) said it was loud too - she heard it." -She said CNA #1 told her she had explained to the staff development coordinator (SDC) that she wasn't being mean, that her voice carries and that she'd been counseled by the SDC. -She said, "I have no concerns with (CNA #1) - she does have a voice that carries, but she's a very caring person." Record Review: Review of CNA #1's record revealed no evidence of disciplinary actions, write-ups, counseling, or resident complaints. Grievance reports from resident #6 or written on his/her behalf were provided for review upon request. -A concern form regarding resident #6 dated 4/26/14 reported resident #6 did not feel s/he had been completely cleaned of feces after an episode of bowel incontinence. It was noted that staff requested CNA #1 return with resident #6 to his/her room. CNA #1 reported resident #6 had been incontinent of urine but there wasn't any fecal matter present. -The registered nurse (RN) reported resident #6 had been incontinent of urine and cleaned up without evidence of feces. "When I spoke with (resident #6) about this s/he said "(CNA #1) was just covering her a--." Reported to (CNA #1 and nurse resident #6's) response and requested RN document. Will follow up with (resident #6) tomorrow as s/he did not want to finish our conversation when (CNA #1) entered the dining room to provide assistance to other residents with eating their dinner." The form was signed by the DON on 4/26/14 and the nursing home administrator on 4/29/14, but there was no resident signature and no evidence of follow-up. Other grievances from resident #6 were related to baths and lighting in his/her room, dated 4/23/14, 4/24/14 and 4/30/14. They were signed by staff but not by the resident. Nurses' notes on 4/26/14 at 6:10 p.m. read, "Res reports to DON that s/he was not properly cleaned after a BM and s/he is burning. Res returned to room, Hoyer lift returned to bed. Res was wet, wipe shown to resident after cleaning. Reports to (DON) on return to dining room that s/he was 'slightly dirty.' RCS (CNA) aware of concern. Resident was wet on return to room and not soiled. Will continue to care for resident and prevent from feeling uncomfortable." There were no nurses' notes or social services notes regarding the resident's complaints of CNA #1 yelling at him/her or treating him/her roughly. Regular Visitor Interview: A regular visitor to the facility was interviewed by phone at approximately 6:30 p.m. on 4/30/14. She said she had been visiting a resident at the facility approximately a week ago, and had overheard a CNA yelling at a resident, "Why do you have to whine so much?" She said the CNA's voice was loud enough to be heard from behind a closed resident room door, and that she told the CNA she should not be talking to residents like that. She said she then reported her observation to the nurse on duty, the SDC and the DON. Additional Staff Interview: The SDC was interviewed at 3:30 p.m. on 5/1/14. -She said, "(The DON) and I were sitting in here and (the visitor) reported how (resident #6) was spoken to, and said (the visitor said) she thought it was not yelling but really gruff. (CNA #1) has one of those voices that can be perceived as yelling." -She said about the visitor's report, "It was (CNA #1). It was something to do with either going to a room to get a shirt changed. (The visitor) caught me at the dining room area with (CNA #1) and the way she (CNA #1 talked to resident #6) might have been perceived as inappropriate. And then we came in here with (the DON) and (the visitor) told (the DON) the same situation and I got called away. There were no reports of abusive behavior with residents. That would be reportable to me." The social services director was interviewed at 4:30 p.m. on 5/1/14. She said, "The first time I heard about (CNA #1) was when I was in the room with (the DON) and she said we'll talk to her and re-educate her to how we perceive big voices and things like that. (CNA #1) just has a strong voice and is very good at the things she does. ... I have no concerns about (CNA #1)." Additional Resident Interviews: Resident #10 was interviewed at 1 p.m. on 5/1/14. Resident #10 was alert and oriented, and resided on the same hall as resident #6. When asked about staff treatment of [REDACTED].#10 said, "We have a CNA (#1) ... She's a rather forceful person and she likes it run her way ... You would think that (residents are) doing something against her personally. She gets angry ... and lets out a heavy sigh like she's perturbed ... She's a little forceful that way ... She's harsh but not abusive." -When asked if CNA #1 provided care for her/him, s/he said, "Yes." When asked if she was rough, s/he said, "She kind of holds that line, where she's a little on the rough side but then the next thing she's doing it's not. It varies depending on how she's doing when she comes in. She knows I don't like her. She doesn't like me. ... She has no people skills. You say something about her and it gets back to her, and then she gets mad, and that's when she gets a little gruff, rough, doesn't say much at all, just comes in, gets it done, gets out. So, I'm watching my mouth which I hate. It's attitude. I think it's just a reaction to what I've said. If I was running the place I wouldn't let people like (CNA #1) work here. Not in my shop. You've got to have good people skills and she doesn't." During a follow-up interview at 4:15 p.m. on 5/1/14, resident #6 reiterated his/her concerns about CNA #1, and said, "I want it to stop. I want her to stop hurting me. And I don't want (CNA #10) to retaliate against me either. (Cross-refer to F165 Retaliation.) I told them I didn't want him in my room today and they disobeyed it. That was at 1:30 today, quarter till 2. He went home at 2 p.m. I told (the nurse consultant) I didn't want him caring for me anymore. With (CNA #1) I don't know. It seems like I've complained about her being too rough before and she never stopped." Asked if s/he felt safe, resident #6 said, "No. I'm scared of (CNA #1) retaliating if she gets in trouble. I'm scared of her not answering my call light. I want something done but I'm scared of retaliation." 2. Resident #7 Resident #7, under [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 3/18/14 MDS, s/he had a BIMS (cognition) score of 14, with no mood or behavioral symptoms. S/he required extensive assistance with activities of daily living, used a wheelchair for locomotion, had a urinary catheter and was incontinent of bowel. The care plan for transfers, dated 3/12/14, noted transfer assistance with transfer board and mechanical full body lift. A new care plan for "behavior symptoms," dated 4/29/14, identified "socially inappropriate/disruptive" behaviors, "resists care, demanding of staff, and rude to visitors and other residents." Approaches included "redirection from the staff." There were no nurses' notes on 4/29/14 to document what precipitated the behavioral symptom care plan. Resident Interview: Resident #7 was interviewed at 2 p.m. on 4/30/14. S/he said s/he had "an incident with one of the therapists (identified as OT #8)," the day before (4/29/14), and stated, "I had an incident with him prior - I'm not the only one ... I had him yesterday ... I had an accident (bowel movement during therapy) and he wanted me to use the slide board, which made poop go everywhere ... He made me feel neglected. He left me sitting out in the lobby half naked - that's when the CNA came and got me." When asked how the facility responded, the resident said, "They're in the process, I've still got to fill out a concern form. It happened yesterday toward the end of the day." S/he said the DON approached him/her, offered to help him/her complete a concern form, and said they had already started an investigation. The resident said s/he talked to the therapy director that morning and she was "in the process of getting the investigation started." The resident said, "His name is (OT #8), he's working today and in the therapy room now. I'm supposed to have therapy this afternoon so they're going to do it as a group so they're watching. He makes me feel belittled, is how I feel. I think he makes things difficult, more than they need to be. Like yesterday, where he did the slide board - yesterday wasn't a good day." -"From the beginning (OT #8) has made things hard and he talks down to me. All I know is it's being handled, and from what I understand, once I fill out the paperwork I don't know where she (therapy director) is at on hers, but I know once all that's in, I know (the DON) wants to have a meeting with him and (the therapy director). The DON let me know this morning, and (the therapy director) also came and spoke to me in private in my room, and asked me about the details and how it happened and how I felt." -"When (OT #8) first started I worked with him a couple or three times and ... I went down and told him I didn't want him working with me anymore. The only reason I let him help me yesterday was because (the therapy director) was gone and they were busy and I needed therapy." -"At first I tried to be positive. As it went on, I was dreading going in the shower room with him but I didn't have a choice at that time. Everything had already been started, and I wanted a shower. Actually I wanted a bath. From now on I'm going to tell him, this is what I want and I don't care what I've got to do and how I've got to get it done." -"He talks to you like you're a little kid, just the way he tells you to do things and how to move. Like when I had that dirty diaper, I said I wanted to be changed using the Hoyer by my nurse. I felt like a kid. He belittles you. When he left me laying there and I had to get somebody to find him to get me in the shower... If it wasn't for the CNA and probably (the DON) getting the CNA to help, I don't know. He left me in bed soiled - my main concern was getting clean and getting in the shower. At one point he said, 'Why don't we just get you in the shower and just get the crap off you?' I wouldn't crap in the shower. He kept telling them he was going to take care of it (instead of calling in the nurse). He told the CNA (#6) that he was going to take me down to the shower. She's the other one that's filling out paperwork. He did several things to her yesterday. (CNA #6) saw how he was belittling me." -Asked how s/he felt about continuing to work with the OT, the resident responded, "The truth is I don't want to work with him again at all ... I just don't feel comfortable working with him period. I don't trust him." Staff Interviews: The therapy director was interviewed at 3 p.m. on 4/30/14. She said she had been out of the facility for a couple of days and when she returned that morning, she heard from resident #7 about problems with OT #8. S/he said the resident told her, "I don't like the way he (OT #8) talks to me," and she told the resident she "would talk to" OT #8. The therapy director added, "More is coming to me. (Two CNAs) said, 'He (OT #8) talks to me like I don't know what I'm doing.' We need to have a separate meeting and training with him on his approach and how he talks to people. Sometimes you have squabbles with staff. There are residents (resident #9) who have issues about (OT #8). Resident #12's wife had an issue. She said, 'I don't want him to work with that shoulder' and he did anyway. I talked to (OT #8) and the resident's wife and that was resolved. ... Just now this is the second concern that's coming up ... When he first started a couple or three weeks ago, there were some concerns ... Now today ... I'm having multiple complaints about him. I need to sit down and think about what I'm going to do, moving forward. ... We're going to do a correction plan about his communication ... I have to call my regional manager and let him know." The therapy director said she would suspend OT #8 pending investigation of the residents' concerns. Additional Resident Interview: Resident #9 was interviewed at 3:25 p.m. on 4/30/14. He was alert and oriented. -When asked about OT #8, he said, "He's very demanding and I don't want to work with the man. I reported that to (the therapy director) and they didn't honor that request. I reported it to her again and she said she just forgot." When asked how he felt about that, he said, "Not good. I thought we had an understanding. We had that conversation this morning. It bothered me and I just came back from the hospital and they totally destroyed my rear end and there's not much as far as therapy that I can do right now ... I tried to explain that to (OT #8) but he just won't let it go and I can't do any therapy right now." -Asked when he told the therapy director he did not want to work with OT #8, he said, "I told her that, months ago, since he first got here. The first day we met he was very demanding, told me what I had to do, I told him I don't have to do squat. I said, 'You're here to help me, I'm not here to help you.'" Record Review: The concern form from resident #7, dated 4/29/14, written by the DON, documented "As discussed with (NHA/DON/therapy director names) by (resident #7), "Resident reported RCS (CNA) was upset about shower he received with COTA this afternoon ... didn't want to get 'anyone in trouble.' Explained to (resident #7) we were happy to hear his concerns and wanted to know his concerns so we could get them resolved. (Resident #7) stated he would prefer to discuss it tomorrow." -The question "Have you previously voiced this concern to a staff member?" was answered "No." The question, "Would you like to personally meet with someone about this concern?" was answered "Yes." The form was signed on 4/30/14 by resident #7. -On the opposite side of the concern form, dated 4/29/14, it was documented: "RCS (CNA #6) spoken to and expressed she was frustrated working with new COTA and became emotional and teary eyed, stated 'he doesn't try to work around my schedule, he just orders me around.' Requested (CNA #6) document events when she was not feeling so emotional on morning of 4/30/14 upon her return to work." There was no signature. Review of OT #8's record revealed his date of hire was 3/19/14. There was no evidence of write-ups, complaints or counseling sessions. Additional Staff Interviews: CNA #6 was interviewed at 2:30 p.m. on 5/1/14. When asked to describe the interaction between OT #8 and resident #7 on 4/29/14, she said, "We have a very encouraging therapist and he was inviting (resident #7) to take a shower, and he finally gave in. (OT #8) is just very persistent on how to do the transfers, the baths, and he left (resident #7) and didn't get him dressed. I wasn't there when he got him up for the shower. We had gotten (resident #7) and got him up and dressed, and (resident #7) just didn't want to do the slide board, and (the OT) was just pushy or encouraging or something. He's very persistent in how he wants it done. He doesn't really like to take no for an answer ... (Resident #7) didn't want to use the slide board. After (resident #7) was already in bed, I didn't like it at all. I told (the DON) ... When (a resident) says no he (the OT) still wants to do it. ...Some of the residents just don't like him because he's pushy ... None of the residents really care for him." The SDC was interviewed at 3:30 p.m. on 5/1/14. She said, "(Resident #7) caught me midstride in the hallway and he was mad. ... He said they're transferring him to the bath chair and that type of stuff. I asked him what was bothering him (and CNA #6). He talked with me and then (the DON) talked to him and that was it." -"(Resident #7) is calmed down about it now. He knows it's being looked into and he trusts that (the DON and NHA and therapy director) are doing what they need to do." The social services director was interviewed at 4:30 p.m. on 5/1/14. She said resident #7 and the therapy director "came in to talk to me about it yesterday. I've been around (OT #8) and I think he just has a different way of coming across. He's very knowledgeable about his job. So it's just a matter of tweaking how he talks to residents." 3. Administrative Interview: The corporate nurse consultant was interviewed at approximately 10:30 a.m. on 5/1/14. -She said she had talked with resident #6 that morning and learned that she had complaints of physical and verbal abuse by CNA #1. She said she was going to ensure the CNA was suspended pending the facility investigation. The consultant said that, evidently, the resident's concerns had been reported before. She said she was in the process of interviewing residents. The DON, NHA and corporate nurse consultant were interviewed at 5 p.m. on 5/1/14 during an exit interview. They acknowledged that the resident concerns above were not adequately documented, had not been thoroughly investigated and steps had not been taken to protect these residents from further abuse, neglect and/or mistreatment. The nurse consultant stated that CNA #1 would be terminated. She stated resident #6 had told her CNA #10 had not provided care for her that day, but stated she would investigate. 4. Follow-up Documentation On 5/5/14 at 5:30 p.m., the facility submitted investigative reports regarding resident #6's concerns about CNAs #1 and #10 and resident #7's concerns about OT #8. -The report summaries stated resident #6 reported being fearful of CNA #1, the CNA would be terminated, and the resident was informed that CNAs #1 and #10 would not be providing care for her any more. OT #8 resigned after being suspended during the investigation. Resident #7 was informed that OT #8 would not be providing therapy for him. An investigation regarding CNA #10 was conducted but all interviewable residents were not documented as having been interviewed. The facility's determination was that there was no evidence or abuse or neglect; however, one resident preferred female caregivers and that request would be honored. -All the facility's reports noted that abuse was not substantiated due to no intent to cause harm, but that the staff members were not treating the residents with dignity and respect.

Based on observation, record review, and interviews, the facility failed to ensure one (#3) of 12 sample residents was provided sufficient fluids to maintain hydration and health. Resident #3 was readmitted to the facility status [REDACTED]. Her hydration status was not reassessed upon readmission or when her condition changed, her risk for insufficient fluid intake was not care planned, and her fluid intake was not monitored. On 4/28/14, after several days of diarrhea, she was transferred emergently to the hospital, unresponsive to verbal stimuli and sterna rub. She was diagnosed with [REDACTED]. The findings include: A. Facility Policy On 5/1/14, the corporate consultant provided the facility's policy and procedure titled, "Hydration Management," released March 2010, which included in pertinent part: "All residents will be assessed by the Registered Dietitian to determine estimated nutritional requirements: kilocalories, protein, and fluids. This will be completed on admission, annually, and when there is a significant change in condition utilizing the Medical Nutritional Therapy Review form ... The Registered Dietitian or Dietary Manager will determine whether Nutritional needs are met based on meal observation and intake reports ... Refer to the Registered Dietitian (Area Dietitian, Consultant Dietitian) when: Resident is identified with inadequate fluid intake, a swallowing problem, nausea or vomiting, diarrhea or constipation, or abnormal labs ...the Registered Dietitian and/or Dietary Manager will ensure that adequate fluids are offered with meals and between meals, including residents receiving thickened liquids ...Fluids are coordinated between Dietary and Nursing Departments ... The Interdisciplinary Team will meet weekly ...to review resident fluid status and interventions ...A care plan will be developed or updated to reflect risk factors, measurable goals, and resident specific interventions ..." B. Resident #3 Resident #3, age early 50s, was admitted to the facility 3/27/14, discharged from the facility on 4/7/14 for brain surgery, returned to the facility for rehabilitation care on 4/23/14, and was emergently discharged to the hospital 4/28/14. 1. Resident status The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, and no [MEDICAL CONDITION] or behavioral symptoms or rejection of care. She required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. She required supervision with eating, and she was frequently incontinent of urine and bowel. admission orders [REDACTED]. 2. Status on initial admission - identified hydration risk and calculated fluid needs Review of Admission Nursing Assessments dated 3/27/14 and 4/23/14 identified as Additional Risk Factors: "Nutrition/hydration deficits." An "Initial Plan of Care" dated 3/27/14, was reviewed, and identified pain, skin, activities of daily living, falls and safety needs. A goal included "(Resident #3) will have adequate nutrition and hydration ... as evident by moist mucosa, adequate skin turgor and stable weight thru next review ..." The "Medical Nutritional Therapy Review" dated 4/2/14 included a dietary assessment estimating resident #3's fluid needs as 1,850 cubic centimeters (cc's) per every 24 hours. Her estimated intake, per this review, was 1,740 cc's. 3. Change in status following readmission 4/23/14 A written faxed order sent to the resident's physician on 4/26/14 at 11:30 a.m. requested an order to test the resident for [MEDICAL CONDITION] (bacterial infection which causes diarrhea), and read in pertinent part, "Resident has had watery loose stools for the previous several days with frequent BMs (bowel movements) each day. Resident also complains of abdominal pain. The physician responded that day and answered "Yes" to the requested order, and wrote "Vitals?" (There was no documentation in the clinical record to indicate that the physician was informed of the resident's vital signs). Review of the nurses' notes for 4/26/14 included no documentation of a resident assessment, including an assessment of vital signs, mucosa, or skin turgor (see initial care plan above). There was no documentation whether and what amount the resident was eating or drinking. The "Nursing Daily Skilled Summary" note dated 4/27/14 at 3:00 p.m. documented "...Resident up to wheelchair for all meals in her room. Blood glucoses (BGs) have (run) low today. OJ (orange juice) and milk administered. Resident refused diabetic medications and blood pressure medications at 9:00 a.m. Resident continues to have confusion ... NOC: At start of shift, day nurse in with resident. Resident's BG (in the) 60s. Nurse gave two packets without increase in BG levels. Day nurse gave Glucoburst at 7:00 p.m. At approximately 7:30 p.m., BG 103. Resident reports dizziness and numbness/tingling in mouth (lips). At 7:50 p.m. BG 84. Resident attempted to eat dinner without success as resident reports feeling 'too dizzy to eat.' Contacted on-call medical doctor (MD). Vital signs at 7:30 p.m. blood pressure 89/50, pulse 87, temperature 97.7. Also at this time RN (registered nurse) noted excessive diaphoresis. MD advised to discontinue [MEDICATION NAME] and follow up with primary MD for further instructions on next (illegible.) MD also advised to check BG again in several hours. BG at 9:30 p.m. was 87. BG at 12:30 a.m. was 86. Resident reports feeling 'not as dizzy' at this time. Resident complained of pain/discomfort at HS ...Resident slept throughout the shift ...4:15 a.m. BG was 62 ...resident unresponsive to verbal stimuli and sterna rub. Contacted MD. BG at 4:25 a.m. = 58. Emergency medical transport contacted for transport to (local hospital). OK to transport per MD for evaluation ..." The dictated emergency department notes dated 4/28/14 read in pertinent part: -"She states she has not had any appetite since her surgery and has not been eating or drinking much ...she was brought here with a pulse in the low 100s (high) and a blood pressure in the 60-70 systolic (low) ...Blood Urea Nitrogen 38 (high) ...Creatinine 9.0 (high) ...Glucose 9 (low) ...She was given intravenous fluids here in emergency department. -Final Impression: 1) Acute [MEDICAL CONDITION], 2) Dehydration, 3) [MEDICAL CONDITION], 4) [DIAGNOSES REDACTED] ..." 4. Facility failure to reassess the resident's fluid risk and needs upon readmission and change of condition, failure to care plan the resident's risk for insufficient fluid intake and failure to monitor the resident's fluid intake upon readmission. a. Failure to reassess the resident's fluid risk and needs upon readmission and with change in condition (diarrhea) See facility policy above; according to facility policy, the resident is to be assessed by the RD upon admission and referred to the RD when the resident exhibits nausea, vomiting, or diarrhea. Review of the resident's entire record revealed the sole entry by the registered dietitian (RD) was the "Medical Nutritional Therapy Review," completed 4/2/14. The dietary manager (DM) was interviewed on the morning of 5/1/14. She said the RD performs the initial assessments for residents and the RD is normally in the facility on Mondays, Wednesdays and Fridays. She confirmed that if a resident is discharged from the facility and then readmitted , an initial assessment should be completed within 72 hours after admission. The RD was interviewed on 5/1/14 at 12:55 p.m. The RD explained that initial nutritional assessments should be completed "Within the next day or so" after admission. She indicated she was out of the facility the week resident #3 was readmitted and stated "My boss was covering for me ..." However, there was no documentation the facility contacted the individual covering for the RD on 4/23/14 or on 4/26/14 when the resident was documented with "watery loose stools for the previous several days with frequent BMs each day." b. Failure to care plan resident #3 hydration risk Review of all of the resident's care plans revealed no care plan addressing the resident's hydration risks, goals, or approaches for staff to ensure the resident maintained sufficient fluid intake. Approaches for all care plans were reviewed and there were none that addressed the resident's hydration needs. c. Failure to monitor to ensure adequate fluid intake Review of the "Meal Detail Report" kiosk documentation from 3/28/14 - 4/27/14 revealed it documented the percentage of breakfast, lunch and dinner consumed by resident #3. Documentation was generally 100%; however, the documentation did not specify how much fluid was consumed per meal. The DM, interviewed the morning of 5/1/14, said, "As far as everyone's fluid intake, we don't currently document that ...I know in the past we did ...we don't do it anymore." The DM said if fluids are to be encouraged "we will get a note from the nurses to encourage fluids ...we will look at their likes and dislikes sheet or go to the resident to see what they prefer. Review of resident #3's record, however, revealed no documentation in the "Fluids preferred" or "Eating habits" sections in the Evaluation of Bowel and Bladder Training form dated 3/27/14 and as of 5/6/14 (5 days after exit), no documentation that showed the resident was being encouraged to drink more fluids. The RD, interviewed on 5/1/14 at 12:55 p.m. stated in response to a question on ensuring resident fluid needs are monitored and met, "Each resident is offered a little bit over 1,700 milliliters (ML) with each breakfast, lunch and dinner. And, we also have hydration stations ...They are frequently offered fluids ...what we do is continuously offer (fluids) to them with the hydration stations and offer those 1,740 MLs with breakfast, lunch and dinner. That is the number that I was given when I first started this position, and that is what my boss told me that we are supposed to give them ..." The DON was interviewed on 5/1/14 at 9:30 a.m. and again at 11:38 a.m. with the consultant DON. -The DON said the facility does not record intake and output measurements for residents unless it is specifically ordered by a physician. The consultant DON stated, in part, "(Residents') preferences are served to them on their table, but we don't document that they drank their coffee or the other fluids. If it is a serious case we might take a look at that ..." -When asked how the facility ensures residents receive sufficient fluids, the DON stated "We have (hydration) stations all over the place, and those residents who can't get fluid themselves ...we do the hydration pass." When asked what she directs her staff to do to observe for dehydration, she stated "Offer them fluids every shift." The consultant DON stated, "We observe them. If they are not cognitive people, we make sure they get plenty of water with medications. We make sure that when they are having meals they get two to three different juices and we watch what they are drinking." -The DON confirmed that if a resident had diarrhea, she would consider that a risk for dehydration, and stated "I would expect the staff to offer them fluids every time they went into the room. I would expect it to be care planned ..." The DON stated, "(Residents) dehydrate quickly when you have diarrhea. 5. Family and Resident Interviews - Failure to ensure fluids were offered as expected per staff interviews above. On 5/1/14 at 1:19 p.m., resident #3's daughter was interviewed over the phone. She stated, in part, "I personally never saw them offer her any kind of fluids." On 5/1/14 at 1:28 p.m., resident #3 was interviewed over the phone while she was still a patient at a local area hospital. -She explained that after her readmission 4/23/14, that it would take like an hour for staff to respond to her call bell and after sustaining a fall, she was "scared to fall" scared to "go the bathroom," so I didn't drink enough because I was scared that nobody would come. I felt really scared and uncomfortable. It made me feel like I wasn't wanted." -She explained she chose to eat her meals in her room and she said, "I don't remember (staff) offering fluids." The resident, when asked about the facility's 'hydration stations' (see DON interview above) stated, "I never knew about those ...They would ask me if I was drinking enough water, and I said 'What's enough? I don't know. You tell me'." She explained that she used a walker and a wheelchair for mobility, and was dependent on staff to help her propel herself throughout the facility. 6. Observations On 5/1/14 at 2:17 p.m., the hydration station on the south hall was observed, and a clear dispenser with a spigot was full of ice water and berries. There was one Styrofoam cup in front of the dispenser. A certified nurse aide (CNA) was observed to pour fluid from the dispenser into her own cup. At 3:22 p.m., there were no cups observed at the hydration station. At 5:39 p.m., there were no cups at the hydration station. On 5/1/14 at 2:19 p.m., the hydration station on the north hall was observed, and a clear dispenser with a spigot was full of ice water and berries. There were no cups at the hydration station. At 5:39 p.m., there were no cups at the hydration station.

Based on observations, record review and staff interview, the facility failed to initiate timely and effective interventions for three (#1, #2 and #3) of four sample residents to prevent falls. Specifically, the facility failed to: -provide adequate supervision and provide an environment as free of accident hazards as is possible. -timely place and document fall prevention measures for resident #2, after he had repeated falls. -update the plan of care to include additional measures put into place for resident #2. -consistently ensure that the fall monitoring alarms were in place and in working condition for residents #1 and #3. These failures contributed to resident #2 suffering fractured ribs, a fractured hip, and further displacement of his fractured hip. The findings include: 1. Resident #2 Resident #2, a [AGE] year-old-male, was admitted to the facility on [DATE]. Minimum Data Set (MDS): According to the MDS, dated [DATE], the resident required one person assistance with dressing, ambulating, transfers and bathing. The resident also had short-term and long-term memory deficits. The area to code the resident's fall history and the number of falls in the last two - six months was left blank. The resident was deceased on [DATE]. Care Plan: The care plan, dated [DATE] and last updated on [DATE], documented in pertinent part as follows: Problem - At risk for falls related to mental status, history of falls, balance problem, and utilizes assistive devices, narcotics in use, resistant to staff assistance. Goal - Residents fall risk will be minimized with reduction interventions. Approaches - resident on falling star program, encourage resident to ask for assistance, ensure proper footwear, interdisciplinary referral as needed for physical/occupational therapy and restorative care, remove wheelchair from bedside (there was no discernable date to indicate start date for wheelchair being removed from the bedside), provide assistive devices, wheelchair and walker, [DATE] pressure bed alarm, place call light within reach, anticipate needs toileting, hunger, pain, [DATE] physical therapy referral, [DATE] assist with transfers, [DATE] fall mat, room change. (No chair alarm was documented to be in use). Record Review: The Physician Order, dated [DATE], in part read: Physical therapy evaluation related to falls. The Physician Order, dated [DATE], read: Pressure pad to bed, fall mat to floor, [DIAGNOSES REDACTED]. The physician progress notes [REDACTED]. On [DATE] the Nurses Note documented in part: Resident continues to decline, new order for non-weight bearing, admit to Hospice, neurological checks continue post fall. Fall Investigation Reports: In part the facility Neurological Records were dated as beginning on [DATE] at 10:15 a.m., [DATE] at 3:15 a.m., [DATE] at 1:15 a.m., [DATE] at 11:30 a.m.. and [DATE] at 12:00 noon. Interdisciplinary Post Fall Review, dated [DATE], documented in part; resident found sitting on floor in front of bathroom, Physician and Family were notified. The Nurses Notes and other facility notes documented in part as follows: -[DATE] Nurses Note - resident remained on neurological checks post un-witnessed fall. -[DATE] Nurses Notes found void of entry from [DATE] through [DATE]. (No documentation related to a description about the fall or post fall monitoring). -[DATE] Interdisciplinary Post Fall Review: Resident found on floor with roommate, unsure of how incident happened-left flank bruising and left hand skin tear noted. Roommate expressed he was trying to help his roommate out of the bathroom and tried to catch him before he fell and the resident fell and hit bed frame, neurological checks initiated (documentation was unclear as to who was trying to help whom). Documented on the bottom section of the Interdisciplinary Post Fall Review form, the Interdisciplinary Team Summary, dated [DATE], read in part; Resident fell against footboard of bed causing injury to left posterior back and flank. Injury assessment after the fall, resident had decreased balance and increased pain, was positive for rib fracture of his left side, referred to therapy to assist with pain and balance. The Intervention Recommendations section documented: Care plan revision and IDT referral for physical and occupational therapy (No mention of fall devices). -[DATE] (2 days after the fall) Nurses Note read in part; resident had fall attempting to assist his roommate and both fell to floor. Resident hit left back on foot board of bed had bruising and fractures of rib 8 and 9. Resident noted to have balance problem while ambulating. Due to confusion resident does not ask for assistance with ambulation. (No mention of fall prevention devices). -[DATE] Nurses Note read in part; resident found on floor in front of the bathroom door, small skin tear to corner of his right eye and a skin tear to his right forearm, resident was noted to be hypoxic with oxygen saturation level of 65%-85% on room air, oxygen applied at 3 liters per nasal cannula. -[DATE] at 3:45 a.m., Interdisciplinary Post Fall Review read in part, "Resident found sitting on floor in front of his bathroom door, Footwear/Assistive Devices at the time of fall-socks (No other devices were documented to be in use). At the bottom of the Interdisciplinary Post Fall Review the section on the form titled Intervention Recommendations documented: pressure pad to bed." --However, this order was not acquired and interventions were not placed until [DATE], six days later, after the resident experienced another fall (see physician orders [REDACTED]. -[DATE] at 3:00 p.m., the Nurses Notes read; Resident transported to hospital post fall (Notes void of how fall occurred). -[DATE] Interdisciplinary Post Fall Review documented the time of the fall was 2:40 p.m. Resident #2 opened the door at the end of North Hall and attempted to propel himself out in his wheelchair and was found lying on his right side, he complained of right hip pain, the resident was alert and oriented times two. The Footwear/Assistive Devices at the time of the fall listed-shoes (No other safety devices were listed). The bottom section of the Interdisciplinary Post Fall Review documented in part; Resident was independent with mobility in his wheelchair, had increased confusion, had balance problem with ambulation, resistant to staff interventions, door alarm sounded and staff responded but unable to reach resident prior to him falling, will evaluate for interventions when resident is readmitted from hospital, wander guard in place, resident had history of elopement. Intervention Recommendations section of the Interdisciplinary Post Fall Review form, dated [DATE], documented resident equipment fall mat and pressure alarms. -Nurses Note, dated [DATE], the facility nurse had a phone conversation with staff at the hospital related to the resident. Resident was admitted to the hospital with [REDACTED]. -[DATE] Nurses Note, Resident readmitted from hospital back to the facility after repair of his hip fracture (No mention of fall prevention devices). Nurses Note, dated [DATE] at 3:00 p.m. Resident was in bed this morning when he attempted to ambulate unassisted, when he fell to the floor, fall witnessed by the roommate, the roommate notified the staff (No mention of pressure bed alarm sounding). At the time staff entered the room the resident was on the floor, resident was unable to appropriately rate pain due to dementia, pressure pad placed on bed, fall mat placed on floor, resident is now on every 15 minute checks to prevent further attempts of unassisted ambulation, resident to start physical therapy. The family and physician were notified via phone, new order obtained for pressure pad and fall mat, will continue to monitor, neurological checks on going, resident responding to questions appropriately. -[DATE] The Interdisciplinary Post Fall Review documented the time of the fall was at 11:30 a.m. Resident attempted to self ambulate unassisted from the bed when he fell to the floor, witnessed by the roommate and staff alerted. Footwear/Assistive Devices at time of fall = socks/non-slip (No other devices listed). The Interdisciplinary Post Fall Review Summary section, documented in part; Resident was readmitted from the hospital related to his hip fracture, resident unable to understand limitations due to dementia, resident requires two person assistance to transfer, physical therapy and occupational therapy working with resident. Pressure alarm to bed. Fall mat at bedside. Resident's room rearranged to allow more room for staff intervention. The Intervention Recommendations section on the form was void of documented intervention recommendations. -[DATE] Nurses Notes; Family notified of appointment on Friday related to increased pain in leg after fall at 1200 noon, family notified of fall, continue to remind resident to use his call light. -[DATE] Interdisciplinary Post Fall Review documented time of fall was 11:50 a.m., resident was found on the floor, appeared the resident tried to push his wheelchair. Footwear/Assistive Devices at time of fall were non-skid socks, fall mat, and pressure alarm on bed. Summary of Interdisciplinary Team; Appeared as though resident was attempting to ambulate behind the wheelchair, he requires assistance for transfers, will make sure staff parks his wheelchair away from his bed and monitor closely. Intervention Recommendations; care plan revision. Safety Checks: Record review of the Safety Check Sheet revealed the resident had been on every 15 minute checks at inconsistent intervals in April of 2012 related to resident to resident altercation and discontinued after [DATE]. The 15 minute checks were started again on [DATE] for resident safety. -[DATE] Hospice note documented in part: Resident slightly jaundiced, he moans and cries out while being turned and bath was given, resident had been incontinent of urine and had soaked the linens, air mattress, and dripped onto the floor in the room, soaking the fall mat, resident appears comfortable and peaceful after bed bath, shave, and linen change, without signs of pain or agitation. Facility staff was provided, education related to use of morphine at end of life. Interviews: On [DATE] at 12:30 p.m., a Licensed Practical Nurse (LPN) was interviewed and expressed that the resident was able to make his needs known, but did have a decline after his hip fracture, she expressed she did not remember the dates of when each intervention was put into place, but the resident did have a pressure alarm, 15 minute monitoring checks, an air mattress, and a wander guard. On the evening of [DATE], a Certified Nursing Assistant (CNA) was interviewed. She expressed that the resident was on every 2 hour checks to assist him in turning and offer toileting assistance, he could make his needs known, and after he had the fall and fractured hip he had a fall mat, pressure alarm, but did not remember the dates of the devices, but that they were put in place after he had the fractured hip, he needed turning assistance after the fracture, and if he expressed signs of pain she let the nurse know. On the evening of [DATE], the Director of Nurses (DON) was informed of the residents' delayed interventions related to fall prevention measures. The DON expressed the facility had regular meetings and discussions related to the resident and the facility had put interventions in place and had even made 15 minute safety checks. 2. Resident #1 Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations: An observation, on [DATE] at 10:22 a.m., during initial tour, revealed the resident sitting in a wheelchair in the secured unit. The resident was observed with an attached alarm to the wheelchair, which was not turned on. A Certified Nursing Assistant (CNA) confirmed the alarm should be on, and proceeded to turn it on. Record Review: Documentation of a fall review revealed the resident "lost balance and fell in dining room" on [DATE]. The documentation went on to read, "Resident was ambulating with a walker and lost her balance and fell to the floor. At this time, the resident had been ambulating independently with the help of a walker. The resident was sent to the hospital for evaluation and returned with a [DIAGNOSES REDACTED]. Change of Condition documentation revealed another fall on [DATE] that read, "Resident attempted to get off chair in D.R. (dining room) after her meal. fell to floor-reopened abrasion left elbow." Documentation also read, "Alarm placed as ordered (pressure sensors chair and bed.)" Record review of the [DATE] Treatment Administration Record (TAR) read, ",[DATE] Pressure alarm bed and chair" to be monitored on both the 7 a.m. to 7 p.m. shift and the 7 p.m. to 7 a.m. shift, with all days and shifts checked as compliant. Faxed documentation to the physician, on [DATE] read, "May we please have orders for Hipsters to be worn at all times, tab alarm to bed and chair? Please advise." This was approved [DATE]. Record review revealed a physician order [REDACTED]." Minimum Data Set (MDS) documentation, dated ---- indicated that prior to the recent falls, the resident did ambulate independently. Nurse notes, on [DATE], indicated that after the falls the resident "remains 2 assist with adl's (activities of daily living) and uses w/c (wheelchair) to get around." Care Plan: The resident's comprehensive care plan contained a care plan for falls, initiated on [DATE] and last reviewed on [DATE]. The stated goal was to reduce fall risks by minimizing with "reduction interventions." The approaches with the updated care plan indicated the resident was on the "Falling Star Program", to ensure the resident wore proper footwear, monitor unassisted ambulation, mat on floor, redirect behaviors as needed, and therapy evaluations and treatments for balance as needed. The approaches documented the "Chair Alarm" had been checked as an acceptable approach, but had been crossed out and "error" was written above it. The current care plan did not indicate the new updated order from the physician to reinstate the chair alarm for fall prevention. 3. Resident #3 Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations: An observation during initial tour, on [DATE] at 10:47 a.m., revealed the resident sitting in the main dining room in a wheelchair. The resident was observed sitting in the wheelchair with an alarm attached to the back. The alarm was turned off. A Certified Nursing Assistant (CNA) confirmed the alarm should be on, and proceeded to turn it on. Record Review for Resident: Record review of a post fall documentation indicated the resident fell on [DATE], and was noted to be, "lying on his left side on floor mat next to bed in his room, head off mat. No injury noted." Review of the fall by the Interdisciplinary Team notes revealed a pressure alarm was put on the bed. Record review of a post fall document indicated the resident had a fall with abrasions on [DATE]. The resident was found sitting on the floor behind the door in the employee break room. The fall review noted the resident was seen by staff in the main dining room prior to falling and the wheelchair alarm was sounding when staff found the resident. Resident was sent to the hospital for evaluation and treatment. Record review of the Minimum Data Set (MDS), dated [DATE], read the resident was a ,[DATE] for transfers indicating that he/she was an extensive assist with limited assistance. Record review of the treatment administration record (TAR) for [DATE], revealed an order for [REDACTED]. Review of the [DATE] TAR revealed that for shifts 7 a.m. to 7 p.m. and 7 p.m. to 7 a.m. both shifts documented compliance with the use of the alarms. A physician order, on [DATE], stated to discharge tab alarm to wheelchair and to change to pressure pad to wheelchair. Physical therapy progress and update information dated [DATE] read, the resident was a maximum assist at time of evaluation. Care Plan: Record review revealed a care plan, dated [DATE], for ADL and mobility concerns due to cognitive loss, decreased mobility related to the CVA and left side weakness. The resident was documented as being an extensive assist with dressing, grooming, and transfers. Also, the resident used the wheelchair for mobility and was able to self-propel. No specific care plan was noted for fall concerns, however, restorative care planning indicated that the resident fluctuates from maximum assist to minimum assist for transfers. Interviews: An interview with a Certified Nursing Assistant (CNA), on [DATE] at 10:22 a.m., during an initial tour of the facility, confirmed there were 4 residents in the secured unit with wheelchair alarms on to alert staff to residents attempting to get up from the chairs, potentially placing residents at risk for falls or injuries. Resident #1 was observed sitting in her wheelchair, with the chair alarm attached to the wheelchair, but turned off. The CNA confirmed that it was off, and then proceeded to turn it back on. The CNA confirmed that the alarm should have been turned on. An interview with a CNA, on [DATE] at 10:48 a.m., during an observation of Resident #3, confirmed that the resident's alarm should be turned on. The CNA proceeded to turn it on for the resident. An interview with a CNA, on [DATE] at 11:45 a.m., revealed that Resident #1 was a fall risk and was supposed to wear an alarm while in the wheelchair, although it had been off during the earlier observation. The CNA stated that the resident had fallen recently, but had not been injured, aside from a small bruise. The CNA stated, "The alarm for the resident had most likely not been turned back on from earlier in the day." An interview with a Licensed Practical Nurse (LPN), on [DATE] at 12:40 p.m., revealed that the chair alarms are documented on the Treatment Administration Record (TAR) and the staff is supposed to check that they are on each shift. The LPN also confirmed that the CNAs are responsible for ongoing monitoring during their shifts and while assisting residents. An interview with a Registered Nurse (RN), on [DATE] at 12:48 p.m., revealed that nurses are responsible to check alarms per physician and TAR orders. The RN stated there was no set policy that she was aware of, for monitoring wheelchair alarms throughout the day. She went on too say, "Once the residents are up they should already be on (alarms)." An interview with a Physical Therapist (PT) and Occupational Therapist (OT), on [DATE] at 1:00 p.m., confirmed that they were looking at Resident #1 for therapy again since the last fall. The staff members stated that they felt the resident had the potential for improvement in strengthening, but was currently hesitant related to a fear of falling. The staff members stated the resident had a wheelchair alarm due to the resident being a fall risk. The PT and OT staff members also confirmed that Resident #3 also "definitely" required a chair alarm. An interview with the Director of Nursing (DON), on [DATE] at 1:20 p.m., revealed that Resident #1 had been ambulating independently with a walker prior to the fall, and did not require a chair alarm. The DON confirmed that the resident had only been placed back with the chair alarm since the fall, due to her fall risk. The DON stated that the facility had charting paperwork for the CNAs to use to ensure that resident chair alarms were monitored frequently. Also, the facility has an ambassador program that provides other staff members to monitor the statuses of residents. The DON confirmed that the chair alarm for Resident #3 should have been on, and the care plan for Resident #1 would be updated to indicate that the resident was now using a chair alarm again. An interview with a CNA, on [DATE] at 1:25 p.m., revealed that Resident #1 had been pretty independent prior to the recent fall, and was now more hesitant since the fall. The CNA confirmed that the resident should have the chair alarm on. The CNA stated, "They had found some chair alarms for residents turned off. Many of these residents can't turn them off by themselves." The CNA was not sure why the alarms were off, but they have started their shift and found residents that did not have their chair alarms on, while the residents were in their chairs. The CNA stated that the aides normally check the residents and the alarms when they come on shift, but that there was no real process to check alarms during the day. The CNA said Resident #3 should have his alarm on too. An interview with the Director of Nursing (DON), on [DATE] at 2:20 p.m., confirmed that the facility did not have a policy in place to monitor for wheelchair alarms for those residents that had them in place and were at risk for falls.

Based on observation, record review and interviews, the facility failed to investigate the cause of resident #1's excoriation and subsequent suspicious bruising, failed to report the resident's bruising to the Police Department and State Health Department, and failed to protect the resident from further injury while investigations were underway. As a result of the facility's failure to investigate, report and protect, resident #1 sustained painful bruising to her lower abdomen, buttocks, hip, and labia. The findings included: 1. Facility History The facility was cited during a recertification survey and complaint investigation conducted 12/5-12/15/11, with failure to investigate an allegation of resident-to-resident abuse, and a large bruise of unknown origin. It was determined that the facility failed to conduct investigations in a thorough and timely manner, and failed to protect residents from further abuse and injury. 2. Resident Status Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including anxiety disorder, [MEDICAL CONDITION], dementia with behavior disturbance, and [MEDICAL CONDITION]. Minimum Data Set (MDS): According to her 10/20/11 MDS, resident #1 had a BIMS score (cognitive status) of 6, indicating she was severely cognitively impaired. She needed support and set-up help only for activities of daily living (ADLs). She was frequently incontinent of bladder, and continent of bowel. Her diagnoses included anxiety and depression. She had experienced no falls, and had no pressure ulcers. There was no family participation in the MDS assessment process. Discharge potential was noted as not feasible. Care Plan: a. Falls - On 12/14/10, the resident was identified as "at risk for falls" related to new admission, mental status, ambulatory/incontinent, impulsiveness. The goal was for fall risk to be minimized with reduction interventions. Falls were noted on: 2/11/11 resulting in redness to right knee, 5/28/11 resulting in a skin tear, and 8/24/11 with no injury. No falls were noted after 8/24/11 in the care plan. Approaches were: Falling Star Program; ensure that resident has proper footwear; interdisciplinary referral to physical therapy, occupational therapy, restorative nursing PRN ("Cont PT 1/3" was handwritten to the side of physical therapy); 1/3 ask for UA; place call light within reach; anticipate needs i.e. toilet, grooming, hunger, water; notify family to supply more approp. footwear; 5/31/11 cue & remind res to use call light; 8/24 offer freq/ assist when on outings; 5/31/11 PT to eval for pain control. b. ADLs - On 12/14/10, the resident was noted to require assistance for ADLs related to dementia. On 2/23/11, a need was identified for "Setup (assistance with) dressing, toileting, personal hygiene, eating, grooming, limited (assistance with) bathing." Approaches included: Encourage independent function as able; provide assistance as needed with toileting/pericare; allow resident time to complete tasks, 8/1 call light within reach. c. Incontinence - On 12/14/10, the problem of incontinence was care planned related to [DIAGNOSES REDACTED]." Approaches included: provide perineal care daily and as needed, encourage fluids, notify physician as needed, observe for incontinence episodes at regular and frequent intervals and as needed, prompted voiding per established toileting plan, AC, PC, HS, PRN; anticipate needs re: toileting. d. Fluid Deficit - On 1/7/11, risk for fluid deficit was identified related to 11/2 pneumonia, infection resolved, and cognitive loss - relies on staff to access fluids. Approaches included to offer fluids frequently throughout the day and PRN. e. Elopement - On 12/14/10, the resident was noted as an elopement risk due to new environment, history of elopement/wandering attempts, dementia. Approaches included: secure unit placement, "1/25/11 trial off unit during day. She goes out for meals. Will evaluate for transfer to general population." f. Activities - On 11/30/10, the activities care plan identified the resident formerly resided on the secure unit, and was "very angry w/ family - states they are dead." g. Communication Deficit - On 12/14/10, due to [DIAGNOSES REDACTED]. h. Non-Pressure Ulcer Skin Impairment - On 12/16/11, the resident was noted to have actual skin impairment, identified as excoriation. The checked-off approaches on the pre-printed care plan were: Observe skin weekly and document findings as indicated; document observation of any non-pressure related skin impairments on facility Non-Pressure Ulcer Wound documentation form; Observe for safety needs with transfer; Wound care as ordered; (handwritten) moisture barrier until healed. No further excoriation or bruising was documented on the care plan. The resident was not taking [MEDICATION NAME] or other anticoagulants per chart review. There was no [DIAGNOSES REDACTED]. The resident had a [DIAGNOSES REDACTED]. 3. Excoriation/Open Areas Not Investigated a. A Non-Pressure Skin Condition Record, dated 12/16/11 (also dated as first observed on 12/26/11), noted the resident had "Two red areas (1) R buttocks (2) R labia - (secondary to) excoriation, (secondary to) bowel incontinent." The areas were noted as "healed" on 12/30/11. b. A Total Body Check form, dated 12/16/11, documented during a tub bath and signed by a CNA and an LPN, noted the following: "right labia - red/open, top right bottom - red/open." A second handwritten note in the margin read, "Noted (not) open, very red & sore." c. There was nothing documented in nurses' notes about the excoriated areas (see nurses' notes below), and no investigation was conducted (see staff interviews below). 4. Evidence of Suspicious Bruising a. Incident/Accident Report: A facility incident/accident report, dated 1/2/12, noted resident #1 experienced an unwitnessed fall at 5:30 a.m. in her room. The room number noted was the room next door to where the resident resided. The "Findings" section read: "Res says she fell as a result of lightheadedness & dizziness, and fell on to the metal foot of her bed, then landed on her L side onto the floor. Res sustained a large hematoma to her L buttock that spreads to her peri area. Res limping while ambulation. Reflexes & pedal pulse intact. C/o hip pain. Denies hitting head." -The resident was identified as confused, as having dementia; no restraint or siderails were noted in use. Equipment involved was noted as Bed(frame). The resident outcome was "bruise/hematoma" and "possible fracture." The physician was notified half an hour later at 6:05 a.m., and the son/power of attorney (POA) at 7 a.m. -The incident report did not document where or how the resident was found, or who reported the injuries. -On the body diagram, small circles were drawn over the crotch and left buttock areas. -The bruised areas were not the same on the incident/accident report as on the Non Pressure Skin Condition Record (see below). b. Non-Pressure Skin Condition Record: This form, completed by the same licensed practical nurse (LPN) as the incident report above, was dated 1/2/12, but the time was not documented. The resident's bruising was noted under "site/location" as "L buttock - spreads to peri area." The bruising was noted as "red" and the pain section was blank. However, on the body diagrams, shown side to side and front to back, bruising was noted to the resident's: -L (side of)hip 16 cm side to side and 11 cm up and down -Peri area (pubic bone/crotch) 6 cm diameter -"Hip to hip" (lower abdomen) side to side 18 cm -Left buttock 8 cm x 10 cm. The initial evaluation notes read: "Resident states that she fell as a result of lightheadedness and dizziness, and fell on to the metal foot of her bed, then landed on her L side onto the floor. resident sustained [REDACTED]. There is a hard, palpable mass (hematoma) to her L buttock. Bruise is a dark red/purple color. Skin integrity is intact. L hip movement, rotation, intact. Pedal pulses & reflexes intact bilat. X-Ray ordered to rule out possible hip fx. 1-2-12 (No) fx per Xray." c. Interdisciplinary Post Fall Review: The post fall review, dated 1/2/12, no time indicated, was worded the same. However, it was further noted that the resident was "limping while ambulating ... c/o hip pain." -Although the resident was limping and complaining of hip pain, review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The summary of the interdisciplinary team review was "Continue (with) PT to work on balance. Ask MD for UA as res inc. B&B & had UTI in 10/11." Intervention recommendations were: "Equipment - sensor pad in bed." The IDT review was signed by the LPN on 1/2, and two RNs and the therapy director on 1/3/12. d. Change of Condition: The LPN completed a change of condition form on 1/2/12 at 5:50 a.m. and noted talking to the physician at 6:05 a.m. to request monitoring vital signs, observation, and an X-ray of the resident's left hip. The LPN documented the resident "sustained a large hematoma to her L buttock that has spread to her peri area ... is limping when she ambulates ... c/o hip pain on left side. Vitals checked. Ice applied." -At 6:05 a.m., the physician ordered ice to the hematoma to reduce swelling, order an Xray to the left hip, monitor vitals closely - report increased size of hematoma or change in vital signs. e. Nurses' Notes: There were no nurses' notes regarding resident #1 from 12/15/11 at 12:30 p.m. until 1/3/12, no time noted. The 1/3 note read, "T.O. rec. from (resident's physician) to obtain a UA with C&S if indicated. Noted. Res is not complaining of pain or discomfort. Bruising continues in previous identified areas, blk, blue & red in color. Staff assisting res (with)_ transfers & mobility. Will cont neuros that are WNL." -On 1/4/12 at 2 p.m., "Res being transported to (physician's) office for an app. Copies of labs sent. Awaiting her return. No delayed injury noted from incident 1-2-12." -On 1/5/11 at 4 p.m., a nurse noted, "Resident started on ABT this AM for UTI, will monitor for any S/sx of adverse reactions. Res is (without complaints of) dysuria or frequency thus far. Using w/c as primary mode of transportation. Cont to have bruising to pelvic area and states (no) pain." -There were no further nurses' notes until: -On 1/7/12 at 9 p.m., "Res states SOB and coughing. Vitals RR 28, BP 116/67, 02 between 87-90%, HR 83, continue to monitor. Call in to (physician)." 15 minutes later, "On call doctor ... called back and ordered chest Xray in morning or to send her out to ER if family wanted." -On 1/8/12 at 1 a.m., "02 saturation is staying around 89-90%, res assisted to toilet, felt like she couldn't catch her breath. When back in bed, res felt better with HOB elevated as high as it could go. Continuing to monitor." At 2:30 a.m., "Res 02 now 85-87%, not increasing. Res coughing - not productive. Wheezing heard when listening to breath sounds. Called (physician on call) and asked to transport to ER." At 2:50 a.m., "(Local emergency medical services) came and transported to (local hospital)." f. Hospital Record Review: Nursing Admission/History, dated 1/8/12, documented "large amt bruising noted to groin area, coccyx, and labia/genital area. petechia noted to trunk, and extremities, unknown origin or length of time." Learning barriers were noted as: "Fear/anxiety, confusion, dementia." Nursing notes, dated 1/8/12 at 11:20 a.m., read in pertinent part: "Lg amt old bruising noted to (lower) abd, peri area & coccyx area. Lg amt [MEDICAL CONDITION] noted to peri area & bilat (lower) legs. Petechia noted to trunk & extremities. Pt incont. urine. Denies discomfort. Reddened areas noted to [MEDICAL CONDITION] areas bilat (lower) legs. 1230 Foley cath placed. Yellow urine returned followed by white milky urine. Sample sent to lab. 1400 Pt trying to eat lunch but having a hard time. NH called. States she is on a regular diet but unsure how well she is eating. States swelling & bruising to groin area d/t falling on the end of the bed. They also state she was walking by self until (after) fall & has progressively been getting worse ..." Physician Consultation Notes, dated 1/11/12, read in pertinent part as follows: "I was notified by head nurse of the telemetry unit ... this morning that there was an investigation in process regarding some bruises that had been noticed on the patient by one of the nurses. Apparently Adult Protective Services and the Sheriff's department had been contacted. I had not been notified of any problems or concerns until this morning. -"(Head nurse) indicated that there were concerns about the bruising in the perivaginal area. There were concerns about swelling of the labia. She indicated that the nursing home had reported a fall and that the bruises had been thought to be secondary to that but investigation was underway. -"Following this, I went back into the room in the presence of the charge nurse ... and the patient's day nurse ... I asked the patient if she had had any problems in the lower abdominal or vaginal area. She indicates that she had had a fall and had injured herself. She indicated that she had fallen on a piece of furniture at the nursing home. I asked her if she had had any type of trauma to the vaginal or perivaginal area. She indicated no. I asked her if anyone had been touching her there and she indicated no. -"PHYSICAL EXAMINATION: Examination of the lower abdomen shows an extensive bruise that extends from the suprapubic region across the right side of the abdomen and around her right lower flank and across the right back. this extends into the superior portion of the gluteus muscle on the back. Examination of the external genitalia does show some mild swelling of the labia bilaterally. I do not see any skin changes, bruising, or abnormalities. There is a prominent vessel on the left external labia that blanches easily. External exam of the vaginal os (opening) shows atrophy of the tissue. I do not see any redness, skin tears, signs of bruising, or other significant changes. -"I reviewed the case with (two nurses). I indicated that if there is concern about any type of inappropriate activity in regards to possible perineal or vaginal trauma that we should have a gynecologist evaluate the patient. I have asked (the head nurse) to contact the hospital administration and notify me of the correct procedure to pursue this. She is continuing to evaluate this. She will contact me if there is concern on the part of the nursing home, the patient or family, the County Sheriff's Department, or Adult Protective Services that further evaluation needs to be done. Per my evaluation, it does not appear that she has had any type of trauma below the pubic ramus or in the vaginal area. The bruising is above this and I think it certainly could be consistent with a fall as described." g. Hospital registered nurse (RN) Interview The hospital RN, who provided care for resident #1 on 1/8/12 and first noticed that she had suspicious bruising, was interviewed by phone at 4:15 p.m. on 1/10/12. She said when she went to catheterize the resident she noticed "a really large bruise across her lower abdomen, a big bruise across her buttocks/coccyx area, and bilateral bruising and [MEDICAL CONDITION] to her labia and inside of her labia." The RN said she thought "it could be [MEDICAL CONDITION], it could be trauma, but [MEDICAL CONDITION] would not cause bruising." The RN said the resident's son and daughter-in-law said she had fallen at the nursing home. The ER didn't know about it. So she called the facility and asked them about it. "They said she'd fallen on the bed post." The RN said she was trained as a sexual assault nurse examiner, and stated, "To me, it's just not adding up. It's unusual ... We see a lot of falls ... The police officer said she'd fallen onto the end of the bed and then fell to the right side. It's hard to fall that way. It doesn't explain that injury." Asked what the injury looked like to her, the RN said, "Some kind of [MEDICATION NAME] force trauma." -The RN said the resident was not fearful. She added the resident was "so confused she couldn't tell us what happened." 5. Failure to report suspicious bruising to the State Health Department and Police Department. a. The facility did not report the resident's bruising to the police department for investigation (see interviews below). b. The facility did not document or save evidence for investigative purposes (see CNA staff interview below where resident Attends found on floor and resident linens were not saved and turned over to police as evidence). c. The facility did not report the resident's suspicious bruising to the health department or the resident's physician for further investigation (see NHA and DON interview below). 6. Observation of resident's room The resident's room was observed on 1/11/12 and 1/12/12. Her room was located at the far end of the hall away from the nurses' station, near an exit door. There was no falling star symbol or indicator on the resident's doorway or elsewhere in the resident's room (see care plan above - falling star program). The resident's bed was by the door, and her bed had a low particle board footboard. It was not readily apparent how the resident could have sustained her bruising by bumping or straddling the footboard of her bed. It also appeared she would have bumped her knee or her shin on the metal bed frame if she fell on the footboard in an attempt to exit via the door. There were no side rails on the bed to cause her to crawl to the bottom of the bed and straddle the footboard. The room next door to resident #1's was unoccupied, but still furnished with two beds, and was used for storage of Hoyer and Sara lifts. 7. Facility Staff Interviews: a. RN #1, who provided care for resident #1 on the day shift, was interviewed at 1:35 p.m. on 1/11/12. She said, "I observed an assessment of (resident #1's) bruising on peri area, buttocks and across with a rather firm place right on the buttocks. After speaking with her it seemed such a puzzle to me, it's almost like she's trying to tell me she straddled the footboard somehow and fell . That's what she tried to tell me. I listened to her lungs, called (the doctor), requested a chest Xray, and (the doctor) refused. (Resident #1) has had several falls, not in the recent past - I suspected pneumonia or a UTI. She had a positive UTI and it could have contributed to her fall. Her injuries seemed to match up with what she said. I provided care for her probably the next day or two. This is my note on 1/2 - a change of condition form, and there's a note on the back regarding the response from the doctor. Her UA was positive. I did a head to toe assessment of her but not on the same day. They're supposed to chart on that in nurses' notes. It should also be documented in nurse's notes in the chart not just a change of condition form." -When asked about resident #1's change of condition form, dated 12/16/11, regarding the excoriation to her buttocks and labia, and the cause, the RN said, "maybe incontinence if a patient is ill ... Yes, it says bowel incontinence." Asked if the resident's bruising and excoriation could have been caused by anything else, the RN responded, "I don't want to answer that question." b. A certified nurse aide (CNA #1) who worked the night shift of 1/1 to 1/2/12, was interviewed by phone at 3:15 p.m. on 1/11/12. She said she worked until 9:30 p.m. on 1/1/12 and had to leave early that night, and another CNA covered for her after that. The CNA said that on the night of 1/1/12 she "toileted (resident #1) and put her to bed at 7:30 p.m." The CNA said that resident had no bruising at that time, because she "did peri care and she was wearing a pull-up." c. CNA #2 was interviewed at 3:20 p.m. on 1/11/12. She had worked the night shift on 1/1-1/2/12. CNA #2 said she "noticed a bruise on (resident #1's) bottom when I went to get her up. We're assuming she fell . She can get herself up - I went in to do my last rounds and when I took her to the toilet I noticed the bruising on her - she was in bed sleeping. I think it was around five-ish. I asked her what happened because there was bruising - she said I think I fell but I don't remember. I found her Attends on the floor when I went in - lying on the floor with some BM on it - a foot and a half from the foot of her bed. The first part of the bruising I saw was on her left lower buttocks area. When I went to give her peri care and have her stand, I noticed bruising on both her hips, across her abdomen and up her peri area. The bruise to her buttocks that went up to her peri area - it worried me a lot. I was scared. I was very concerned because it wasn't there the night before - I wasn't the one who checked on her during second rounds. (CNA #3) would've done it at about 12 midnight). Ten, 12, 2 and 4 are when we do rounds. (CNA #3) would've done 12 and 2; I did 10. I did 4 a.m. rounds around fivish. I didn't see anything out of the ordinary that night. I reported (the resident's bruising) to (the LPN). I said (resident #1), is your bottom hurting? Did you fall last night; are you in pain? She said she wasn't in pain and she didn't know if she fell . She was able to go to the bathroom herself. She needs supervision with walking at night, with peri care, and in the mornings I help her get dressed." -"She can take her depends off on her own but she can't put them on." -"There was a little BM on her attends and on her bed - just a little bit." Asked if there were any other times she had seen the resident's Attends on the floor, CNA #2 said, "If she has an accident she'll take off her Attends and drop it on the floor." Asked if that was a typical place for the resident to drop her Attends, she said no, it was usually right next to the bed. -Asked if management staff had asked her questions about what occurred that night, she said, "My nurse asked me what happened - nobody else asked me any questions about this. I let my charge nurse know, also the other two nurses (RN #1 and RN #2) were the nurses I reported (the bruising) to." d. CNA #3 was interviewed at 6:20 p.m. on 1/11/12. She said, "I was only here for four hours (the night of 1/1-1/2/12) - I checked on trash and stuff. I got here at midnight and was here from midnight to four. I went into her room, checked the trash. My last rounds were around 2 or 2:30 a.m. - I think the other CNA might have done the check and change." The CNA said she did not see or hear anything out of the ordinary that night. She said nobody asked her questions about what occurred that night. e. LPN #1 was interviewed at 7:10 p.m. on 1/11/12. She said, "(CNA #2) came out and told me about the bruising and we started neuros - they were normal. I asked (the resident) what happened and she said she had fallen into the foot of her bed and then she fell on to the floor on her side and it knocked the wind out of her. Those were her exact words. She said it just happened so fast. I tried to ask her to elaborate and she said it just happened so fast. I didn't see or hear anything out of the ordinary. "(RN #1) and I both looked at her - I looked at her the morning of the 2nd and (nurse's name) looked at it with me when she came on because I just thought it was a weird bruise. She said she fell into it in her front, because she's so tiny I thought she must have straddled the foot board. She could have straddled the footboard. The CNA changed her and saw the bruising and alerted me to it, I looked at her body after I interviewed her. The bruising was really dark red, almost black, and she had a mass on her bottom, a really hard mass on one of her buttocks, that felt like a hematoma. With a fall like that I called the doctor and requested a hip X-ray because it was such a horrible bruise and it was that dark and had spread up into her peri area. The doctor ordered a hip X-ray. -"I got my nursing license in August - this is my first nursing job. The first thing I thought was she might have a fracture or internal bleeding or something. The doctor said just order an xray and ice it. (The resident) said it was tender to the touch. There was no bruising to her lower abdomen - I think the bruising came from when she walked into the footboard and then fell . I think her cognition is pretty good." -"I can't think of anything else that would cause that type of injury. At this time she's pretty minimally assisted. She'd get up on her own and walk the halls. She was independent with toileting. I noticed lately she was having some night time incontinence but she'd just been sick (with a UTI). I think she has pneumonia right now." -"Staff should do 2-hour rounds with (resident #1), check everyone and make sure they're dry. (Resident #1) gets awakened and asked if she needs to toilet, if she says no and she's dry they let her sleep. I asked for a bed alarm after this but I'm not sure if she got it." -Asked if supervision was increased after the resident's bruising was discovered, LPN #1 said, "For my shift absolutely - we'd check on her every half hour when we did neuro checks, periodically in between." -"After I assessed the bruising I asked two other night nurses to come down and look at it - (RN #2 and RN #3). I was like what do you think happened? They said I think she fell . We were all puzzled about the peri bruising and she said the same thing about falling into the footboard." -"I had to ask (resident #1) a couple times - she'd say I forgot - okay so you fell do you remember how you fell ? I got dizzy & light headed & fell into the bed and hurt my front and then I fell on to the floor. Everything I wrote down were her own words. I hope if anything else happened she'd feel comfortable sharing with us but I had no reason to doubt that that's how it happened. -It was pretty dark red, it was purple, it made me nervous thinking fracture or hematoma or something like that. She just had a bruising in her peri area and up to her butt. -Who does the investigation? Not entirely sure, I assume it was the DON & management - they had me fill out a post fall review, fill out the paperwork & put it in their box. I passed on what happened. They came out & did the Xray - not sure if her doctor came out here too. The dr was aware of the bruises. -The dr wanted us to assess to ensure the bruise wasn't getting any bigger (sign of internal bleeding) - should've been in nurses notes. It didn't get any bigger that she's aware of - but day nurses would've done the assessments." e. RN #2 was interviewed at 7:50 p.m. on 1/11/12. She said, "One of the CNAs asked me to come take a look at her and she was black & blue across her lower abdomen, bottom and a big knot on her left butt cheek. We asked her what happened and she said she must've fallen. She must've fallen on that hard spot - she wasn't able to give any more details. I had no idea how she might have gotten all that bruising. We were trying to think of what could've made that - we were thinking maybe she broke something, (LPN #1) called the doctor and I think he just ordered an X-ray." She said management staff did not ask her about it. When asked, she said she thought it would justify an investigation. "I had never seen bruising like that. At first I thought maybe a gait belt but it was pretty low. I really truly have no idea why it was like that." -"When she has her UTIs, which is frequent, you've got to watch her even more. Nothing unusual happened. I don't think her cognition is very good. She'll walk down the hall and say I had an accident and this never happens - she's able to tell us she needs her bed changed or whatever." f. A nurse who provided care for resident #1 on the day shift was interviewed at 3 p.m. on 1/12/12. The nurse said she had worked the night shift, and the expectation was for staff to toilet the resident's every two hours for "skin, safety, and general overall care. The standard is every two hours minimum. We do 10, 12, 2, 4, and 6 rounds at night," and were supposed to ask resident #1 if she needed to go to the bathroom, or if she was wet, to change her. The nurse said she was unaware of resident #1's excoriation to her labia and buttocks on 12/16/11. Asked how she monitored the resident after her bruising was discovered, the nurse said, she kept her up at the nurses' station unless she wanted to lie down or go to the bathroom. She said the resident had no bed alarm before the 1/2/12 incident, but "I think she would have yelled for help." She said the resident "ended up in a wheelchair unable to walk" after the 1/2/12 incident. g. A CNA who provided care for resident #1 on the evening shift was interviewed at 3:30 p.m. on 1/12/12. She said resident #1 was "pretty independent before her pneumonia three months ago, but after that we checked on her every two hours to see if she was wet. We kept her down a lot (after the 1/2/12 incident) because she was pretty sore. She would worry but about small things." Asked if she reported the resident's pain, the CNA said she reported to the nurse. Asked about night rounds, the CNA said, "I think night shift starts rounds at midnight and checks every two hours to make sure everybody's dry." Regarding resident #1, she said "she didn't understand why she fell and her butt hurt." Asked if she'd had recent problems with diarrhea, the CNA said she did not have diarrhea "but she was incontinent of urine." She said she was unaware of the resident's excoriation on 12/16/11. h. Another CNA who provided care for resident #1 on the evening shift was interviewed at 3:50 p.m. on 1/12/12. She said the expectation was to "check and change" resident #1 every two hours starting 12, 2, 4, etc. She said the 10 p.m. check was done by the evening shift. Asked the reason for this she said, "Probably the fall risk," and added, "After the incident she was more confused about the time of day, etc." Asked about the resident's excoriation on 12/16/11, the CNA said she was unaware of it, but stated, "Usually when resident's get like that (excoriated) they tell us about it." i. The facility social services director was interviewed on 1/12/11 at 4:15 p.m. She said, "Yesterday was the first time I heard about all the bruising on (resident #1). I was aware of a fall and aware she was sent out to the hospital, but not all the bruising." She said she was in the facility all day on January 2nd, but nobody told her about what had happened with the resident so she could "check on her," and added that she did not recall seeing resident #1 that day. She said she likewise did not hear about the resident's excoriation on 12/16/11. The SSD said she would have investigated the bruises had she known. 8. Hospital Interviews a. An RN who provided care for resident #1 in the hospital was interviewed at 9:35 a.m. on 1/12/11. She said she observed bruising to resident #1's pelvic bone. When asked, she said the resident told her she fell on a piece of furniture. b. Resident #1 was interviewed at the hospital on [DATE] at 9:40 a.m. She was asked what happened that caused all her bruises. She said she had "blocked it" from her mind and did not know what happened. Asked if she had been hurt or mistreated by anyone, she responded, "Not that I know of." c. The hospital discharge planner was interviewed at 10 a.m. on 1/12/12. She said she was concerned the resident had bruising to the front, back and peri area, which was inconsistent with the facility's description of what might have occurred. She said the resident had expressed fear and asked nurses at the hospital not to leave her. 9. Resident Roommate Interview Attempts were made to interview resident #1's roommate on the afternoon of 1/11 and 1/12/12. Facility staff had stated the resident was not interviewable. During both interview attempts, the resident stated sh

Based on observation, resident, staff and physician interviews and record review, the facility failed to ensure that nine of 43 sample residents (#3, #4, #20, #37, #45, #57, #69, #104 and #105) received the care and services necessary to attain and maintain their highest practicable level of well-being. Specifically: I. The facility failed to provide adequate emergency care to residents #45 and #105 and failed to ensure such care would be provided to resident #57. Specifically, the facility failed to respond adequately to resident #45 and #105's emergent respiratory and/or cardiac declines. Resident #57 was at risk for emergency respiratory complications and staff lacked training and equipment to respond appropriately. Resident #45, age 55, who had a chronic complex [MEDICAL CONDITION] [DIAGNOSES REDACTED]. Upon discovery of the resident's decline, the facility, including Registered Nurse (RN #26) failed to adequately monitor, assess and implement timely, appropriate interventions. The resident experienced respiratory distress and subsequently, a respiratory and a [MEDICAL CONDITION]. The resident was emergently admitted to the hospital, placed on a ventilator in the Intensive Care Unit and expired with a [DIAGNOSES REDACTED]. Resident #105, age 42, also a Full Cor, was found unresponsive on [DATE] at approximately 1:35 a.m., by the registered nurse (RN #24). RN #24 did not immediately assess the resident or begin cardiopulmonary resuscitation (CPR); rather, she left the resident to get staff support. Six minutes after discovering the resident unresponsive, the RN called emergency medical services (EMS). Staff did not initiate CPR either before or after calling EMS or after the crash cart (with emergency supplies) was brought to the resident's room. The resident expired. Resident #57, age 45, a current resident in the facility and also a Full Cor, had a complex history including a permanent [MEDICAL CONDITION] with multiple recent hospital encounters. During her most recent hospitalization on [DATE] she was placed on a ventilator in the Intensive Care Unit and was in the hospital for fourteen days. She was at high risk for another potential emergent medical situation for which the staff was unprepared and emergent bariatric supplies were unavailable. The facility's failure to ensure adequate monitoring, an adequate response to emergent medical situations, and adequate staff training on emergency response, as well as the facility's lack of equipment to facilitate emergency response for these residents - all whom required bariatric equipment for their care - placed these and other facility residents at risk for serious harm. II. The facility failed to adequately manage and timely address resident #4's bowel needs. Resident #4 had three documented bowel movements from [DATE] to [DATE], when resident #4 was hospitalized for [REDACTED]. III. The facility failed to manage residents #20 and #37's pain. IV. The facility failed to ensure resident #69's [MEDICAL CONDITION] disorder was adequately monitored and managed. V. The facility failed to manage residents #3, and #45's diabetes and residents #3 and #104's anticoagulation therapy. The findings include: I. IMMEDIATE JEOPARDY - FAILURE TO PROVIDE ADEQUATE EMERGENCY CARE A. Imposition of Immediate Jeopardy On [DATE] at 9:45 a.m., the facility was notified by the Health Facilities and Emergency Medical Services Division (HFEMSD) of the State Health Department that the failure to provide residents adequate emergency care posed a situation of Immediate Jeopardy for resident #57. On [DATE] at 3 p.m., the facility presented to HFEMSD a plan to remove the Immediate Jeopardy. The plan, implemented by the facility immediately, included: 1. [MEDICAL CONDITION] Emergency Care Resident #57 will be assessed when she returns from procedure on [DATE] by the ADON (assistant director of nursing). Primary care physician will be notified of clinical assessment conducted on [DATE]. The resident will be assessed every 8 hours for 72 hours and as clinically indicated to ensure respiratory status remains stable. This includes assessing pulse ox to ensure resident oxygen saturations are above 90%. LPN #28 was re-educated by DON (director of nursing) on [DATE] on identifying emergent signs and symptoms, assessing and evaluating emergent treatment options and communication with house RN and MD to treat and care for resident #57's potential emergent [MEDICAL CONDITION]/respiratory needs. Education to Licensed nurses was started on [DATE] by the DON/designee regarding assessing respiratory status,[MEDICAL CONDITION], and appropriate interventions and follow up for bariatric residents. DON or designee will start competencies on [DATE] [MEDICAL CONDITION], respiratory care, bariatric care, transfers, and CPR. Bariatric transfers will be completed per facility transfer assessment completed by a licensed nurse. If patient is unable to bear weight the bariatric resident will be transferred by a mechanical lift. Staff were also educated on the facility's Full Code/DNR system. DON/designee started education on [DATE] for resident care specialists on early warning signs of clinical decline and notifying a licensed nurse of any changes. Respiratory therapy to provide education on respiratory distress and [MEDICAL CONDITION] care starting on [DATE] for licensed nurses. 2. Cardio-Pulmonary Resuscitation / Prompt Emergency Medical Service The code status of all residents have been reviewed and placed on Medication Administration Record by the ADON on [DATE]. Fourteen residents were identified as full code. Code status has been implemented on the MAR as "Full Code" or "DNR." The fourteen residents that are listed as Full COR will be assessed by the IDT (interdisciplinary team) starting on [DATE] to ensure proper equipment is available on the emergency crash cart at each nurses' station for emergency situations to include ambu bag, oxygen tank, nasal cannula, oxygen masks, oxygen tubing, suction machine, suction catheter, suction tubing, sterile water or normal saline, suction canister, and back board. The IDT met to decide staffing needs for the night shift to ensure the safety needs of the residents are met if an emergency/emergencies should arise. ... The IDT team will re-evaluate the staffing needs of the residents and evaluate by the QA (quality assurance) team. The facility is located directly beside the fire department for emergent needs as well. A bariatric lift, holding up to 650 pounds, will be delivered to the facility on [DATE]. The lift will require ,[DATE] staff members to transfer bariatric residents as needed during an emergency. Staff will be educated starting on [DATE] by the SDC (staff development coordinator), under the direction of the DON on how to utilize the lift with bariatric residents during routine and emergency care. CPR classes started [DATE] by a certified CPR instructor for recertification's and initial certifications will be started [DATE] for licensed nurses and unlicensed staff. The human resources coordinator will track certifications. Nurses were also educated and instructed by the DON/designee starting on [DATE] that they were in charge of the code process and they were required to assign responsibility to other staff based on individual situations and needs. The first licensed nurse on the scene will be in charge of the code and will assign responsibility to other staff. When a code is called the nurse will assign a staff member to announce over the facility intercom system that there is a "code blue in room ---." Facility staff will respond immediately to receive assignments from the nurse in charge. The same procedure will be initiated for a simultaneous emergency. Education also includes that lack of respiratory rate or apical pulse rate will have CPR started as indicated and 911 to be called immediately. The facility has purchased 2 way radios for each nurse to carry starting on [DATE] to contact other staff members during an emergency, as back up if unable to use paging system. Staff were educated on the 2 way radio use by the SDC/designee starting [DATE]. New admissions are reviewed by the IDT team to ensure the residents needs can be met utilizing the admission screening tool. If the facility is not able to meet needs they will contact the regional clinical director for direction on accepting or denying the resident. The management and corporate staff will review the staffing matrix to identify appropriate staffing model for residents to ensure resident's needs are met daily and per shift on [DATE]. Newly hired licensed nurses will be educated during orientation, regarding the facility's medical emergency management policy to include CPR, respiratory care,[MEDICAL CONDITION] as indicated for bariatric and non bariatric residents, to be validated by SDC (staff development coordinator)/designee, under the direction and oversight of the DON prior to working independently on the nursing unit with residents. Newly hired new graduate licensed nurses will be assigned a preceptor upon hire and will obtain competencies by the SDC with oversight by the DON/designee RN regarding assessment skills,[MEDICAL CONDITION], bariatric care, and emergency management policies including CPR. Policy and procedure manuals will be ordered for each nurse's station on [DATE] by the NHA (nursing home administrator). Licensed nurses will be educated starting on [DATE] on how to access the policies by using the master index located in the front of each manual. The facility IDT including the medical director will meet weekly for four weeks to assure that the measures described above are in place and effective. The regional clinical director or a member of the corporation's region, division or field support team will validate ongoing compliance in person until the team determines that the facility has achieved and can maintain compliance. B. Removal of Immediate Jeopardy The facility was informed on [DATE] at 4:45 p.m., that the Immediate Jeopardy was removed, based on the surveyors' review and facility's implementation of their plan as described above. After the removal of the Immediate Jeopardy, deficient practice remained at G level, representing actual resident harm. C. Failure to Provide Emergency Care 1. Resident #45 Resident #45, a [AGE] year-old male, was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], revealed that resident #45 was moderately impaired in cognitive skills for daily decision-making, required assistance with all ADLs (activities of daily living) including extensive assistance with transfers and bed mobility, used a walker or wheelchair for mobility, was incontinent of bladder and bowel, weighed 435 pounds, had one stage II pressure ulcer noted [DATE] - acquired in the facility, received daily insulin injections and received oxygen therapy. An Advance Directive dated [DATE], signed by resident #45, directed the facility that he was Full Cor (wished to be resuscitated should he have a respiratory and/or [MEDICAL CONDITION]). a. History of respiratory complications - discharge to hospital [DATE] According to the medical record, resident #45 was readmitted to the facility from the hospital on [DATE]. The resident had been hospitalized [DATE] with acute [MEDICAL CONDITION] embolism with [MEDICAL CONDITION]. The physician's admission orders 02 (Oxygen) Titrate to 90% on 3L NC Q (3 liters nasal cannula every) Shift." The resident's Care Plan, dated [DATE], documented the resident's problem as Respiratory Risk related to: Oxygen delivery and SOB (shortness of breath). Approaches included: monitor breath sounds as needed, monitor vital signs as needed, administer oxygen as ordered, notify physician of change in status, observe resident for signs and symptoms of infection, [MEDICAL CONDITION] (bi-level positive airway pressure device) as ordered and oxygen saturations levels as ordered. Noted on the side was [DATE] [MEDICAL CONDITION] at HS and when sleeping. Titrate 02 to keep > 90%. And with no date: "Resident attempted to use [MEDICAL CONDITION] and refused to use due to feeling of 'suffocation." On [DATE] the resident was sent from the facility to the hospital. The hospital History and Physical, dated [DATE], documented the resident was admitted with a chief complaint of "shortness of breath and dyspnea on exertion" and that "the patient came off his oxygen therapy and was noted to have oxygen saturations of 45%." The resident remained in the hospital through [DATE], and according to the hospital's Discharge Summary, his discharge [DIAGNOSES REDACTED]." Review of the Nursing Daily Skilled Summary documentation prior to the resident's hospitalization on [DATE], revealed no notes from [DATE] in the resident's record. There was no copy of the completed hospital transfer form. There was nothing to indicate what precipitated the resident's need for emergent care and subsequent hospitalization . During an interview with the Director of Nursing (DON) at 9:53 a.m. on [DATE], the DON was advised of the missing documents and she responded that she would look for them. These missing documents were not submitted prior to the survey exit on [DATE]. b. Readmission [DATE] - Failure to clarify orders The physician's admission orders 02 (Oxygen) Titrate to 90% on 3L NC Q Shift" was continued on readmission. However, an additional telephone order was obtained that was not clarified. Specifically: -[DATE] "[MEDICAL CONDITION] at HS (hour of sleep) when sleeping. Titrate 02 to keep Sp02 (oxygen saturation levels) above 90%. Diagnosis: [REDACTED]. There was no dosage (LPM=liters per minute) on this order; the nursing staff had failed to clarify this with the attending physician. Furthermore, a review of the Medication Administration Record (MAR) showed the nurses had signed off on the record that resident #45 was receiving the [MEDICAL CONDITION] as ordered (this included a signature by the nurse on [DATE]) but there was no documentation on the Nursing Daily Skilled Summary of his being on the [MEDICAL CONDITION] machine the night of [DATE]. c. Decline in respiratory status ,[DATE] - Failure to adequately monitor, identify, assess, and communicate resident's increased oxygen needs. The Nursing Daily Skilled Summary notes were reviewed for the month of [DATE] and revealed inconsistent, inadequate monitoring of the resident's oxygen saturation levels. In addition, the notes revealed oxygen administration that exceeded the physician orders [REDACTED]. [DATE] - No oxygen; oxygen saturation level 95%. [DATE] - No dosage of oxygen; oxygen saturation level 95%. [DATE] - No oxygen; no oxygen saturation monitoring performed. [DATE] - Oxygen at 5 LPM; oxygen saturation level 95%. [DATE] - Oxygen at 4 LPM; oxygen saturation level 98%. [DATE] - No Nursing Daily Skilled Summary was completed. [DATE] - No oxygen; oxygen saturation level 95%. (Chest x-ray ordered this date for shortness of breath, [MEDICAL CONDITION]) [DATE] - No oxygen; no oxygen saturation monitoring performed. [DATE] - No oxygen; no oxygen saturation monitoring performed. [DATE] - Oxygen at 8 LPM; oxygen saturation level 91%. [DATE] - No oxygen; oxygen saturation level 96%. [DATE] - No oxygen; oxygen saturation level 95%. [DATE] - Oxygen at 8 LPM; oxygen saturation level 98%. [DATE] - No Nursing Daily Skilled Summary was completed. [DATE] - No Nursing Daily Skilled Summary was completed. [DATE] - Oxygen at 4 LPM; oxygen saturation level 91%. [DATE] - Oxygen at 8 LPM; oxygen saturation level 95%. "Resident had slight confusion spell. Checked resident's vital signs - WNL (within normal limits). Glucose 87. Gave resident some food and after ? hour seemed to be fine . . ." Review of the resident's oxygen saturation levels as documented on the Medication Administration Record (MAR) revealed that the recorded levels often did not correspond with what was documented on the Nursing Daily Skilled Summary. Although review of the Daily Skilled Nursing Summaries in ,[DATE] revealed that on six occasions the nurses were exceeding the physician's orders [REDACTED]. d. Failure to timely and appropriately respond to resident's respiratory distress [DATE]. (1) Respiratory distress [DATE] Nurses' Notes: Nurses Notes, dated [DATE], by the nurse assigned to care for resident #45 on the night of [DATE] and early morning of [DATE], stated, "At 0400 (4:00 a.m.) resident was checked by nurse. BG - 113. Resident was having DOB (difficulty breathing?). Noticed that resident was confused. Got vital signs. B/P ,[DATE], 02 - 57% on 5 LPM, P 107 (normal is ,[DATE]). T 97.2. Pumped oxygen at 10 LPM. 02 went up to 87%. Got an order from (physician) to transfer to (hospital). Resident couldn't tell where he was at. Would arouse when talked to but then falls back to sleep. Then when resident was getting transported became unresponsive at 0430 (4:30 a.m.)." A Change of Condition report, dated [DATE] at 4:30 a.m., and completed by the same nurse reported the above vitals and it asked RN's "What do you think is going on with the resident?" The nurse filled in "[MEDICAL CONDITION]." And she also added New Orders - "Increase oxygen to 10 LPM, and rebreather mask, send to hospital." Nurses Notes (included on the second page of the Change of Condition report) stated, "Recheck BG's at approximately 0400. BG 113. Resident verbalized he thinks his BG's are still low and not feeling ok. Resident was having SOB and call (sic) RCS (CNA) to take vital signs. 02 sats where (sic) 57% and noticed resident was cyanotic. Called (physician) got order to increase oxygen to highest possible which is 10 LPM and do non-rebreather mask. After phone call went inside immediately to room and increased oxygen at 10 LPM probably at 402 (4:02 a.m.) and some other RCS (CNA) looked for non-rebreather mask. (Physician) called at 4:18 (4:18 a.m.) for an order to sent (sic) resident out. Resident sent out at 0430 (4:30 a.m.)." There was another Nurse's Note written by the same nurse dated [DATE] that reported: -"Resident's blood sugar was running low before start of shift. Checked blood sugar at 2100 (9:00 p.m.). BG approximately ,[DATE] and resident verbalized he feels his BG was low. Gave him 2 sandwiches, re-checked after 15 minutes - it was still on (sic) 80's. Rechecked at sometime 2200 (10:00 p.m.). Resident verbalized he felt it was still low. BG at this time was 80. Gave him orange juice and requested for milk and gave him another sandwich and fruit. At around midnight resident verbalized he was feeling better. Was using his call light to empty urinals too at around these times. Checked BG still just to be sure it was still on (sic) 80's. Gave him a whole bottle of (soda) and checked it at 0100 (1:00 a.m.). BG went up to 97. -Then went into resident's room at sometime between 0330 and 0400 (3:30 a.m. and 4:00 a.m.). Resident BG =113, but verbalized he thinks his BG is still low. Then I called aid (sic) told her to check his vitals because resident was having DOB at this time and was cyanotic a little bit. Notified (physician) immediately. (Physician) ordered increase 02 at highes (sic) LPM and did non-rebreather mask. -The RCS (CNA) from another all (sic) came to help, but at this time resident was still answer question (sic) but doesn't know where he is at nor who we are. The RCS's were cleaning resident because he had a BM. 02 sats at this time went up to 87% or 86%. At this time nurse did all transfer forms to get ready for transport. (Physician) called and ordered to sent (sic) to (hospital). Called 911. After approximately ,[DATE] minutes EMS got here and resident wasn't responsive at this time, just staring off of (sic) space at the time of transport at 0430 (4:30 a.m.). Left POA (power of attorney) a message." (The DON, in an interview on [DATE] at 9:53 a.m., stated that she had requested the RN to write more detailed account and that was why there were two documentations of the same event.) EMS Patient Care Report and Hospital Records: Review of the EMS Patient Care Report and hospital records (pre-hospital report, neurology consult, Hospital discharge summary) revealed resident #45's condition worsened. -On the way to the hospital, a resuscitative mask with Ambu bag was placed, he received manual respiratory assistance; he then displayed ventricular fibrillation (abnormal heart rhythm) initially and immediately changed to asystole (absent heart beat) for which he required manual defibrillation. -At the hospital, the resident was diagnosed with [REDACTED]. It was felt that the patient likely had a non-survivable [MEDICAL CONDITIONS]. Life support was withdrawn on [DATE]. (2) Facility Failures Record review and interviews revealed nursing staff failed to recognize and respond promptly to the resident's respiratory distress [DATE]. Specifically, ordered equipment (non-rebreather mask) was not readily available and once the equipment was found, staff was not familiar with its use. Moreover, orders to call 911 and transfer the resident to the hospital were not promptly implemented. Finally, following the incident [DATE], the facility failed to ensure staff was trained in emergency response, use of emergency equipment, and that emergency equipment was readily available for residents with known risk of respiratory complications. Record Review: Review of physician orders [REDACTED]. -[DATE] 4:00 a.m. - "Increase 02 at highest LPM, put non-rebreather mask on resident. Diagnosis: [REDACTED]. -[DATE] timed at 4:30 (a.m.) The nurse wrote the time as 4:30 a.m. but then crossed it out and changed it to 4:20 a.m. The order was to "Transfer to (hospital). Diagnoses: [REDACTED]. The EMS Patient Care Report dated [DATE], included the following in pertinent part: "Dispatcher Notes: . . . Problem: turning blue trouble breathing . . . not alert . . . not responding appropriately . . . has difficulty speaking between breaths . . . patient is larger approximately 400 pounds . . . Alarm Received [DATE] 4:14, Dispatched at 4:19, On Scene at 4:20 . . . This Encounter - Classification: Medical, Onset of Symptoms: 20 minutes prior to call. First Patient Contact: [DATE] 4:21 a.m. . . . Initial Condition: Serious . . . 4:23 a.m. BP ,[DATE]; Pulse 107; Respirations 40 (normal range is ,[DATE]); SPO2 (oxygen saturation levels): 57 on oxygen . . . Unresponsive . . ." Interviews: Resident #45's physician was interviewed at 12:40 p.m. on [DATE]. She related: -"He (resident #45) had a lot of co-morbidities with severe [MEDICAL CONDITION] conditions and [MEDICAL CONDITION] was attempted but unsuccessful. -On [DATE], I received a call from a nurse (#26) at 4:00 a.m. She did not seem alarmed or concerned and reported his vital signs to me. She mentioned that his 02 sats were 57%. I stopped her right there because she glossed over that critical level. ... I asked her what she had done about his sats and she said, 'I think the CNA turned him up to 5L.' At that point I ordered a non-rebreather mask, to turn up his oxygen to highest 02 level, call 911 and transport him. -I called back at 4:18 a.m. and CNA (#22) answered and said she was on her way to his room with the non-rebreather mask and that his sats were up to the low 70's. When I asked her where the nurse was, she said that she couldn't find her. I told her to hang up and dial 911 now. -At 4:25 a.m. I called again and was told that the paramedics had arrived. I asked the nurse (#26) how he was doing and she said she didn't know because there was another nurse (#21) with him now but that she thought his sats were up to 78%. I asked her to have nurse (#21) call me after he left. I talked with both RN (#21) and CNA (#22) about what happened. Also EMS reported that non-rebreather mask had been hooked up incorrectly." The RN (#26) who was assigned to care for resident #45 on [DATE] -[DATE] was interviewed at 6:00 a.m. on [DATE] prior to review of resident #45's record. -She said that this was her first nursing job and that she had worked in the facility for a year and three months. She related that a non-rebreather was "if you breathe in, you breathe mostly 02 and not room air, when you breathe out the bulb closes so you breathe out the carbon [MEDICATION NAME] - makes you take approximately 90% of oxygen all of the time." -She further stated, "I've had experience with one - it was the first time. I was up on North (north hall), had a resident (resident #45) whose 02 sats were down to 57 and another nurse had to put it on him, put it in his mouth and connect it to 02. I had to get another nurse to help me. . . " -When asked what happened with resident #45, she replied, "He's a diabetic. I check his blood sugar before 3 or 4 a.m. His blood sugar wasn't going up, it only goes up to 112 or 113. He told me he wasn't doing okay, so it had to be something else. I got my aide and told her to go get the vitals machine. The only problem was that his 02 sat was low. I can't remember how low it was. Then I told the aide to call the nurse while we turned up the 02." -She stated, "I called the doctor and she ordered me to turn on the 02 and put on the non-rebreather mask. That was my first time. I was doing paperwork and we called 911 and 911 came and he was sent to (hospital) . . . I connected (the non-rebreather mask) to his 02 and put it in his mouth, he was still responsive at that time too. We called 911, they came in and checked on him, he wasn't coding; they took him out and they coded him on the ambulance on the way to the hospital." Two phone messages were left on this RN's (#26) voice mail on [DATE] and [DATE] requesting that she return the call for a further interview. No return calls were received. The CNA (#22) who cared for resident #45 on [DATE] - [DATE] was interviewed at 1:00 p.m. on [DATE]. She gave the following account: -"I got the 6 pm report . . . The nurse I was working with usually worked on the Alzheimer's Unit. We were told that his blood sugars had been running low and the nurse (#26) told me to give him snacks throughout the evening which I did to try to get his blood sugars up. -Later, I was coming out of another resident's room and I saw that the nurse had gotten the vital sign cart and was taking it into (resident #45's) room . . . I can't remember exactly but I think it was about 3:50 (a.m.) or so. She (the nurse) told me that his blood sugars were up but he didn't look right. He was responding but didn't act like himself. His vital signs, yes I took them . . . I believe his oxygen level was 57. -I noted that he needed to be changed . . . Yes he was incontinent of bowel and urine so I went and got two other CNAs to help me change him and we bumped his oxygen up to 6 liters. While we were changing him the nurse (#26) called his doctor. He wasn't getting enough oxygen because he had a nasal cannula on and he was only breathing through his mouth so I put the oxygen cannula down in his mouth so he got get more oxygen. The doctor called back and the nurse talked to her . . . (Resident #45) looked grey to me at that time." -The CNA said no one told her to get the non-rebreather mask for the resident; she just knew he needed it. She said, "So I went to find one. I would have gotten an AED (defibrillator) machine but the facility doesn't have one. I had to go clear over to South (the other unit) to get it. When I was running back to his room, the phone rang and I thought it might be the doctor so I answered it. His doctor was on the line and she asked me how he was doing. I told her 'not very well" and that I was taking the mask to his room right then. The doctor told me to call 911 immediately which I did. I used my own cell phone ... and called 911. I told them that he weighed 500 pounds and that we needed an extra pair of hands. I got back to his room and put the mask on him." -The CNA said she was not trained to use a non-rebreather mask, but she "made sure that I put the crease over his nose and tried to get it tight. We raised the head of his bed up and turned the oxygen up to 10 L." -The CNA said that nurse (#26) went to go fill out the paperwork - there was some confusion about finding the right papers to fill out - and another nurse (#21) who was working on the unit (secure unit) come in. The CNA said the paramedics arrived and the resident was transferred with the non-rebreather mask on. According to the CNA, the resident's highest his oxygen saturation level before the paramedics came was in the low 70's. The DON was interviewed about resident #45 at 9:53 a.m. on [DATE]. The corporate Regional Clinical Director was present. In response to questions about the events on [DATE] involving resident #45, she said: -"I was notified early in the morning. I was notified that they had some problems with him. They said it was a respiratory problem and that he had been sent out. I may have gotten a text from (the resident's physician) that morning. I can't remember. So when I came in that morning we started the investigation." -At that time a copy of the facility's investigation was requested and a copy of the incident report as well. (Again, on [DATE] a copy of the facility's investigation was requested. The investigation report for the [DATE] event involving resident #45, was never submitted by the facility for review.) The DON said she did not believe the facility had completed an incident report. She said that regarding the investigation, the two nurses and the CNA that were involved in the resident's care on [DATE] were called in and interviewed separately. -The DON reported that according to the statements by these staff: The patient had been having problems with blood sugars and he was being monitored; at 3:50 a.m., the patient reported to staff that he felt his blood sugar was low and his pulse ox was 57%; the patient's 02 was turned up and at 4:02 a.m. the doctor was called, gave an order to increase 02 as high as it would go - it was a 10L, and to place a non-rebreather mask. The patient was never left alone. -The DON further reported according to the statement by staff: The doctor called back at 4:18 a.m. and told staff to ship him to the hospital; 911 was called immediately and the non-rebreather mask was placed. -The DON said, "When I see someone that is cyanotic I would call 911, but I have done education with these nurses on not needing a doctors order before sending send them (the residents) out." She said that during the investigation, it was determined that the non-rebreather mask was in the resident's room, but not seen by the nurse or the CNA, so the CNA had to go to the other unit to find one. The DON acknowledged, "There might have been a few minutes in breakdown there." -The DON said she and the Nursing Home Administrator (NHA) went to the hospital the next day to talk with the emergency room (ER) doctors but they were not available. The NHA was interviewed at 10:37 a.m. on [DATE]. He stated, "We tried to get the EMS report but they would not provide it to us. I went to talk to the ER doctor because (resident #45's physician) told me that something had happened here with us. He (the ER physician) wasn't there. The next day he wasn't there again, so I talked with the Emergency Director on the phone. I asked him about the patient, if they