Every finding on record at City Scape Rehabilitation & Care Center LLC

Based on record review and interviews, the facility failed to ensure three (#7, #3 and #5) of four residents reviewed for abuse out of seven sample residents were kept free from abuse.On 5/21/25 Resident #7 was physically abused by Resident #2. Resident #2 used a belt to hit Resident #7 on top of his head and struck Resident #7 with his belt buckle. Resident #7 sustained a laceration to his head, requiring transfer to the emergency room where Resident #7 received five sutures.Additionally, Resident #5 was physically abused by Resident #1 on 3/22/25 and Resident #3 and Resident #1 were physically abused by each other on 5/3/25. Specifically, the facility failed to:-Protect Resident #7 from physical abuse by Resident #2;-Protect Resident #5 from physical abuse by Resident #1; and, -Protect Resident #3 and Resident #1 from physical abuse by each other.Findings include: I. Facility policy and procedure The Abuse Neglect and Exploitation policy, dated 5/16/25, was provided by the nursing home administrator (NHA) on 6/30/25 at 3:00 p.m. The policy read in pertinent part, “It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. “The facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Establish policies and procedures to investigate any such allegations, and establish coordination with the QAPI (quality assurance and performance improvement) program. “New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. Existing staff will receive annual education through planned in-services and as needed. “The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.” II. Incident of physical abuse of Resident #7 by Resident #2 on 5/21/25 A. Facility investigation The 5/21/25 facility investigation was received from the NHA on 6/30/25 at 1:25 p.m. The investigation documented that Resident #2 and Resident #7 were roommates in a double occupancy room. On 5/21/25 at 4:00 a.m. Resident #7 began using profanity and shouting at Resident #2 causing Resident #2 to become upset. Resident #2 used a belt to hit Resident #7 on top of his head and struck Resident #7 in the head with the belt buckle. The investigation documented facility staff responded to the altercation and separated the residents. The nurse completed an assessment on both residents and documented that Resident #7 was bleeding from his head as a result of being hit on his head with the belt buckle. Resident #7 was sent to the emergency room for treatment. Resident #2 had no injuries. Resident #7 returned to the facility on 5/21/25 with five sutures on the left side of his scalp as a result of the laceration sustained from the belt buckle. Resident #7 was placed in a different room upon his return to the facility and Resident #2 was continued on one-on-one staff supervision. The investigation documented Resident #7 was interviewed by the NHA on 5/21/25 at 9:30 a.m. Resident #7 said he felt comfortable and safe in the facility. Resident #7 was not able to explain what happened and had no memory of the altercation. The investigation documented Resident #2 was interviewed by the NHA on 5/21/25 at 10:00 a.m. Resident #2 said Residen t#7 cursed at him causing Resident #2 to become upset. Resident #2 was not willing to explain the event and said he was sorry for what he did. Resident #2 said he did not mean to hurt Resident #7. The facility investigation indicated physical abuse was substantiated. B. Resident #2 (assailant) 1. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included schizophrenia (mental illness), anxiety and dementia. The 4/29/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #2 was independent with ambulation and hygiene, however he was on one-to-one supervision by staff for a history of elopement. The MDS assessment documented the resident had no physical or behavioral symptoms directed towards others during the assessment look back period. 2. Record review The behavioral care plan, revised 7/17/24, revealed Resident #2 could have behavioral outbursts related to schizophrenia exhibited by anger, poor impulse control and physical aggression toward staff and other residents. Pertinent interventions included administering medications as ordered, monitoring/documenting for side effects and effectiveness of medications (initiated 7/17/24), intervening immediately if potential for abuse was observed (initiated 8/6/24), observing interactions with other residents to ensure the residents’ safety and removing the resident from situations that may result in harm to residents immediately (initiated 8/6/24), when the resident became agitated, intervening before the agitation escalated and guide the resident away from sources of distress and engaging the resident calmly in conversation (initiated 7/17/24). -The care plan did not reveal documentation to indicate the interventions were reviewed following the incident for effectiveness of the current interventions or that additional interventions were implemented to prevent reoccurrence of the incident. The 5/1/25 behavioral progress note, documented at 5:05 p.m., revealed Resident #2 refused oral psychiatric medication recently. The nurse on duty educated Resident #2 on medication necessity and side effects of missing scheduled medication, especially psychotropic medications. The physician had been notified that day (5/1/25) and had assessed and educated the resident. A psychiatric nurse practitioner was additionally notified and assessed the resident that day (5/1/25) The resident still refused his medications, said he was feeling good and he did not need any medication messing with his head. A new physician’s order was received to administer Resident #2’s psychotropic medication via an intramuscular route (injection into the muscle). A nurse progress note, dated 5/21/25 at 4:00 a.m., revealed the one-to-one caregiver for Resident #2 called the nurse on duty to notify the nurse of a resident to resident altercation. Resident #7 was found by the nurse on duty lying on his bed and was noted to have active bleeding from the left side of his head. The physician was informed of the altercation. The physician declined for Resident #2 to be transported to the ER for psychiatric evaluation. Resident #2 was placed in a private room until he could be evaluated by a physician. Resident #2 appeared saddened by his actions. Review of Resident #2's electronic medical record (EMR) revealed Resident #2 was monitored for 72 hours after the altercation with Resident #7 on 5/21/25 and no additional behaviors were documented. C. Resident #7 (victim) 1. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included traumatic brain injury, schizophrenia and dementia. The 4/23/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of four out of 15. Resident #7 required maximum staff assistance with chair to chair transfers and bathing. The MDS assessment documented the resident had no physical and behavioral symptoms directed towards others during the assessment look back period. 2. Record review The behavioral care plan, initiated 11/1/23, revealed Resident #7 had the potential to be verbally aggressive toward other residents related to impulse control and a diagnosis of schizophrenia. Pertinent interventions included administering medications as ordered, monitoring/documenting for side effects and effectiveness of medications (initiated 11/1/23), intervening before agitation escalated when the resident was agitated (initiated 11/1/23), observing for target behaviors, such as refusal of care, verbal aggression toward staff and/or other residents and crying and reporting observed behaviors to the nurse (initiated 8/7/24), observing interactions with other residents, and removing Resident #7 from the situation if signs of frustration or agitation were noted (initiated 8/7/24). -The care plan did not reveal documentation to indicate the interventions were reviewed following the incident for effectiveness of the current interventions or that additional interventions were implemented to prevent reoccurrence of the incident. A nurse progress note, dated 5/21/25 at 4:00 a.m., revealed the one-to-one caregiver for Resident #2 called the nurse on duty to notify the nurse of a resident to resident altercation. Resident #7 was found by the nurse on duty lying on his bed and was noted to have active bleeding from the left side of his head. The nurse on duty applied pressure to stop the bleeding with no effect. Resident #7 was sent out to the emergency room for treatment. A nurse progress note, dated 5/21/25 at 4:30 a.m. revealed the director of nursing (DON), the NHA, the resident’s representative and the physician were called to report the alleged altercation involving Resident #7 and Resident #2. A nurse progress note, dated 5/21/25 at 8:12 a.m. revealed Resident #7 returned from the emergency room with a laceration to his left scalp with five sutures. Review of Resident #7's EMR revealed the resident was monitored for neurological changes and psychosocial distress for 72 hours after the 5/21/25 incident with Resident #2. Resident #7 denied pain or feeling afraid of other residents. D. Staff interviews Nurse aide (NA) #2 was interviewed on 6/30/25 at 11:45 a.m. NA #2 said he was hired as the one-to-one caregiver for Resident #2 on the dayshift around November 2024 months ago due to the resident’s history of elopement. NA #2 said he heard about the incident between Resident #2 and Resident #7. NA #2 said he had not witnessed any physical aggression from Resident #2 towards other residents or staff. Licensed practical nurse (LPN) #2 was interviewed on 6/30/25 at 4:40 p.m. LPN #2 said after the incident with Resident #2 and Resident #7, the facility continued one-to-one staff monitoring for Resident #2 to ensure no other altercations would occur. LPN #2 said before or after the incident, she had not observed any aggression from Resident #2 towards other residents or staff. The DON was interviewed on 6/30/25 at 4:52 p.m. The DON said Resident #2 had a history of wandering throughout the facility and attempting to leave the facility without supervision. The DON said Resident #2 had a care plan for physical aggression toward others and was assigned a one-to-one caregiver to monitor the resident for elopement attempts. The DON said he was contacted the morning of the altercation (5/21/25) between Resident #2 and Resident #7. The DON said the two residents were separated and an investigation was started immediately. The DON said the care plans were updated for both residents involved with new interventions to keep the residents safe. He said the nursing staff were educated regarding the residents’ past behavioral histories along with the new interventions for the residents. -However, review of Resident #2 and Resident #7’s care plans did not reveal new interventions that were added following the 5/21/25 incident between the residents or documentation to indicate the care plans were reviewed following the incident for effectiveness of the current interventions (see record review for Resident #2 and Resident #7 above). NA #1 was interviewed on 6/30/25 at 8:14 p.m. NA #1 said both Resident #2 and Resident #7 had resided in the same room. NA #1 said she was assigned as the one-to-one caregiver for Resident #2, due to his history of elopement, on the overnight shift when the altercation occurred (5/21/25). NA #1 said she was sitting outside of Resident #2 and Resident #7’s room when she heard yelling coming from inside the room. NA #1 said the residents’ room door was closed at the time of the incident. NA #1 said when she went inside of the room, she witnessed Resident #7 bleeding from his head and went to alert the nurse. NA #1 said she had not known that she needed to leave the door open while being a one-to-one caregiver because she had not received any training from the facility before or after the incident happened. NA #1 said both residents usually got along just fine. The NHA and the regional clinical resources (RCR) were interviewed together on 7/1/25 at 10:05 a.m. The NHA said staff responded promptly to the altercation and separated Resident #7 and Resident #2 for safety. The NHA said the investigation was started on 5/21/25 and all involved staff were interviewed. The NHA said Resident #2 had a history of elopement behaviors and that the facility had implemented a one-on-one caregiver prior to the resident’s altercation with Resident #7. The NHA said a one-to-one caregiver for a resident should always be able to visualize the resident for safety and to verbally intervene before any physical aggression occurred. The NHA said after the 5/21/25 incident, Resident #2 and Resident #7 had no additional aggressive behaviors. The RCR said she was unsure if staff received training on the one-to-one caregiver policy because the facility changed ownership in May 2025, however, she said the facility planned to provide training to all nursing staff going forward. The RCR said the one-to-one caregiver (NA #1) should have had Resident #2 and Resident #7’s door open at the time of the altercation. The RCR said both of the residents would have their care plans updated to address the behaviors displayed during the altercation on 5/21/25. III. Incident of physical abuse of Resident #5 by Resident #1 on 3/22/25 A. Facility investigation The 3/22/25 facility investigation of the incident involving Resident #5 and Resident #1 was provided by the NHA on 6/1/25 at 4:00 p.m. The investigation documented that on 3/22/25 at approximately 2:00 p.m., registered nurse (RN) #1 reported an incident involving Resident #5 and Resident #1 to the former NHA. RN #1 stated that yelling was heard from the memory care unit at approximately 2:00 p.m. on 3/22/25. Resident #1 was observed on the floor, lying on his right lateral side, with Resident #5 on the floor as well, in the main hallway of the memory care unit. Resident #1 was observed aggressively grabbing and kicking Resident #5. Staff members immediately separated both residents to different areas within the memory care unit. Resident #1 was placed back into his wheelchair and Resident #5 was placed on a chair. Resident #5 had a scratch on his ear and Resident #1 had a scratch on his nose. The investigation documented that certified nurse aide (CNA) #3 was in the living room area of the memory care unit when Resident #1 came out of his room in his wheelchair. Resident #1 wheeled himself into the living room area and next to where Resident #5 was sitting. Resident #1 then stood up from his wheelchair and grabbed Resident #5. Resident #5 tried to stand up and both Resident #5 and Resident #1 fell to the floor. Both residents started kicking and holding each other while on the floor. Resident #5 and Resident #1 were separated from each other, with Resident #1 being taken out of the memory care unit. Both residents were assessed for injuries. Resident #1 was transported to the hospital by ambulance for evaluation of aggressive behavior. The investigation documented the former NHA interviewed Resident #5 about the incident on 3/22/25. Resident #5, when asked what happened, stated that he was attacked with a knife and now his ear was bleeding. Then Resident #5 stated that he did not know what happened. The investigation documented the former NHA stated that he received a call from the facility about an incident involving Resident #5 and Resident #1. When he arrived at the facility, he noticed Resident #1 sitting in his wheelchair at the nurses station with the nurse cleaning an abrasion on the left side of his nose. The former NHA interviewed Resident #1 on 3/22/25 at 3:00 p.m. about the incident. Resident #1 was not able to answer any questions during the interview. Resident #1 appeared frustrated and was still agitated. A physician’s order was placed by the physician to send Resident #1 to the hospital for evaluation of aggressive behavior. Resident #1 was placed on a one-to-one basis and physician and nurse practitioner (NP) were called for behavioral assessment. The facility’s conclusion was that they were unable to substantiate a willful act of physical abuse in a resident-to-resident altercation as neither Resident #5 or Resident #1 could recall the situation upon interview. -However, physical abuse occurred because Resident #1 grabbed Resident #5 and pulled him to the ground. B. Resident #1 (assailant) 1. Resident status Resident #1, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2025 CPO, diagnoses included encephalopathy, vascular dementia without other behavioral disturbances, cerebral infraction and difficulty walking. The 6/16/25 MDS assessment indicated that the BIMS assessment was not unable to be completed because the resident was rarely/never understood. According to the staff assessment for mental status, the resident had short term and long term memory problems and his cognitive skills for daily decision making were moderately impaired. He required maximal staff assistance for most activities of daily living (ADL) and moderate staff assistance with transfers and ambulation. The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms directed toward others during the assessment look back period. 2. Record review The behavior care plan, revised 6/2/25, revealed Resident #1 had a history of behavior problems with confusion and dementia. He paced the facility and tried to enter areas that were for staff, and enter other residents’ rooms. He would rummage and take things that did not belong to him. He had also exhibited impulsive behaviors when attempting to complete inappropriate tasks such as leaving the facility or entering residents' rooms. He had thrown items, rammed into things, or struck out at residents or staff. Pertinent interventions included providing one-to-one staff monitoring, frequent checks, redirecting the resident, maintaining the resident’s personal space, monitoring, recording, and reporting any behavior to the physician of the resident harming others, and monitoring for increased anger, labile mood or agitation, if the resident felt threatened, or was thinking was thinking of harming someone. A note, dated 3/22/25 and attached to the facility’s investigation report documented Resident #1 was taken off the unit (memory care unit) to de-escalate, as he continued to seek out Resident #5 and was striking out and aggressive towards staff. The on-call physician was notified and verbal orders were received for Resident #1 to be transferred to the hospital and to administer Ativan to the resident every six hours as needed for agitation for 48 hours. Resident #1 was transferred to the hospital by emergency medical services (EMS) for increased behaviors of combativeness and agitation at approximately 2:45 p.m. A skin assessment for Resident #1, dated 3/24/25, two days after the incident with Resident #5, noted Resident #1 had bilateral bruising on his forearms and a scabbed open scratch that was being monitored and had treatment orders. Additionally, a right upper lip abrasion was noted, reportedly sustained during a resident-to-resident altercation. The resident declined to shower but was receptive to a bed bath. The skin assessment revealed warm, dry, and clean, and mucus membranes that were clean, moist, and pink. There were no signs or symptoms of infection. The resident denied any pain or discomfort associated with the wound areas. Treatment was administered to the wound areas with vitamin A&D ointment twice daily per physician orders. The resident displayed cooperation throughout care. C. Resident #5 (victim) 1. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included cognitive communication deficit, adjustment disorder with mixed anxiety and depressed mood and Alzheimer’s disease with late onset. The 6/5/25 MDS assessment revealed Resident #2 had severe cognitive impairments with a BIMS score of six out of 15. The resident required moderate staff assistance with ADLs and was able to perform sit-to-standing transfers and ambulate a distance of 10 feet without direct staff assistance, utilizing a walker for support. The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms directed toward others during the assessment look back period. 2. Record review -Review of Resident #5’s electronic medical record (EMR) revealed there was no documentation related to the incident with Resident #1 on 3/22/25. -Review of Resident #5’s comprehensive care plan revealed there was no care plan focus for behaviors. IV. Incident of physical abuse between Resident #3 and Resident #1 on 5/3/25 at 10:00 a.m. A. Facility investigation The 5/3/25 facility investigation was provided by the NHA on 6/30/25 at 4:00 p.m. The investigation revealed that Resident #1 got into an altercation and with Resident #3 and both residents were grabbing/scratching each other. Staff were not sure what precipitated the altercation. The residents were kept separated, and RN #1 spoke to them separately. The residents were calm and RN #1 did skin assessments for both residents, noting scratches on Resident #1. Staff members did not witness what started the incident between Resident #1 and Resident #3. Staff members could not provide accounts of what happened or who was the aggressor in the incident. The investigation documented staff heard yelling from the memory care unit at 10:05 a.m. and observed Resident #3 and Resident #1 in the dining room. The residents appeared agitated and Resident #3 had a superficial scratch mark, with intact skin, on his left forearm. Resident #1 had a skin tear to his right forearm Resident #3 was separated from Resident #1 and both residents were placed on fifteen-minute checks for seventy-two hours. Resident #3 claimed Resident #1 hit him. The investigation documented the NHA interviewed certified nurse aide (CNA) #3 on 5/3/25 at 10:40 a.m. about the incident between Resident #1 and Resident #3. CNA #3 said she heard and saw another staff member trying to separate the residents around 10:00 a.m. She said she saw Resident #1 scratching Resident #3 and staff members pulled Resident #1’s wheelchair away from Resident #3. The investigation documented the facility substantiated physical abuse by Resident #3 and Resident #1. B. Resident #1 (assailant and victim) 1. Record review -Review of Resident #1’s EMR revealed there was no documentation related to the incident with Resident #3 on 5/3/25. C. Resident #3 (victim and assailant) 1. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses including dementia without behavioral disturbance, lack of coordination, and cerebral infarction without residual deficits. He required maximal staff assistance for most ADLs and transfers. The 6/20/25 MDS assessment indicated the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms directed toward others during the assessment look back period. 2. Record review The psychiatric nurse practitioner (NP) was contacted by the assistant director of nursing (ADON), on 5/4/25, concerning the altercation involving Resident #3 and another resident (Resident #1) within the memory care unit. The communication included the suggestion that a review of the resident’s current psychiatric medications might be beneficial. The NP confirmed her intent to perform a direct evaluation with Resident #3 upon her availability at the facility. -Review of Resident #3’s comprehensive care plan revealed there was no care plan focus for behaviors. V. Staff interviews CNA #1 was interviewed on 6/30/25 at 3:15 p.m. CNA #1 said a physical altercation occurred between Resident #5 and Resident #1 in March 2025. CNA #1 said Resident #5 showed no behavioral changes afterward, and the residents involved no longer interacted with each other or appeared to have a memory of the incident. CNA #1 said the incident was reported to the administration who then investigated the incident. The NHA was interviewed on 7/1/25 at 12:00 p.m. The NHA said he was not the NHA during the incidents involving Resident #5, Resident #1 and Resident #3. He said residents should be monitored for a continuous 72-hour period following a resident-to-resident altercation, ensuring their emotional and psychological stability. The NHA said the policy on how to manage and respond to resident-to-resident altercations was available to staff for reference and training. The NHA said walkie-talkies might be beneficial for staff to have available when critical or emergent situations arose with residents, such as physical altercations, in order to ensure quicker response times from other staff and improve coordination with staff members.said walkie-talkies might be beneficial for staff to have available when critical or emergent situations arose with residents, such as physical altercations, in order to ensure quicker response times from other staff and improve coordination with staff members.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents reviewed for accidents out of three sample residents. Resident #4 was admitted on [DATE] for long term care with a diagnosis of dementia. According to the care plan, Resident #4 was determined to be a high fall risk. On 5/28/25 Resident #4 was found on the floor in her room with blood coming from her head. Resident #4 was transported to the hospital for further evaluation. Resident #4 sustained a subdural hematoma (brain bleed) and was diagnosed with a traumatic brain injury. The facility failed to implement person-centered interventions after the resident sustained a fall on 5/28/25. Observations revealed the facility failed to consistently implement the fall interventions on the resident's care plan. Specifically, the facility failed to implement person-centered fall interventions after Resident #4 sustained a fall that resulted in a traumatic brain injury or ensure that staff were consistently following the resident's care planned interventions Findings include: I. Facility policy and procedure The Accident and Supervision policy, implemented 5/16/25, was provided by the nursing home administrator (NHA) on 6/30/25 at 3:44 p.m. It read in pertinent part, The residents' environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. The facility shall establish and utilize a systematic approach to address residents risk and environmental hazards to minimize the likelihood of falls. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency and based on the individual residence assess needs and identified hazards in the residence environment. The facility will use monitoring and modification to evaluate the effectiveness of care plan interventions and adjust interventions as needed to make them more effective. Monitoring and modification process include ensuring that interventions are implemented correctly and consistency, evaluating the effectiveness of interventions, modifying or replacing interventions as needed, and evaluating the effectiveness of new interventions II. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included dementia, muscle weakness, abnormal mobility, confusion and history of falls. The 3/24/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for a mental status (BIMS) score of zero out of 15. She required maximal assistance with toileting hygiene and partial or moderate assistance with chair to bed transfers. The MDS assessment indicated the resident did not have a fall after admission. B. Observations During a continuous observation on 6/30/25, beginning at 12:30 p.m. and ending at 4:30 p.m., the following was observed: At 12:30 p.m. Resident #4 was sitting at the dining room table while eating her lunch. The resident had pink socks on both of her feet that did not have anti-slip material on the bottom of them. At 1:15 p.m. licensed practical nurse (LPN) #1 asked the surveyor to keep an eye on the residents while LPN #1 left the locked unit. No other nursing staff were present in the locked unit. At 1:25 p.m. LPN #1 returned to the secured unit. At 1:30 p.m. Resident #4 was sitting alone at the dining room table after completing her meal. She did not have shoes or socks with anti-slip material on the bottom of them. At 2:00 p.m. Resident #4 was sitting at the dining room table alone. Nursing staff were sitting at a dining room table adjacent to Resident #4 looking at their cell phones. At 3:15 p.m. Resident #4 got up out of her chair independently and ambulated in the hallway with her walker without nursing staff supervision. At 3:30 p.m. Resident #4 was ambulating in the hallway and wandered into another resident's room. Upon prompting, LPN #1 assisted and guided Resident #4 back to a chair in the dining room to watch television. At 3:41 p.m. Resident #4 was observed ambulating in the hallway with visibly wet pants and no staff assistance. C. Record review Resident #4's fall care plan, revised 6/10/24, revealed the resident was a high fall risk due to having confusion, gait/balance problems, rheumatoid arthritis, incontinence, poor communication and comprehension and being unaware of safety needs. Interventions included anticipating and meeting the resident's needs (initiated 10/21/22), ensuring the call light was within reach and encouraging the resident to use it (initiated 10/21/22), providing her with hands on assistance to stand/sit as needed for safety (initiated 6/10/24), encouraging the resident to participate in strengthening activities (initiated 10/21/22), following the facility's fall protocol (initiated 10/21/22), providing hands on assistance and ensuring that the resident was wearing appropriate footwear such as hard soled non-skid shoes, slippers, or non-skid socks when ambulating (initiated 10/21/22). -However, observations revealed the staff failed to ensure the resident was wearing appropriate footwear such as hard soled non-skid shoes, slippers, or non-skid socks when ambulating (see observations above). The 5/28/25 facility investigation for Resident #4's fall was received from the NHA on 7/1/25 at 9:15 a.m. The investigation documented that on 5/28/25 Resident #4 was reported to have an unwitnessed fall. Resident #4 was found on the floor by nursing staff, next to her bed bleeding from her head. Resident #4 was sent to the hospital for further evaluation and treatment. A computed tomography (CT - medical imaging) scan was completed and revealed the resident sustained two subdural hematomas. The resident returned to the facility the same day. The facility investigation revealed Resident #4 could not describe what had happened. The investigation documented pressure was applied to the area until emergency services (EMS) arrived. The investigation documented Resident #4 was headed to the bathroom around 2:30 a.m. when a staff member heard a noise coming from Resident #4's room. The staff member immediately went into the room and saw Resident #4 on the floor next to bed. The nursing staff member then quickly alerted the nurse on duty. The nursing staff member said the last time she had checked on Resident #4 was around 1:40 a.m. and the resident was noted to be sleeping in her bed with no concerns. A nursing progress note, dated 5/28/25 at 2:50 a.m., revealed Resident #4 was found on the floor next to her bed with blood coming from her left forehead, a swollen black left eye and blood was noted on the floor and on the resident's gown. The RN on duty obtained physician's orders to send Resident #4 to the emergency room for treatment. A nursing progress, dated 5/28/25 at 6:02 p.m., revealed Resident #4 returned to the facility from the emergency room with multiple injuries, including swelling and bruising to the left forehead and left shoulder. Resident #4 also sustained a laceration to the left forehead requiring dissolvable sutures to be placed. Resident #4 returned from the hospital to the facility with a diagnosis of a traumatic brain injury. III. Staff interviews LPN #1 was interviewed on 6/30/25 at 4:10 p.m. LPN #1 said she was told to watch Resident #4 while she was out of bed because of her recent falls. LPN #1 said she was not aware of any additional interventions to prevent Resident #4 from falling again. -However, LPN #1 asked the surveyor to keep an eye on the residents in the unit, including Resident #4, when she left the secured unit (with no other nursing staff members visible) for 10 minutes (see observations above). The director of nursing (DON) was interviewed on 6/30/25 at 4:42 p.m. The DON said Resident #4 should always have non-slip shoes or socks on her feet because of her recent fall with injury. The DON said there should be at least two staff members visible on the secured unit at all times to monitor and assist the residents. The DON said Resident #4 should not be left alone due to her history of falls with injury. The DON said he would provide additional training for nursing staff regarding fall prevention interventions. The NHA and the regional clinical resources (RCR) were interviewed together on 7/1/25 at 10:05 a.m. The NHA said the facility started an investigation after Resident #4 sustained a fall on 5/28/25. The NHA said the nursing staff did not check on the resident enough because they were not trained on purposeful rounding. The NHA said the nursing staff should monitor residents with dementia and a history of falls to check if they needed assistance. The NHA said after Resident #4 sustained a fall on 5/28/25, Resident #4 had not had another fall. The NHA said there should always be at least two staff members on the secured unit to monitor, provide care to residents and anticipate residents' needs to prevent falls from occurring. The NHA said it was not beneficial to the residents to have been left alone by LPN #1. The RCR said she believed Resident #4's fall was preventable and the staff did not have enough training regarding purposeful and meaningful rounding. The RCR said the facility provided training to all nursing staff on purposeful rounding immediately after the fall occurred. The RCR said the failure of the nursing staff to provide meaningful rounding resulted in Resident #4 sustaining a fall resulting in brain injury.

Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of four sample residents. Specifically, the facility failed to implement person-centered fall interventions in a timely manner. Findings include: I. Facility policy The Fall/Accident Assessment Prevention and Review policy, undated, was provided by the nursing home administrator (NHA) on 5/1/25 at 12:42 p.m. It read in pertinent part: The goal of the facility is for residents to remain as free from falls and accidents as possible. To provide guidelines for the assessment, prevention and review of falls and/or accidents. The interdisciplinary team (IDT) will review the forms at the morning quality improvement meeting to determine what immediate action may be necessary. The IDT will again review the forms in greater detail at the weekly IDT meeting. Data collected will be reviewed in an attempt to determine causal factors and trends. Specific approaches to prevent further falls will be determined based on the reasons for the falls as determined in the assessment and review. The care plan will be updated and interventions will be put into place. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included Parkinson's disease with dyskinesia (involuntary movements), difficulty in walking, generalized muscle weakness, lack of coordination and chronic pain. The 2/9/25 minimum data set (MDS) assessment revealed that Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #1 required partial to moderate assistance for sit-to-stand and all surface transfers. B. Resident interview Resident #1 was interviewed on 5/1/25 at 12:00 p.m. Resident #1 said she fell a lot because she waited for help from staff for a long time and transferred herself. She said she did not have fall interventions in place. C. Record review Resident #1's fall care plan, revised 4/25/25, revealed the resident was a high fall risk due to having Parkinson's disease, gait and balance issues and using psychoactive drugs. Interventions were documented as anticipating and meeting the resident's needs, ensuring the call light was within reach and encouraging the resident to use it, educating the resident about safety and what to do if a fall occurred, encouraging the resident to participate in strengthening activities, following the facility's fall protocol, physical therapy to evaluate and treat the resident as ordered and as needed and reviewing information on past falls to determine the cause of the fall. Review of Resident #1's electronic medical record (EMR) revealed the following: Resident #1 had an unwitnessed fall in her room with no injuries on 9/2/24 at 4:30 p.m. A fall intervention was implemented on 10/7/25 to remind and encourage the resident to lock her wheelchair brakes before she transferred herself. -However, the facility did not implement the fall intervention until 35 days after the resident's fall on 9/2/24. Resident #1 had an unwitnessed fall in her room with no injuries on 10/1/24 at 7:00 p.m. A fall intervention was implemented on 10/7/24 for Resident #1 to have a restorative transfer program that focused on consistently locking her wheelchair brakes. -However, the facility did not implement the fall intervention until six days after the resident's fall on 10/1/24 and three days after she sustained another fall on 10/4/24 (see below). Resident #1 had an unwitnessed fall with no injuries in her room while reaching for her water pitcher on 10/11/24 at 3:50 p.m. A fall intervention was implemented on 10/17/24 to ensure frequently used items were within the resident's reach. -However, the facility did not implement the fall intervention until six days after the resident's fall on 10/11/24. Resident #1 had an unwitnessed fall in her room with no injuries on 12/16/24 at 4:48 p.m. A fall intervention was implemented on 1/15/25 for physical therapy to evaluate and treat the resident for strengthening. -However, the facility did not implement the fall intervention until 30 days after the resident's fall on 12/16/24. Resident #1 had a witnessed fall with a skin tear to her left shin while trying to turn off the bedroom light on 4/4/25 at 9:15 p.m. A fall intervention was implemented on 4/24/25 to educate the resident to ensure she was fully in bed and sitting upright before reaching for the light. -However, the facility did not implement the fall intervention until 20 days after the resident's fall on 4/4/25. Resident #1 had an unwitnessed fall with no injuries on 4/5/25 at 3:45 p.m. while sliding out of bed. A fall intervention was implemented on 4/24/25 to encourage the resident to remain centered and properly positioned in bed. -However, the facility did not implement the fall intervention until 19 days after the resident's fall on 4/5/25. III. Staff interviews The NHA and the assistant director of nursing (ADON) were interviewed together on 5/1/25 at 12:42 p.m. The NHA said implementing a fall intervention a week or more after a resident's fall was not prompt and interventions needed to be implemented sooner. The ADON said interventions needed to be implemented as soon as possible to help prevent another fall and to ensure the resident benefited from the fall intervention.

Based on record review and interviews, the facility failed to ensure an appropriate facility-initiated discharge procedure was followed for one (#105) of two residents reviewed for discharge out of 31 sample residents. Resident #105, who had a diagnosis of rheumatoid arthritis, anxiety disorder, depression, attention-deficit hyperactivity disorder and chronic pain, was admitted to the facility on [DATE] and involuntarily discharged to a homeless shelter on 2/20/24. The facility failed to provide preparations for a safe and orderly facility-initiated discharge or provide a reason for the discharge. Resident #105 began discharge planning with the facility on 1/11/24 during a care conference where his stated goal was to discharge to an assisted living facility (ALF). The last discharge plan discussion occurred on 2/16/24 when the facility offered to discharge the resident to homeless shelters and he declined this option. On 2/20/24 the facility had Resident #105 escorted from the facility by law enforcement. Resident #105 was crying and begging not to be kicked out of his home. The facility failed to provide the resident with a 30-day discharge notice or any form of written discharge notice and failed to provide written notice to the ombudsman of the discharge. Cross-reference F623 for failure to provide a written discharge notice to the ombudsman to include the reasons for the discharge. Additionally, the facility failed to provide Resident #105 with discharge instructions or his medications. Due to the facility's failures, Resident #105 was in and out of the hospital and homeless shelters following the involuntary discharge. Resident #105 suffered psychosocial harm stating he had a lot of confusion and anxiety when he first left and he was crying and begging at discharge not to be kicked out of his home. Resident #105 was angry about how the facility treated him and said it made him feel like he was a big problem and depreciated. Resident #105 said the experience was horrible when he was threatened with either discharging from the facility or going to jail. Findings include: I. Facility policy and procedure The Transfer or Discharge, Facility-Initiated policy and procedure, dated October 2022, was provided by the nursing home administrator (NHA) on 7/11/23 at 5:05 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Facility-Initiated transfer or discharge means a transfer or discharge which the resident objects to, and/or is not in alignment with the resident's stated goals for care and preference. The resident and his or her representative are given a thirty (30)-day advance notice of an impending transfer or discharge from the facility. The resident and representative are notified in writing of the following information: -The specific reason for the transfer or discharge, including the basis; -The effective date of the transfer or discharge; -The specific location to which the resident is being transferred or discharged ; and, -An explanation of the resident's rights to appeal the transfer or discharge to the state, including: -The name, address, email and telephone number of the entity which receives such appeal hearing requests; -Information about how to obtain an appeal form; and, -How to get assistance in completing and submitting the appeal hearing request; -The notice of facility bed-hold and policies; -The name, address, and telephone number of the office of the state long-term care ombudsman; -The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental disabilities; and -The name, address and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. A copy of the notice is sent to the office of the state long-term care ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. Nurses notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. Documentation of facility-initiated transfer or discharge: When a resident is transferred or discharged from the facility, the following information is documented in the medical record: -The basis for the transfer or discharge; -If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: the specific resident needs that cannot be met; this facility's attempt to meet those needs; and the receiving facility's services that are available to meet those needs; -That an appropriate notice was provided to the resident and/or legal representative; -The date and time of the transfer or discharge; -The new location of the resident; -The mode of transportation; -A summary of the resident's overall medical, physical, and mental condition; -Disposition of personal effects; -Disposition of medications; -Others as appropriate or as necessary; and, -The signature of the person recording the data in the medical record. -However the above information was not documented in Resident #105's electronic medical record (EMR) (see record review below), and the resident and/or representative did not receive any written notice of an impending facility-initiated discharge. II. Resident #105 A. Resident status Resident #105, age less than 65, was admitted on [DATE] and discharged on [DATE] to a homeless shelter. According to the February 2024 computerized physician orders (CPO), diagnoses included rheumatoid arthritis, anxiety disorder, depression, attention-deficit hyperactivity disorder and chronic pain. The 2/20/24 discharge 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. He was independent for all functional activities of daily living (ADL). The assessment documented the resident had no behavioral symptoms including physical, verbal, or other and there was no rejection of care. The assessment documented active discharge planning was already occurring for the resident to return to the community and a referral had been made to the local contact agency. -Discharge planning according to the residents goals and preferences was to discharge to an ALF. However, the facility suddenly discharged him to a homeless shelter against his wishes (see interviews and record review below). B. Resident interview Resident #105 was interviewed via phone on 7/11/24 at 12:28 p.m. Resident #105 said the facility discharged him with no written discharge notice or reason. He said the facility gave him no discharge instructions or his medications. He said the facility called the police on him when he did not want to go and said he would either go to jail or go to a homeless shelter. Resident #105 said the facility had retaliated against him because he had filed a complaint that the facility was cold and within a week he was told to leave. He said it was a horrible humiliating experience and made him feel like he was a huge problem and depreciated. He said the experience made him furious. He said he had been cold in the building and so he said something. He said he was not provided assistance by the ombudsman and he was not involved in selecting the new location to discharge to. He said he wanted to go to an assisted living facility and he said he was in the middle of that process when the facility suddenly discharged him without notice or reason. Resident #105 said he worked with a psychiatrist and had a lot of confusion and anxiety when he was discharged from the facility. He said he had to go back to the hospital. He said the homeless shelter where he went had put him on a list for housing assistance. C. Resident representative interview The resident's representative was interviewed via phone on 7/11/24 at 11:38 a.m. The representative said the facility initiated Resident #105's discharge and he was not treated properly. The representative said neither she nor the resident had received a written discharge notice or a reason for the discharge. She said at the time of the discharge, she was on facetime with the resident because she lived out of state and had screen recorded the resident crying and begging for the facility not to kick him out. The resident's representative said she was crying as she viewed how the resident was being treated. She said when Resident #105 would not leave, the facility called the police on him and the police forced him out. The resident's representative said she thought the facility was retaliating against the resident because he spoke up about things that concerned him during his stay, such as the heat being turned off and being cold in the building and his clothing coming back from the laundry not cleaned or with holes. The resident's representative said the discharge happened right after he said something and the facility forced him to leave without a written discharge notice. The resident's representative said since his discharge from the facility, the resident had been in and out of the hospital and homeless shelters. D. Frequent visitor (FV) interview A frequent visitor (FV) was interviewed on 7/15/24 at 10:21 a.m. The FV said she did recall Resident #105. She said he was discharged for non payment and he did not want to apply for Medicaid. She said Resident #105 did not call her for assistance. She said she did not see the facility process the required discharge paperwork and no one followed up with her. She said the discharge process just got away. She said the facility was not consistent with their discharge processes and was changing social workers. The FV said she did not receive a written copy of the 30-day discharge notice. E. Record review The long term care (LTC) care plan, initiated 12/29/23, revealed Resident #105 planned to remain at the facility for LTC and may have needed time to adjust to his new environment. However, he would be asked about his interest in discharging from the facility on a quarterly assessment. Interventions included to assist the resident to activities as needed, and to monitor for signs and symptoms (s/s) of decrease in mood or s/s of depression and inform social services if noticed such as little interest in doing things or number of depressed episodes, or experiencing pain. -The care plan was not updated with a new discharge plan. Review of Resident #105's EMR revealed the following progress notes: The 1/11/24 care conference note revealed the resident planned to be discharged by the end of January 2024 and social services would meet the resident's discharge plan needs. The 1/18/24 psychosocial note revealed the resident would like to be discharged to the community independently or in an ALF. The resident had been made aware (company name) independent living had a short waiting list and had indicated he was interested in completing the application and the application was provided to the resident on 1/17/24. The 1/19/24 psychosocial note revealed the writer spoke to the ombudsman regarding the resident's interest in living in an ALF or an independent living facility. The ombudsman recommended (company name) ALF. The 1/25/24 psychosocial note revealed the ALF would come to do a resident assessment of Resident #105 on 1/29/24. The 1/30/24 psychosocial note revealed the resident would not be attending an assessment for (company name) ALF because the resident would be going to the independent living of (company name). The admission coordinator would be contacting the resident to relay the message to him. The 2/1/24 psychosocial note revealed the writer had met with the resident on 1/31/24 and discussed a tour of (company name) ALF. The resident had indicated that he liked the place and was willing to move forward with admission to the ALF. The resident was unsure of the admission to the new facility therefore the writer reached out to the admission coordinator via email and she had indicated that the potential admitted would be in about two weeks (mid-February 2024). The 2/9/24 physician discharge visit note revealed the resident was being seen at the request of the facility administrator for a discharge visit. It revealed the resident suffered from chronic pain due to rheumatoid arthritis and spinal stenosis. It revealed the staff had been dealing with issues regarding behaviors with the resident. The police had been called by the NHA after the resident had an outburst and had yelled inappropriate racial statements and also stated he would kill the people sitting here and still get away with it. The note further revealed the police said they did not have enough reason to take him on a mental hold since he was not suicidal or homicidal and since he did not have a previous history, they could not detain him. The resident's health improved to the extent that the resident no longer needed the services of the facility and the resident would be discharged to a safe housing/shelter and the facility would provide transportation. The 2/9/24 CPO revealed the resident may discharge to safe housing/shelter. The 2/14/24 psychosocial note revealed the writer visited the resident to discuss his discharge plans and the resident was open to discuss his plans. When talking about the ALF location the resident was interested in going to, the resident stated he was not going there because they continued to ask him about another facility he had never been to. However when speaking to the ALF, the writer spoke with the admission coordinator and she had stated that the executive director had declined Resident #105's admission due to his behaviors. During the visit, the resident stated he was not depressed regarding the situation but continued to visit with his own therapist weekly. The resident's goal was to be cordial with others to meet his goal of being discharged to an ALF or independent living. The 2/16/24 psychosocial note revealed the facility met with the resident to discuss discharge plans. The facility offered to discharge him to homeless shelters and he declined this option. The plan was to follow up the following week for any further instructions needed to aid the resident in the discharge transition. The 2/17/24 nurses note revealed the police had been called by the resident to report that the facility's heater was turned off and the resident was cold. The police spoke with the resident and left. The nurse asked the resident if he was still cold and needed more blankets and he had said he was fine. The 2/20/24 at 7:13 a.m. psychosocial note revealed the writer had spoken with the resident's representative on 2/19/24 to discuss the resident's discharge plan. The representative had stated she would help find a location for the resident. The writer and the resident's representative planned to meet with the resident via computer facetime, and if possible with the resident's therapist, on 2/21/24 to discuss the discharge plan. The 2/20/24 at 10:02 a.m. psychosocial note revealed that, during the call on 2/19/24, the resident's representative had asked if the manager of the facility's ownership company could give her a call to understand what was going on at the facility. The writer had spoken to the CEO (chief operating officer) and CFO (chief financial officer) and addressed the concerns of the representative and they planned to call the resident's representative as requested. -The resident's representative revealed during her interview on 7/11/24, the company management had never given her a call. The 2/20/24 at 3:49 p.m. nurses note revealed at approximately 3:50 p.m. Resident #105 was escorted from the facility accompanied by law enforcement. The resident was cooperative. The 2/20/24 at 4:46 p.m. psychosocial note revealed the resident was presented with multiple options when planning to discharge, however, he refused to comply with any option. The resident was discharged that day (2/20/24) and he refused to leave. The writer met with the resident along with a civilian emergency response team, clinicians and the police because of the resident's refusal to leave after being successfully discharged from the facility and the resident was considered to be trespassing. The administrative staff assisted with the process to have the resident transported to a homeless shelter where he would be able to coordinate housing with the shelter's available options. The 2/21/24 at 8:47 a.m. psychosocial note revealed the ombudsman was contacted on 2/20/24 about an emergency discharge of Resident #105 due to the ombudsman being a part of the discharge planning from the beginning. Review of Resident #105's EMR on 7/11/24 at 9:49 a.m. revealed the following: -There was no discharge summary or assessment documentation; -There were no nurses note documentation of appropriate orientation and preparation of the resident prior to transfer or discharge; -There was no reason for the discharge documented in the record; and, -There was no written discharge notice documentation. III. Staff interviews The regional operations consultant (ROC), the NHA, and the social services director (SSD) were interviewed together on 7/11/24 at 3:06 p.m. The NHA said she had started in the NHA position in May 2024 but she was at the facility in other capacities in the month of February 2024. She said the current SSD started in January of 2024. The NHA said the current SSD was fairly new at the time of Resident #105's discharge in February of 2024 but had help from another regional social services consultant who was now no longer with the company. The SSD said the facility initiated the discharge of Resident #105. The NHA said when the discharge process began, Resident #105 was in favor of discharging but she said, at the very end of the process, the discharge became facility-initiated. The NHA said the facility used a third party organization who worked with the community to assist with the discharge. The ROC said there were several factors for why Resident #105 was discharged but the main reason was because the resident was not happy at the facility. The NHA said the ombudsman talked to everyone to help the process. The NHA and the ROC said they did not know what the facility's policy was on discharge notification and they could not give a reason why the discharge was facility-initiated. The NHA said they did not formally notify Resident #105 regarding the discharge. The NHA and the ROC were interviewed again on 7/15/24 at 8:46 a.m. They reiterated that the discharge started as a resident-initiated discharge but they were not sure how or why the discharge became facility-initiated. The NHA and the ROC acknowledged that the progress note documented that it was an emergency discharge and that the police were called but they did not know the reason why the progress note documented that. The NHA and the ROC said they did not know why it was determined that Resident #105 would be discharged on that day (2/20/24) when the resident did not want to be discharged . They said they did not know the reason why the facility discharged the resident or why the facility had not issued a 30-day discharge notice. The director of nursing (DON) was interviewed on 7/16/24 at 10:10 a.m. The DON said on the day a resident was discharged the nurses made preparations to be sure all the resident's medications were ready. The DON said the social services department would handle the transportation arrangements. The DON said the nurses would go over the medications to make sure the resident understood how and when to take the medications. The DON said the discharging resident could take their medications with them. The DON said the nurses would get discharge orders. The DON said the nurse should document the education provided to the resident prior to the discharge. -However, there was no documentation that Resident #105 was provided with his medications or any education regarding medications or his discharge prior to his involuntary discharge on 2/20/24.

Based on interviews and record review, the facility failed to ensure that two (#155 and #25) of two residents reviewed for abuse out of 31 sample residents were kept free from physical abuse. Resident #38 had a known history of physically aggressive behaviors towards others. Nursing progress notes documented the resident had a tendency to throw food, drinks, plates and cups in the dining room. On 3/22/24, the facility initiated behavior monitoring of Resident #38's physically aggressive behavior, including biting and scratching, during activities of daily living (ADL) and refusal of care. However, staff did not consistently document the behavior monitoring. Additionally, the facility failed to identify specific person-centered interventions to address Resident #38's physically aggressive behaviors. On 4/9/24, Resident #38 bit her roommate, Resident #155, on the finger after Resident #155 touched Resident #38's puzzle book. Resident #155 sustained a wound on her left finger which required wound care, a tetanus vaccination and antibiotics. Following the 4/9/24 incident, the facility failed to identify and implement interventions to prevent Resident #38 from biting other residents. Due to the facility's failure to implement person-centered interventions to prevent further episodes of biting, Resident #38 bit Resident #25 on 7/8/24. Findings include: I. Facility policy and procedure The Identifying Types of Abuse policy and procedure, last reviewed September 2022, was provided by the nursing home administrator (NHA) on 7/10/24 at 4:01 p.m. It revealed in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse toward a resident can occur as resident to resident abuse, staff to resident abuse, or visitor to resident abuse. Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. II. Facility investigation of abuse between Resident #38 and Resident #155 on 4/9/24 The 4/9/24 abuse investigation documented an unwitnessed resident to resident altercation between Resident #38 and Resident #155. It indicated that Resident #155 was in her room and started screaming that her roommate, Resident #38, had bitten her on the finger. A certified nurse aide (CNA) entered the room and removed Resident #155 from the room and Resident #155 told her that Resident #38 had bitten her after she (Resident #155) had touched Resident #38's puzzle book. The on duty nurse and the director of nursing (DON) were notified. A skin assessment was performed and a skin tear of 1 centimeter (cm) by 2.5 cm was observed. The provider was notified and orders for wound care, tetanus vaccination and antibiotics were received. -However, the facility failed to substantiate or unsubstantiate the allegation of physical abuse in the conclusion of the internal investigation. III. Resident #38 A. Resident status (assailant) Resident #38, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician order (CPO), diagnosis included dementia with behavioral disturbance and cognitive communication deficit. The 4/18/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 12 out of 15. She required substantial/maximal assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The assessment indicated the resident exhibited physical behaviors towards others. B. Record review The behavioral care plan, initiated 2/21/24 and revised on 5/29/24, indicated Resident #38 exhibited physically aggressive behaviors towards staff and had a history of physical abuse by her husband. It indicated she did not like male caregivers. It indicated on 4/9/24 she bit a roommate's finger with injury and on 7/8/24 bit another resident's hand without injury. The interventions included two persons for all cares, analyzing times of day, places, circumstances, triggers and what deescalates behavior and documenting, assessing and anticipating the resident's needs and providing physical and verbal cues to alleviate anxiety. -An intervention of attempting to position Resident #38 out of reach of other residents unless supervised, was added on 7/10/24 (following a second incident of biting another resident). The cognition care plan, initiated 1/15/24, indicated Resident #38 was alert and only oriented to self and family consistently and chose when she wanted to speak to others. Interventions included staff meeting and anticipating the resident's needs. The activities care plan, initiated 2/7/24 and revised 5/29/24, indicated Resident #38 was dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits and behaviors. Interventions included staff to converse with the resident while providing care, encouraging family involvement, providing the resident with an activities calender and providing the resident with assistance to activity functions. -A review of Resident #38's comprehensive care plan did not reveal effective personalized communication interventions when she was unable to communicate an unmet need. It did not reveal effective personalized behavioral interventions for identification or prevention of triggers for the resident's aggressive behaviors towards other residents. -The comprehensive care plan did not reveal any additional interventions added until 7/10/24, after a second incident occurred of Resident #38 biting another resident. The facility initiated daily behavior monitoring of resident's aggressive behaviors, including biting and scratching, during activities of daily living (ADL) and refusals of care on 3/22/24. -However, a review of Resident #38's electronic medical record (EMR) did not reveal routine behavior monitoring towards other residents or documentation of frequent behavior monitoring after incidents of resident to resident aggressive behaviors. A 3/11/24 nursing progress note documented Resident #38 threw her food, juice and water on the floor in her room when she was served her dinner. -There were no interventions implemented to address the resident's behaviors (see care plan review above). A 3/15/24 nursing progress note documented Resident #38 was throwing her cup and plates on the floor in the dining room and was taken back to her room to avoid hurting other residents or caregivers. -There were no interventions implemented to address the resident's behaviors (see care plan review above). A 4/9/24 nursing progress note documented Resident #38 had an altercation with Resident #155, her roommate, and bit her left index finger over word search books and personal space and inflicted a wound. Resident #38 was moved to another room. -There were no interventions implemented to address the resident's behaviors (see care plan review above). A 4/10/24 nursing progress note documented Resident #38 was being monitored related to an altercation with Resident #155 and was not cooperating with staff. Resident #38 was taken to the dining area and was not cooperative. She was then taken to her room and moved to her bed when she scratched a certified nurse aide (CNA). A 7/8/24 nursing progress note documented Resident #38 was witnessed by a staff member biting another Resident #25 on the hand in the television room. Resident #25 was assessed, did not sustain an injury, did not have any pain and was unable to remember the incident. -A review of Resident #38's EMR did not reveal documentation of an interdisciplinary team (IDT) note with a root cause analysis or further interventions identified to prevent behaviors immediately after the 4/9/24 or the 7/8/24 incidents. -An intervention of attempting to position Resident #38 out of reach of other residents, unless supervised, was added following the 7/8/24 incident, however, the intervention was not added until two days after the incident. IV. Resident #155 (victim) A. Resident status Resident #155, age 85, was admitted on [DATE] and discharged to the hospital on 4/16/24. According to the April 2024 CPO, diagnoses included end stage renal disease (ESRD) and hypertension. The 3/29/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She was dependent with transfers, required substantial/maximal assistance with personal hygiene and required partial/moderate assistance with toileting and bed mobility. B. Record review The abuse care plan, initiated 4/12/24, indicated Resident #155 was at risk for being abused related to a dementia diagnosis. Interventions included administering medications, analyzing circumstances and triggers and what deescalated behavior, providing physical and verbal cues to alleviate anxiety, giving the resident choices about care and activities, monitoring any signs of resident posing danger to self and others, removing the resident from harm's way providing a safe environment and intervening when the resident was agitated before escalation and guiding away from sources of distress. The skin impairment care plan, initiated 1/10/24 and revised 4/12/24, indicated Resident #155 had skin integrity impairment related to a bite received from another resident. Interventions included avoiding scratching and keeping hands and body parts from excessive moisture, keeping fingernails short, encouraging nutrition and hydration, following up with facility protocols for treatment of injury, monitoring for side effects of antibiotics, monitoring treatment and documenting location of injury, obtaining blood work of any open wounds as ordered by physician. -A review of Resident #155's comprehensive care plan did not reveal personalized interventions to prevent further abuse from aggression by other residents. The 4/9/24 nursing progress notes documented Resident #155 hollered for help and the CNA alerted the nurse about Resident #155's left index finger which had a skin tear with some blood. The resident was grimacing in pain. The assessment documented the resident had a skin tear of 1 centimeter (cm) by 2.5 cm. An order was received for wound care and to administer tetanus vaccine and Augmentin (an antibiotic). It documented Resident #155 was bitten by her roomate after an altercation over word search books and personal space. The 4/10/24 nursing progress note documented an order for an x-ray to the left index finger and the x-ray result was negative for fracture or dislocation. V. Resident #25 (victim) A. Resident status Resident #25, age greater than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included anxiety and encephalopathy. The 5/28/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of two out of 15. She was dependent with personal hygiene, transfers, required substantial/maximal assistance with toileting, bed mobility and required supervision with eating. B. Record review The skin integrity care plan, initiated 11/10/22 and revised 6/10/24, indicated Resident #25 was bitten on the right hand by another resident on 7/8/24. Interventions included observing the resident's right hand for bruising for 72 hours. -A review of Resident #25's comprehensive care plan did not reveal an abuse care plan or personalized interventions to prevent abuse by other residents after Resident #38 bit Resident #25 on 7/8/24. The 7/8/24 nursing progress note documented Resident #25 was in the television room when a CNA observed Resident #38 biting Resident #25. Resident #25 denied pain or discomfort. Resident #25's right posterior hand was assessed and the skin was observed intact without redness VI. Staff interviews CNA #1 was interviewed on 7/15/24 at 10:25 a.m. CNA #1 said Resident #38 had a history of fighting and biting staff and other residents. She said she observed the 7/8/24 interaction of Resident #38 biting Resident #25's hand. She said Resident #38 reached out for Resident #25's arm and bit her. She said she reported it to the on duty nurse and obtained vital signs on the victim. She said the victim was assessed, had no injury and did not recall the incident. She said a report was filled out and submitted to the DON. She said staff separated the two residents. She said after the incident occurred, staff monitored Resident #38 but she said staff were not given a set frequency of how often to check on the resident. She said staff did not fill out a frequent 15 minute check form for the resident. She said the interventions staff would try with Resident #38 were redirection, separating her from other residents and giving her plenty of personal space. She said staff would also try other activities such as coloring books. She said interventions and special requirements for residents were communicated in the change of shift report. She said she was not sure where to get further pertinent information regarding interventions for residents and would get further guidance. Licensed practical nurse (LPN) #2 was interviewed on 7/15/24 at 10:30 a.m. LPN #2 said Resident #38 was known to refuse medications and care. She said she knew Resident #38 had a history of behaviors which included fighting and biting. She said she had not personally seen those behaviors. She said she knew in the past Resident #38 had to have a sitter but she did not have one anymore. She said if Resident #38 exhibited behaviors towards other residents, staff would separate the residents, redirect, diffuse the situation and provide distractions. LPN #2 said staff would report instances of abuse to the DON, obtain vital signs and assess the victim. She said staff would monitor both the assailant and the victim. She said staff would check on the residents involved in the abuse incident every five minutes but this was not documented. She said staff had a frequent 15-minute check sheet where they could document frequent monitoring but she did not know if this was part of the residents' permanent record. She said any pertinent information regarding behaviors would be documented on the care plan. CNA #1 was interviewed again on 7/15/24 at 11:00 a.m. CNA #1 said pertinent information regarding resident behaviors and safety interventions was found on the Kardex (a tool utilized to provide consistent care to residents),which was populated from the care plan. The DON and the NHA were interviewed together on 7/15/24 at 12:15 p.m. The NHA said she was the abuse coordinator. The DON said when an incident of alleged physical abuse occurred, to ensure safety, the residents were removed from the situation. She said the nurse on duty would notify the DON and NHA and notify the physician and family or legal decision maker. The DON said the root cause analysis and interventions that were put into place depended on the outcome of the investigation, after staff and resident witness interviews were conducted. She said instances of alleged abuse were discussed in the morning meetings, which included the DON, the NHA and the social services director (SSD). She said these meetings were not documented in the medical record, she said all risk management documentation was included in the incident report. The DON said new interventions that were identified were documented in the alert nurse charting and updated in the care plan. The DON said she was not at the facility at the time of the 4/9/24 incident and could not speak to what was done after that incident. She said however, she was at the facility for the 7/8/24 incident and frequent monitoring was not conducted due to the victim did not have an injury and did not recall the incident. She said the new intervention identified after the 7/8/24 incident was to keep Resident #38 out of arm's reach of other residents unless supervised. She said frequent monitoring sheets were part of the residents' permanent medical record. The DON said she was not aware if Resident #38 had one on one caregivers in the past, but a family member was with her every day. She said she was aware Resident #38 liked puzzles in her room but did not think she was open to doing any other activities. She said there were currently ongoing conversations and education with facility staff about personalizing interventions in care plans. She said since there was a history of behaviors there needed to be a care conference set up with Resident 38's family and her care plan needed to be updated with personalized behavior interventions.

Based on record review and interviews, the facility failed to ensure in-service training for certified nurse aides (CNA) consisted of annual training for dementia management and/or annual abuse training for three out of three CNAs reviewed. Specifically, the facility failed to: -Ensure a system was in place to track the CNAs training to ensure they met the annual training requirements; -Ensure CNA #1 and CNA #3 received the required 12 hours of training per year; and, -Ensure CNA #2 received abuse and dementia training upon hire. Findings include: I. Facility policy and procedure The In-Service Training, Nurse Aide policy and procedure, dated August 2022, was provided by the nursing home administrator (NHA) on 7/17/23 at 12:13 p.m. It read in pertinent part, All nurse aide personnel participate in regular in-service education. Annual in-services: are no less than 12 hours per employment year; include training in dementia management and resident abuse prevention. Nurse aide participation in training is documented by the staff development coordinator, or his or her designee and includes: the date and time of the training; the topic of the training; the method used for training; a summary of the competency assessment; and the hours of training completed. II. Record review A review of the CNA training records was completed on 7/16/24 at 12:48 p.m. -CNA #1 was hired on 7/4/08. The training records revealed the hours of training in the previous calendar year were not documented. -CNA #2 was hired on 6/3/24. Her training records did not reveal she had received abuse or dementia training upon hire. -CNA #3 was hired on 7/1/21. The training records revealed the hours of training in the previous calendar year were not documented. III. Staff interviews The director of nursing (DON) was interviewed on 7/16/24 at 12:55 p.m. The DON said they did not have a staff development coordinator (SDC) but she and the assistant director of nursing (ADON) had been handling those tasks. The DON said she started working in the facility in May 2024 and the ADON was also new. The DON said she planned to have a skills fair so that she could complete a lot of staff training. The DON said she wanted to be sure the CNAs had the 12 hours of required minimum training. The DON said she had not implemented a record keeping system yet, but she would implement a spreadsheet and every staff member would be added to keep track of the hours. The DON said the CNAs needed to complete certain training at hire such as dementia and abuse training before working with the residents. The DON said she was going to complete an audit of the staff so she would know which employees needed training.

Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to effectively implement and reassess their pest control program. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, revised July 2019, retrieved on 7/18/24 from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, Cockroaches, flies, and mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility, especially any areas where immunosuppressed patients are located. From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: -Eliminating food sources, indoor habitats, and other conditions that attract pests; -Excluding pests from entering the indoor environments; and, -Applying pesticides as needed. Rodents can transmit viruses such as Lymphocytic choriomeningitis, bacteria such as Campylobacteriosis, Leptospirosis, Plague, Salmonellosis, Tularemia, Yersiniosis, and fungi such as Dermatophytosis. II. Facility policy and procedure The Pest Control policy, revised May 2008, was received from the nursing home administrator (NHA) on 7/16/24 at 11:45 a.m. It read in pertinent part, This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Maintenance services assist, when appropriate and necessary, in providing pest control services. III. Observations On 7/10/24 at 10:26 a.m. several house flies and gnats were observed flying in the main hallway near the common area. On 7/15/24 at 8:15 a.m. small gnats/flies were flying around the medication cart while medications were being administered in the memory care unit. On 7/15/24 at 12:21 p.m. a glue trap was observed under the resident snack refrigerator in the main wing of the facility. Several cockroaches were stuck to the trap, along with a cockroach egg sac and its hatchlings. On 7/16/24 at 10:04 a.m. the same glue trap was observed under the resident snack refrigerator in the main wing of the facility. Several cockroaches were stuck to the trap, along with a cockroach egg sac and its hatchlings. At 12:14 p.m. daylight was visible at the bottom of the fire exit door near room [ROOM NUMBER]. Daylight was visible in a gap between the main entrance doors. Daylight was visible at the bottom of the door leading to the courtyard from the living area/activities room. Several house flies were observed flying around the main hallway outside of the resident rooms. IV. Resident group interview Seven residents (#20, #18, #33, #34, #35, #41 and #31) who frequently attended the monthly resident council meetings and were identified as alert and oriented by facility and assessment were interviewed on 7/11/24 at 3:13 p.m. All residents in attendance said they had seen pests in the facility. Residents #31, #33 and #41 said they had seen mice in the facility and a squirrel in the dining room. Residents #31, #33 and #41 said the pests in the facility bothered them. Resident #41 said he had seen mice running around his room. Resident #33 said the insects in the facility were very bad and he thought he was getting bit by them. V. Record review On 7/16/24 at 9:12 a.m. the NHA provided the pest control service records on 7/16/24 at 9:12 a.m. for 1/10/24, 2/15/24, 2/27/24, 3/13/24, 4/10/24, 5/8/24, 6/12/24 and 7/15/24. The invoices revealed the following: On 1/10/24 the kitchen and employee break room were treated for German cockroaches. From February 2024 through May 2024 only the kitchen was treated for German cockroaches. In June 2024 and July 2024 the entire facility underwent treatment for German cockroaches. The entire facility underwent treatments for house mice each month from February 2024 through July 2024. -None of the invoices documented the facility was treated for house flies and/or gnats. The quality improvement plan, dated 6/24/24, was received by the NHA on 7/16/24 at 12:40 p.m. The goal of the plan was to eliminate pest issues and educate staff on deep cleaning. A staff inservice was completed on 6/30/24 regarding deep cleaning schedules and proper deep cleaning procedures. Other tasks were marked as ongoing and included resident and family education, obtaining quotes from other pest control companies, and staff education on cleaning procedures. -The quality improvement plan failed to address the multiple points throughout the facility in which daylight was visible and pests could potentially enter the facility. V. Staff interviews The dietary director (DM) was interviewed on 7/10/24 at 9:18 a.m. The DM said the facility did not have an issue with pests in the kitchen but she said she had found a mouse in the dining room. The NHA and the regional operations consultant (ROC) were interviewed on 7/16/24 at 11:59 a.m. The NHA said a few of the residents at the facility had complained about seeing mice more frequently and the facility had responded by creating a quality improvement plan for the issue. -However, the quality improvement plan failed to address the multiple points throughout the facility in which daylight was visible and pests could potentially enter the facility (see record review above). The NHA said the facility had an increase of pests in the facility the week of 6/24/24 and a regional team came to do a deep cleaning of the facility and train staff on pest control measures. The NHA said the regional team worked with the facility to identify possible entry points for pests and repaired them. -However, there were still multiple points observed throughout the facility in which daylight was visible and pests could potentially enter the facility. The ROC said the facility identified they were falling behind on their deep cleaning schedule. The ROC said the facility's pest control company had traps, glue traps and bait boxes set out along the perimeter and within the facility and the pest control company sprayed pesticide around the perimeter. -However, cockroaches, flies and gnats were observed present in the facility on several occasions during the survey (see observations above). The NHA said the facility was still working on eliminating the roaches but that they had a plan in place. The NHA said they had identified that residents were putting food in their drawers, and the facility had given sealed containers to the residents that often had food brought in by their families for better food storage. Regarding flies, the NHA said the facility identified one room in particular as being an issue due to the resident's family bringing in a great deal of fruit. The NHA said the facility was able to eliminate the fruit flies by working with the resident and their family. The NHA said the issue was not really widespread but was more of a one-off incident. -However, there were several observations throughout the survey of houseflies and gnats flying around residential areas (see observations above). The NHA said the facility was looking into switching pest control companies and she was waiting to hear back from another pest control vendor.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one of two units. Specifically, the facility failed to: -Ensure residents' rooms were cleaned in a sanitary manner; and, -Ensure staff and residents performed hand hygiene during mealtime. Findings include: I. Failure to clean resident rooms in a sanitary manner A. Professional reference The Centers for Disease Control and Prevention (CDC), Environment Cleaning Procedures (5/4/23), was retrieved on 7/18/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Clean patient areas (patient zones) before patient toilets. Proceed from high to low to prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas. B. Manufacturer's recommendations According to the Bright Solutions HP202 #7 (hydrogen peroxide) manufacturer guidelines, reviewed 2024, retrieved on 7/23/24 from https://mybrightsolutions.com/wp-content/uploads/046200BSL_Lit.pdf, For Use as a One Step Cleaner/Disinfectant. Spray 6-8 (six to eight) inches from the surface, making sure to wet surfaces thoroughly. All surfaces must remain visibly wet for 10 minutes. For use as a Virucide. All surfaces must remain visibly wet for 5 (five) minutes. A one minute contact time is required for HIV (human immunodeficiency virus, the virus that causes AIDS), Influenza Virus type A, SARS Coronavirus 2 (the virus that causes COVID-19). C. Facility policy and procedure The Cleaning and Disinfection of Environmental Surfaces policy and procedure, revised August 2019, was provided by the nursing home administrator (NHA) on 7/17/24 at 1:25 p.m. It read in pertinent part, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) standard. D. Observations On 7/16/24 at 10:30 a.m. the maintenance assistant (MA), who helped the housekeeping staff, was observed cleaning room [ROOM NUMBER]. The MA put on gloves. He sprayed the bathroom sink, toilet, rails and soap dispenser with Bright Solutions HP202 #7 and placed the bottle on the floor. He proceeded to wipe the outside of the sink, top of the toilet tank, around the outside of the toilet lid, the toilet seat, underneath the toilet seat (which had visible brown material on it), the top of the toilet bowl and down the side of the toilet bowl. After wiping all of the surfaces, the MA disposed of the rag. Without changing gloves or performing hand hygiene, the MA obtained a new rag from the housekeeping cart and wiped the rails next to the toilet and the rails in the shower. -The MA failed to ensure the surfaces remained visibly wet for the five minute virucidal time and the ten minute total disinfection time specified by the manufacturer's guidelines (see guidelines above). -The MA failed to ensure the bottle of disinfectant/cleaning solution was kept sanitary by keeping it off the floor in the bathroom. -The MA failed to change gloves, perform hand hygiene or obtain a clean rag after cleaning the dirty toilet seat and before cleaning the toilet bowl. -The MA failed to change gloves and perform hand hygiene after cleaning the toilet and before touching clean supplies on the housekeeping cart. The MA proceeded to spray and clean the mirror in the bathroom and again placed the disinfectant bottle on the floor. He sprayed and scrubbed the inside of the toilet bowl with a toilet brush. He returned the supplies back to the housekeeping cart. He then got a new rag and proceeded to clean the top of the television (TV) in the room. -The MA again failed to ensure the bottle of disinfectant/cleaning solution was kept sanitary by keeping it off the floor in the bathroom. -The MA failed to change gloves or perform hand hygiene after cleaning the toilet and touching clean supplies on the housekeeping cart and before cleaning the resident's room. -The MA failed to clean the resident's room before cleaning the bathroom and toilet. The MA obtained a reusable mop head, which was soaking in the disinfectant solution on the housekeeping cart. He started in the bathroom and proceeded into the resident room with the same mop head. -The MA failed to mop the resident's room before mopping the bathroom. E. Staff interviews The MA was interviewed on 7/16/24 at 10:45 a.m. He said rooms should be cleaned from top to bottom and clean to dirty. He said rooms should be cleaned in a methodical manner and in a circular fashion around the room. He said he liked to clean the bathroom first so he could get it out of the way before he cleaned the residents' rooms. He said he should have cleaned the resident's room first before the resident's bathroom. He said he should have changed gloves and performed hand hygiene after touching a dirty area and before touching a clean area. The regional maintenance supervisor (RMS), who oversaw the housekeeping staff, was interviewed on 7/16/24 at 10:50 a.m. The RMS said the residents' rooms should be cleaned before the bathrooms and rooms should always be cleaned from clean areas to dirty areas. He said the mop head should be changed out after cleaning the bathroom. He said hand hygiene should be performed and gloves should be changed after touching something dirty and before touching clean supplies on the housekeeping cart. II. Hand hygiene A. Professional reference The Centers for Disease Control and Prevention (CDC). Clean Hands: About Handwashing 2/16/24), was retrieved on 7/23/24 from https://www.cdc.gov/clean-hands/about/index.html. It read in pertinent part, Many diseases and conditions are spread by not washing hands with soap and clean, running water. If soap and water are not readily available, use a hand sanitizer with at least 60% alcohol to clean your hands. Key times to wash hands: before, during and after preparing food and before and after eating food. B. Observations On 7/10/24 during a continuous observation of the lunch meal, beginning at 11:30 a.m. and ending at 12:30 p.m., the following was observed: Ambulatory and wheelchair bound residents were observed entering the dining room and sitting at tables. -Hand hygiene was not offered to ambulatory or wheelchair bound residents. -Dependent residents were not offered or assisted with hand hygiene before the meal. -Canisters of hand wipes were observed on two tables, however, they were not used by residents before or after the meal. Staff was observed bringing lunch plates on trays from the kitchen to the residents and then returning to the kitchen for another lunch plate. Hand sanitizing dispensers were observed on the wall next to the doors to the kitchen. -Staff did not use the hand sanitizer dispensers upon exiting or entering the kitchen area. On 7/26/24 during a continuous observation of the lunch meal, beginning at 11:30 a.m. and ending at 12:15 p.m., the following was observed: Ambulatory and wheelchair bound residents were observed entering the dining room and sitting at tables. -Hand hygiene was not offered to ambulatory or wheelchair bound residents. -Dependent residents were not offered or assisted with hand hygiene before the meal. -Canisters of hand wipes were observed on two tables, however, they were not used by residents before or after the meal. Staff was observed bringing lunch plates on trays from the kitchen to the residents and then returning to the kitchen for another plate. Hand sanitizing dispensers were observed on the wall next to the doors to the kitchen. -Staff did not use the hand sanitizing dispensers upon exiting or entering the kitchen area. C. Staff interviews The DON and ADON were interviewed together on 7/16/24 at 12:30 p.m. The DON said ambulatory residents should be encouraged to wash their hands before leaving their room and going to the dining room. She said dependent and wheelchair bound residents should be offered hand hygiene when they entered the dining area. She said staff should be performing hand hygiene when serving food to residents in the communal dining area. The DON said education on hand hygiene was done quarterly and as necessary. She said a future skills fair for all staff was planned and hand hygiene was a topic that would be discussed.

Based on observations and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen. Specifically, the facility failed to: -Ensure kitchen staff handled ready-to-eat foods in an appropriate sanitary manner to prevent cross contamination; and, -Ensure safe holding temperatures for food items were maintained. Findings include: I. Inappropriate handling of ready-to-eat foods A. Professional reference The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 7/17/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. B. Facility policy The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, revised November 2022, was provided by the nursing home administrator (NHA) on 7/16/24 at 11:45 a.m. It read in pertinent part, Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed and gloves are replaced between handling soiled and clean dishes. Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper, and spatulas as tools to prevent foodborne illness. C. Observations On 6/25/24 the lunch meal service was observed during a continuous observation, beginning at 10:30 a.m. and ending at 12:10 p.m. The following was observed: At 11:16 a.m. cook (CK) #1 began preparing a side salad for dinner service. CK #1 donned (put on) a pair of gloves and tore open the plastic packaging using both hands for a bag of lettuce. -CK #1 did not change his gloves after touching the outside of the lettuce bag. -CK #1 chopped the lettuce and used the knife to scoop the lettuce into his gloved hand using the same pair of gloves before placing it into a metal bin. CK #1 grabbed a cucumber and diced it, then used the knife to scoop into his gloved hand using the same pair of gloves before placing it into the metal bin. -Using the same gloves, CK #1 touched the outside of a bag of shredded cabbage, ripped the bag open, reached in and grabbed a handful of cabbage, then sprinkled it on top of the salad mixture in the metal bin. -At several points during the lunch service, dietary aide (DA) #1's name tag and apron strings rested on top of and dragged across the surface of the plates that were then used to serve lunch to the residents while DA #1 was reaching over the steam table to scoop food out. D. Staff interview The dietary manager (DM) was interviewed on 7/15/24 at 12:40 p.m. The DM said ready-to-eat foods should be handled with gloves. The DM said dietary staff should wash their hands before putting gloves on and only handle one ready-to-eat food at a time. The DM said dietary staff should change their gloves in between handling packaging and handling ready-to-eat foods. CK #1 was interviewed on 7/16/24 at 1:00 p.m. CK #1 said he had been told he was supposed to change gloves after touching the salad bag and before touching the salad. CK #1 said he did not know he was supposed to do that. II. Maintain safe holding temperatures for food items A. Professional reference The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 7/17/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Stored frozen foods shall be maintained frozen. Time/temperature control for safe food cold holding shall be maintained at 5 (five) degrees Celsius (C) (41 degrees Fahrenheit) or less. According to the product guidelines for MedPass Fortified Nutritional Shake, retrieved on 7/17/24 from https://www.hormelhealthlabs.com/resources/for-healthcare-professionals/product-protocols/med-pass-fortified-nutritional-shake-medication-pass-program/, MedPass products can safely remain on a medication cart as long as it is kept at refrigerated temperature range 34 to 40 degrees Fahrenheit (F). Cover, label and refrigerate opened containers of MedPass products and discard after four days as long as the product has been kept at the proper refrigerated temperature range. B. Facility policy The Food Receiving and Storage policy, revised November 2022, was provided by the NHA on 7/16/24 at 11:45 a.m. It read in pertinent part, Frozen foods are maintained at a temperature to keep the food frozen solid. All food items to be kept at or below 41 degrees Fahrenheit (F) are placed in the refrigerator located at the nurses'station and labeled with a'use by'date. C. Observations On 7/10/24 at 9:18 a.m. an initial tour of the kitchen was conducted. The following was found in the main kitchen walk-in refrigerator: -An opened bag of vegetarian chorizo crumbles was found in the walk-in refrigerator. The refrigerator temperature was 40 degrees F. -On the vegetarian chorizo crumble bag, there were instructions indicating to keep the product frozen until time of use. At 12:09 p.m. two cartons of MedPass Shake were on a nurse's medication cart in a plastic bin without a lid. The plastic bin had ice in it that reached approximately one-quarter to one-third the height of the MedPass Shake bottle. On 7/15/24 at 10:25 a.m. a carton of MedPass Shake was on a nurse's medication cart in a plastic bin without a lid. The plastic bin had mostly melted ice and water in it that reached approximately 1.5 inches up the MedPass Shake carton. At 12:50 p.m. on the medication cart there was a container of MedPass nutritional supplement that measured 58 degrees F. The carton of MedPass Shake was on a nurse's medication cart in a plastic bin without a lid. The plastic bin had fresh ice in it that reached approximately one-quarter to one-third the height of the MedPass Shake carton. -The temperature of this nutritional supplement was above the safe temperature parameter for cold foods of 41 degrees F or less. E. Staff interviews The DM was interviewed on 7/10/24 at 9:28 a.m. The DM said the chorizo crumbles could be kept refrigerated. The DM said she read the bag and it indicated to keep the product frozen. The DM said she would throw the product away because it had not been used in a while. The DM was interviewed again on 7/15/24 at 12:40 p.m. The DM said the ideal holding temperatures for cold food items was below 40 degrees F. The DM said the dietary department supplied the MedPass Shakes but did not prepare or maintain the supply on the nurses'carts.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of two certified nurse aides (CNA). Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for CNA #1 and CNA #3. Findings include: I. Facility policy and procedure The In-Service Training, Nurse Aide policy and procedure, dated August 2022, was provided by the nursing home administrator (NHA) on 7/17/24 at 12:13 p.m. It read in pertinent part, The facility completes a performance review of nurse aides at least every 12 months. In-service training is based on the outcome of the annual performance reviews. II. Record review Annual performance reviews were requested on 7/15/24 at 8:12 a.m. for CNA #1 and CNA #3. The facility was unable to provide annual performance evaluations for 2023/2024 for CNA #1 (hired on 7/4/08) and CNA #3 (hired on 7/1/21). The CNA's did not have an annual performance review completed and the CNAs did not have an in-service education plan based on the outcome of the review. III. Staff interviews The director of nursing (DON) was interviewed on 7/16/24 at 12:55 p.m. The DON said the performance evaluations needed to be done. The DON said she was unsure why the annual performance evaluations had not been completed as she was new to the facility. The DON said she believed the competency assessments and performance reviews needed to be done on an annual basis. The DON said she would perform an audit to determine which employees needed a performance review.

Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#27) of two residents reviewed for hospice services out of 31 sample residents. Specifically, the facility failed to maintain written communication records with the hospice providers for Resident #27. Findings include: I. Facility policy The Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 7/17/24 at 12:11 p.m. It read in pertinent part, Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents. II. Resident #27 A. Resident status Resident #27, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included cerebrovascular disease, dementia, and hypertension. The 4/30/24 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. He required substantial to maximal assistance with almost all activities of daily living. The assessment documented the resident was receiving hospice services. B. Record review The 4/16/24 care plan, revised 5/17/24, revealed Resident #27 was receiving hospice services care due to senile degeneration of the brain. Pertinent interventions included checking with Resident #27 to see if he wanted clergy visits, hospice care to be provided by the hospice agency of the resident's choice and having social services provide support to the resident as needed. The July 2024 CPO revealed a physician's order from 4/18/24 that documented Resident #27 had been admitted to hospice services. An additional physician's order dated 4/19/24 revealed the hospice certified nurse aide (CNA) would offer showers to Resident #27. Resident #27's hospice binder was reviewed on 7/15/24 at 1:08 p.m. The hospice binder contained communication notes from the hospice CNA and hospice providers. -There were no hospice communication notes in Resident #27's hospice binder between the dates of 4/22/24 and 7/15/24. -Resident #27's electronic medical record (EMR) did not reveal any documentation of communication from the hospice staff regarding the care they had provided to the resident. C. Staff interviews The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 7/16/24 at 10:07 a.m. The DON said the contracted hospice provider would come to the facility to perform an evaluation and create an initial care plan for the resident so the facility could coordinate care with the hospice provider. The DON said any hospice CNA services would be coordinated with the facility. The DON said hospice communication records were kept in a binder at the nurses' station, and might also be in Resident #27's EMR. -However, there were no hospice communication records in Resident #27's EMR (see record review above). The DON said the hospice CNAs came to the facility twice a week, filled out a shower sheet, and provided the shower sheet to the facility nurse. The DON said the hospice binder was where the hospice providers documented the services they provided and the facility nurses should check the binders routinely. When reviewing Resident #27's hospice binder, the DON said the documentation included in the binder was not what she expected to see. The DON said the most recent communication in the binder was from 4/22/24. The DON said the facility had previously used communication sheets to have the hospice providers document what was done at each visit. The ADON said the most recent documentation from the hospice provider she could find was an updated hospice care plan dated 5/10/24. The DON said the care plan was an overview of any changes made by the hospice provider to Resident #27's ongoing care. She said the hospice care plan did not include information regarding what care was being provided for Resident #27 at each visit by the hospice providers.

Based on observations, record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (#7) of one resident out of 31 sample residents. Specifically, the facility failed to ensure Resident #7's medical record was consistently accurate regarding the pressure injury to the resident's left heel. Findings include: I. Resident #7 A. Resident status Resident #7, age 66, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included traumatic brain injury, muscle weakness, muscle wasting and atrophy, and type 2 diabetes. The 5/17/24 minimum data set (MDS) assessment revealed Resident #7 was significantly cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. Resident #7 was dependent on staff for all care, hygiene and mobility. The assessment indicated Resident #7 was at risk of developing pressure ulcers/injuries and that the resident did not reject care. B. Observations On 7/15/24 at 1:45 p.m. Resident #7's left heel wound was observed with the assistant director of nursing (ADON). When Resident #7's pressure relieving boot and dressing were removed, a small open area, which was approximately 0.5 centimeters (cm) in diameter, was observed. The old dressing contained moderate serosanguinous (wound discharge that contains both blood and blood serum which is light pink to red in color) drainage. The wound bed was difficult to visualize due to the slough (creamy or yellow-white dead tissue) in the wound bed. C. Record review The June 2024 CPO revealed the following physician's orders: Right heel wound: apply iodine and leave open to air daily and as needed, ordered 6/26/24 and discontinued 6/28/24. -The physician's order documented the wound care was to be provided to Resident #7's right heel, however, the wound was on the resident's left heel (see wound observation above and 7/16/24 wound physician (WP) note below). Left heel wound: apply iodine and leave open to air daily and as needed, ordered 6/29/24 and discontinued 7/2/24. The July 2024 CPO revealed the following physician's orders: Right heel wound: clean wound with wound cleanser, pat dry, apply medihoney alginate to wound bed and cover with bordered gauze daily and as needed, ordered 7/10/24 and discontinued 7/11/24. -The physician's order documented the wound care was to be provided to Resident #7's right heel, however, the wound was on the resident's left heel (see wound observation above and 7/16/24 WP note below). Right heel wound: clean wound with wound cleanser, pat dry, apply medihoney alginate to wound be, and cover with bordered gauze daily and as needed, ordered 7/9/24 and discontinued 7/11/24. -The physician's order documented the wound care was to be provided to Resident #7's right heel, however, the wound was on the resident's left heel (see wound observation above and 7/16/24 WP note below). Left heel wound: clean wound with wound cleanser, pat dry, apply medihoney alginate to wound bed and cover with bordered gauze daily and as needed, ordered 7/11/24. The 6/11/24 weekly skin assessment revealed Resident #7 had a pressure injury to the left heel. The 6/18/24 weekly wound assessment revealed Resident #7 had a facility-acquired pressure/deep tissue injury on the right heel. Preventative measures that were in place included offloading, elevation, air mattress, and pressure-relieving boots. The wound was entirely epithelial tissue and measured 6.9 cm long by 4.4 cm wide. Treatment included iodine soaked gauze and kerlix daily and as needed. -The wound assessment incorrectly documented the wound was on Resident #7's right heel, however, the wound was on the resident's left heel (see wound observation above and 7/16/24 WP note below). The 6/25/24 weekly wound assessment revealed Resident #7 had a facility-acquired pressure/deep tissue injury on the right heel. The wound was entirely epithelial tissue and measured 6.8 cm long by 3.6 cm wide. The assessment revealed the wound was improving. Treatment course was changed to iodine and being open to air daily and as needed. -The wound assessment incorrectly documented the wound was on Resident #7's right heel, however, the wound was on the resident's left heel (see wound observation above and 7/16/24 WP note below). The 7/2/24 weekly wound assessment revealed Resident #7 had a facility-acquired pressure/deep tissue injury on the right heel. The wound consisted of granulation (new healthy tissue on the surface of a wound) and necrotic tissue (dead tissue). The wound was 40% (percent) slough and 60% eschar (tan, brown or black dry, dead tissue in a wound) and measured 6.7 cm long by 3.5 cm wide and 0.1 cm deep. The assessment revealed the wound was improving. The wound was debrided (removal of damaged tissue ) to the subcutaneous tissue (deepest layer of skin), and the treatment course was changed to medihoney, gauze pad and kerlix daily and as needed. -The wound assessment incorrectly documented the wound was on Resident #7's right heel, however, the wound was on the resident's left heel (see wound observation above and 7/16/24 WP note below). The 7/9/24 weekly wound assessment revealed Resident #7 had a facility-acquired pressure/deep tissue injury on the left heel. The wound consisted of granulation, slough, and necrotic tissue. The wound was 40% slough, 30% granulation, and 30% eschar and measured 5.6 cm long by 3.4 cm wide and 0.1 cm deep. The assessment revealed the wound was improving. The wound was debrided to the subcutaneous tissue, and the treatment course was changed to honey alginate, gauze, and dry dressing daily and as needed. A 7/16/24 wound care assessment revealed a note from the wound physician (WP) that the left heel wound was an unavoidable injury. The note revealed Resident #7 was very non-adherent with proper offloading and dressing changes and frequently refused care from nursing staff. The WP documented Resident #7 developed the wound despite proper measures taken by the facility staff. E. Staff interviews The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 7/16/24 at 10:24 a.m. The ADON said the facility found the left heel wound while assessing Resident #7's buttock wounds. The ADON said Resident #7's wound prevention interventions included pressure-relieving boots, an air mattress, and repositioning in bed. The WP was interviewed on 7/16/24 at 11:14 a.m. The WP said Resident #7 needed help transferring and was incontinent, and had issues due to lack of mobility that resulted in skin breakdown. The WP said Resident #7 had a pressure wound on his right heel. The WP said the pressure injury for Resident #7 was unavoidable, as the facility used reasonable measures to try to avoid it. -During the interview, the WP incorrectly described the wound as being on Resident #7's right heel when it was on the resident's left heel (see wound observation and 7/16/24 WP note above.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent. Specifically, the facility's medication error rate was 7.14%, or two errors out of 28 opportunities for error. Findings include: I. Professional reference According to [NAME], A., [NAME], L. M. (9/14/23). Nursing Rights of Medication Administration. Stat Pearls. National Library of Medicine. retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/ on 7/22/24 at 4:16 p.m., Right time: administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. Right dose: incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. II. Facility policy and procedure The Administering Medications policy and procedure, revised April 2019, was provided by the nursing home administrator (NHA) on 7/16/24 at 11:45 a.m. It read in pertinent part, Medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. III. Medication administration to Resident #52 On 7/15/24 at 7:39 a.m. licensed practical nurse (LPN) #2 checked Resident #52's order for Empaglifozin (a medication used for glucose control in diabetes) ten milligrams (mg) one tablet by mouth once a day for diabetes mellitus. LPN #2 looked through Resident #52's medication cards and was unable to find the medication. LPN #2 proceeded to administer Resident #52's other morning medications. -LPN #2 did not administer the Empagliflozin to Resident #52. IV. Medication administration to Resident #33 On 7/15/24 at 8:10 a.m. LPN #1 checked Resident #33's order for Sinemet 25/250 mg one tablet once a day for tremors in Parkinson's disease. She looked through Resident #33's medication cards and was unable to find the Sinemet 25/250 mg card. LPN #1 proceeded to administer Resident #33's other morning medications. -LPN #1 did not administer the Sinemet 25/250 mg to Resident #33. V. Staff interviews LPN #2 was interviewed on 7/15/24 at 7:40 a.m. LPN #2 said Resident #52's Empagliflozin had been ordered but it had not been received. She said she would check again with the pharmacy to find out when it would be delivered. She said when medications were not available for administration, the provider should be notified and it should be documented on the medication administration record (MAR) and the progress notes why the medication could not be administered. LPN #1 was interviewed on 7/15/24 at 8:12 a.m. She said an order had been placed two days prior (7/13/24) for Resident #33's Sinemet 25/250 mg but the medication had not been received and was unavailable for administration. She said the physician needed to be notified and the reason why the medication was not given should be documented. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 716/24 at 12:30 p.m. The DON said residents'medications needed to be reordered from the pharmacy eight days before the medication was to run out. She said it was the nurses responsibility every shift to make sure medications were ordered timely so they did not run out. She said the pharmacy was only dispensing a three day supply of Resident #52's Empagliflozin because his insurance was only allowing a three day supply at a time. She said the facility was working with the provider to change the resident to another medication so that the facility did not run out of the medication. The DON said Resident #33's Sinemet 25/250 mg was not reordered in a timely manner because the nursing staff did not pull the old card out of the medication cart to get it reordered. The ADON said the facility obtained a physician's order for a one time dose of Sinemet 25/100 mg for the morning to cover until the facility received the resident's correct dose of Sinemet 25/250 mg.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for services that were to be provided in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for one (#19) of two residents reviewed for care planning out of 31 sample residents. Specifically, the facility failed to identify and implement an appropriate care plan in a timely manner for Resident #19's exit seeking behaviors. Findings include: I. Facility policy and procedure The Wandering and Elopement policy, revised March 2019, was provided by the nursing home administrator (NHA) on 7/16/24 at 11:45 a.m. It read in pertinent part, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. II. Resident #19 A. Resident status Resident #19, age less than 65, was admitted to the facility on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included dementia and schizophrenia (mental illness that affects a person's mood and behavior). The 4/30/24 minimum data assessment (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required supervision and touching assistance with all activities of daily living. B. Record review A progress note dated 5/19/24 revealed Resident #19 was found with many stolen items, some of which belonged to a woman in the apartment complex next-door to the facility. A physician's note, dated 6/4/24, revealed Resident #19 was interested in leaving the facility and did not want to come back. Resident #19 was sent to the emergency room for further medical and mental health workups. A progress note, dated 6/12/24, revealed Resident #19 was crying, upset and said he wanted to leave. A progress note, dated 6/15/24, revealed Resident #19 shoved a staff member aside while a visitor was entering the facility and walked outside. A certified nurse aide (CNA) attempted to stop Resident #19. The CNA was unable to stop the resident from leaving the facility. The note documented two people nearby, a CNA and the assistant director of nursing (ADON) attempted to redirect the resident back to the facility. Resident #19 was combative with those trying to redirect him and refused to go back into the facility. The paramedics were called to the facility and transported Resident #19 to the hospital for an evaluation. Fifteen minute checks were initiated for Resident #19 upon his return to the facility. A progress note, dated 6/18/24, revealed the interdisciplinary team (IDT) reviewed Resident #19 and found that his elopement attempts had decreased. Resident #19's fifteen minute checks were discontinued during this meeting. A progress note, dated 6/19/24 at 2:48 p.m., revealed Resident #19 followed a visitor out of the facility. Resident #19 made multiple attempts to leave the facility premises but was prevented from doing so by facility staff members. A registered nurse (RN), the nursing home administrator (NHA) and the social services director (SSD) were able to redirect Resident #19 back into the building with significant difficulty. Fifteen minute checks were restarted by nursing staff for Resident #19. A progress note, dated 6/19/24 at 4:47 p.m., revealed Resident #19 was walking in and out of the facility courtyard. A progress note, dated 6/19/24 at 11:54 pm., revealed Resident #19 tried to follow a staff member as she left the facility. Resident #19 was redirected back to the common room where he was crying and looking for his father. A progress note dated 6/20/24 at 5:53 a.m. revealed Resident #19 was exit seeking and crying throughout the preceding night, and required redirection multiple times. A progress note, dated 6/20/24 at 1:18 p.m., revealed Resident #19 required frequent redirection away from the facility exits and continued on fifteen minute checks for safety. A progress note, dated 6/27/24 at 7:46 p.m., revealed at 6:10 p.m. that day Resident #19 exited the facility through a fire exit in the dining room. The facility staff followed Resident #19 and attempted to stop him, but Resident #19 ran after a public bus. All available staff were notified and searched the neighborhood for Resident #19 but were unable to find him. The police were called and Resident #19 was reported as a missing at-risk person. A progress note, dated 6/28/24 at 3:56 a.m., revealed at 1:45 a.m. that morning Resident #19 was found by the police and escorted back to the facility. The nursing staff continued fifteen minute checks on Resident #19 before sending the resident to the emergency room for evaluation. A progress note, dated 6/28/24 at 2:42 p.m., revealed a one-to-one caregiver was assigned to Resident #19 due to his high risk for elopement and poor safety awareness. The 6/28/24 care plan, revised 7/4/24, revealed Resident #19 was an elopement risk due to impaired safety awareness, refusal of medications, and prior elopement attempts. Pertinent interventions included distracting Resident #19 from wandering by offering pleasant diversions, assessing the resident's needs (initiated 6/28/24 and revised on 7/4/24), one-to-one monitoring (initiated 6/28/24 and revised on 7/4/24) and identifying a pattern in the resident's wandering (initiated 6/28/24). -The care plan for elopement risk was not implemented until after Resident #19 returned to the facility after his elopement episode on 6/27/24, despite the resident's numerous attempts to elope prior to 6/27/24. The 6/28/24 elopement evaluation revealed Resident #19 was at a high risk for elopement with a score of 21. C. Staff interviews The SSD was interviewed on 7/15/24 at 11:56 a.m. The SSD said the facility staff usually created a care plan within approximately seven days after a concern had been identified. The SSD said Resident #19 kept to himself when he was first admitted , but started to refuse his medications and escalate in his behaviors. The SSD said Resident #19's exit-seeking behaviors started around his second or third week at the facility and worsened over time. The SSD said Resident #19 started waiting by the main entrance and trying to sneak out the door when visitors were coming and going. The SSD said the facility staff had been able to successfully redirect Resident #19 back inside after his elopement attempts. The director of nursing (DON) was interviewed on 7/16/24 at 10:07 a.m. The DON said the nursing staff or the SSD complete elopement evaluations for residents. The DON said Resident #19 would start hanging out near the main entry, at which point the staff knew to keep a close eye on him. The DON said Resident #19 was able to slip out the door one day following behind a staff member, but they were able to redirect him back into the facility by offering to let him make phone calls. The DON said Resident #19 became a missing person after his last elopement, and the facility had since initiated one-on-one monitoring. The DON said Resident #19's exit-seeking behaviors started to amplify on 6/4/24. The DON said Resident #19's care plan for elopement behaviors was not initiated until 6/28/24.

Based on record review and staff interviews, the facility failed to ensure one (#105) of two residents and/or their responsible person and the ombudsman were provided a written discharge notice to include the reasons for the move in a language and manner they would understand out of 31 sample residents. Specifically, the facility failed to provide Resident #105 an appropriate written notice of discharge from the facility that included: -The reason for transfer or discharge; -The effective date of transfer or discharge; -The location to which the resident was transferred or discharged ; -A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal-hearing request; and, -The name, address (mailing and email) and telephone number of the Office of the State. Additionally, the facility failed to provide written notice to the ombudsman of Resident #105's facility-initiated discharge. Findings include: I. Facility policy and procedure The Transfer or Discharge, Facility-Initiated policy and procedure, dated October 2022, was provided by the nursing home administrator (NHA) on 7/11/23 at 5:05 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Facility-Initiated transfer or discharge means a transfer or discharge which the resident objects to, and/or is not in alignment with the resident's stated goals for care and preference. The resident and his or her representative are given a thirty (30)-day advance notice of an impending transfer or discharge from the facility. The resident and representative are notified in writing of the following information: -The specific reason for the transfer or discharge, including the basis; -The effective date of the transfer or discharge; -The specific location to which the resident is being transferred or discharged ; and, -An explanation of the resident's rights to appeal the transfer or discharge to the state, including: -The name, address, email and telephone number of the entity which receives such appeal hearing requests. A copy of the notice is sent to the office of the state long-term care ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. II. Resident #105 A. Resident status Resident #105, age less than 65, was admitted on [DATE] and discharged on [DATE] to a homeless shelter. According to the February 2024 computerized physician orders (CPO), diagnoses included rheumatoid arthritis, anxiety disorder, depression, attention-deficit hyperactivity disorder, and chronic pain. The 2/20/24 discharge 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. He was independent for all functional activities of daily living (ADL). The assessment documented the resident had no behavioral symptoms including physical, verbal, or other and there was no rejection of care. The assessment documented active discharge planning was already occurring for the resident to return to the community and a referral had been made to the local contact agency. -Discharge planning according to the residents goals and preferences was to discharge to an assisted living facility. However the facility suddenly discharged him to a homeless shelter against his wishes (see interviews and record review below). III. Record review -Record review revealed the facility failed to provide a written notice for the facility initiated discharge to Resident #105, to include his appeal rights, and failed to send a written copy of the notice to a representative of the office of the state long-term care ombudsman. -The facility failed to provide a reason for the sudden discharge (cross-reference F622 for transfer and discharge requirements). On 7/11/24 at 3:06 p.m documentation of the discharge notice that was provided to the resident and the written notification of the ombudsman were requested from the facility. -However, the facility failed to provide documentation of the discharge notice and notification to the ombudsman (see interviews below). Review of Resident #105's electronic medical record (EMR) revealed the following progress notes: The 2/20/24 at 3:49 p.m. nurses note revealed at approximately 3:50 p.m. Resident #105 was escorted from the facility accompanied by law enforcement. The resident was cooperative. The 2/20/24 at 4:46 p.m. psychosocial note revealed the resident was presented with multiple options when planning to discharge, however, he refused to comply with any option. The resident was discharged that day (2/20/24) and he refused to leave. The writer met with the resident along with a civilian emergency response team clinicians and the police because of the resident's refusal to leave after being successfully discharged from the facility and the resident was considered to be trespassing. The administrative staff assisted with the process to have the resident transported to a homeless shelter where he would be able to coordinate housing with the shelter's available options. The 2/21/24 at 8:47 a.m. psychosocial note revealed the ombudsman was contacted on 2/20/24 about an emergency discharge of Resident #105 due to the ombudsman being a part of the discharge planning from the beginning. Review of Resident #105's EMR on 7/11/24 at 9:49 a.m. revealed the following: -There was no discharge summary or assessment documentation; -There were no nurses note documentation of appropriate orientation and preparation of the resident prior to transfer or discharge; -There was no reason for the discharge documented in the record; and, -There was no written discharge notice documentation. IV. Staff interviews The social services director (SSD) was interviewed on 7/11/24 at 3:06 p.m. The SSD said he did not issue a written facility-initiated discharge notice to Resident #105 or the ombudsman. The NHA and the regional operations consultant (ROC) were interviewed together on 7/15/24 at 8:46 a.m. The NHA and the ROC said the facility did not issue a facility-initiated discharge notice to Resident #105 or provide written notice to the ombudsman. The NHA and the ROC said they did not know the reason why the facility discharged the resident or why the facility had not issued a 30-day discharge notice.

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to have the state contact information posted in a readable font size and placed in an area that had ease of access for the residents. Findings include: I. Resident council interview Seven residents (#20, #18, #33, #34, #35, #41 and #31) who frequently attended the monthly resident council meetings and were identified as alert and oriented by facility and assessment were interviewed on 7/11/24 at 3:13 p.m. The residents said they did not know how to file a complaint with the State Agency. II. Observations -Observations on 7/15/24 at 8:47 a.m. and at 2:57 p.m. did not reveal the required postings throughout the facility. III. Staff interviews The social services director (SSD) and nursing home administrator (NHA) were interviewed together on 7/15/24 at 1:58 p.m. The SSD and NHA said they were unable to locate the contact information for the State Agency and nursing home advocacy groups anywhere in the facility. The NHA said she was sure that the posting was hanging up earlier in the day, but could not locate it. The SSD and the NHA were interviewed again on 7/15/24 at 2:04 p.m. The NHA and SSD said they had found a poster on the bulletin board in the common area that had only the information for the facility's corporate contact information. The NHA said she had found another required posting in the administration office that included the information for the State Agency and police department contact information on her bulletin board in her office. -The State Agency posting was not accessible for the residents.

Based on observations, interviews and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to have a qualified activities director. Findings include: I. Facility procedure The Activity Director Job Description, not dated, was provided by the nursing home administrator (NHA) on 11/30/23 at 3:40 p.m. It revealed in pertinent part: Job Description: Activities Director Supervisor: Administrator General Description: Plans, coordinates and directs the resident's activity program. Record in the resident's records, necessary documentation regarding activities assessments. Serves on the following committees; infection control, resident care planning, safety disaster and resident care policies. Qualifications: Qualification in basic education course for activity professionals. Working Conditions: Interacting with the general public, often in adverse conditions; many residents and their families are under emotional stress dealing with issues of illness, hospice, death, and grief. Activities: Organize a program of both group and individual activities based on individual resident needs (that) are identified in each resident's care plan. Maintain a balance of recreational activities including physical, social, religious, intellectual, and creative and crafts. Ensure that group activities are scheduled at a time that would provide maximum involvement by interested residents, including evening and weekend programming. Recognize abnormal signs and symptoms, which signify a physical change in a resident's condition that would require nursing intervention and report it. Keep records of resident activity participation in individual medical records, may keep group records of individual records of participation in specific activities scheduled. II. Observations On 11/20/23 at 1:00 p.m., the activity assistant read a devotional to two female residents. On 11/30/23 from 10:00 a.m. through 2:30 p.m., no activities were observed for the residents from the activity department staff. -The secured unit calendars documented several group activities that were scheduled for that day. III. Staff interviews The activity director (AD) was interviewed on 11/30/23 at 2:00 p.m. with the director of nursing (DON) present in the interview. The AD said she had not been trained to be an activity director and had not attended any classes in person or online to get educated on what the job required. She said she did not have a consultant who helped to train her. She said she did not know how to make calendars or that certain activities were to be on a calendar, such as a church or spiritual group. She said she did not know what was required for evening activities. She said she did not have any activity dementia care training specific to use for those who lived in the secured unit. She said she worked for a few months in social services in the facility and then a few months ago was offered the activity director position. She said she did not know any of the state or federal regulations pertaining to the activity department. She said she did not know how to become a certified activity director. The AD said on the morning of 11/30/23 she was told by management to come help on the other units and that was why there were no activities observed today (11/30/23) on the secured unit. The AD said she would like to be trained to do her job or to have the facility supply an activity consultant for her. The AD provided an individualized participation calendar which was used for the residents on the secured unit. She said she did not record any one to one visits with people on the secured unit or throughout the facility. She said she could not provide any documentation of one to one visits for the residents. She said she did not keep track of what was done while visiting residents individually. She said she did not keep track of how long visits were for each resident either. She said she did not have a lot to provide for activity records as proof that activities occurred. The NHA was interviewed on 11/30/23 at 3:30 p.m. He said he would speak with the corporate office for the facility and get the matter handled so that the facility had a qualified AD.

Based on observations, interviews and record review, the facility failed to ensure residents were kept free from abuse for one (#1) of three residents out of three sample residents reviewed for abuse. Specifically, the facility failed to prevent a resident to resident altercation between Resident #1 and Resident #2. Findings include: I. Professional reference According to the Centers for Disease Control (CDC) website, Preventing Elder Abuse https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html 6/2/21, (Retrieved 12/4/23), Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial abuse. Physical abuse is when an elder experiences illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning. II. Facility policy and procedure The Identifying Types of Abuse policy, revised September 2022, was provided by the nursing home administrator (NHA) on 11/20/23 at 11:20 a.m. It revealed in pertinent part, Abuse of any kind against residents is strictly prohibited. Abuse prevention includes recognizing and understanding the definitions and types of abuse that can occur. It is understood by the leadership in this facility that preventing abuse requires staff education, training, and support, and a facility-wide culture of compassion and caring. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Abuse toward a resident can occur as: resident-to-resident abuse. Physical Abuse Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. Examples of injuries that could indicate physical abuse include, but are not limited to: Injuries that are non-accidental or unexplained; Bite marks, scratches, skin tears, and lacerations with or without bleeding, including those that are in locations that would unlikely result from an accident; Bruises, including those found in unusual locations such as the head, neck, lateral locations on the arms, or posterior torso and trunk, or bruises in shapes and; Facial injuries, including but not limited to, broken or missing teeth, facial fractures, black eye(s), bruising, bleeding or swelling of the mouth or cheeks. Psychosocial outcomes Some situations of abuse do not result in an observable physical injury or the psychosocial effects of abuse may not be immediately apparent. In addition, the alleged victim may not report abuse due to shame, fear, or retaliation. Other residents may not be able to speak due to a medical condition and/or cognitive impairment (stroke, coma, Alzheimer's disease), cannot recall what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. Neither physical marks on the body nor the ability to respond and/or verbalize is needed to conclude that abuse has occurred. III. Physical abuse between Resident #1 and Resident #2 The 10/12/23 facility incident report which involved Resident #1 and Resident #2 was provided by the director of nursing (DON) on 11/20/23 at 11:00 a.m. It revealed that the incident took place on the secured unit, in the common dining and activity area at approximately 3:00 p.m. Resident #1 and Resident #2 were seated at two different tables approximately five feet away from each other certified nurse aide (CNA) #1 and CNA #2 were approximately six to eight feet from the residents in the same room (see CNA #2's interview below). CNA#1 had her back to the residents while in the same common area. CNA#1 was getting snacks out of a refrigerator. Resident #1 was seated sideways at the table with her body facing Resident #2 at the other table. CNA #2 served Resident #1 a juice drink. CNA #2 turned her back to Resident #1. Resident #1 asked Resident #2 if he would like her drink. Resident #2 said no and shook his head no. Then Resident #1 stood up and walked over to Resident #2 and dumped her drink on his shirt. Resident #1 walked back to her table where she remained standing. Resident #2 rose up out of his chair, walked over to Resident #1 and punched her four times on the right side of her forehead. The report documented no staff witnessed the drink getting poured on Resident #2. CNA #1 and CNA #2 said the incident happened so quickly that they were not able to prevent the situation that occurred between the two residents. CNA #1 said she was unaware of the tensions that started between the two residents prior to the incident but she did hear them talking to each other. CNA #1 said as Resident #2 was punching Resident #1, CNA #1 said she distracted Resident #2 and was able to get him to stop hitting Resident #1. CNA #1 said she was able to escort Resident #2 out of the common area and back to his room. CNA #2 said even though she was close to Resident #1 and Resident #2 she did not hear or see any of the events between the two residents. CNA #1 went out of the secured unit and into the facility to have registered nurse (RN) #1 come help after Resident #1 had been punched. Resident #1 was still standing with her hands on the table when RN #1 came to help. CNA #2 used her phone to call for help from licensed practical nurse (LPN) #1 who had been delivering medications to residents not on the secured unit. RN #1 said Resident #1 would not let him do a skin assessment on her. RN #1 said because of the refusal he called 911 to come and take Resident #1 to the hospital where she received sterile adhesive bandages and returned that day to the facility (see RN #1's interview below). IV. Resident #1 A. Resident status Resident #1 Resident #1, age 80, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke) affecting the left non-dominant side, age related macular degeneration, dementia with agitation and behavioral disturbances, obsessive-compulsive disorder (OCD) and rheumatoid arthritis. The 9/26/23 minimum data set (MDS) assessment revealed the resident was not assessed for a brief interview for mental status score (BIMS). She had short and long term memory problems, and was severely impaired for cognitive skills for daily decision making. The resident had inattention, disorganized thinking, was short tempered, and easily annoyed. The resident had verbal behavioral symptoms directed towards others. The resident did not reject care from staff. The resident enjoyed reading books, newspapers or magazines, listening to music and doing things with groups of people. The resident required supervision with eating, limited assistance with bed mobility, transfers, walking in her room and corridors and was totally dependent upon staff for toilet use and personal hygiene. The resident used a front wheel walker to ambulate. The resident resided on the secured unit. B. Record review The comprehensive care plan, revised 10/16/23, revealed Resident #1 had aggressive behavior (s), confusion, and dementia. The resident had a behavior problem with a diagnosis of dementia. When being redirected she could become aggressive toward staff, would hit, spit and scratch. Resident #1 would also push or hit her front wheel walker on the secured unit door. Resident #1 had the potential to be verbally and physically aggressive toward staff. Interventions included staff to anticipate and meet the resident's needs, staff to intervene as necessary to protect the rights and safety of others, remove the resident from a situation and take her to an alternative location as needed, redirect the resident as needed, staff to intervene before agitation escalated, staff to guide the resident away from sources of distress, remove the resident to a calm safe environment when conflict arose and allow the resident to vent and share her feelings. The November 2023 medication review report was provided by the DON on 11/28/23 at 2:00 p.m. It revealed the resident was admitted from a different nursing home with a diagnosis of dementia with behaviors. She was to be monitored for restlessness, agitation, hitting, biting, kicking, spitting, cussing, racial slurs, stealing, delusions, hallucinations, psychosis, aggression, and refusing care. Staff were to monitor her behaviors by documenting a N for no behaviors or Y for yes behaviors in the behavior tracking. The October 2023 behavior tracking revealed the resident had a Y for yes behaviors documented on the following dates: 10/6/23, 10/15/23, 10/20/23, 10/27/23 and 10/31/23. The other dates 10/1/23 through 10/30/23 were documented with N for no behaviors. -Staff had documented a N for no behaviors on 10/12/23, the date the resident to resident altercation occurred between Resident #1 and Resident #2. The hospital emergency room report where Resident #1 was sent on 10/12/23 was provided by the DON on 11/30/23 at 10:30 a.m. The report revealed Resident #1 was seen for a facial laceration and received sterilized gauze strips as indicated for trauma, head injury. The strips would fall off within a week of their application. The 10/12/23 nursing progress note documented the resident had an altercation in the memory care unit. Upon assessment (the) resident had sustained a laceration on her right lateral eyebrow area. The laceration measured 1.8 cm (centimeter) by 0.8 cm by 0.2 cm and was actively bleeding at the time of the assessment. Wound care was completed after pressure was applied and bleeding had stopped. The 10/16/23 physician note for Resident #1 revealed after the altercation the resident's medication of Lorazepam (an antianxiety medication) was to be increased from 0.25 mg (milligrams) daily to 0.5 mg two times per day. V. Resident #2 A. Resident status Resident #2, age younger than 65, was admitted on [DATE]. According to the November 2023 CPO, diagnoses included vascular dementia with behavioral disturbances, acute and chronic respiratory failure, memory deficit following cerebrovascular disease (affects blood flow in the brain), aphasia (disorder affecting communication) following cerebral infarction (stroke), type 2 diabetes mellitus, unspecified alcohol-induced disorder and hypertension (high blood pressure). The 10/22/23 MDS assessment revealed the resident was not assessed for a BIMS. He had short and long term memory problems. He had physical behavioral symptoms directed towards others with hitting, kicking, pushing or scratching. He did not reject care from staff. The resident required setup or clean up assistance with eating. He required substantial maximum assistance with dressing and personal hygiene. The resident was able to walk on the unit without any ambulation devices. The resident resided on the secured unit. B. Record review The comprehensive care plan, revised 11/20/23, revealed Resident #2 preferred to keep to himself much of the time. He had behavior problems with confusion and dementia. Resident #2 had impulsive behaviors. Resident #2 would throw items, ram into things or strike out at residents and staff. Resident #2 had the potential to be physically aggressive with poor impulse control, confusion and a history of aggressive behavior, including hitting staff and showing physical aggression toward residents. He could become aggressive when staff or residents interfered with his intended behavior. Interventions included assisting the resident to develop more appropriate methods of coping and interacting, encouraging the resident to express feelings more appropriately, intervening as necessary to protect the rights and safety of others, approaching/speaking to the resident in a calm manner, removing the resident from a situation and taking him to an alternative location as needed, observing for unsafe situations and intervening as needed before agitation escalated, guiding the resident away from sources of distress and ensuring the safety of others around him. The 10/24/23 physician note for Resident #2 revealed the resident was started on Depakote Sprinkles (an anticonvulsant medication used to treat mental/mood conditions) on 10/16/23, four days after the incident with Resident #1. The physician documented that the resident had been much calmer since the medication was started. VI. Staff interviews RN #1 was interviewed on 11/30/23 at 10:58 a.m. RN #1 said he was the house supervisor on duty the day of the resident to resident physical abuse (10/12/23) between Resident #1 and Resident #2. He said CNA #1 came and alerted him that there was a problem on the secured unit. He said when he went back to the secured unit he saw Resident #1 was bleeding on the right side of her head between her forehead and hairline. He said he put a dressing on the area with some pressure and the bleeding stopped. He said he was able to get some measurements but not any depth measurements of the cut because Resident #1 would not let him look at the cut closely to determine a depth. He said at that time he called the physician, and because Resident #1 did not allow him to investigate the cut, along with the physician's determination, they decided to send Resident #1 to the emergency room . He said when she returned from the emergency room she had gauze strips on her head where the cut was. He said he was instructed by the hospital paperwork to monitor Resident #1 for infection and to let the gauze strips fall off on their own over the upcoming week. He said he had to take precautions and send her to the emergency room so that she would allow herself to be treated. RN #1 said Resident #2 was very impulsive and that he would punch people right away so staff had to be watchful of his demeanor. He said after the hitting incident, Resident #2 was put on Depakote and it seemed to have helped. He said Resident #1 at times could be redirected to read, or to look at a picture of the solar system because she liked to name the planets. He said Resident #1 could be agitated all through the day and he said the staff needed to be more vigilant, especially at the end of the day to watch for sundowning. CNA #1 was interviewed on 11/30/23 at 11:15 a.m. She said at the time of the incident between Resident #1 and Resident #2 she was at the refrigerator in the common area where the residents were seated. She said she thought she had them separated by them being seated at different tables. She said her back was to the residents when she was in the refrigerator when the altercation happened. She said CNA #2 also had her back turned to the residents when she had prepared drinks and snacks. She said she heard Resident #1 ask Resident #2 if he would like her drink and he said no. She said Resident #1 stood up, walked approximately five feet over to Resident #2, poured her drink down the front of his shirt, and walked back to her table. CNA #1 said she assumed that was how Resident #2 had the drink poured on him but since CNA #1 had her back to the residents, she did not witness the drink being poured. She said neither CNA witnessed Resident #1 pour the drink on Resident #2, only the observation that Resident #2's shirt was wet. She said Resident #2 got up and walked approximately five feet to where Resident #1 stood. She said Resident #2 punched Resident #1 on the side of the face four times with his closed fist. She said she was able to get Resident #2 to stop, and distracted him to let her walk him back to his room. She said she went to get the house supervisor that day, RN #1, and CNA #2 stayed with the residents and used the phone to call the LPN. She said both CNAs had their backs to the residents and the CNAs were not quick enough to stop the incident. She said as long as Resident #2 was left alone he did not have outbursts. CNA #1 said Resident #1 had poured a drink on her once but she said she did not expect Resident #1 to pour a drink on Resident #2. LPN #1 was interviewed on 11/30/23 at 11:25 a.m. She said she did not witness the altercation but CNA #2 called her on the phone to come back to the memory care unit to help the staff and residents. She said she was the nurse on the secured unit but due to a lot of transition with staff, she also had some medications to be given to a few residents on the other hallway that was not in the secured unit. She said that normally there were two CNAs, one nurse and often a sitter that was a facility CNA that helped with another resident and as needed the sitter helped the other staff on the secured unit. She said typically there were three staff for 12 residents on the secured unit, but that day there were only two CNAs on the unit when the incident happened. She said Resident #2 was much more cooperative than Resident #1 when the staff offered them food. She said Resident #1 and Resident #2 were not interviewed after the incident due to their cognition. She said at one time the facility had a system to interview non-interviewable residents, like the ones on memory care. She said she did not think the facility had that system to interview non-interviewable residents anymore (see NHA interview below). CNA#2 was interviewed on 11/30/23 at 1:30 p.m. She said she gave Resident #2 a snack and then CNA #2 turned her back to Resident #1 but was next to the table where Resident #1 sat. She said she did not hear Resident #1 ask Resident #2 if he would like her drink. She said she did not hear anything until she heard CNA #1 shout no. She said when she turned around she saw CNA #2 put herself in between Resident #1 and Resident #2. She said CNA #1 was able to get Resident #2 to stop punching Resident #1 and she said CNA #1 distracted Resident #2 and walked him back to his room. CNA #2 said she did not see the build-up to the altercation, nor the movements of the two residents between the tables. She said she did not see Resident #1 walk over to Resident #2 and pour her drink on him. CNA #2 said she did not see Resident #2 walk to Resident #1 and punch her repeatedly. CNA #1 said even though she was in the common area room close by the residents she did not hear or see anything. The NHA was interviewed on 11/28/23 at 2:00 p.m. He said he was an interim NHA and had only been at the facility for a few weeks. He said since the survey began he had both CNA #1 and CNA #2 performed a reenactment, a return demonstration of how the abuse occurred (see facility follow-up). He said he was unaware if the facility had a policy and procedure for interviewing non-interviewable residents. He said he understood the importance of communication with residents after an altercation even if they had dementia. The DON was interviewed on 11/30/23 at 11:30 a.m. She said she was home on 10/12/23, the day of the altercation. She said she was not called by the NHA for approximately three weeks. She said had he called her she would have come in immediately. She said shortly after the incident she provided dementia and abuse training to all of the staff in the facility (see facility follow-up below). She said the facility did not interview Resident #1 and Resident #2 because they were non-interviewable and the facility did not have a process to interview residents with cognitive impairments. The DON said the social service director (SSD) had quit unexpectedly a few days prior, during the survey. She said the SSD did not get involved or do assessments with the residents after the altercation. She said the SSD said she did not want to get involved in the situation. She said the facility was currently looking to hire a new SSD. She said the resident did not get stitches at the hospital. She said the hospital put gauze strips across the skin tear. She said the area where the skin tear was had healed well. She said she taught the staff that they must have visual eye contact on the residents and to separate the residents if danger was anticipated. VII. Facility follow-up On 11/28/23 at 12:55 p.m. the DON provided a copy of the Alzheimer's/dementia in-service training that she provided to the staff on 10/13/23. The training included how to care for residents with dementia, behavioral management and how to report situations to facility management. The training included signatures of the facility staff who attended the training. On 11/28/23 at 1:00 p.m. the NHA provided a report he did, during the survey, on 11/20/23. The NHA said he had CNA #1 and CNA #2 perform a demonstration on the memory care unit of a reenactment of the altercation between Resident #1 and Resident #2. He said he would continue to have the DON and himself educate staff on how to care for residents with dementia. He said he would look into a system of how to interview non-interviewable residents. The report did not add or change any of the information provided previously about the altercation.

Based on observation, record review and interviews, the facility failed to ensure two (#41 and #154) of five residents reviewed for accidents out of 31 sample residents remained as free from accident hazards as possible. The facility failed to thoroughly investigate what happened when Resident #41 sustained a left hip and rib fracture on 2/12/23 that required hospitalization . The facility identified the resident's numerous fall risks which included gait problems, forgetfulness and overestimation of limits, muscle weakness, and cognitive communication deficit. The facility determined the likely cause of the resident's fractures were due to an unwitnessed fall (see medical directors interview). In addition, for Resident #154 the facility failed to investigate, identify and put interventions in place to prevent trauma injury on the resident's right shin. Findings include: I. Facility policies and procedures The Accidents and Incidents: Investigating and Reporting policy, revised in July 2017, was provided by the director of nursing. The policy read in pertinent part: All accidents or incidents involving residents, employees, visitors, vendors, occuring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included: circumstances surrounding the accident/incident, the injured person's account of the incident/accident, the condition of the injured person, including vital signs, and follow up information. The medical director or attending physician shall review and verify conclusions about the possibility of a medical or other similar cause of the finding. Injury of unknown source is defined as an injury that meets both the following conditions: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury, or the location of the injury, the number of injuries observed at one particular time, or the incidence of injuries over time. II. Resident #41 A. Resident status Resident #41, age 80, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included encephalopathy (brain disease that alters brain function), cognitive communication deficit, muscle weakness, and vascular dementia with behavioral disturbance. The 1/16/23 minimum data set (MDS) assessment revealed the resident was not assessed for a brief interview for mental status and did have memory problems. The resident had moderate difficulty hearing, adequate vision, and difficulty communicating and finishing thoughts. The resident required supervision for all activities of daily living. For walking, he was unsteady but able to stabilize without staff assistance. The fall section of the MDS assessment revealed the resident did not have a fall in the last six months. The behavior section of the MDS assessment indicated the resident did resist care intermittently but did not have any other types of behaviors. B. Record review The care plan for falls, was initiated on 1/18/21 and last revised on 11/9/22, revealed the resident was at risk for falls due to confusion, gait/balance pr blem, poor communication, hearing problems and unawareness of safety needs. Interventions included to anticipate the residents needs, keep the call light within the reach, making sure the resident was wearing appropriate footwear, and bed in low position at night. -The care plan was not updated with new interventions after a potential fall on 2/12/23. Nursing progress notes dated 2/12/23, documented that the resident was complaining of pain at midnight, when a nurse went in to empty the resident's catheter. On examination it seems the resident was having pain in the left hip and left knee. The physician was contacted to get an order for x-ray of the resident's left hip/knee. At 5:12 p.m. the x-ray results concluded the resident had a fracture to the left hip. The physician was contacted and recommended hospital treatment. C. Incident investigation Incident/accident report was received from the director of nursing on 2/27/23 at 4:15 p.m. revealed on 2/12/23 at 12:30 a.m. registered nurse entered the resident room to empty the catheter bag at midnight. The resident started to complain of left leg, hip, and knee pain. Investigation follow-up was received from the director of nursing on 2/27/23 at 4:15 p.m. revealed on 2/13/23 the resident was lying in bed complaining of hip pain. Summary: Charge nurse reported that he went into the resident's room about midnight to empty the foley catheter and observed the resident guarding left leg and grimacing in pain. Called the medical doctor to get orders. Recommendations: Monitor resident pain as necessary. X-ray confirmed the resident had a hip (left) and orders were obtained. Resident sent out to the hospital for evaluation and treatment. On the reverse side of the investigation follow up form the director of nursing documented resident does not have history of falls and has not fallen to the knowledge of any staff member. Facility concluded that the resident was injured of unknown origin and was probably a result of spontaneous fracture as the resident has a diagnosis of osteoarthritis which has been shown to have a positive association with fractures in men. -The investigation did not include interviews with staff members who worked with the resident on that day. A primary care physician or medical director was not contacted to clarify the possibility of the spontaneous fracture. D. Hospital records The hospital discharge summary dated 2/21/23 documented that resident was admitted to the emergency room and was diagnosed with left hip fracture. Resident #41 returned back to the facility on [DATE] after the left hip was surgically repaired on 2/13/23. His hospital records were reviewed by a nurse practitioner on 2/24/23, who documented that during the hospital stay resident was diagnosed with left hip fracture and rib fracture. On 2/25/23 the resident was hospitalized again for shortness of breath and at the time of the survey was not in the facility. E. Staff interviews The director of nursing (DON) was interviewed on 3/1/23 at 1:00 p.m. She said the resident had no fall history, the resident was found in bed by a staff member, investigation completed without determination of how the resident developed a hip and rib fracture. The DON concluded the fracture was spontaneous due to the resident's history of osteoarthritis. The director of nursing stated she researched and researched to determine how this could have happened to the resident; found information on spontaneous fractures and thought it fit the situation. The medical director was interviewed on 3/2/23 at 12:26 p.m. She said she reviewed the resident's record and she believed that resident sustained an unwitnessed fall. She said she reviewed his hospitalization records and the resident was diagnosed with hip and rib fracture on 2/12/23. She said rib fracture was only mentioned on computed tomography (CT) scan results and not in actual discharge summary. She said she was not notified about the fractures that the resident sustained in the facility. She said her expectation was that a primary care physician would be notified and consulted for the potential causes of fractures. The vice president of operations was interviewed in the presence of DON on 3/2/23 at 2:30 p.m. He said all injuries of unknown origin should be investigated and include the staff interviews who worked with the resident on that day and a primary care physician should be contacted for clarification if staff were unable to determine the cause. He said the facility did rule out potential abuse/neglect and concluded that the resident sustained an unwitnessed fall. F. Facility follow up On 3/2/23 at 4:15 p.m. the DON submitted a progress note documented by a medical director. The note summarized the resident's medical conditions, and documented the resident resided in the dementia care unit because of poor memory, safety awareness, insight and increased level of care needs. Stated the resident was physically active in terms of ambulation around the unit prior to the event. She said there was no indication of pain prior to the acute onset to hip pain, therefore, questioning if the resident had suffered a fall that was not reported to staff and may have gotten up. She concluded that given the resident's low vitamin D level, old fractures, abnormal heart rate, oxygen needs, and osteoporosis put him at high risk for fractures. No evidence per chart review and discussion with the director of nursing that there was any evidence of any altercation or obvious fall but given the resident's dementia, cannot exclude an unreported fall as the resident can have the ability to get up. Of note, even in hospital notes there is mention in the history and physical examination the resident was trying to ambulate on the fractured extremity. Reiterated there have been known causes of spontaneous fracture, although given the rib fracture concurrently, the medical director would first consider an unwitnessed fall. 37166 III. Resident #154 A. Resident status Resident #154, age over [AGE] years, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnosis included acute and chronic respiratory failure, pressure ulcers, dementia and malnutrition. The 2/10/23 minimum data set (MDS) assessment section for cognition, functional status and skin was not completed. B. Record review The comprehensive care plan review revealed that the care plan was initiated on 2/13/23. The care plan did not have a section for skin integrity. The review of physician's orders for March 2023 revealed the resident was receiving treatments for multiple wounds on his legs. According to the electronic and paper records of skin condition from 2/10/23 to 3/2/23, the resident had a total of four skin altercations. He was admitted to the facility with two pressure injuries (left heel and left lateral malleolus) and one trauma injury to his left shin. The wound care note by wound care physician (WCP) #1 documented on 2/28/23 the resident developed a new trauma injury to his right shin, measuring 4 centimeters (cm) by 3.1 cm. The investigation regarding the acquired trauma wound was requested from the DON on 3/1/23 and was not provided. C. Wound observations Wound observations were conducted on 2/28/22 at 1:32 p.m. in the presence of registered nurse (RN) #2 and wound care physician (WCP) #1. A total of four wounds were observed on the resident's leg, including a trauma injury to the right shin measuring 4 centimeters (cm) by 3.1 cm. D. Staff interviews RN #2 was interviewed on 3/2/23. He said the resident had multiple wounds that he was admitted with. He said some wounds were pressure injuries and some were trauma wounds. He said he did not know how the trauma wound occurred. He said his role in wound care was to follow physician treatments and provide dressing changes. The director of nursing (DON) was interviewed on 3/2/23 at 2:30 p.m. She said resident was admitted with multiple wounds, three of the wounds were mentioned on the hospital records and wound #4 (the trauma wound to the right shin) occurred in the facility. She said she did not know how the resident acquired his right shin trauma wound and she did not investigate it.

Based on observations, record review and interviews, the facility failed to implement appropriate and timely interventions to ensure two (#24 and #44) of six sample residents received the necessary care and treatment to prevent the development of a pressure injury out of 31 sample residents. The facility failed to put interventions in place to prevent pressure injury for Resident #24. Resident #24 was admitted to the facility on [DATE]. At the time of the admission she was evaluated to be at risk for developing pressure injuries. On 11/1/22 resident developed two unstageable pressure injuries on her legs. She was evaluated by a wound care physician who recommended treatments. However, the resident's care plan was not updated with new interventions, and on 12/30/22 she developed a large unstageable pressure injury on her hip. On 12/31/22 resident experienced a change of condition and was sent to the hospital emergency room where she was diagnosed with sepsis due to wound infection on her legs. In addition, the facility failed to consistently implement interventions for a healed pressure injury to Resident #44's left lateral ankle to prevent reoccurrence. Findings include: I. Professional References The National Pressure Ulcer Advisory Panel, https://npiap.com/page/PressureInjuryStages accessed on 3/8/23 read in pertinent part: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. The National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. [NAME] Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. From http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf (2/17/2017), accessed on 3/8/23. It read in pertinent part, Steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: - Positioning that places pressure on the pressure injury should be avoided. - The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. - The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. - Signs of deterioration in the wound should be addressed immediately. - The assessment should include: location, category/stage, size, tissue type, color, periwound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility Policy The Pressure Ulcer Prevention policy, last revised on April 2018, received by director of nursing (DON) on 2/28/23 at 1:20 p.m. read in pertinent part: Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. ???In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status; current treatments, including support surfaces; and all active diagnoses. The physician will clarify the status of relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, and the impact of comorbid conditions on healing an existing wound. III. Resident #24 A. Resident status Resident #24, age 84, was admitted on [DATE] and discharged [DATE] to the hospital and did not return to the facility. According to the March 2023 computerized physician orders (CPO), her diagnoses included multiple sclerosis and type 2 diabetes mellitus with other circulatory complications. The 11/11/22 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of one out of 15. The resident required total assistance of two staff for bed mobility, transfers and activities of daily living. The resident did not have any skin issues upon admission. She had no behavior issues. B. Record review The care plan for skin integrity, was initiated on 6/21/17 and last revised on 3/28/2020, identified the resident had a potential for skin impairments related to compromised mobility related to immobility, cognitive impairment due to diagnosis of dementia, and history of incontinence. Interventions included to inform the resident/family/caregivers of any new area of skin breakdown, teach resident/family the importance of changing positions for prevention of pressure ulcers, encourage small frequent position changes, and weekly skin checks. -However, the care plan was not updated after the pressure injuries were found by the facility staff on 3/1/23 and wound treatment began. -Resident #24 did not have a care plan for refusal of care or any behaviors. 1. Pressure injury development and progression The first pressure wound was initially documented on 11/1/22. The nursing note read: Blister noted (on) the resident's left heel while getting her ready for breakfast. Blister popped into an open wound. MD (medical doctor) notified and order was received. Dressing applied as per order. Resident's shoes changed to house slippers. Resident's son was in the facility with breakfast for the resident and was notified. Will monitor. From 11/2/22 to 12/30/22 Resident #24 was seen by the wound care physician (WCP) #2 for weekly wound checks as well as by the facility nursing staff for weekly pressure ulcer progress reports. Based on wound care physician notes from 11/9/22 to 12/30/22 resident continued to have two unstageable pressure injuries, wound #1 on left heel and wound #2 on the outer left foot. A third unstageable wound was documented on 12/29/22 located on the left hip. Recommendations included to cleanse wounds and apply silver based wound cream and cover with a dry dressing two times a day for wound care. Review of treatment administration orders (TAR) between 11/1/22 and 12/30/22 revealed Resident #24 received following wound treatments: -Left heel wound, cleanse wound to left foot and heel with cleanser apply wet to dry gauze with cleanser solution to wound bed. Two times a day for wound care. The treatments were consistently documented as completed. Review of skin assessments between 11/3/22 and 12/29/22 in electronic medical records revealed that resident's wounds were not consistently documented. On 11/3/22 skin assessment documented no location of wounds or measurements. Assessment missing left foot wound. Notes section contained the following, Wound to left heel wound (physician)assessed yesterday applied Medi honey and medicated dressing covered with border gauze. On 12/29/22 skin assessment documented no location of wounds or measurements. Assessment missing left foot wound. Notes section contained the following, Wound to left heel wound cleanse, apply Dakins to wounds and cover with clean dressing. No new concerns at this time. Wound doctor coming tomorrow. Review of wound care binder, provided by DON) on 3/2/23 revealed Resident #24's wounds were documented on the paper by DON during her rounds with the wound care physician. The paper records were consistent with wound care physician notes. The binder was not a part of the resident's medical electronic or paper record and was kept at the DON's office. The resident's care plan was not updated with the above information and continued to read that the resident was at risk for pressure injury. 2. Change of condition and hospitalization The nurses note on 12/31/22, documented that the resident's daughter came for a visit and was very concerned that her mother was not her usual self, she was lethargic. The daughter requested to transfer the resident to the hospital for evaluation. The resident was transported to the emergency room where she was evaluated and diagnosed with septic shock due to left lower extremity purulent(drainage producing pus) ulcer and cellulitis (skin infection). C. Staff Interviews Certified nurses aide (CNA) #1 was interviewed on 3/1/23 at 10:30 a.m. CNA #1 said Resident #24 was a two person total assist and was unable to reposition herself in bed as well as her wheelchair. She said the resident was frequently observed to be hanging over the left side of her wheelchair. CNA #1 said she would assist the resident in repositioning herself but stated some staff did not. Licensed practical nurse (LPN) #1 was interviewed on 3/1/23 at 10:00 a.m. She said the resident spent a good portion of her day in her wheelchair. She said the resident propelled herself around with her left foot even after the wounds were found on her left foot and left heel. LPN #1 said she was the nurse who called for a hospital transfer on 12/31/22. She noted that the resident did seem more sleepy than usual but found the resident's vital signs to be within normal limits. She said she contacted the on call physician to receive an order to transfer the resident and then called for transport. LPN #1 said any resident with a change of condition would have a progress note generated in their electronic record. The DON was interviewed on 3/1/23 at 11:18 a.m. She said while the facility looked to staff a dedicated wound nurse, she was filling in for the role of wound nurse. She said Resident #24 had a care plan at admission that outlined ways to prevent pressure injuries but said the resident never had a revised care plan stating what the goals and interventions were discussed to improve the pressure wounds Resident #24 received, and to prevent further injury. She said the facility's policy for acute issues were logged in a binder but she said Resident #24 never received an acute care plan either. The DON said the wound that was found on Resident #24's left hip was so large (8 cm x 8 cm) because that was not being assessed during skin checks until that day and had most likely been developing for awhile before it was found. Wound care physician (WCP) #2 was interviewed on 3/2/23 at 10:48 a.m. She said she believed all wounds that resident developed on her legs were vascular wounds. She said she referred the resident on several occasions to vascular specialists, but the family refused the testing. She said the resident was able to change position and move her legs. She said the resident was at risk for developing pressure injuries due to impaired mobility and diabetes. She said her recommendations were to elevate the legs and use multi Podus boots. She said she observed the resident being non-compliant with care when she refused dressing changes on several occasions. She said she evaluated the resident's wounds on 12/30/22 (day prior to hospitalization ), and she did not observe any signs of infection or cellulitis. The wounds appeared the same way and there was no indication of systemic infection. Regarding the hip wound that the resident developed on 12/29/22, she said the fact the wound was discovered at such a significant size indicated that the resident's skin was not checked regularly, otherwise it could have been caught earlier. She said the etiology of the hip wound was pressure. The medical director was interviewed on 3/2/23 at 12:26 p.m. She said she reviewed the resident's record and she believed that resident's wounds were unavoidable. She said the resident's appetite and food intake was steadily declining, and her overall condition as well. She said the resident was followed by a wound care physician regularly, wound care treatments were adjusted and modified based on the wounds presentation. She said the resident was able to communicate to staff her likes and dislikes and she was on nutritional supplements for low intake and wound healing. She said progression of the wounds despite all treatments that the resident received demonstrated skin failure. Regarding sepsis, she said she reviewed resident's vital signs and most recent labs. She said there was no clinical indication that the resident was developing sepsis. She said the primary indication of sepsis was increased heart rate and fluctuations in blood pressure. She said the resident had stable blood pressure and heart rate prior to her hospitalization . She said sepsis could develop very rapidly that appeared to be in this case. She said the resident did have mildly elevated white blood cells that potentially was indication of systemic infection, however such elevation was expected in any individual with wounds and was not an indication of sepsis. She said she did not identify any failures in care based on the notes review and her interviews with facility staff. She said the hospitalization was unavoidable due to the resident's decline and acute onset of sepsis. -However, there was no documentation in the resident's medical record to indicate that her wounds were unavoidable. In addition, due to the lack of consistent skin assessments with her being at risk for pressure ulcers, the resident developed an unstageable wound to her left hip. D. Facility follow-up On 3/2/23 DON provided a progress note completed by the medical director. The note was dated 3/2/23 and read in pertinent part, Until her hospitalization , several nursing notes indicate ongoing intermittent non compliance with nutritional supplements, sometimes refusing food and stating 'I eat what I want'. Facility implemented interventions such as different shoe ware, air mattress, offloading booties, supplements (including zinc, vitamin C, glucerna per nutrition notes). Wound care orders had to be changed several times as the wound was not healing (medihoney, wet to dry, Dakins, santyl) In the 24 hours prior to hospitalization patient had normal vital signs without tachycardia or fever and normal blood pressure. Wound care reportedly rounded day prior to hospitalization on ,d+[DATE] and point click care (computer system for electronic records) notes indicate that her wound was debrided and there was no report of any infection/cellulitis or new order for antibiotic at the 12/30 assessment. In fact, the patient not treated on antibiotics from what I can see in her medication orders. Cannot rule out vascular compromise to her extremities and also if a patient developed acute sepsis/infection she could have generalized skin organ failure which is not uncommon at the end of life or during an acute illness (a good example is a Kennedy ulcer) which can occur rapidly. There was no clear indication there was an acute wound infection or vital signs evidence of sepsis prior to hospitalization transfer based on nursing notes. Given her rapid change in mental status, ER evaluation was appropriate for further evaluation. 47351 IV. Resident #44 A. Resident status Resident #44, age under 65, was admitted on [DATE]. According to the March 2023 CPO diagnoses included unspecified transient ischemic attack, traumatic brain injury, encephalopathy, and dementia with behavioral disturbances. The 10/27/22 MDS showed the resident was severely impaired in cognitive ability to make decisions with a zero out of 15 for the brief interview for mental status. The resident required extensive assistance and was totally dependent on staff for activities of daily living. He was identified at risk for pressure injuries and had no pressure injury at the time of assessment. B. Observations On 2/27/23 at 2:26 p.m. the resident was sitting in the dining room with a left ankle dressing that was dated 2/26/23. At 4:30 p.m. the resident was seated in a wheelchair with the left lateral ankle resting on the floor. On 2/28/23 at 9:00 a.m., the resident was being pushed in a wheelchair by a staff member with the left lateral ankle dragging along the floor. At 9:48 a.m. the wound care physician arrived at the facility to assess the resident's wound. CNA #1 and #2 transferred the resident from wheelchair to the bed. RN #1 changed dressing and the resident fell asleep. The Podus boot (protective boot) remained on the floor at the head of the resident's bed. It was not applied while the resident was in bed as indicated in the physician orders (see below). At 1:45 p.m., the resident was sitting in front of the television with feet resting on the wheelchair footrest with right leg crossed over left leg. C. Wound care observations On 2/28/23 at 2:30 p.m. wound care observations were conducted in the presence of wound care physician (WCP) #1. RN #1 donned gloves and removed the dressing wrapped around the resident's left ankle while the resident was lying in bed. WCP #1 donned gloves and assessed the wound and removed a paper ruler from the carry-on bag to measure the wound (0.4 x 1.6 x 0.0). The wound appeared dry and pink with mild scabbing and swelling, slight scarring at the outer edges of the wound surrounding the left outer ankle. There were no signs of infection. D. Record review The care plan for skin integrity reviewed 11/10/22 revealed Resident #44 had the potential for pressure ulcer development related to disease process, decreased mobility, decreased range of motion, and incontinence. Interventions included follow facility policies/protocols for the prevention/treatment of skin breakdown, Inform the resident/family/caregivers of any new area of skin breakdown and monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. Nursing progress note dated 11/25/22 documented a small open area was noted to the resident's left outer ankle. Weekly pressure ulcer report dated 11/25/22 revealed Resident #44 developed an unstageable pressure injury area to the left outer leg area (left lateral malleolus) measured at 3 centimeters (cm) by 2.8 cm by 2 cm. The wound had no drainage or odor. The weekly pressure ulcer reports continue through 2/27/23 with the wound measured at 1 by 1.5 by 0 centimeters on that last date (decreasing in size). Wound care notes by wound care physician on 12/14/22 revealed a wound on the left lateral malleolus measured at 1.3 by 1.5 by 0.1 centimeters. The weekly wound notes continued through 2/14/23 with the wound measured at 1.2 x 1.4 x 0 on that date. The etiology of the wound was documented as pressure. On 12/14/22 the physician ordered for a Podus boot while in bed was added to the resident's orders. This intervention was not added to the resident's care plan. -The plan of care did not mention special care to the resident's left lower extremity after the weakness was identified by nursing notes on 2/18/22 (see note below). Nursing progress note dated 2/18/22 documented an order for therapy to evaluate for possible brace for left lower extremity due to weakness. . -The care plan was not updated in 2022 or 2023 to reflect the development of pressure injury to the resident's left leg on 11/25/22, and no personalized interventions were in place prior to the injury. The care plan referred to policies and procedures for prevention/treatment of skin breakdown. The resident's treatment administration record for February 2023 revealed consistent daily assessments for pain and administration of oral supplements for nutritional support. -The care plan was not updated after the injury was healed 3/2/23 (at the time of the survey) to make sure the resident's leg was protected from repeated injury. E. Staff interviews The wound care physician (WCP) #1 was interviewed on 2/28/23 at 1:50 p.m. The physician said the wound was on the left lateral malleolus and the wound developed due to the resident crossing the right foot over the left foot causing the left lateral malleolus to drag on the floor as the resident propelled in the wheelchair. The wound measured at 0.4 x 1.6 x 0.0 centimeters and commented the wound was now closed and improved. The physician recommended continuation of weekly betadine and foam dressings. The physician said a protective boot was prescribed but the resident kicked it off on a continual basis. The physician said the wound was progressing nicely but will likely resurface as a result of the resident dragging his left malleolus on the floor while up in the wheelchair. The physician said the resident's wound was a healed stage 3 injury. The DON was interviewed on 2/28/23 at 4:22 p.m. The DON stated the resident's wound was unstageable and there would always be a difference between DON and the wound care physician's measurements of the wound. The DON said the resident's wound was facility acquired and the wheelchair footrest was removed by physical therapy because the footrest was not used by the resident. The DON said the resident kicked off the bunny boot whenever it was placed on the resident's left foot. She reviewed the resident's record and confirmed that there were no documented interventions in the resident's care plan prior to the injury, and the resident did not refuse care. LPN#1 was interviewed on 3/1/23 at 10:30 a.m. LPN #1 said the interventions implemented to protect the resident's left lateral malleolus, included, a Podus boot and repositioning while in bed, wheelchair footrest and repositioning the left ankle while in wheelchair, monitoring for pain, assessing for changes in progress notes, administering supplements, and facilitated nutrition to support wound healing. CNA#1 was interviewed on 3/1/23 at 10:34 a.m. CNA#1 reported if the resident's left foot fell off the footrest the resident was asked if staff could touch the resident's foot first then reposition the foot. If the resident's foot was dragging when the resident took his feet off the footrest CNA#1 redirected, reminded and asked the resident to lift the left foot off the floor. CNA#2 was interviewed on 3/1/23 at 10:39 a.m. CNA #2 stated the resident's left foot was monitored to avoid it from falling off the footrest. CNA#2 reported the resident always took the left foot off the footrest to propel in the wheelchair. The director of rehabilitation (DOR) was interviewed on 3/2/23 at 12:32 p.m. The DOR picked up the resident for therapy and recommended an ankle foot orthosis but the resident complained about it because it was uncomfortable, so the DOR advised the staff to not use it while the resident was in the wheelchair. Explained the left ankle was positioned in an inverted manner and the DOR informed staff to place orthosis to correct the inversion of the left foot as needed. The DOR said ongoing and consistent communication with care staff was needed and ongoing repositioning of the resident's left foot was required. The DOR stated the resident was non-compliant with the recommended interventions. The DOR acknowledged there was no formal staff education about rehabilitation recommendations and planned to meet with nursing staff to reassess the need for formal education.

Based on record review, and interviews, the facility failed to ensure one (#93) of four residents out of 29 sample residents received care, consistent with professional standards of practice, to promote healing of pressure injuries and to prevent new pressure injuries from developing. Specifically, the facility failed to ensure Resident #93's risk factors for pressure injury were identified, failed to ensure a pressure injury on her coccyx (3/11/2020) was comprehensively assessed, monitored and treated by qualified providers, and failed to prevent the development of right and left heel ulcers (4/16/2020). The resident's coccyx wound, documented by the facility as a stage 2 on 4/16/2020, was assessed as a stage 4 foul-smelling and necrotic pressure injury four days later when the resident was hospitalized . The facility's failures contributed to worsening of the resident's coccyx injury and the development of two additional pressure injuries. Findings include: I. Professional reference The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (2/4/2018) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. II. Facility policy and procedures The Skin and Wound Management Protocol, not revised, was provided by the nursing home administrator (NHA) on 9/6/2020 at 10:26 a.m. It documented the following pertinent information: -Avoidable means the resident developed a pressure ulcer/injury and that one or more of the following was not completed: 1. Evaluation of the resident's clinical condition and risk factors. 2. Definition or implementation of interventions that are consistent with resident's needs, resident's goals, and professional standards of practice. 3. Monitoring or evaluation of the impact of the interventions or revision of the interventions as appropriate. III. Resident #93 Resident #93, age 89, was admitted to the facility on [DATE] and discharged to the hospital for evaluation and treatment on 4/19/2020. According to the April 2020 computerized physician orders [REDACTED]. The resident's 4/7/20 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) exam conducted due to her cognitive impairment. She was at risk for pressure ulcers, unhealed pressure ulcers and was documented with skin issues noted as stage 1 and stage 2. She required extensive assistance of two staff members with bed mobility, transfers, and dressing. She was totally dependent, one person assistance for toilet use, and personal hygiene. She was always incontinent of urine and bowel. Certified nurse aide (CNA) #1 was interviewed on 9/17/2020 at 9:15 a.m She said Resident #93 was difficult to care for, but she would let staff assist with her incontinence care and activities of daily living. CNA #3 was interviewed on 9/17/2020 at 9:35 a.m. She said Resident #93 had wounds on her coccyx and her heels. She said Resident #93 was difficult to care for, but she would let staff do her care. She said Resident #93 required two staff to do activities of daily living. She said Resident #93 would not reposition herself. A. Resident status upon discharge 4/19/2020 Resident #93 was discharged to the hospital 4/19/2020 with fever and lethargy. The hospital assessment revealed the resident's coccyx injury was a stage 4 foul smelling wound with necrotic tissue. Her right heel wound presented with hard black eschar and her left heel with soft back eschar and foul smelling drainage. The note read: Resident #93 was admitted from a nursing home. Resident #93 COVID-19 positive and in intensive care at this time. Nurse was consulted for a pressure ulcer. Resident #93 has a stage four pressure ulcer to the coccyx measuring 5.5cm X 4.5cm at unknown depth due to necrotic tissue and yellow slough noted to 90% of (the) wound bed. There are multiple protrusions of bone that were easily felt to the medial wound bed. Very foul smelling and no undermining or tunneling noted. Wound bed irrigated with normal saline and gauze used to manually debride, But necrotic tissue remains in the wound bed, wound proximity to anus in approximately 2cm. [MEDICATION NAME], and therahoney placed in a wound bed and covered with [MEDICATION NAME]. Bilateral heels present with wounds as well. Right heel black hard eschar measuring 7cmX5cm with no depth due to 100% wound bed is hard with clack eschar. Area covered with [MEDICATION NAME] and EHOB boot in place, left heel measuring 6cm X 10cm with soft black eschar, boggy in nature with 90% of wound bed edges lifting and purulent foul smelling drainage noted. Cleaned with normal saline and therahoney applied then [MEDICATION NAME]. Resident #93 did not tolerate well and moaned during movement. Resident #93 turned every two hours will continue to monitor. B. Facility failure to ensure Resident #93 received care, consistent with professional standards of practice, to promote healing of a coccyx pressure injury and to prevent new pressure injuries from developing, contributing the hospital findings above. 1. Failure to properly assess resident's risk for pressure injuries Despite the resident's cognitive impairment, dependency, and incontinence (see MDS above), her Braden Scale for predicting pressure sore risk, dated 4/9/2020, documented the resident was at mild risk because she was limited in her ability to respond to verbal commands to relieve pressure-related discomfort, had rarely moist skin, was chairfast and had very limited mobility, adequate nutrition and had problem in moving. Previous Braden assessments, 4/18/18, 7/10/19, 10/10/19, and 1/9/2020, consistently identified the resident risk as mild, despite noting her limited ability to respond to verbal commands, chairfast condition and very limited mobility. 2. Failure to ensure the resident's pressure injuries were comprehensively assessed, monitored and treated by qualified individuals. a. Weekly Ulcer Progress Reports Review of the Weekly Ulcer Progress Reports revealed documentation weekly beginning 3/11/2020, regarding a pressure injury on the resident's coccyx. There was no evidence in any of the weekly reports that the pressure injury was reported to a wound physician for evaluation. Notice to the resident's physician was provided 3/11/2020, but not thereafter. Further, the reports inaccurately read the resident turned herself and that the depth of her coccyx wound decreased when no depth was previously recorded. The 3/11/2020 Weekly Pressure Ulcer Progress Report revealed: -Resident #93 had a stage 2 on her coccyx measuring 7.5 cm x 6.5 cm. Scant drainage, no odor, pink color, physician notified, skin turgor fair and resident turns herself. Interventions included air mattress. This report was completed by the director of nursing (DON), and there was no evidence in the record it was reported for evaluation to a wound physician. The 3/13/2020 Weekly Pressure Ulcer Progress Report revealed: -Resident #93 had a stage 2 on her coccyx measuring 7.5 cm x 6.0 cm. Scant drainage, no odor, pink color, skin turgor fair and resident turns herself. Resident #93 had documented decreased wound size and depth. Interventions included air mattress. This report was completed by the DON, and there was no evidence in the record it was reported for evaluation to a wound physician or the resident's physician. The 3/20/2020 Weekly Pressure Ulcer Progress Report revealed: -Resident #93 had a stage 2 on her coccyx measuring 7.0 cm x 6.0 cm. No drainage, no odor, pink color, skin turgor fair and resident turns herself. Resident #93 had documented decreased wound size and depth. Interventions included air mattress. This report was completed by the DON, and there was no evidence in the record it was reported for evaluation to a wound physician or the resident's physician. The 3/27/2020 Weekly Pressure Ulcer Progress Report revealed: -Resident #93 had a stage 2 on her coccyx measuring 6.5 cm x 6.0 cm. No drainage, no odor, pink color, skin turgor fair and resident turns herself. Resident #93 had documented decreased wound size and depth. Interventions included air mattress. This report was completed by the DON, and there was no evidence in the record it was reported for evaluation to a wound physician or the resident's physician. The 4/3/2020 Weekly Pressure Ulcer Progress Report revealed: -Resident #93 had a stage 2 on her coccyx measuring 6.0 cm x 6.0 cm. No drainage, no odor, pink color, skin turgor fair and resident turns herself. Resident #93 had documented decreased wound size and depth. Interventions included air mattress. This report was completed by the DON, and there was no evidence in the record it was reported for evaluation to a wound physician or the resident's physician. The 4/10/2020 Weekly Pressure Ulcer Progress Report revealed: -Resident #93 had a stage 2 on her coccyx measuring 5.0 cm x 5.5 cm. No drainage, no odor, pink color, skin turgor fair and resident turns herself. Resident #93 had documented decreased wound size. Interventions included air mattress. This report was completed by the DON, and there was no evidence in the record it was reported for evaluation to a wound physician or the resident's physician. No heel injuries were not noted on the 4/10/2020 Weekly Pressure Ulcer Report. The 4/16/2020 Weekly Pressure Ulcer Progress Report revealed new pressure injuries on the resident's heels: -Resident #93 had a stage 2 on her coccyx measuring 3.0 cm x 2.0 cm. No drainage, no odor, pink color, skin turgor fair and resident turns herself. Resident #93 had documented decreased wound size. Interventions included air mattress.This report was completed by the DON, and there was no evidence in the record it was reported to a wound physician or the resident's physician for evaluation/treatment consideration as the wound had been present for a month. -Resident #93 had a stage 2 on her left heel with no measurements. Resident #93's left heel remains intact, no longer soft and mushy. Interventions included elevate heel and podius boots. This report was completed by the DON, and there was no evidence in the record it was reported for evaluation to a wound physician or the resident's physician despite documentation of a new pressure injury. -Resident #93 had a stage 2 on her right heel with no measurements. Resident #93 left heel remains intact, less soft and mushy. Interventions included elevate heel and podius boots. This report was completed by the DON and was never reported for evaluation to a wound physician or the resident's physician. b. Weekly skin/wound notes 4/8 - 4/15/2020 Review of weekly skin/wound notes revealed the notes were not consistent with the Weekly Pressure Ulcer Reports, referencing bilateral heel issues as early as 4/8/2020. Further, the skin/wound notes that referenced the resident's heel injuries did not include measurements, how the coccyx wound looked or anything associated with the care of the wounds. -On 4/8/2020 at 3:20 p.m., the weekly skin/wound note written by a registered nurse (RN) read weekly skin assessment completed, skin warm to touch, mucous membranes pink and moist, cap refill<4 seconds. wound to coccyx still present. Bilateral leg wound healing. Bilateral heel discoloration still present. Bilateral boots in place. -On 4/15/20 at 10:55 a.m. the skin/wound note read, weekly skin assessment completed; skin warm to touch; mucous membranes pink and moist; cap refill <3seconds. wound care to coccyx and left heel done per order. The DON stated in an interview on 9/17/2020, that the skin/wound notes were skin assessments as she had looked at the wounds, too. c. Wound physician and resident physician notes Further record review for physician notes from 3/1/2020 to 4/19/2020 confirmed Resident #93 did not have a wound physician note documenting the number, location, and size (length, width, and depth) of the resident's pressure injuries and assessment of the presence (or lack) of exudate, odor, sinus tracts, necrosis or eschar formation, tunneling, undermining, infection, healing (granulation and [MEDICATION NAME]), and wound margins. Further record review 3/11/2020 - 4/16/2020 also confirmed no assessment by the resident's physician of the resident's pressure injuries. Indeed, the Medical [DIAGNOSES REDACTED].#93 was an unspecified open wound, left lower leg, dated 2/20/20. d. Interview revealed the DON was responsible for monitoring, managing and documenting residents' pressure injuries, and further revealed she had not had any recent training on wound care. -Certified nurse aide (CNA) #2 was interviewed on 9/15/2020 at 12:53 p.m. She said CNAs do not monitor skin integrity when they provide incontinence care for residents. -Unit Manager #1 was interviewed on 9/16/2020 at 9:44 a.m. and again on 9/17/2020 at 9:53 a.m. She said wound measurements were completed by the DON on Thursdays during weekly wound rounds. She said the facility ' s process was for the DON to look at the wounds and do the measurements. -The minimum data set coordinator (MDS Coordinator) was interviewed on 9/17/2020 at 8:30 a.m. She said every morning there was a meeting with the DON, NHA MDS coordinator and other department heads on residents' change of condition. She said the DON informed the interdisciplinary team in morning meetings on residents ' care such as wound treatment. She said only the DON made decisions on wound care. -The DON was interviewed on 9/17/2020 at 10:38 a.m. The DON said that the process at the facility was for the nurses to do weekly skin assessments to look at residents ' skin. She said the unit managers would do checks to see if the assessments were completed. She said she was not wound care certified but she took a couple of classes many years ago at a different organization. She said she did the measurements and evaluation for Resident #93. She said at the time Resident #93 was at the facility and acquired the wounds, the facility did not have a wound doctor. The DON acknowledged that pressure ulcers/injuries should be monitored weekly and appropriate evaluations, and interventions should be assessed by a wound doctor. 3. Failure to evaluate interventions and treatments There was insufficient evidence interventions and treatments were revised when the pressure injury did not heal or when new pressure injuries were identified. Review of the resident's CPOs revealed an order, dated 3/25/2020, to cleanse wound on coccyx with wound cleanse, pat dry, apply wound gel, cover with boarder gauze, and change dressing every shift until resolved. This was the first and only documented order from the physician orders [REDACTED]. There were treatment orders for the resident's heel injuries on 4/14/2020, which was four days after the heel injuries were identified 4/10/2020 (per the 4/16/2020 Weekly Pressure Ulcer Report). Review of the resident's care plan revealed it was initiated 7/31/17 and there were no care plan revisions until 4/23/2020, after the resident had been hospitalized . As revised, the care plan read Resident #93 had an open area to coccyx, open area to left heel and was at risk for pressure ulcer development related to incontinence, immobility, wheelchair primary mode of mobility, cognitive impairment, and refused showers at times. - Interventions in place after revision included to administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the medical doctor. -Interventions in place prior to revision included: inform the resident/family/caregivers of any new skin breakdown (7/31/17); Instruct/assist to shift weight in wheelchair frequently and as needed (7/31/17 and revision 7/10/18); Keep the bed as flat as possible to reduce shear (7/31/17, revision 7/10/18); weekly skin assessments (7/31/17, revision 7/101/18); obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated (7/31/17); Pressure relieving/reducing device on wheelchair (7/31/17 and revision on 7/10/18). Although the facility had sheets of paper that list two hour increments from 12:00 midnight to 10:00 p.m. for staff to turn resident right, left, back and the sheets were documented with check marks or by saying yes, neither the initial care plan, the revised care plan, nor the Kardex included a directive for staff to reposition the resident who was totally dependent and not able to reposition (contrary to the Weekly Pressure Ulcer Report documentation). Further, record review revealed no evidence the IDT considered the effectiveness of care planned interventions as the resident's coccyx wound failed to heal and she acquired additional pressure injuries. Finally, record review revealed the interventions documented in the skin/wound note on 4/8/2020 and the 4/16/2020 Weekly Pressure Ulcer Report (air mattress, elevate heel and podius boots) were not listed in the care plan. C. Action taken by facility after Resident #93's discharge Record review revealed the facility developed an action plan after the resident's hospitalization on [DATE], to initiate preventive measures to promote and maintain skin integrity and to treat and monitor pressure injuries once they develop. The action was the DON would collaborate with the resident's primary physician to ensure appropriate treatment and interventions were put in place for all residents with pressure injuries. (Cross-reference F684; failure to ensure a resident with a history of pressure injury received the care and services necessary to prevent recurrent skin injuries.) However, the plan did not address pressure injuries not being assessed by a wound physician. The DON, during her interview on 9/17/2020 at 10:38 a.m. said the facility had recently hired a wound doctor to follow up on wounds to make sure the residents receive the proper treatments and evaluations.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19 novel coronavirus in four of four resident neighborhoods. The failure affected all residents present in the facility which placed the facility in an immediate jeopardy situation. Specifically, the facility failed to: -Timely and appropriately provide an infection control training for staff and residents with emphasis on COVID-19; -Ensure residents had face masks/coverings while outside of their rooms; -Timely and appropriately assess residents for signs and symptoms of upper respiratory infection of COVID-19; and -Label chemicals with the chemical name and manufacturer information, and appropriately dilute bleach, used by the facility staff to disinfect surfaces, according to CDC guidelines. The facility's failure to monitor residents' upper and lower respiratory tract infection for signs and symptoms of possible COVID-19 novel coronavirus, according to standards of practice, coupled with the staff lack of knowledge and training created the situation for serious harm likely to occur at a level of immediate jeopardy due to potential transmission of [MEDICAL CONDITION]. Findings include: I. Record review - resident and staff status The Resident Line List, a template for data collection, dated [DATE], revealed that out of 52 residents in the facility, 51 were tested for COVID-19. Twenty-four residents were positive for COVID-19. Eleven residents' laboratory results were negative for COVID-19. Sixteen residents were hospitalized . The Staff Line List, a template for data collection, dated [DATE], revealed that out of 53 facility staff tested for COVID-19, 20 had positive laboratory results. II. Face masks for residents A. CDC recommended guidelines The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings ([DATE]), https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, (Update [DATE]), included: Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. B. Observations On [DATE] at 12:15 p.m., a male resident was observed in the hallway, propelling his wheelchair towards the patio/garden door. The resident said he was going outside to smoke a cigarette. The resident did not have a face mask or other face covering. On [DATE] at 12:45 p.m., a male resident was observed ambulating in the hallway. He had no face mask or face covering. On [DATE] at 12:46 p.m., a male resident in a wheelchair was propelling in the hallway. He had no face mask or face covering. On [DATE] at 12:59 p.m., a female resident was ambulating in the hallway. She had no face mask or face covering. On [DATE] at 1:12 p.m., a male resident in a wheelchair was propelling himself in the hallway. He had no face mask or face covering. C. Interviews Resident #1 was interviewed on [DATE] at 1:14 p.m. He said he walks the halls two to three times a day. He said the facility had not offered him any kind of mask or face protection. Resident #2 was interviewed on [DATE] at 1:16 p.m. He said he went outside to smoke frequently, or as much as they will let me. He said he did not have a face mask or face protection. He said he had not been offered anything and he would wear one. Certified nurse aide (CNA) #1 was interviewed on [DATE] at 12:30 p.m. She said the residents did not have any type of face masks in their rooms. She said, The facility has not been enforcing use of facemasks by residents when they come out of their rooms. The regional clinical nurse (RCN) said that two of the residents had been offered face masks. He could not recall which two residents. He said the residents should have a face mask when they are out of their rooms. He said, We need to work on this. II. Resident screening for signs and symptoms of COVID-19 A. Professional reference The Centers for Disease Control and Prevention https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (updated [DATE]), read in part: Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness. Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0oF might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19. People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear ,[DATE] days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: cough, shortness of breath, fever, chills, muscle pain, sore throat, and new loss of taste or smell. This list is not all possible symptoms. Other less common symptoms have been reported, including gastrointestinal symptoms like nausea, vomiting, or diarrhea. Colorado Department of Public Health and Environment Covid-19 Preparation and Rapid Response Checklist for Long Term Care Facilities (LTCF's), retrieved from: https://covid19.colorado.gov/ltcf on [DATE]. Rapid response, Increase active monitoring of all residents to two times daily to include temperature, heart rate, blood pressure, respiratory rate, pulse oximetry, changes in mental status, cough, shortness of breath, difficulty breathing, fever, chills, rigors, myalgia, headache, sore throat, new smell or taste disorder, rhinorrhea (runny nose), diarrhea, nausea or vomiting. B. Record Review Resident #2 The resident's medical record was reviewed for the month of [DATE] on [DATE] at 1:30 p.m. It did not document a screening twice daily or daily. The record documented the following: On [DATE] (no time documented) this resident was assessed once, his temperature was 97.9 degrees Fahrenheit and he had no respiratory symptoms. He was assessed three days later on [DATE] (no time documented), his temperature was 98.2 degrees Fahrenheit and he had no respiratory symptoms. He was assessed once daily from [DATE] to [DATE] for a temperature and respiratory symptoms. He had no fever or symptoms. As of [DATE], the resident had not been assessed. The resident's monitoring/assessment for signs and symptoms of COVID-19 was not completed for 10 days. Resident #3 The resident's medical record was reviewed on [DATE] at 1:34 p.m. The record documented the resident had been assessed on [DATE], [DATE], [DATE], [DATE], once daily for signs and symptoms of COVID-19. He was not assessed on [DATE] and [DATE]. He was assessed once to twice daily from [DATE] to [DATE]. He was not assessed on [DATE]. He was assessed once on [DATE]. The resident's monitoring/assessment for signs and symptoms of COVID-19 was not completed for 10 days. Resident #4 The resident's medical record was reviewed on [DATE] at 1:38 p.m. There was no documentation that the resident had been assessed for signs and symptoms of COVID-19 since [DATE]. The resident's monitoring/assessment for signs and symptoms of COVID-19 was not completed for 10 days. C. Interview The regional clinical nurse (RCN) was interviewed on [DATE] at 1:55 p.m. He said the residents should be screened every shift. He said on the COVID positive unit they were screened every 12 hours and on the non-COVID positive unit they were screened every eight hours. The RCN said he had reviewed the nurses' notes for the above three residents. He said the residents were not screened as they were supposed to be screened. He said all of the residents should be monitored twice daily. He said, We will have to work on that. III. Disinfectants A. Professional reference Centers for Disease Control and Prevention (CDC) Cleaning Spaces where COVID-19 Cases Spent Time ([DATE]) retrieved from https://www.cdc.gov/coronavirus/2019-ncov/community on [DATE], read in part, Unexpired household bleach will be effective against coronaviruses when properly diluted. Prepare a bleach solution by mixing: five tablespoons (,[DATE]rd cup) bleach per gallon of water or four teaspoons bleach per quart of water. B. Observation On [DATE] at 11:18 a.m. in the main dining room, a spray bottle containing blue colored liquid, ¾ (three quarters) full and a bottle containing yellow colored fluid in a clear spray bottle ¼ (one quarter) full were observed on a counter at the entry to the dining room. The spray bottles were not labeled. The nursing home administrator (NHA) and regional clinical nurse (RCN) were present. They both said they did not know what kind of fluid was in the bottles, but they would find out. The regional nurse said it should be some kind of disinfectants and that the bottles should have been labeled. C. Interviews The assistant administrator (ANHA) was interviewed on [DATE] at 11:20 a.m. He said the spray bottle with yellow fluid was bleach and the blue fluid was Virex II. He said he did not know the dwell time for either of the disinfectants. He said he did not know the ratio of water to bleach for the bleach solution or who had mixed it. He said he would follow up with maintenance and housekeeping. He said the bottles should be labeled. The regional maintenance director (RMD) was interviewed on [DATE] at 11:30 a.m. He said the blue solution was Virex II disinfectant and the yellow solution was bleach and water. He said he did not know who was mixing the bleach solution but he would take over this task as of today. He said the correct ratio of bleach to water was one teaspoon of bleach to 32 ounces of water; he said he thought the kitchen staff had mixed the solution. The RMD said the bottles needed to be labeled for safety reasons. The regional dietary director (RDD) was interviewed on [DATE] at 12:57 p.m. He said a dietary aide had mixed the unlabeled bleach solution last night. He did not know what ratio of bleach to water she had used. He said the correct ratio was ,[DATE], 50 percent bleach to 50 percent water. D. Record review The Virex II label manufacturer information was reviewed on [DATE] at 1:30 p.m. The information documented the product was a one step cleaner, surfaces needed to remain wet for 10 minutes, and it caused severe skin burns, severe eye damage, and serious damage to mouth, throat and stomach. Keep tightly closed. Keep only in the original container. IV. Facility notice of Immediate Jeopardy On [DATE] at 1:15 p.m., the ANHA was notified of the Immediate Jeopardy under F880, infection prevention and control. A. Facility plan to remove Immediate Jeopardy On [DATE] at 4:00 p.m., the ANHA provided a plan to remove the Immediate Jeopardy. The plan read: All staff will be educated by NDA/designee prior to working their next shift on wearing PPE appropriately. NHA/designee will complete an audit twice daily during walking rounds to ensure compliance in this area. This audit will be conducted twice daily for 30 days to ensure compliance. Further education and disciplinary action will occur as needed. All staff will be educated prior to working their next shift that all residents will have face covering and they are to be worn when in commons areas. Residents who refuse to wear face covering will be provided education and reminders on why they need to wear a mask. This education will be noted in the progress notes. NHA/designee will complete an audit twice daily during walking rounds to ensure compliance in this area. This audit will be conducted twice daily for 30 days to ensure compliance. Further education and disciplinary action will occur as needed. All nurses will be educated prior to working their next shift that residents will be screened twice daily and PRN to ensure signs and symptoms of COVID are not present. This documentation will be noted in the progress notes. NHA/designee will complete an audit of 50% of residents to ensure compliance in this area. This audit will be conducted daily for 30 days to ensure compliance. Further education and disciplinary action will occur as needed. All staff will be educated prior to their next shift regarding appropriate disinfectants for COVID according to CDC. NHA/designee will complete an audit twice daily during walking rounds to ensure compliance in this area. This audit will be conducted twice daily for 30 days to ensure compliance. Further education and disciplinary action will occur as needed. All staff will be educated prior to their next shift that only educated personnel will be allowed to mix bleach/water solution to avoid confusion. These personnel will ensure there is adequate supply of mixture at all times. This mixture will then be placed into containers for use that are properly labeled. NHA/designee will oversee and document compliance with every bleach mixture for the next 14 days to ensure compliance. Further education and disciplinary action will occur as needed. B. Removal of Immediate Jeopardy On [DATE] at 4:30 p.m. the ANHA was notified the Immediate Jeopardy situation was removed. However, deficient practice remained at an H level.

Based on record review, video evidence and staff and family interviews, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and adequate supervision and assistance devices to prevent accidents for one (#1) of three sample residents. Specifically, the facility failed to provide appropriate oversight for fall prevention. This failure resulted in resident #1's admission to the hospital for the treatment of [REDACTED]. Cross refer F309 and F224 and F157. Findings include: Sample resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses, according to her face sheet, that included mental disorder, diabetes, hypertension and Alzheimer's disease. According to her most recent Minimum Data Set (MDS), an annual assessment (that assessed the resident's abilities in a specific seven day time frame) completed on 1/14/11 her physical/behavioral ability was assessed as follows, in pertinent parts: her BIMS (Brief Interview for Mental Status) was not completed due to her inability to participate (related to dementia and behaviors); she was noted to be understandable but rarely able to understand what others said; she was coded as having been severely impaired in her cognitive skills for Daily Decision Making; noted to have delusions and exhibit behaviors that put herself and others at risk for physical injury; she was independent in ambulation in her room, but required supervision outside of her room. MDS Details According to thew MDS, assessment completed on 1/14/11 her physical/behavioral ability was assessed as follows, in pertinent parts: Balance During Transitions and Walking: Moving from seated to standing position Walking (with assistive device if used) Turning around and facing the opposite direction while walking Moving on and off toilet Surface-to-surface transfer (transfer between bed and chair or wheelchair) Coded as: Steady at all times Not steady but able to stabilize without human assistance Not steady, only able to stabilize human assistance Her behaviors per the MDS were documented as to significantly interfere with the resident's care, put others at significant risk for physical injury and to significantly disrupt care or living environment. Resident #1 was also documented to reject care one to three days. She was also put at significant risk by being outside of the secure unit and left near the main entrance without being under the constant observation of staff. The Wandering section of the MDS revealed: -wandering placed the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility). She was noted to be unsteady, but able to stabilize herself without assistance in the areas of moving from sitting to standing position; walking; turning around and facing the opposite direction while walking; moving on/off toilet and transfer from surface-to-surface. Record Review -The care plan, dated 1/14/11, revealed the resident was at risk for falls. -Nurses' Notes documented: 1/25/11 - 3:00 a.m. "Res. was found on the floor in her room at 2300 (11:00 p.m. on 1/24/11) & states that she fell from the bed to the floor. At first resident was not sure if she hit her head & later this was evidenced by the swelling to the right side of her head. Neuro(logical) checks were initiated & MD was notified. No new orders for the moment. Res was medicated with PRN (as needed) Tylenol for H/A (headache). Family will be notified in a.m. ..." 1/25/11 - 6:00 a.m. "Swelling to head decreased this a.m. after 3x (times) cold compresses were applied to site ...family notified.. 1/25/11 - 2:00 p.m. "Res. refused VS (blood pressure, temperature, pulse and respirations). C/O (complained of) headache, prn pain med given. Mild swelling noted on patient's head. ) confusion noted, no N/V (nausea/vomiting).." 1/26/11 - 4:00 a.m. " ...Res. is alert & oriented X1 (meaning she knew who she was), denies pain or discomfort and is compliant with only some of the nursing care, minimum swelling still (present) to Right side of head ..." 1/26/11 - 3:00 p.m. "Resident continues on charting for IFU (Incident Follow Up) for fall. Ambulating independently, C/O (complaining of) pain and received pain medications as ordered. Refused to be assessed and uncompliant (SIC) with the care. Refused the V/S." 1/27/11 - 5:10 a.m. " ...Slept for long period and denied any form of pain and discomfort. Remains on neuro checks and no concerns noted ..." 1/27/11 - 2:30 p.m. "Resident continues on charting for IFU for fall. C/O pain and received pain meds as ordered. ROM (range of Motion) & Neuros WNL (within normal limits) ..." Note: No additional documentation in the notes were included until 2/18/11, after the resident experienced another fall and another head injury. The DON (Director of Nursing) was asked about the lack of documentation since the end of the 72 hour follow up after her previous fall 1/24/11. The DON acknowledged it was "a little strange." (Please cross refer to interview with the DON in F309.) -Staff Interviews Registered Nurse (RN) Interview and Record Review On 5/10/11 at approximately 10:45 a.m., the RN (registered nurse) on duty the evening/overnight of 2/18/11 through 2/19/11 was interviewed via telephone. He stated he had been employed at the facility for approximately four years. When asked why resident #1 was left in the main lobby so late at night. He stated she "doesn't like the unit (the Secure Unit) and likes to sit in the lobby." There was a nurse's note, dated 2/18/11 at 9:20 p.m. It read, in pertinent parts: "Resident has been sleeping in chair in the day room of the main unit. Several attempts have been made to assist her to her room in the locked unit but has refused. Will continue to make attempts to assist her to her room and also promote safe environment." The next note referred to resident being found on the floor at 12:10 a.m. on 2/19/11. The RN confirmed that resident #1 was often out in the main lobby as was her preference. He also stated he had last seen her at approximately 9:30 p.m. There was no evidence the resident had been under constant surveillance, although she resided in the Secure Unit for her own safety and history of elopement attempts. CNA #1 The 1st CNA, a female who had worked at the facility for approximately two years, was interviewed via telephone on 4/28/11 at 11:30 a.m. When asked about the resident's fall on 2/18/11, she recounted the evening as follows: "I had a resident that had an accident (diarrhea). I had the dirty linen in a bag and was on the way to the dirty linen room when I saw (resident #1) on the floor. I walked past her, dropped of the dirty linen and then told the RN and another CNA that (resident #1) was on the floor." When asked how much time elapsed before she notified the RN, she stated it was about two minutes. She stated she did not stop and render first aid immediately because she had a bag of soiled linen. The CNA also stated, "I didn't think she was really hurt." CNA #2 The 2nd CNA, was interviewed via telephone on 5/6/11 at 10:15 a.m. When asked about the fall of resident #1 on 2/18/11, he recounted the evening as follows: "_______ (CNA #1) told me (resident #1) had fallen. She said the resident doesn't respond well and that I needed to help her in to a wheelchair. I noticed the injury (a bump on her forehead). She was hitting at me and punching at us. She said her head hurt. It took 45 minutes or so for her to settle down. Then the RN and I got her in to a wheelchair and took her to her room." He said the RN applied an ice pack to the resident's forehead as she continued to complain that her head hurt. The resident was given Tylenol 650 mg at 4:40 p.m. on 2/19/11, just before the family took her to the ER. -Hospital Records Review of the hospital record for resident #1 after the fall on 2/18/11 revealed, in pertinent parts: Discharge Summary (admitted [DATE] and discharged to a skilled nursing facility 3/1/11) "Discharge Diagnoses: [REDACTED]. Multiple falls Dementia Hypertension Diabetes Reason for admission: " ...She was in the nursing home for approximately 2 years secondary to dementia. At baseline, she is able to talk; however she talks nonsensically and is unable to carry on a conversation or perform her own ADLs. Her family reports she has suffered multiple falls in the preceding several weeks and had subsequently become more confused and had developed slight slurring of her speech. Because of this change in mental status after her fall, she was brought to (name of hospital) ER for evaluation. Once here she was seen in the ER. A CAT scan of the head was obtained, which showed bilateral acute subdural hematomas with mass effect. She was admitted to the ICU, and was seen in consultation with (name of neurosurgeon) ... who took her to the operating room and performed bilateral craniotomies with evacuation of these hematomas ....she remains "weak and debilitated" with decline in her previous level of mentation, and because of this we will transfer her to a skilled nursing facility as she remains max dependent for bed transfers at the current time ..." "...she does awake and is oriented to self, but other than that she does not follow commands and can be agitated at times ...She has also developed some degree of dysphagia (difficulty swallowing). She will follow up with her physicians at her new facility ..." (Please refer to F309 for additional hospital record review.) Video Recording Review On 3/17/11 (the first day of the abbreviated/complaint survey), the Administrator (NHA) showed the surveyor the video tape of the fall sustained by resident #1. He stated video cameras had been installed throughout the facility, including one placed across from where resident #1 fell , in the main lobby area of the open unit The resident was lying on the floor, motionless, for two minutes after falling directly on her face. When a staff member did appear in the video, she passed by without evidence she spoke to or acknowledged the resident. After two additional minutes, a registered nurse (RN) and a CNA (certified nurse aide) approached the resident. For more than 45 minutes, the two staff members approached the resident and tried to convince her to let them assist her. This delayed a timely assessment one hour of a neurological assessment (assessment of a potential brain injury) and an evaluation of the resident's overall condition. Nor did not attempt to ask the family to come in and offer support that would have calmed the resident down. Moreover, the facility did not call the family until 6:45 a.m., the next day. (Cross reference F 157.)

Based on record review, and staff and family interviews, the facility failed to ensure that they provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of three sample residents (#1). Specifically, the facility neglected to provide appropriate assistance and oversight in regard to fall prevention and timely, comprehensive post fall assessment. The resident had a history of [REDACTED]. The resident sustained [REDACTED]. Cross refer F323 and F224 and F157. Findings include: Sample resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses, according to her face sheet, that included mental disorder, diabetes, hypertension and [MEDICAL CONDITION]. According to her most recent Minimum Data Set (MDS), an annual assessment (assessment of the resident's abilities in a specific seven day time frame) completed on 1/14/11, her physical/behavioral ability was assessed as follows, in pertinent parts: her BIMS (Brief Interview for Mental Status) was not completed due to her inability to participate (related to dementia and behaviors); she was noted to be understandable but rarely able to understand what others said; she was coded as having been severely impaired in her cognitive skills for daily decision making; noted to have [MEDICAL CONDITION] and exhibit behaviors that put herself and others at risk for physical injury; she was independent in ambulation in her room, but required supervision outside of her room. Video Recording Review On 3/17/11, the NHA showed the surveyor the video tape of the fall sustained by resident #1. He stated they had installed video cameras throughout the facility including one situated across from where resident #1 fell , in the main lobby area of the open unit. Details of the fall are as follows: -10:45 p.m. - The NHA also stated the time on the tape was off by four or five minutes but the stamped times on the tape were used for purposes of documentation. The resident was observed to be sitting in a high back chair sleeping. She was seated directly beside the exit, as per viewing the video tape (which could be opened from the inside without an alarm sounding). There were two other residents in the lobby area. They were both seated and had their backs to resident #1. There were no staff members visible on the tape. -10:50 p.m. - CNA #1 (see other staff interviews) was observed to be cleaning up the area, -10:51 p.m. - The CNA was no longer in the area. No other staff was observed to be in the area. -10:54 p.m. - The resident #1 woke up and then stood up. She then bent over to pick up her purse (on the floor beside the chair). The resident then fell over and landed on her face primarily to the left side. She was lying on the floor completely still for two minutes. -10:56 p.m. - Resident #1 rolled over on to her back. She made an attempt to sit up but at first could not. After a few minutes, she was able to sit up while supporting her weight on her arms, which she placed behind her back. -10:57 p.m. - CNA #1 walked in to the frame of the camera carrying what appeared to be a bag of trash. She was not observed speaking to the resident. She did not stop to offer assistance. She exited out of camera range. -10:58 p.m. - The CNA returned with the RN on duty. The RN approached the resident observed her. He ran his hand across the top of resident #1's head. The resident appeared to be refusing assistance and was pushing the RN away. CNA #1 was noted to have left the area. -10:59 p.m. - CNA #2 entered the area. -10:59 p.m. - 11:09 p.m. - Both the RN and CNA #2 stayed with the resident, sometimes standing trying to talk to her, at other times noted to be seated in nearby chairs. The resident was noted to push their hands away. NOTE: See Care Plan where it states she does not respond well to male caregivers. -11:09 p.m. - Resident #1 allowed the two staff members to assist her to a standing position and transfer her to a wheelchair (brought by CNA #2). She was then wheeled out of camera range. Staff Interviews Nursing Home Administrator The NHA was questioned (during the viewing of the video tape) about CNA #1 not stopping and offer assistance to resident #1 when she was first observed on the floor. He stated it was because she had a bag of garbage in her hands and needed to dispose of it. The NHA stated the CNA (#1) told him she did speak to the resident, before she appeared in camera range. Neither the RN or either CNA were observed attempting to take vital signs (blood pressure, temperature, pulse or respirations) or to have begun neurological (neuro) checks (see facility neurological checks policy listed below). The NHA had also been interviewed on 3/17/11 at 12:00 p.m. and asked about the hour delay before neuro checks were started. He stated he had no explanation for the delay. Director of Nursing (DON) Interview The DON was interviewed on 5/10/11 at approximately 10:30 a.m. When asked what her expectations were in regard to a resident fall (unwitnessed or the resident was known to have hit their head) she stated staff was to: -Assess the resident from head to toe and observe -Check vital signs and determine any injuries before moving the resident -Began neuro checks, including vital signs -Call the physician right away -Notify families within an hour The DON stated that the PCP for resident #1 was also the facility Medical Director and the PCP for the majority of their residents. She also stated that Dr. (name of PCP\Medical Director) "declined to send residents to the ER about 90% of the time." The DON was asked about the lack of documentation regarding resident #1 since the end of the 72 hour follow up after her previous fall 1/24/11. The DON did acknowledge that was "a little strange." Registered Nurse (RN) Interview and Record Review On 5/10/11 at approximately 10:45 a.m., the RN (Registered Nurse) on duty the evening/overnight of 2/18 through 2/19/11 was interviewed via telephone. He stated he had been employed at the facility for approximately four years. When asked why resident #1 was left in the main lobby so late at night, he stated she "doesn't like the unit (the Secure Unit) and likes to sit in the lobby." Note: Record review showed the resident got out of the unit with exiting visitors and then the staff was unable to persuade her to go back. Nurse's Notes, dated 2/18/11 at 9:20 p.m. read, in pertinent parts: "Resident has been sleeping in chair in the day room of the main unit. Several attempts have been made to assist her to her room in the locked unit but has refused. Will continue to make attempts to assist her to her room and also promote safe environment." The next note referred to resident being found on the floor at 12:10 a.m. on 2/19/11. There had been no documentation in the nurse's notes since 1/27/11, which was the last of three days worth of follow up charting after her previous fall 1/24/11. The RN confirmed resident #1 was often out in the main lobby as was her preference. He also stated he had last seen her at approximately 9:30 p.m. There was no evidence the resident had been under constant surveillance, although she resided in the Secure Unit for her own safety and history of elopement attempts. CNA #1 The 1st CNA, who had worked at the facility for approximately two years, was interviewed via telephone on 4/28/11 at 11:30 a.m. When asked to explain her involvement with the fall of resident #1 on 2/18/11, she recounted the evening as follows: "I had a resident that had an accident (diarrhea). I had the dirty linen in a bag and was on the way to the dirty linen room when I saw (resident #1) on the floor. I walked past her, dropped of the dirty linen and then told the RN (a male) and another CNA (a male) that (resident #1) was on the floor." When asked how much time elapsed before she notified the RN, she stated perhaps two minutes. When asked why she did not stop and render first aid immediately, she stated it was because she had a bag of dirty linen. The CNA stated that the other resident was not on isolation. The CNA stated, "I didn't think she was really hurt." CNA #2 The 2nd CNA, a male who had worked at the facility for approximately four years, was interviewed via telephone on 5/6/11 at 10:15 a.m. When asked to explain his involvement with the fall of resident #1 on 2/18/11, he recounted the evening as follows: "(CNA #1) told me (resident #1) had fallen. She said the resident doesn't respond well and that I needed to help her in to a wheelchair. I noticed the injury (a bump on her forehead). She was hitting at me and punching at us. She said her head hurt. It took 45 minutes or so for her to settle down. Then the RN and I got her in to a wheelchair and took her to her room." He did say the RN applied an ice pack to the resident's forehead as she continued to complain that her head hurt. Record review showed the resident was administered Tylenol 650 mg at 12:10 a.m., over one hour after her initial complaint of a headache. She was also given Tylenol 650 mg at 4:40 p.m. on 2/19/11, just before the family took her to the ER. Family Member #1 Two different family members were interviewed in the course of the complaint investigation. The first family member (#1) was interviewed via telephone on 5/3/11 at approximately 3:45 p.m. She was very upset stated resident #1 had lived at home with another family member (#2) prior to moving to the facility. She also stated that while her mentation had deteriorated (due to the progression of her dementia) the main reason they moved her to the facility two years ago was due to her wandering. She stated the family was very worried she would elope and get hurt. She denied that the resident had fallen at home; and stated that she had fallen "several" times at the facility and that she had eloped on at least one occasion as well. Family Member #2 Family #2 (also the resident's power of attorney-POA) was interviewed via telephone on 5/6/11 at approximately 1:30 p.m. She was upset and over what had occurred. Her primary concerns was not notified about the fall on 2/18/11 for seven hours and that the resident was not in the Secure Unit. The POA stated that if she had been notified at the time of the fall, she would have immediately gone to the facility. She stated she was the legal guardian and POA and it was her understanding she would be notified of any changes in condition. She stated that the RN on duty told her that resident #1 was found on the floor in the front lobby area by two other residents. The POA questioned the staff as to why resident was left unattended in the front lobby when she had been placed on the Secure Unit. Family member#2 stated the family had specifically requested the resident not be left in the main lobby because she had eloped from the building before. Note: She also stated that she spoke with the physician on the phone and he told her that if an ambulance was called to the facility and the resident refused to go, they would be responsible for the costs, which could be as high as $1500. The family member stated "there was no way I could afford that. So we tried to decide what to do. Finally, we took her (to the ER) in our own car. Yes she resisted, but she always did that, due to her dementia." The family member expressed regret over not knowing what to do. "Dr. (name of PCP) threw me for a loop with the threat of being responsible for the bill." The POA also stated she hung up on the physician, because she was so angry. "I asked him if he was going to send her out to the hospital and he said no. He said she would just "refuse treatment" and we would be stuck with the bill! I then asked him if he was planning on coming in to the facility to examine her and he said no. I was so upset-she looked like she had be beaten and he did not think it was important enough to come and see her- so I hung up!" She stated that the nurse then called the physician back and he stated that if the family "insisted" he would authorize sending her to the ER. "At that point, we (as a family) just decided to take her ourselves. She was in bad shape when we got there and wound up having brain surgery." The POA was asked if the resident had a prior history of falls, and she stated, "No. She never fell when she lived with me. We moved her to (name of facility) because she was getting out (eloping) and we feared for her safety. They promised she would be in a Secure Unit and be safe." She also confirmed a previous fall on 1/24/11. The POA/family member stated, "It is so difficult to see her now. She can't walk or transfer alone. She makes no sense when she talks ...her speech is slurred and she is way more confused. She does not even recognize all of her family! I can't believe they (the facility) did not watch her better or respond quicker when she fell ." Physician Interviews Primary Care Physician/Medical Director On 5/6/11 at approximately 11:05 a.m., a telephone interview was conducted with resident #1's Primary Care Physician. He was also the facility Medical Director. The PCP was informed the of the video tape of the fall on 2/18/11. The PCP confirmed he had viewed the tape as well. The PCP stated, "I thought it was a routine fall ...These things happen." He stated that based on the information he received from the RN, he did not feel the resident need to be sent to the emergency room . Record review showed he give an order to send the resident to the ER. The actual order read: "Res. (resident) to go out to the ER upon noted family insistence." The order was written on 2/19/11 with no time documented. He also stated there was "a reported clinical change that made things a little more worrisome," but could not recall specifics. Additional record review did not show any evidence of a clinical change documented or reported. He stated he spoke with a family member via telephone the morning of 2/19/11. He stated based on past history of refusing care, the would refuse to go. He acknowledged he spoke to the family about the possibility they might incur charges for the ER visit and the ambulance ride if they were later deemed to be not medically necessary. emergency room Attending Physician On 5/4/11 at approximately 2:40 p.m., the attending physician who saw resident #1 in theER on [DATE] was interviewed via telephone. (See ER Notes below). The main question was the documentation of both chronic and acute subdural hematomas. He stated the "chronic" hematoma was most likely due to a prior fall. The ER physician was informed the resident had also sustained a fall on 1/24/11, and was noted to have sustained a bump on the head. He stated that while there was no way to specifically site that previous fall, it was likely the cause of the chronic subdural hematoma vs. the acute subdural hematoma sustained on 2/18/11. He stated he recalled that resident #1 was confused and not a reliable historian. He also confirmed her combativeness. When asked about the significance of her injuries, he confirmed she had to have surgical intervention (craniotomies with evacuation of the hematomas - see hospital report below). Facility Falls - Clinical Protocol The NHA provided the surveyor with their "Clinical Protocol" for falls on 3/17/11. It was dated 2005, revised April 2007. It read, in pertinent parts: "Assessment and recognition ...Monitoring and Follow-Up: The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall ..." Note: Resident #1 had also fallen in the facility on 1/24/11. physician progress notes [REDACTED]. Review of the most recent physician progress notes [REDACTED]. Under Review of Systems, the physician wrote, in part; " ...Neurological: Mod dementia with behavior disturbances is reported. No falls ..." There was no evidence the physician was aware resident #1 had fallen on 1/24/11, based upon his documentation. Facility Policy for Neuro Checks The facility provided a copy of their policy on 5/6/11. It (was undated) and it read: "_ (name of facility) Policy and Procedure for Neuro Checks Policy - To ensure close, timely and accurate neurological monitoring of un-witnessed falls and head trauma to prevent complications. Procedure - Obtain a NEUROLOGICAL ASSESSMENT FLOW SHEET Fill out the form with pertinent resident information Neuro checks must be completed as follows: Every 15 minutes x 4 (one hour) Every 30 minutes x 2 (one hour) Every hour x 4 (four hours) Every two hours x 1 (2 hours) Every four hours x 4 (16 hours) Every 8 hours x 6 (48 hours) Any negative findings or change in the resident's condition must be documented in the nurse's notes and reported to the attending physician immediately as well as to the family and/or responsible party." Review of the Neurological Assessment Flow Sheet for 2/19/11 showed that although the fall occurred on 2/18/11 at approximately 10:54 p.m., the first neuro check documented was not until 11:45 p.m. on 2/18/11 - almost one hour after she fell . Much if the form was marked Ref (refused) and the facility maintained that the resident refused to let them do the checks. Professional Standards 1. According to the Resident Assessment and Monitoring for Long-term Care, Established Tools and Guidelines for Clinicians, HC Pro publishing, 2006, Barbara Acello, pages 58 and 59: -Standards of long-term care nursing practice require for an unknown or suspected head injury, neuro-checks (neurological checks) for a minimum of 72 hours. -Immediately after a fall, monitor neuro-checks should be done every 15 minutes. If the resident is stable, time between neuro-checks may be increased to every 30 minutes for two hours, every 60 minutes for two hours, every four hours for 24 hours and then once a shift. 2. According to Mosby's Clinical Nursing, 5th Edition, (2002), page 238, neurological assessment includes determination of the patient's baseline status, ability to verbalize, ability to follow commands, orientation to person, time, place and situation, responsiveness to pain, light pressure, pupillary response to light, and use of the Glascow Coma Scale. The Glascow Coma Scale rates responsiveness for three faculties: eye opening, motor response, and verbal response to various stimuli and creates a score for comparative value. Diminishing function on all of these assessments indicates a deterioration of the patient's neurologic condition. Neuro checks (for the fall on 2/18/11) were as follows: 2/18/11 11:45 p.m. (1st documented neuro check) All vital signs and pupil response was documented and she was noted to be combative and NOT oriented. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was positive for knowing her name and confirmed pain. 12:00 midnight - From that point on the resident was documented as refusing to have her blood pressure, or temperature checked again. Only her pulse and respiratory rate were documented. She was positive for knowing her name and confirmed pain. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was noted to be combative and oriented. 2/19/11 12:15 a.m. - The resident was documented as refusing to have her blood pressure, or temperature checked again. Only her pulse and respiratory rate were documented. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was positive for knowing her name and confirmed pain. 12:30 a.m. - The resident was documented as refusing to have her blood pressure, or temperature checked again. Only her pulse and respiratory rate were documented. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was positive for knowing her name and confirmed pain. 12:45 a.m. - The resident was documented as refusing to have her blood pressure, or temperature checked again. Only her pulse and respiratory rate were documented. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was positive for knowing her name and confirmed pain. 1:15 a.m. - The resident was documented as refusing to have her blood pressure, or temperature checked again. Only her pulse and respiratory rate were documented. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was positive for knowing her name and confirmed pain. 1:45 a.m. - The resident was documented as refusing to have her blood pressure, or temperature checked again. Only her pulse and respiratory rate were documented. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was positive for knowing her name and confirmed pain. 2:45 a.m. - The resident was documented as refusing to have her blood pressure, or temperature checked again. Only her pulse and respiratory rate were documented. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was positive for knowing her name and confirmed pain. 3:45 a.m. - The resident was documented as refusing to have her blood pressure, or temperature checked again. Only her pulse and respiratory rate were documented. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was positive for knowing her name and confirmed pain. 4:45 a.m. - The resident was documented as refusing to have her blood pressure, or temperature checked again. Only her pulse and respiratory rate were documented. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was positive for knowing her name and confirmed pain. 5:45 a.m. - The resident was documented as refusing to have her blood pressure, or temperature checked again. Only her pulse and respiratory rate were documented. Pupil response noted to be a 3 (cm) and reaction to light was brisk. She was positive for knowing her name and confirmed pain. 7:45 a.m. - At that point, the form was marked refused and there were no more vital signs documented. The pupil response remained the same, as did confirmed pain. 11:45 a.m. - The form was marked refused and there were no more vital signs documented. The pupil response remained the same, as did confirmed pain. 3:45 p.m. - She was not marked as knowing her name and orientation level not documented, but remained positive for pain. There was no more pupil response being documented. 7:45 p.m. - Resident documented as being out of the facility (the family had transported her via their personal vehicle). In summary, the facility did not begin neuro checks immediately, as per their policy. From 7:45 a.m. until she left the facility at approximately 4:45 p.m., they documented her refusing to have pulse checked and respirations. Respiratory rates are done by observation and should have continued to be monitored. The resident's cognitive status was clearly documented throughout the chart as being not oriented, yet the facility documented her to be oriented. Care Plan Review of resident #1's care plan revealed the following pertinent problems, goals and approaches (in pertinent parts as it related to falls, supervision): Last updated 1/14/11 ... Note: Her care plan was not updated after the fall on 1/24/11 or the most recent fall on 2/18/11. "Approaches: -Assess resident's balance, vs. Blood Pressure (lying down and standing) at least every PRN (as needed). Document results and report abnormalities to physician ... ...Supervision on and off the (Secure) unit, as well as during activities ..." Hospital Records Review of the hospital record for resident #1 after the fall on 2/18/11 revealed, in pertinent parts: Discharge Summary (admitted [DATE] and discharged to a skilled nursing facility 3/1/11) "Discharge Diagnoses: [REDACTED]. Multiple falls Dementia Hypertension Diabetes Reason for admission: ...She was in the nursing home for approximately 2 years secondary to dementia. At baseline, she is able to talk; however she talks nonsensically and is unable to carry on a conversation or perform her own ADLs. Her family reports she has suffered multiple falls in the preceding several weeks and had subsequently become more confused and had developed slight slurring of her speech. Because of this change in mental status after her fall, she was brought to (name of hospital) ER for evaluation. Once here she was seen in the ER. A CAT scan of the head was obtained, which showed bilateral acute subdural hematomas with mass effect. She was admitted to the ICU, and was seen in consultation with (name of neurosurgeon) ... who took her to the operating room and performed bilateral craniotomies with evacuation of these hematomas ....she remains "weak and debilitated" with decline in her previous level of mentation, and because of this we will transfer her to a skilled nursing facility as she remains max dependent for bed transfers at the current time ..." ...she does awake and is oriented to self, but other than that she does not follow commands and can be agitated at times ...She has also developed some degree of dysphagia (difficulty swallowing). She will follow up with her physicians at her new facility ..." History & Physical The physical examination (as documented on the History & Physical obtained from the hospital) showed: "SKIN: Most remarkable for bruising on the central forehead ulcer around the cheeks, particularly on the left ..." Operative Report "Date of surgery: 2/20/11. Surgeon: (name of neurosurgeon) History: ... The family noted that she has had several falls while in the nursing home, one specifically, where other occurred three weeks ago. She had an additional fall on 2/19/11..Her family noted some change in personality in recent weeks with some increased combativeness. She has described occasional headache in recent days. Pertinent findings at the time of hospital admission include a confused patient who is awake and responsive verbally, but is oriented only to person. She recognizes some family members ...There is evidence of some ecchymosis (bruising) around her face and nose from recent trauma. CT scan of the head completed on 2/19/11, demonstrates bilateral chronic subdural hematomas, larger on the left hemisphere than on the right. There was significant brain compression and mild midline shift left to right. The patient was taken to surgery for [REDACTED]. Prior to the procedure, the risks were reviewed with the patient's daughter and other family members including the risk of hemorrhage, stroke, increased neurological deficits, [MEDICAL CONDITION] and recurrence of the subdural hematomas ..." Note: See interview with Attending Physician Interview above re: chronic vs. acute subdural hematomas.

The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Based on record review, video evidence, and staff and family interviews, the facility failed to ensure one (#1) of three sample residents was free from neglect. Specifically, the facility neglected to provide appropriate assistance and oversight in regard to fall prevention, based on the resident's history of a fall 1/24/11; and timely, comprehensive post fall assessment for a second fall 2/18/11. This failure resulted in the resident being admitted to the hospital for the treatment of [REDACTED]. Cross refer F323, F309 and F157. Findings include: Sample resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses, according to her face sheet, that included mental disorder, diabetes, hypertension and [MEDICAL CONDITION]. According to resident #1's most recent Minimum Data Set (MDS), completed on 1/14/11, the resident's cognitive skills for daily decision making were impaired. The BIMS (Brief Interview for Mental Status) was not completed due to her inability to participate (related to dementia and behaviors). The resident was noted to be understood but was rarely able to understand what others said. She was noted to have [MEDICAL CONDITION] and exhibit behaviors that put herself and others at risk for physical injury. She was independent in ambulation in her room, but required supervision outside of her room. Furthermore, the MDS indicated that the resident had a history of [REDACTED]. She could also be resistive to care. It also revealed that the resident wandered on a daily basis. She was noted to be at significant risk of getting to a potentially dangerous place such as the stairs or outside of the facility. The resident resided on a locked, secured unit in the facility due to her elopement risk and history of wandering. The nursing noted revealed that the resident had two recent falls on 01/24/11 and 02/16/11. Record Review The record review revealed: Nursing Notes 1/25/11 - 3:00 a.m. "Res. was found on the floor in her room at 2300 (11:00 p.m. on 1/24/11) & states that she fell from the bed to the floor. At first resident was not sure if she hit her head & later this was evidenced by the swelling to the right side of her head. Neuro checks were initiated & MD was notified. No new orders for the moment. Res was medicated with PRN (as needed) Tylenol for H/A (headache). Family will be notified in a.m. ..." 1/25/11 - 6:00 a.m. "Swelling to head decreased this a.m. after 3x cold compresses were applied to site ...family notified ... " 1/25/11 - 2:00 p.m. "Res. refused VS (blood pressure, temperature, pulse and respirations). C/O (complained of) headache, prn pain med given. Mild swelling noted on patient's head. Confusion noted, no N/V (nausea/vomiting)." 1/26/11 - 4:00 a.m. " ...Res. is alert & oriented X1 (meaning she knew who she was), denies pain or discomfort and is compliant with only some of the nursing care, minimum swelling still (present) to Right side of head ..." 1/26/11 - 3:00 p.m. "Resident continues on charting for IFU (Incident Follow Up) for fall. Ambulating independently, C/O (complaining of) pain and received pain medications as ordered. Refused to be assessed and uncompliant (SIC) with the care. Refused the V/S." 1/27/11 - 5:10 a.m. " ...Slept for long period and denied any form of pain and discomfort. Remains on neuro checks and no concerns noted ..." 1/27/11 - 2:30 p.m. "Resident continues on charting for IFU for fall. C/O pain and received pain meds as ordered. ROM (range of Motion) & Neuros WNL (within normal limits) ..." Review of the nursing notes revealed there was no further documentation in resident #1's record until her next fall on 02/18/2011. The DON (Director of Nursing) was asked about the lack of documentation since the end of the 72 hour follow up after the resident's previous fall on 1/24/11. The DON did acknowledge that was a "little strange." Please cross refer to interview with the DON in F309. Physician Visits Record review showed that the primary care physician (PCP) saw the resident on 1/19/11 and again on 2/16/11. Even though a fall was sustained on 1/24/11, the physician documented no falls on his 2/16/11 visit. There was no evidence that in spite of swelling to her head, repeated complaints of headache as well as sleeping for long periods of time, the physician ever came in to assess the resident timely after the first fall. Video Recording Review On 3/17/11 (the date the complaint was opened), the NHA offered to show the surveyor the video tape of the fall sustained by resident #1. He stated they had installed video cameras throughout the facility and that there was one situated across from where resident #1 fell at 10:54 p.m., in the main lobby area of the open unit. Cross reference F309 for details of the video recording. In summary, the resident was lying on the floor, motionless for two minutes, after falling directly on her face. When a staff member did appear in the video, she passed by without evidence she spoke to or acknowledged the resident. Approximately two minutes more elapsed before two staff members approached the resident. The resident appeared to be resistive to care and for approximately 45 minutes, which delayed a proper, timely post-fall and neurological assessment. The resident's daughter, who lives within driving distance(?), was not contacted during the resident's resistance. According to the resident's daughter, she was not contacted until 6:45 a.m. the following day. The resident's daughter may have been able to redirect the resident, expediting the appropriate assessments and care. In an interview with a registered nurse (via telephone on 5/4/11 at approximately 10:45 a.m.), he stated, the resident resided on a locked, secured unit in the facility due to her elopement risk and history of wandering. The nurse stated, she "didn't like the unit and likes to sit in the lobby." Nurse's notes, dated 2/18/11 at 9:20 p.m., documented in pertinent parts, "resident has been sleeping in a chair in the day room of the main unit. Several attempts have been made to assist her to her room in the locked unit but has refused. Will continue to make attempts to assist her to her room and also promote safe environment." As displayed on the video, the resident was not being monitored by staff and fell approximately 10:54 p.m. Hospital Record Review emergency room Attending Physician On 5/4/11 at approximately 2:40 p.m., the attending physician who saw resident #1 in theER on [DATE] was interviewed via telephone. (See ER Notes below.) The question was the documentation of both chronic and acute subdural hematomas. He stated that the "chronic" hematoma was most likely due to a prior fall. The ER physician was informed the resident had also sustained a fall on 1/24/11 and was noted to have a bump on her head. . He stated he recalled that resident #1 was confused and not a reliable historian. He also confirmed her combativeness. When asked about the significance of her injuries, he confirmed she had to have surgical intervention (craniotomies with evacuation of the hematomas-see hospital Discharge Summary). Discharge Summary in pertinent parts: (admitted [DATE] and discharged to a skilled nursing facility 3/1/11) "Discharge Diagnoses: [REDACTED]. Multiple falls Dementia Hypertension Diabetes Reason for admission: ...She was in the nursing home for approximately 2 years secondary to dementia. At baseline, she is able to talk; however she talks nonsensically and is unable to carry on a conversation or perform her own ADLs. Her family reports she has suffered multiple falls in the preceding several weeks and had subsequently become more confused and had developed slight slurring of her speech. Because of this change in mental status after her fall, she was brought to (name of hospital) ER for evaluation. Once here she was seen in the ER. A CAT scan of the head was obtained, which showed bilateral acute subdural hematomas with mass effect. She was admitted to the ICU, and was seen in consultation with (name of neurosurgeon) ... who took her to the operating room and performed bilateral craniotomies with evacuation of these hematomas ....she remains "weak and debilitated" with decline in her previous level of mentation, and because of this we will transfer her to a skilled nursing facility as she remains max dependent for bed transfers at the current time ..." ...she does awake and is oriented to self, but other than that she does not follow commands and can be agitated at times ...She has also developed some degree of dysphagia (difficulty swallowing). She will follow up with her physicians at her new facility ..."

Based on record review, video evidence, staff and family interviews, the facility failed to immediately notify the family after the resident experienced two different falls resulting in injuries that required physician intervention for one resident (#1) of three sample residents. Specifically, resident #1 sustained head injuries (chronic subdural hematomas from a fall 1/24/11 and acute subdural hematomas from the second fall on 2/18/11) and the facility did not notify the family in a timely manner. This prolonged the time immediately after the incident when the resident, who was very confused related to her dementia, did not have the emotional support of her family. Moreover, it was the family who took the resident to the hospital where she was admitted for brain surgery resulting in a hospital stay until 3/3/11. Cross reference F323, F309 and F224. Findings include: Sample resident #1, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses, according to her face sheet, that included mental disorder, diabetes, hypertension and [MEDICAL CONDITION]. According to her most recent Minimum Data Set (MDS), an annual assessment (an assessment used to determine the resident's abilities in a specific seven day time frame), was completed on 1/14/11, including her physical/behavioral ability; assessed as follows, in pertinent parts: her BIMS (Brief Interview for Mental Status) was not completed due to her inability to participate (related to dementia and behaviors); she was noted to be understood but rarely able to understand what others said; she was coded as having been severely impaired in her cognitive skills for daily decision making; noted to have [MEDICAL CONDITION] and exhibit behaviors that put herself and others at risk for physical injury; and was independent in ambulation in her room, but required supervision outside of her room. Director of Nursing (DON) Interview The DON was interviewed on 5/10/11 at approximately 10:30 a.m. When asked what her expectations were in regard to a resident fall (unwitnessed, or the resident was known to have hit his/her head), she stated expectation included staff notify families within an hour. 01/24/11 Fall Nurses' notes revealed the following: 1/25/11 - 3:00 a.m. "Res. was found on the floor in her room at 2300 (11:00 p.m. on 1/24/11) & states that she fell from the bed to the floor. At first resident was not sure if she hit her head & later this was evidenced by the swelling to the right side of her head. Neuro checks were initiated & MD was notified. No new orders for the moment. Res was medicated with PRN (as needed) Tylenol for H/A (headache). Family will be notified in a.m. ..." The facility did not call the family until 6:45 a.m., the next day. 02/18/11 Fall: Video Recording Review On 3/17/11 (the first day of the abbreviated/complaint survey), the Administrator (NHA) showed the surveyor the video tape of the fall sustained by resident #1. He stated video cameras had been installed throughout the facility, including one placed across from where resident #1 was seated in the front lobby on 02/18/11 at 10:45 p.m. The resident fell at 10:54 p.m. after standing up and bending over to pick up her purse. (Cross reference F309 for details of the video recording.) The resident was lying on the floor, motionless, for two minutes after falling directly on her face. When a staff member did appear in the video, she passed by without evidence she spoke to or acknowledged the resident. After two additional minutes, a registered nurse (RN) and a CNA (certified nurse aide) approached the resident. Though the resident had a documented history of sexual abuse, and a preference for female caregivers, the two male staff members, approached and tried to convince the resident to let them assist her for more than 45 minutes. This delayed a timely assessment one hour of a neurological assessment (assessment of a potential [MEDICAL CONDITION]) and an evaluation of the resident's overall condition. And though a female CNA was available, the male staff members did not request her assistance. Nor did they attempt to ask the family to come in and offer support that would have calmed the resident down. Family Interview Family member #2 (also the resident power of attorney-POA) was interviewed via telephone on 5/6/11 at approximately 1:30 p.m. The POA was quite upset and tearful at times over what had occurred. Her primary concern was not being notified about the resident's 2/18/11 fall for seven hours, and that the resident was not in the Secure Unit at the time of the most recent fall. The POA stated if she had been notified at the time of the fall, she would have immediately gone to the facility. As the resident's legal guardian and POA, it was her understanding she would be notified of any changes in the resident's condition. She stated the RN on duty told her resident #1 was found on the floor in the front lobby area by two other residents. She also stated she spoke with the physician by phone and he told her that if an ambulance was called to the facility, and the resident refused to go, they would be responsible for the costs, which could be as high as $1500. The family member stated, "there was no way I could afford that. So we tried to decide what to do. Finally, we took her (to the ER) in our own car. Yes she resisted, but she always did that, due to her dementia." The family member expressed regret over not knowing what to do. "Dr. (name of PCP) threw me for a loop with the threat of being responsible for the bill." The POA also stated she hung up on the physician, because she was so angry. "I asked him if he was going to send her out to the hospital and he said no. He said she would just "refuse treatment" and we would be stuck with the bill. I then asked him if he was planning on coming in to the facility to examine her, and he said no. I was so upset-she looked like she had been beaten, and he did not think it was important enough to come and see her- so I hung up!" She stated the nurse then called the physician back, and he stated that if the family "insisted," he would authorize sending her to the ER. "At that point, we (as a family) just decided to take her ourselves. She was in bad shape when we got there and wound up having brain surgery." The POA/family member tearfully stated, "It is so difficult to see her now. She can't walk or transfer alone. She makes no sense when she talks ...her speech is slurred and she is way more confused. She does not even recognize all of her family! I can't believe they (the facility) did not watch her better or respond quicker when she fell ."