Every finding on record at Colonial Rehabilitation and Nursing, LLC

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours, seven days a week. Specifically, the facility failed to schedule a RN for at least eight consecutive hours on 3/2/26, 3/3/26 and 3/4/26.Findings include:I. Record reviewA review of the 3/2/26, 3/3/26 and 3/4/26 nursing staff schedule revealed there were no RNs scheduled to work on those three days.II. Staff interviewThe nursing home administrator (NHA) was interviewed on 3/9/26 at 2:55 p.m. and said there were no RNs available in the facility for 3/2/26, 3/3/26 and 3/4/26, while the director of nursing (DON) was on vacation. The NHA said the scheduling coordinator was responsible for the staffing schedule to ensure a RN was available for at least eight hours a day. The NHA said a RN had been scheduled to work the night shift on 3/5/26 and 3/6/26 and the scheduler would ensure a RN was scheduled at least eight consecutive hours a day in the future.

Based on record review and interviews, the facility failed to ensure one (#5) of eight residents reviewed for abuse out of 12 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #5 from verbal abuse by Resident #15.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy and procedure, dated 4/11/25, was provided by the regional clinical resource on 12/4/25 at 5:21 p.m. It 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 implement policies and procedures to prevent and prohibit all types of abuse and achieve the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.II. Facility investigationThe facility investigation, dated 12/3/25 was provided by the nursing home administrator (NHA) and the regional clinical resource on 12/4/25 at 8:57 a.m. The investigation revealed the following:On 10/1/25 at 11:00 a.m. Resident #15 initiated verbal aggression towards Resident #5. A statement from the business office manager, dated 12/3/25 at 6:57 p.m., revealed on the day of the incident (10/1/25) she heard Resident #15 in a threatening manner in the dining room. When the business office manager entered the dining area, she heard Resident #15 threatening to hurt Resident #5. Resident #15 initially raised his fist, then proceeded to grab a dining room chair to hit Resident #5 with it. The assistant director of nursing (ADON) intervened and grabbed the chair from Resident #15. Resident #15 then continued to be verbally abusive to the facility staff who tried to speak with him.A statement from another staff member, dated 12/3/25 at 7:46 p.m., revealed the staff member was in another area of the facility on 10/1/25 and heard Resident #15 shouting at Resident #5 in the dining room. Resident #15 was cursing at Resident #5 when the staff member heard a loud noise. When the staff member entered the dining room Resident #15 still appeared agitated and one of the dining room chairs was on the floor. All residents, including Resident #5, were taken out of the dining room so the staff could deescalate and calm Resident #15 down.Resident #5 was interviewed on 12/3/25 and did not recall the incident that occurred on 10/1/25. Resident #5 said he ate in his room because he felt like it, and said he felt safe in the facility.The facility substantiated the abuse allegation.III. Resident #15 (assailant)A. Resident statusResident #15, age [AGE], was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included bipolar disorder, anxiety disorder and schizoaffective disorder.The 9/10/25 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. The resident was independent for most activities of daily living (ADL).The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others.B. Record reviewThe schizoaffective diagnosis care plan, initiated 10/25/24 and revised 12/4/25 (during the survey) revealed Resident #15 had potential to be verbally aggressive due to his diagnosis of schizoaffective disorder. Resident #15's trigger was identified as being when someone new was seated at his table in the dining room. Pertinent interventions included administering medications as ordered and analyzing key times, places, circumstances, triggers, and what de-escalated Resident #15's behaviors. On 12/4/25, an intervention was added to the care plan to have no other residents seated at Resident #15's table besides his friend whenever possible; if another resident was seated at the table, staff would speak to the other resident.The behavior care plan, revised 10/25/24, revealed Resident #15 had the potential to be physically aggressive. Pertinent interventions included assessing and anticipating the resident's needs, assessing and addressing contributing sensory deficits and administering medications as ordered.A progress note, dated 8/26/25 at 2:55 p.m., revealed while in the dining room, a staff member approached Resident #15 and asked him if he would mind turning the common area television volume down, as he had the remote. Resident #15 became rageful, screamed at the top of his lungs and raised his fists at the staff member and threatened to knock her out. Resident #15 said the remote was his, and he would kill anyone who touched it. The staff member attempted to speak with Resident #15 and de-escalate his behavior but was unsuccessful. Another staff member approached Resident #15 and asked if she could help, and Resident #15 cursed at her and attempted to lunge at her from his wheelchair. Staff members called the NHA and had Resident #15 speak to him, and Resident #15 went outside after the conversation without further issues.A progress note, dated 8/28/25 at 11:07 a.m., revealed Resident #15 approached a nursing staff member at the nurses' station and asked for his medications. The staff member explained to Resident #15 that he had left the building when the nurse had attempted to give him his medications, and it was past the time ordered by the physician for those medications. Resident #15 began yelling and cursing at the nurse, and repeatedly tried to lunge forward at the nurse from his wheelchair. Multiple staff members attempted to de-escalate Resident #15 to no avail before the NHA stepped in and worked to de-escalate the situation. A progress note, dated 9/10/25 at 2:05 p.m., revealed Resident #15 had finished working with physical therapy in the therapy gym and began to demand the therapy staff allow him to exit the building through a side door. Staff members attempted to explain to Resident #15 why he could not exit through those doors and the resident began cursing at them and using insults.A progress note, dated 10/1/25 at 11:14 a.m., revealed Resident #15 approached the business office manager to inquire about money in his account. Resident #15 began yelling and cursing at the business office manager when she was working with another resident. Resident #15 continued yelling and began approaching the other resident the business office manager was working with. A staff member intervened and told Resident #15 she would have the NHA handle the resident's request, but he needed to leave the business office manager's office as his language was inappropriate. Resident #15 told the staff member if they got the NHA involved, he would get a club and beat their heads in.A progress note, dated 10/1/25 at 1:44 p.m., revealed that at approximately 11:00 a.m. the morning of 10/1/25 a staff member was standing in the hallway when they heard Resident #15 screaming and cursing at the business office manager. Resident #15 went into the dining room afterward, still screaming obscenities. At approximately 11:20 a.m., the staff member witnessed Resident #15 picking up a dining room chair and telling another resident I told you not to put this chair here, you fat (expletive). The ADON was in the dining room at the time and was able to take the chair away from the resident. A staff member tried to redirect Resident #15 while other staff members worked to escort other residents away from the dining area. Another staff member called the police. Resident #15 eventually calmed down, ate his lunch and requested to go outside. Resident #15 returned to the facility after talking to the police.A progress note, dated 10/1/25 at 2:02 p.m., revealed another staff member witnessed the incident in the dining room that morning (10/1/25). The staff member heard yelling and loud banging and responded to the dining room. Resident #15 was yelling and throwing his hands up in the air saying he would kill everyone and beat them with the chair. The staff member stepped forward and grabbed the chair Resident #15 was attempting to pick up. Resident #15 said it was another resident's spot. Resident #15 attempted to strike the nurse with the chair, but the nurse was able to take the chair away from the resident. Resident #15 then swung his fists around but did not make contact with any other staff or residents. The nurse attempted to ask Resident #15 what was wrong and see why he was upset, but the resident continued screaming and swinging his fists. The police were notified and other residents were removed from the dining room, as multiple residents were crying or covering their faces/ears. Resident #15 was able to stop screaming when he was given his meal tray. After talking with the police, Resident #15 came back into the building and said to the staff that he could do whatever he wanted to them. Resident #15 then went into a female resident's room and shut the door. Nursing staff asked the female resident if she was comfortable with Resident #15 being in her room, and she said she was fine as she did not want to upset him. A progress note, dated 11/13/25 at 12:40 p.m., revealed Resident #15 was noted to be in another resident's room who was positive for COVID-19. A nurse asked Resident #15 to leave the other resident's room, to which Resident #15 responded saying he wished he had COVID-19 so he could kill the nurse with it. The nurse asked Resident #15 to lower his voice as he was making the resident's roommate start to cry. The resident whose room Resident #15 was in asked him to leave, to which Resident #15 responded by throwing a mask at the resident's roommate, hitting her in the face. Resident #15 left the room after spitting at the nurse. The resident whose room Resident #15 had been in said she did not know why he acted like that, and said she did not want him acting like that in her room.A progress note, dated 11/17/25 at 2:41 p.m., revealed Resident #15 had been kicking a door violently and later complained of having foot and toe pain. Resident #15 told the staff he was kicking the door because the staff did not give him the code to use the door. A progress note, dated 12/3/25 at 1:56 p.m., revealed during wound assessment rounds with the wound care physician, Resident #15 and the wound care physician discussed the resident's wounds. Resident #15 became agitated and raised his voice at the wound care physician. The wound care physician attempted to de-escalate the resident and said he was just giving the resident recommendations. Resident #15 told the wound care physician not to talk to him and that he did not have to listen to him, and began posturing back and forth with clenched fists at the wound care physician.An interdisciplinary team (IDT) event review note, dated 12/4/25 at 7:54 a.m., revealed the IDT reviewed Resident #15's incident of verbal aggression on 10/1/25. The root cause was determined to be that Resident #15 did not like having another resident sit at his table in the dining room. Interventions put in place included not having other residents seated at Resident #15's table in the dining room when possible.A psychotropic meeting review, dated 10/2/25 at 10:49 a.m., documented Resident #15's target behaviors for his psychoactive medications included verbal aggression and threatening behaviors. Resident #15's target behavior frequency was documented as too many to count. The meeting recommendations included increasing Resident #15's Lamictil (a mood stabilizer) and to continue monitoring the resident.IV. Resident #5 (victim)A. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the December 2025 CPO, diagnoses included anxiety disorder and major depressive disorder.The 11/12/25 MDS assessment revealed the resident had mild cognitive impairments with aBIMS score of 12 out of 15. The resident required supervision to substantial assistance from staff for most ADLs.The MDS assessment documented the resident did not have physical or verbal behaviors directedat others or other behavioral symptoms not directed toward others.B. Record reviewA progress note, dated 10/1/25 at 2:20 p.m., revealed a nurse heard yelling and loud thumps in the dining room, and saw Resident #5 being screamed at by another resident (Resident #15). Resident #5 was sitting in his chair watching Resident #15 attempt to lift a chair, threatening to beat Resident #5 with the chair and saying the seat in the dining room was not his. A nurse responded and was able to intervene by standing between the residents and removing the chair before Resident #5 was struck with it. Resident #5 and other residents in the dining room were moved away from the area for safety. When the police responded, Resident #5 said he had put a chair in the wrong place and Resident #15 became irate and started screaming. Resident #5 told the police he was scared for his life and thought Resident #15 was going to hit him with the chair. Resident #5 said he would not be going into the dining room again because the situation kept happening and he did not understand why.An IDT event review note, dated 12/4/25 at 8:45 a.m., revealed Resident #5 received verbal aggression on 10/1/25. The root cause of the incident was determined to be due to Resident #5 sitting at a different table in the dining room. Interventions put into place included having Resident #5 eat at a different table in the dining room. The note documented Resident #5 felt safe and did not recall the incident.V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 12/4/25 at 10:43 a.m. CNA #1 said there were not enough CNAs working on either hall of the facility. CNA #1 said the facility had a lot of aggressive residents who needed one-on-one attention and the staff could not watch everyone.Registered nurse (RN) #1 was interviewed on 12/4/25 at 1:57 p.m. RN #1 said the nursing staff documented residents' behaviors in their electronic medical records (EMR) as progress notes. RN #1 said interventions for residents' behaviors varied from resident to resident and were generally documented in their care plans. RN #1 said Resident #15 had a history of verbally aggressive behaviors, and the facility had to call the police for him at one point because of his behaviors. RN #1 said she had seen Resident #15 become verbally aggressive with a physician at one point. RN #1 said she did not think Resident #15's care plan had any documented triggers for his behaviors, and said she had not noted any triggers while working with him. RN #1 said it was important to give Resident #15 time to cool down whenever he became agitated, and to use different staff members to calm him down if he was irritated with a specific person. RN #1 said Resident #15 was eventually able to be redirected once he was given time to calm down.CNA #2 was interviewed on 12/4/25 at 3:25 p.m. CNA #2 said Resident #15 became angry frequently, and threw objects just about every time he became angry. CNA #2 said Resident #15 was disrespectful to staff and other residents whenever he was in one of his moods. CNA #2 said the only trigger she knew of for Resident #15's behaviors was regarding his medication times. CNA #2 said she knew Resident #15 had smashed chairs and had yelled at a female resident a lot, but the female resident liked Resident #15 too much and did not see his behavior as disrespectful.The director of nursing (DON), the ADON and the regional clinical resource were interviewed together on 12/4/25 at 3:59 p.m. The DON said the social services staff conducted interviews with residents to identify triggers for their behaviors and give the nursing staff a basis to work with. The DON said each resident entered the facility with behavioral health services and their behaviors were monitored in the monthly psychotropic meeting. The DON said the nursing staff updated the residents' care plans with interventions and identified triggers as needed and quarterly. The DON said Resident #15 was verbally aggressive. She said Resident #15's triggers included having no patience with others, confrontation, and when other residents were sitting in his spot in the dining room. The DON said Resident #15 was also known to kick the front door of the facility.The regional clinical resource said a lot of Resident #15's issues were with the facility staff, as he did not like to follow the facility rules. The regional clinical resource said the dining room seating arrangement trigger was in Resident #15's care plan and had been added that day (12/4/25) as the management team had just found out about the incident. The regional clinical resource said she did not see any other identified triggers in Resident #15's care plan.The DON said Resident #15 was sometimes redirectable but not very easily. The DON said Resident #15 had not been redirectable at all more recently. The DON and the regional clinical resource said Resident #15's behavior care plan had interventions added to it on 3/25/25 and 10/4/25.The DON said Resident #15's behaviors had been increasing, and the physician had completed a psychotropic medication review and adjusted some of the resident's psychoactive and pain medications.The regional clinical resource said Resident #15 was seen by the facility's behavioral health services. The regional clinical resource said following the incident on 10/1/25, the facility implemented increased monitoring in the dining room by staff.The NHA was interviewed on 12/4/25 at 8:57 a.m. The NHA said he had not been informed there were other residents involved during the 10/1/25 incident with Resident #15. The NHA said Resident #15 had a history of being verbally abusive to staff, and the facility staff had called him to calm Resident #15 down but did not inform him Resident #5 was involved in the situation on 10/1/25.The NHA was interviewed again on 12/4/25 at 5:00 p.m. The NHA said Resident #15's mental health diagnoses were the underlying cause of his behaviors. The NHA said Resident #15 got agitated and escalated quickly. The NHA said Resident #15's behaviors were primarily focused on staff, and he lashed out at the staff nearly every day. The NHA said he had talked with the facility staff about de-escalation techniques for Resident #15, and he had been the resident's primary de-escalator since he began working at the facility. The NHA said he was able to redirect Resident #15 outside when he was agitated, let him calm down and talk through different ways the resident could have approached the situation. The NHA said this technique had worked for a while, but it was becoming harder to de-escalate Resident #15.The NHA said Resident #15's best friend had discharged from the facility recently, and he thought Resident #15 missed her and was subsequently acting out. The NHA said the facility staff were wary of Resident #15 when he became upset. The NHA said Resident #15's behaviors sometimes involved other residents. The NHA said Resident #15 usually did not instigate incidents but needed prodding to escalate. The NHA said Resident #15 had been involved in other resident-to-resident altercations prior to the incident on 10/1/25. The NHA said Resident #15 had been involved in an incident in 2024 in which he and a female resident were yelling at each other and pulling at a salt shaker stand in the dining room. The NHA said Resident #15's trigger seemed to be having his space invaded, as the resident always ate in the same spot in the dining room and stuck to the same schedule. The NHA said both incidents with other residents were in the dining room and seemed to deal with having Resident #15's space invaded. The NHA said Resident #15 did not talk to women very nicely, especially staff, but responded okay to the NHA talking to him man-to-man. The NHA said Resident #15 was able to think rationally when he calmed down, but when the resident was agitated, no one could get through to him.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#7) of three residents reviewed for accident hazards out of 12 sample residents.Specifically, the facility failed to ensure the safe and appropriate use of mechanical lifts when working with Resident #7.Findings include:I. Facility policy and procedureThe Safe Resident Handling/Transfers policy and procedure, dated 4/11/25, was received from the regional clinical resource on 12/4/25 at 5:21 p.m. It read in pertinent part, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe. Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur.II. Resident #7A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis on one side of the body), generalized muscle weakness and cerebral infarction (stroke).The 10/24/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) assessment score of three out of 15. The resident was dependent on staff for most activities of daily living (ADL). The resident was dependent on staff for most transfer activities.B. Facility investigationThe facility investigation, dated 12/3/25 at 6:20 p.m. was received from the regional clinical resource on 12/4/25 at 8:57 a.m. The investigation revealed that on 10/17/25 Resident #7 was being transferred from his wheelchair to his bed after dinner using a Hoyer lift (mechanical lift). The investigation documented the staff using the manual Hoyer lift did not extend the lift's legs fully, so the lift began to tip and was partially caught by one of the staff members. Resident #7 landed on the floor on his back, and did not sustain any injuries. Radiograph (Xray) results, dated 10/20/25, revealed Resident #7 received radiographs of his right hip which did not show any evidence of fractures or breaks.The investigation included Hoyer lift competencies for four licensed practical nurses (LPN), one rehabilitation nurse aide, and 11 certified nurse aides (CNA) with dates ranging from 11/7/25 to 12/3/25. -However, not all nursing staff competencies were included. Additionally, the staff competencies were assessed starting three weeks after the incident on 10/17/25.Additional documentation was provided by the regional clinical resource on 12/4/25 at 5:35 p.m., including an in-service on mechanical lift use and safety that was conducted on 10/18/25. -However, only one-third of the nursing staff signed off that they had participated in the in-service.C. ObservationsAn initial tour of the facility was conducted on 12/3/25 at 10:45 a.m. Three electric Hoyer lifts were stored in the back hallway of the facility along the wall with several items of furniture or other appliances between them. The lifts and the appliances were pushed together so the lifts were not easily accessible.On 12/3/25 at 4:40 p.m. CNA #3 and CNA #4 performed hand hygiene, donned gloves and entered Resident #7's room with the manual Hoyer lift. The CNAs provided incontinence care for Resident #7 and positioned a Hoyer lift sling under the resident while he laid in bed. CNA #3 maneuvered the Hoyer lift arm over the resident and attached the loops of the sling to the lift while CNA #4 adjusted Resident #7's bed to better position the resident for the transfer. CNA #3 pumped the lever arm of the Hoyer lift to raise Resident #7 from his bed while CNA #4 lowered Resident #7's bed so the resident had enough clearance to swing from the bed to his wheelchair. CNA #3 then released the pump on the lift and Resident #7 was lowered into his wheelchair.A second tour of the facility was conducted on 12/4/25 at 7:40 a.m. The three electric Hoyer lifts were in the same position as they were on the initial observation of the back hallway, and remained pushed between furniture and appliances. D. Record reviewThe ADL care plan, revised 11/25/24, revealed Resident #7 had an ADL self-care performance deficit. Pertinent interventions included Resident #7 required a Hoyer lift for all transfers.A progress note, dated 10/17/25 at 6:58 p.m., revealed Resident #7 was being transferred from his wheelchair to his bed after dinner. Once suspended, the Hoyer lift tipped and was partially caught by the registered nurse (RN) assisting with the transfer. Resident #7 landed on his back on the floor and was witnessed to not hit his head. Resident #7 complained of head pain and stated his head did hit the floor, but did not complain of any other pain. Resident #7 was lifted from the floor to his bed and assessed, with no injury or redness to his skin noted. The assistant director of nursing (ADON), the director of nursing (DON), the hospice provider and the resident's representative were all notified.A progress note, dated 10/20/25 at 2:53 p.m., revealed Resident #7 complained of pain to his right hip from his fall on 10/17/25. Radiographs were ordered.An interdisciplinary team (IDT) event review note, dated 10/20/25 at 12:41 p.m., revealed the IDT team reviewed the incident on 10/17/25. The root cause of the incident was determined to be staff improperly using the lift equipment. Interventions put into place included training staff on the proper use of the lift.-However, not all of the staff were trained on the proper use of the lift (see above).III. Staff interviewsCNA #4 was interviewed on 12/3/25 at 4:48 p.m. CNA #4 said it was her first day working at the facility, and she had never seen a manual Hoyer lift like the one used in the facility. CNA #4 said the bigger, electric Hoyer lifts felt more sturdy, and the manual Hoyer lift felt more flimsy and like it could tip over. CNA #4 said she heard the electric Hoyer lifts had issues with their batteries, so the facility just had the one manual Hoyer lift. CNA #4 said there were quite a few residents in the facility who used the Hoyer lift for transfers.CNA #1 was interviewed on 12/4/25 at 10:43 a.m. CNA #1 said the facility only had one manual Hoyer lift. CNA #1 said the manual Hoyer lift tipped over, especially when working with heavier residents. CNA #1 said she and other staff members had reported to the management team that the manual Hoyer lift tipped over repeatedly, but the management team told the staff it was their fault and that they were using the lifts wrong. CNA #1 said the Hoyer lift still tipped over even when the lift's legs were spread out appropriately. CNA #1 said she had started working at the facility several months prior, and there had only been one manual Hoyer lift since she started.RN #1 was interviewed on 12/4/25 at 1:57 p.m. RN #1 said she worked with at least 12 residents who required a Hoyer lift for transfers. RN #1 said the manual Hoyer lift was the only lift they had, and it worked on pneumatic pressure. RN #1 said the manual Hoyer lift was stable for the most part if it was used appropriately. RN #1 said there had been one instance where the manual Hoyer lift tipped over, but it was not being used appropriately in that instance. RN #1 said she received education on how to use the manual Hoyer lift immediately after that incident (with Resident #7). RN #1 said she had worked at the facility for several months, and the electric Hoyer lifts had not been operational since she started. RN #1 said she did not know why the electric Hoyer lifts did not work.CNA #2 was interviewed on 12/4/25 at 3:25 p.m. CNA #2 said the nursing staff were nervous about using the manual Hoyer lift at first because it was flimsy. CNA #2 said the manual Hoyer lift tipped frequently, even when the legs were fully spread out, because of the way the lift was designed and how it fit under residents' beds and wheelchairs. CNA #2 said there were several residents for whom the manual Hoyer lift tipped over every time they transferred a resident. CNA #2 said the nursing staff had had to use the manual lift for months since the electric Hoyer lifts had issues with their batteries. CNA #2 said she never received education on how to use the manual Hoyer lift. CNA #2 said she was told she would receive education on using the Hoyer lift but was never provided with education on the subject.The ADON, the DON and the regional clinical resource were interviewed together on 12/4/25 at 3:59 p.m. The DON said the incident with Resident #7 on 10/17/25 involved the manual Hoyer lift. The DON said two staff members were assisting with the transfer, and the incident was caused by user error, as the staff members had not opened the Hoyer lift's legs all the way. The DON said the lift started to tip over, and Resident #7 was assisted to the ground. The DON said there were no injuries resulting from the incident.The DON said the facility's management team initiated education for proper manual and electric Hoyer lift operation. The DON said the electric Hoyer lifts were currently being used, and had been back in operation for several weeks prior. The DON said there had not been any other instances of the Hoyer lifts tipping over or other identified issues with the lifts.The DON said there were issues with the old set of electric Hoyer lift battery chargers which had been replaced. The regional clinical resource and the DON both said the staff were currently able to charge the electric Hoyer batteries without issue. The DON and the regional clinical resource said they had not identified any issues with the manual Hoyer lift tipping with the legs appropriately extended. The DON said the nursing staff complained to her about not liking to use the manual Hoyer lift as they had to use their arm strength to crank the lift up, but she had not been told about any tipping of the lift.The ADON and the DON said they had put a notice on their electronic medical record (EMR) system dashboard about the electric Hoyer lifts being operational again. The DON said she had texted multiple CNAs about the electric Hoyer lifts being operational again, and told them to add it to their shift report. The DON said the facility was storing the electric Hoyer lifts in a separate area of the facility when they were non-operational, and returned them to the floor once they were operational again.-However, interviews with several nursing staff members revealed they were not aware the electric Hoyer lifts were operational and observations revealed the electric Hoyer lifts were stored on a back hallway of the facility amongst other appliances (see interviews and observations above).

Based on observations, record review and interviews, the facility failed to ensure one (#18) of four residents reviewed for treatment and care in accordance with professional standards of practice out of 39 sample residents. Resident #18 was admitted on [DATE] for long term care with diagnoses of hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body), wound on the right ankle, contracture of muscles on the right lower leg, gait and mobility abnormalities and generalized muscle weakness.On 1/3/25 Resident #18 had a wound to his right lateral malleolus (outer ankle) that was healing per the wound physician. On 4/21/25 the wound physician documented the resident's wound had resolved.On 6/9/25 Resident #18 developed a new trauma wound to his right lateral malleolus. The wound physician began regularly rounding on the resident upon the redevelopment of the wound. The physician's orders directed staff to place a boot to Resident #18's ankle at all times. However, observations and interviews revealed the staff did not consistently implement the boot and offloading as ordered by the physician. Interviews revealed the wound physician determined the wound was created by friction from Resident #18's wheelchair. However, the facility failed to implement an intervention to prevent further friction from the wheelchair. Specifically, the facility failed to implement interventions to prevent Resident #18's recurring wound. Findings include:I. Facility policy and procedureThe Provision of Quality Care policy, dated 4/11/25, was provided by the regional clinical resource (RCR) via email on 7/24/25 at 5:34 p.m. It read in pertinent part, Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choice. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan.II. Resident #18A. Resident statusResident #18, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 computerized physician's orders (CPO), diagnoses hemiplegia and hemiparesis , wound on the right ankle, contracture of muscles on the right lower leg, gait and mobility abnormalities and generalized muscle weakness.The 7/9/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. The resident was dependent on staff for most activities of daily living (ADLs).The assessment documented the resident did not have any issues with his skin. B. Resident interview and observationsResident #18 was interviewed on 7/21/25 at 10:46 a.m. Resident #18 said he had a skin issue on his right ankle. Resident #18 said he had the skin problem on his right ankle for years, and said it started when he received a wheelchair with smaller wheels that rubbed against his ankles. On 7/22/25 at 11:25 a.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right foot was in a plastic bag attached to a Vaporox machine (a wound treatment device that used vapor and high oxygen concentrations for rapid wound healing). Resident #18 said it was the first day the facility had used the Vaporox machine for him.At 11:57 a.m. licensed practical nurse (LPN) #4 left Resident #18's room after applying a dressing to his right ankle. -However, LPN #4 did not apply a boot to Resident #18's right foot.At 11:59 a.m. Resident #18 was sitting in his wheelchair in his room wearing nonskid socks and was not wearing any boots or pressure-relieving devices. Certified nurse aide (CNA) #3 entered Resident #18's room and gave him his lunch tray.At 1:20 p.m. Resident #18 was sitting in his wheelchair in his room wearing nonskid socks and was not wearing any boots or pressure-relieving devices.At 3:25 p.m. Resident #18 was lying on his bed on his back. Resident #18 was wearing nonskid socks and was not wearing any boots or pressure-relieving devices.On 7/23/25 at 8:26 a.m. Resident #18 was sitting in his wheelchair in his room wearing nonskid socks and was not wearing any boots or pressure-relieving devices. Resident #18 said his right ankle hurt and rated his pain a 9 out of 10. Resident #18 said he did not tell his nurse he was in pain. At 1:10 p.m. Resident #18 was sitting in his wheelchair in his room wearing nonskid socks and was not wearing any boots or pressure-relieving devices.At 1:35 p.m. Resident #18 was lying on his back in bed with his legs under the blanket with a boot on his right foot visible through the blanket. Resident #18 said he was wearing one boot and the boot was not comfortable.On 7/24/25 at 8:39 a.m. Resident #18 was sitting in his wheelchair in his room wearing nonskid socks and was not wearing any boots or pressure-relieving devices.-There was padding to the wheelchair next to Resident #18's right ankle.C. Record reviewThe skin integrity care plan, revised 7/10/25, revealed Resident #18 had the potential for skin impairment and had trauma to the right malleolus (ankle). Pertinent interventions included ensuring good nutrition and hydration, using enhanced barrier precautions and wearing an offloading boot on his right foot (initiated 1/19/24 and revised 9/2/24).Review of the July 2025 CPO revealed the following orders:-Right outer ankle treatment: once a day, cleanse with wound cleaner, pat dry, apply skin prep to periwound area, apply honey-based gel to the wound bed and cover with bordered foam. Change daily and as needed,. ordered 7/1/25 and discontinued 7/7/25; -Right outer ankle treatment: once a day, cleanse with wound cleaner, pat dry, apply skin prep to periwound area, apply honey-based gel to the wound bed and cover with bordered gauze. Change three times weekly and as needed, ordered 7/7/25 and discontinued 7/22/25; -Right outer ankle treatment: once a day, cleanse with wound cleaner, pat dry, apply skin prep to periwound area and cover with bordered foam. Change three times weekly and as needed, ordered 7/22/25; -Ensure boot is on right foot every shift, ordered 1/5/25;-Ensure right ankle is offloaded, Podus (pressure relieving) boot on when in bed, every shift for wound care, ordered 1/5/25; and,-ProSource nutritional supplement for wound healing, two times per day for wound care, ordered 7/10/25.The wound care physician (WCP) note, dated 12/16/24, revealed Resident #18 had an abrasion on his right lateral malleolus. The wound was 100% epithelialized and the periwound skin was healthy. Orders included applying skin prep and foam dressings every day.The wound observation note, dated 1/3/25, revealed Resident #18 had an abrasion on his right lateral malleolus. The wound was improving. The wound bed was 100% granulation tissue and had moderate serous discharge. Orders for the wound included using calcium alginate and bordered gauze once per day.The WCP note, dated 4/21/25, revealed Resident #18 had a resolved abrasion to his right lateral malleolus. The WCP note, dated 6/9/25, revealed Resident #18 had a new trauma wound to the right lateral ankle. The wound measured 0.3 centimeters (cm) in length, 0.3 cm in width and 0.1 cm in depth. There was a small amount of serosanguineous (a fluid that is a mixture of serous (clear, watery fluid) and blood) drainage noted. The wound bed had 100% epithelialization. Orders included cleansing the wound with wound cleanser, applying skin prep and bordered gauze and changing the dressing three times per week and as needed. The WCP note, dated 6/16/25, revealed Resident #18 had a trauma wound to the right lateral ankle. The wound measured 0.3 cm in length, 0.3 cm in width and 0.1 cm in depth. The wound bed had 50% eschar and 50% epithelialization. There was no change noted in the wound progression. Orders included cleansing the wound with wound cleanser, applying skin prep and bordered gauze and changing the dressing three times per week and as needed. The WCP note, dated 6/23/25, revealed Resident #18 had a trauma wound to the right lateral ankle. The wound measured 0.5 cm in length, 0.5 cm in width and 0.1 cm in depth. There was a small amount of serosanguineous drainage noted. The wound bed had 100% epithelialization. The wound was deteriorating. Orders included cleansing the wound with wound cleanser, applying skin prep, xeroform and bordered gauze and changing the dressing daily and as needed. The WCP note, dated 6/30/25, revealed Resident #18 had a trauma wound to the right lateral ankle. The wound measured 0.5 cm in length, 1.0 cm in width and 0.1 cm in depth. There was a small amount of serous (clear, watery fluid) drainage noted. The wound bed had 60% granulation and 40% slough. The wound was deteriorating. Orders included cleansing the wound with wound cleanser, applying skin prep, honey-based gel and bordered foam and changing the dressing daily and as needed. The WCP note, dated 7/7/25, revealed Resident #18 had a trauma wound to the right lateral ankle. The wound measured 0.5 cm in length, 0.5 cm in width and 0.1 cm in depth. There was a small amount of serous drainage noted. The wound bed had 90% granulation and 10% slough. The wound was improving. Orders included cleansing the wound with wound cleanser, applying skin prep, honey-based gel and bordered foam and changing the dressing three times per week and as needed.The WCP note, dated 7/14/25, revealed Resident #18 had a trauma wound to the right lateral ankle. The wound measured 3.0 cm in length, 1.0 cm in width and 0.1 cm in depth. There was a small amount of serous drainage noted. The wound bed had 20% granulation and 80% epithelialization. The wound was deteriorating. Orders included cleansing the wound with wound cleanser, applying skin prep, honey-based gel and bordered foam and changing the dressing three times per week and as needed.The WCP note, dated 7/21/25, revealed Resident #18 had a trauma wound to the right lateral ankle. The wound measured 2.5 cm in length, 1.0 cm in width and 0.1 cm in depth. There was a small amount of serous drainage noted. The wound bed had 30% granulation and 70% epithelialization. The wound was improving. Orders included cleansing the wound with wound cleanser, applying skin prep and bordered foam and changing the dressing three times per week and as needed.A dietitian note, dated 7/17/25 at 2:39 p.m., revealed Resident #18 was tolerating his diet and accepted 100% of his ProSource supplement. Resident #18 had a trauma wound on his ankle that was worsening, so the dietitian added two vitamin supplements to help speed healing.Review of the May 2025 treatment administration record (TAR) revealed a physician's orders to ensure boot was on right foot every shift and ensure right ankle was offloaded were marked complete twice per day nearly every day. It was documented that Resident #18 refused to wear his boot and otherwise offload his right ankle once on the evening of 5/28/25. No other refusals of the orders were documented.-However, observations revealed the resident was not consistently wearing the boot (see observations above).Review of the June 2025 TAR revealed the orders to ensure boot was on right foot every shift and ensure right ankle was offloaded were marked complete twice per day every day. No refusals of either order were documented.Review of the July 2025 (7/1/25 to 7/24/25) TAR revealed the orders to ensure boot was on right foot every shift and ensure right ankle was offloaded were marked complete twice per day every day. No refusals of either order were documented.III. Staff interviewsPhysical therapy assistant (PTA) #1 was interviewed on 7/23/25 at 1:54 p.m. PTA #1 said Resident #18 was on the physical therapy caseload for his wound. PTA #1 said Resident #18 received treatments with the Vaporox three times per week. PTA #1 said Resident #18 was not compliant with other types of therapy. PTA #1 said the therapy team had an education sheet for the nursing staff indicating Resident #18 was supposed to wear a boot and have wedge pillows placed in bed, but said the resident tended to kick off the wedge pillows and boot.-However, review of Resident #18's electronic medical record (EMR) did not reveal documentation indicating that the resident consistently refused treatment (see record review above).CNA #1 was interviewed on 7/23/25 at 2:10 p.m. CNA #1 said Resident #18 did not have any skin issues she knew of. CNA #1 said Resident #18 used to wear a boot on his right foot to offload the weight off his right ankle. CNA #1 said Resident #18 only wore the boot when in bed. -However, the physician's orders indicated the resident was to wear the boot to his right foot at all times (see physician's orders above).CNA #4 was interviewed on 7/23/25 at 2:56 p.m. CNA #4 said Resident #18 got out of bed first thing in the mornings and sat in his chair from morning until after lunch. CNA #4 said Resident #18's right ankle had a wound on it and the nursing staff put dressings on it. CNA #4 said the therapy team had not given her any specific instructions for Resident #18. CNA #4 said Resident #18 would usually remind the nursing staff to put his boot on his right foot. CNA #4 said Resident #18 only wore a boot in bed, not when he was in his wheelchair. CNA #4 said Resident #18 used to wear boots on both feet when he was in his wheelchair, but said she was not sure what happened to those. CNA #4 said if Resident #18 refused his boot she would tell the nurse about the refusalLPN #5 was interviewed on 7/24/25 at 9:46 a.m. LPN #5 said she had not seen Resident #18 wearing any boots or splints. LPN #5 said Resident #18 may wear a boot when in bed, but said she had only ever seen the resident when he was up in his wheelchair. LPN #5 said Resident #18 had an ankle on his right ankle and said she did not know what caused it. LPN #5 said if Resident #18 refused any of his treatments she would mark refused in the TAR.The WCP was interviewed on 7/24/25 at 1:13 p.m. The WCP said Resident #18 had a wound on his ankle that had come and gone a few times. The WCP said he theorized the wound had something to do with the footrest of Resident #18's wheelchair causing friction. The WCP said Resident #18's wheelchair had a particular plastic piece in the same area of his wound. The WCP said he had seen other cases in which people attached pillows or foam to their wheelchairs, and thought a pillow or foam could help with Resident #18's foot rest trauma so his ankle would not come into contact with the footrest. The WCP said he had talked with the facility's infection preventionist about this a week or two prior. The WCP said Resident #18's ankle wound was stable.The DON was interviewed on 7/24/25 at 2:42 p.m. The DON said Resident #18 had a trauma wound on his right ankle. The DON said Resident #18 did not move his lower extremities, so the wound was caused by poor placement.The DON said Resident #18 refused to wear his boots, refused repositioning and generally liked to be left alone. The DON said Resident #18 was supposed to wear his boot both in bed and when in his wheelchair. The DON said Resident #18 wore his boot in his wheelchair but tended not to want to wear it in bed. The DON said the nursing staff should document any refusals. The DON was interviewed again on 7/24/25 at 4:54 p.m. The DON said interventions in place for Resident #18's wound included turning and repositioning him and wearing his boot. The DON said Resident #18 was also receiving Vaporox treatments. The DON said the wound on Resident #18's ankle was caused by him lying in bed and said she did not know about any issues or interventions related to his wheelchair.-However, Resident #18 was not observed wearing the boot in his wheelchair during the survey period.-Additionally, there were no physician's orders for any Vaporox treatments or documentation of these treatments in the electronic medical record (TAR).

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for tone (#4) of four residents reviewed for accidents out of 39 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 3/4/25 Resident #4 had an unwitnessed fall in her room and sustained an abrasion to her left knee and a bruise to her forehead. The facility failed to implement a new person-centered fall intervention after the fall. On 3/17/25 Resident #4 sustained another unwitnessed fall in her room where she sustained a right hip fracture that was diagnosed when she was sent to the hospital for evaluation. Upon return to the facility, the facility failed to implement person-centered interventions to prevent or reduce future falls. Resident #4 sustained 12 additional falls (two falls on 4/11/25, 4/21/25, two falls on 4/25/25, 5/8/25, 5/13/25, two falls on 5/16/25, 6/2/25, 6/12/25 and 6/14/25). Observations revealed the facility failed to consistently implement the fall interventions on the resident's care plan. Specifically, the facility failed to ensure timely person-centered fall interventions were implemented and added to the care plan for Resident #4 after she sustained multiple falls and sustained a major injury from a fall. Findings include: I. Facility policy and procedureThe Fall Prevention Program policy and procedure, implemented 4/11/25, was providedby the regional clinical resource (RCR) on 7/24/25 at 3:01 p.m. It read in pertinent part, Each resident will be assessed for fall risk and will receive care and services inaccordance with their individualized level of risk to minimize the likelihood of falls. The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. Low/Moderate Risk Protocols: implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to a clear pathway to the bathroom and bedroom doors. The bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. Call light and frequently used items are within reach. Adequate lighting. Wheelchairs and assistive devices are in good repair. Implement routine rounding schedule. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. Encourage residents to wear shoes or slippers with non-slip soles when ambulating. Ensure eye glasses, if applicable, are clean and the resident wears them when ambulating. Monitor vital signs in accordance with facility policy. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes. High Risk Protocols: The resident will be placed on the facility's Fall Prevention Program. Indicate fall risk on care plan. Implement interventions from Low/Moderate Risk Protocols. Provide interventions that address unique risk factors measured by the risk assessment tool such as medications, psychological, cognitive status, or recent change in functional status. Provide additional interventions as directed by the resident's assessment, including but not limited to: Assistive devices. Increased frequency of rounds. Increased supervision, if indicated. Medication regimen review. Low bed. Alternate call system access. Scheduled ambulation or toileting assistance. Family/caregiver or resident education. Therapy services referral. When a resident who does not have a history of falling experiences a fall, the resident will be placed on the facility's Fall Prevention Program. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. The plan of care will be revised as needed. When any resident experiences a fall, the facility will review the resident's care plan and update as indicated.II. Resident #4A. Resident statusResident #4, age [AGE], was admitted on [DATE]. According to the July 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 four out of 15. She required supervision assistance with transferring, toileting and personal hygiene. The MDS assessment indicated the resident had a fall prior to her admission. B. ObservationsOn 7/21/25 at 10:50 a.m. Resident #4 was lying on her left side in bed staring at the wall. The bed was in a low position and her tray table was next to her bed. The floor was cluttered with miscellaneous items. Her wheelchair was next to her bed. There was not a floor mat next to her bed. Her call light was not within reach and was lying on the floor under her bed. C. Record reviewResident #4's fall care plan, initiated 7/2/22 and revised 1/3/25, revealed the resident was at risk for falls related to muscle weakness and dementia. Interventions included ensuring the resident's call light was within reach and encouraging the resident to use itfor assistance as needed (initiated 7/7/22), ensuring bed was in the lowest position (initiated 3/6/25), ensuring the resident was wearing appropriate footwear such as non-skid footwear when ambulating or mobilizing in a wheelchair (initiated 7/2/22), ensuring a fall mat was in place (initiated 12/31/24), reviewing information on past falls and attempting to determine cause of falls, recording possible root causes and altering/removing any potential causes if possible (initiated 7/7/22), Resident #4 needed a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night, handrails on walls, personal items within reach (initiated 7/7/22) and toileting the resident when she awoke, after meals and before bed (initiated 12/31/24).-However, the care plan was not updated after each fall to indicate that the care planned fall interventions were reviewed for effectiveness or when a new intervention was put into place (see falls below).Review of Resident # 4's electronic medical record (EMR) revealed the resident sustained the following falls from 3/4/25 to 6/20/25:1. Fall incident on 3/4/25 - unwitnessedThe nursing progress note, dated 3/4/25 documented the nursing staff found the resident on the floor next to her bed. Nursing staff reported she hit her head on the bedside table. Resident #4 was assessed and was noted to have a small abrasion to her left knee and a bruise on her forehead. The interdisciplinary team (IDT) review note, dated 3/6/25, revealed the IDT met and discussed the resident's 3/4/25 fall. The note indicated the new intervention for the resident was to ensure the bed was in the lowest position. 2. Fall incident on 3/17/25 - unwitnessedThe nursing note note, dated 3/17/25 documented the nursing staff heard a loud noise from Resident #4's room. When the nursing staff entered Resident #4 room, the resident was on the floor on her right side near the doorway of the room. Resident #4 was assessed to have limited range of motion in her right lower extremity with complaints of pain. The nursing progress note, dated 3/18/25, documented Resident #4 was sent to the hospital for assessment after a fall. The resident was diagnosed with a right hip fracture and was readmitted to the facility on [DATE]. The IDT review note, dated 3/20/25, revealed the IDT met and discussed the resident's 3/17/25 fall. The note indicated the root cause of her fall was poor safety awareness. -However, there was no documentation to indicate additional fall interventions were put into place to prevent or reduce future falls. 3. Fall incidents on 4/11/25 - unwitnessedThe nursing progress note, dated 4/11/25, documented that at approximately 1:19 p.m. the nursing staff walked by Resident #4's room and observed her on her knees on her floor mat next to her bed. Resident #4 stated I wanted to go to the bathroom and the staff observed that her call bell was not within reach. The note documented that neurological assessments were initiated per protocol and were within normal limits. The note documented that staff members assisted the resident back to bed.The nursing progress note, dated 4/11/25, documented that at approximately 9:18 p.m. Resident #4 was found face down in her room. The resident said that she was getting out of her bed to get some dinner. The resident was assisted to bed with staff members. The note documented there were no new skin injuries noted.An IDT note, dated 4/21/25, documented the IDT met and discussed the 4/11/25 falls. The root cause of the falls was determined to be Resident #4's was poor safety awareness. Interventions included offering to take into the dining room for lunch and dinner.-Review of the care plan did not reveal the intervention of offering to take the resident to the dining room for meals (see care plan above).5. Fall incident on 4/21/25 - unwitnessedThe nursing progress note, dated 4/21/25, documented that at approximately 9:31 a.m. Resident #4 had an unwitnessed fall and was observed on the floor near her doorway on her left side. The resident was assessed for injuries and it was noted the resident had redness on the left side of her forehead and abrasions to her buttocks. Neurological checks were started and the resident was assisted with two staff members back to her bed. Education was provided to the resident to always use her call light for assistance. The resident's bed was placed in the lowest position and a floor mat was in-place. The note documented that neurological assessments and vital signs were initiated. The physician and the resident's representative were notified.-There was no documentation in Resident #4's EMR to indicate the IDT had reviewed the resident's 4/21/25 fall to determine the effectiveness of the resident's care planned fall interventions or to determine if there was a need for additional interventions.6. Fall incidents on 4/25/25 - unwitnessedThe nursing progress note, dated 4/25/25, documented Resident #4 was found on the floor in her room at 2:15 p.m. and again at 3:15 p.m. Resident #4 was given medication because the resident was yelling out saying she was in pain. The resident was assessed for both falls physically and neurological checks were initiated. The resident's vital signs were at baseline. An IDT note, dated 5/1/25, documented the IDT met and discussed the 4/25/25 fall. The new intervention was to offer television or music if she appears to be restless. -However, review of the care plan did not reveal the new intervention was added to the care plan (see care plan above).7. Fall incident on 5/8/25 - unwitnessedThe nursing progress note, dated 5/8/25, documented that at approximately 6:46 p.m. Resident #4 was heard yelling from her bedroom. When staff members arrived to Resident #4's room nursing staff found the resident on the floor lying on her back. The note documented the resident's vital signs were obtained and a head-to-toe assessment was completed. The resident was transferred to her wheelchair with the assistance of staff. -The note did not indicate if the resident's bed was in the lowest position or if her fall mat was in place.An IDT note, dated 5/22/25 documented the IDT met and discussed the 5/8/25 fall. The root cause was identified to be the Haldol (antipsychotic medication) injection effects were wearing off. The IDT recommended to contact the resident's provider to increase the frequency of the Haldol injections. -However, the review of the fall was not completed until two weeks after the fall. 8. Fall incidents on 5/13/25 - witnessedThe nursing progress note, dated 5/13/25 documented that at approximately 11:47 p.m. Resident #4 was heard yelling in her room. The note documented when the nursing staff asked the resident if she needed anything, the resident said she did not know. As the nursing staff proceeded to leave the room, the resident rolled herself out of her bed and developed a skin tear to her left knee. Resident #4 was assisted back to her bed. An IDT note, dated 5/19/25, documented the IDT met and discussed the 5/13/25 fall. The root cause was identified to be the resident was curious as to what was going on outside of her room. The recommended intervention was to offer the resident coffee and snacks when she was calling out.The nursing progress note, dated 5/16/25, documented that at approximately 7:58 p.m. the nursing staff observed the resident on the floor on her stomach next to her bed. The resident was assessed and assisted back to bed. The note documented her neurological status was at baseline and the physician, the resident's representative and the director of nursing (DON) were notified. -The note did not indicate if the resident's bed was in the lowest position or if the fall mat was in place.An IDT note, dated 5/19/25, documented the IDT met and discussed the 5/16/25 fall. The root cause was identified that the resident did not want to wait for staff assistance. 10. Fall incident on 6/2/25 - unwitnessedThe nursing progress note, dated 6/2/25, documented that at approximately 12:24 p.m. nursing staff found Resident #4 was heard screaming from her room. The note documented when the staff arrived to Resident #4's room they found her lying on the floor and screaming for help. Resident #4 was assessed for pain and assisted back to bed. A head-to-toe assessment was completed and the resident had no noted physical injury. The physician, the resident's representative and the on-call nurse were notified.-There was no documentation in Resident #4's EMR to indicate the IDT had reviewed the resident's 6/2/25 fall to determine the effectiveness of the resident's care planned fall interventions or to determine if there was a need for additional interventions.11. Fall incident on 6/12/25 - unwitnessedThe nursing progress note, dated 6/12/25, documented at approximately 10:35 p.m. Resident #4 fell out of her wheelchair in the dining room. The resident was assessed for injury by the nursing staff. Neurological checks were initiated and were noted to be at baseline. A skin assessment was completed. The resident sustained small abrasions to bilateral knees. The resident was assisted back to her wheelchair. An IDT note, dated 6/20/25, documented the IDT had reviewed Resident #4's 6/12/25 fall. The root cause of the fall was behavioral with interventions set in place to ensure wheelchair breaks were locked while the resident was in the dining room. -However, review of the care plan did not identify the new intervention was added to the care plan.12. Fall incident on 6/14/25 - witnessedThe nursing progress note, dated 6/14/25, documented at approximately 7:24 p.m. Resident #4 was witnessed ambulating without her walker or wheelchair in the hallway and then threw herself on the hallway floor and started crawling resulting in a small abrasion to her left knee. Resident #4 was assisted back to bed. The resident at that time, threw herself out of bed onto her floor mat and continued to do this for approximately 90 minutes requiring constant one-to-one supervision. An IDT note, dated 6/20/25, documented the IDT had reviewed Resident #4's 6/14/25 fall. The root cause of the fall was behavioral with interventions medication review from hospice. D. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 7/24/25 at 2:00 p.m. CNA #5 said Resident #4 has sustained several falls so she knew to keep an eye on her. CNA #5 said she did not know of any specific interventions. CNA #5 said she did not know where to look for specific interventions in the resident EMR. License practical nurse (LPN) #6 was interviewed on 7/14/25 at 3:00 p.m. LPN #6 said there were no specific interventions for Resident #4 regarding her falls. LPN #6 said she was not provided with any education for Resident #3's fall interventions.The DON and the infection preventivist (IP) were interviewed together on 7/24/25 at 4:30 p.m. The DON said the fall investigations were not consistently related to the root cause analysis of the fall and this resulted in a failure to identify the true underlying reason for the fall. The DON said resident-centered specific fall interventions should have been implemented after each of Resident #4's. The DON said resident centered fall interventions were important to prevent falls from occurring and keeping the residents safe. The DON said she would implement resident centered fall interventions for Resident #4. The DON said Resident #4's falls could have been prevented if more thorough fall investigations were completed and appropriate interventions were implemented. The DON said even though the root cause for several falls were identified as poor safety awareness, due to her cognitive status, the resident should have been assessed for more appropriate interventions.

Based on record review and interviews, the facility failed to take steps to protect four (#67, #39, #36 and #31) of five residents reviewed for abuse out of 39 sample residents. Specifically, the facility failed to protect Resident #67, Resident #39, Resident #36 and Resident #31 from physical abuse by Resident #17.Findings include: I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy and procedure, revised 4/11/25, was provided by the regional clinical resource (RCR) on 7/21/25 at 10:19 a.m. It read in pertinent part, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include resident-to-resident altercations. It includes physical abuse.II. Incident of physical abuse between Resident #17, Resident #67 and Resident #39 on 6/19/25A. Facility investigationThe 6/19/25 nurse note revealed the nurse was in the nurses' station when a certified nurse aide (CNA) called for help in the hallway. The nurse went to assist and found three residents in a physical altercation. Resident #17 was hitting Resident #39 in the face and then pulled Resident #67's hair. The CNA and the nurse separated all three residents. The CNA told the nurse that Resident #17 took Resident #39's walker. Fifteen minute checks were initiated. Cares and monitoring for the residents were ongoing. The facility's conclusion of the internal investigation was the incident was substantiated. III. Incident of physical abuse between Resident #17 and Resident #36 on 6/22/25A. Facility investigationThe witness statement by the housekeeper, dated 6/23/25, documented the housekeeper was cleaning Resident #36's bathroom in room [ROOM NUMBER]. Resident #36 was standing by her bed and the housekeeper noticed the resident go to the door. Resident #17 entered the room. The housekeeper came out of the restroom and asked Resident #17 to leave because Resident #36 did not like anyone in her room. Resident #17 became verbal and started to push Resident #36. The housekeeper tried to separate the two residents but Resident #17 immediately pushed Resident #36 down. Resident #36 said she was fine. Resident #17 continued to curse at Resident #36 and grabbed Resident #36's sweater cuffs and did not let go. The housekeeper called for help and a CNA immediately came in and tried to separate the two residents. The CNA took Resident #17 out of the room. The nurse came in and checked Resident #36 for any possible injuries and blood. Resident #36 appeared to be okay. The witness statement by CNA #6, dated 6/22/25, documented CNA #6 saw Resident #36 attacked by Resident #17. She heard yelling and hitting. CNA #6 quickly rushed over to see what was going on. Resident #17 was hitting Resident #36 and the housekeeper and CNA #6 immediately tried to separate the residents from each other. Resident #17 did not want to let go until CNA #6 loosened her grip on Resident #36's shirt. CNA #6 took Resident #17 out of the room. The facility's investigation summary revealed a housekeeper was in Resident #36's room and attempted to intervene and de-escalate. Resident #17 pushed Resident #36 to the floor. The housekeeper called for help, and a CNA came to separate the two residents. The facility's conclusion of the internal investigation was the incident was substantiated. IV. Incident of physical abuse between Resident #17 and Resident #31 on 6/23/25A. Facility investigation of the altercation on 6/23/25The victim's statement (Resident #31), dated 6/23/25, documented Resident #31 was sitting on her bed watching television. Resident #17 (assailant) came over and grabbed her arm. Resident #31 said she did not like that. Resident #31 said Resident #17 grabbed her arm so Resident #31 pulled her arm away and Resident #31 slipped off the bed. The 6/23/25 nurse incident note revealed a nurse heard yelling from Resident #31's and Resident #17's room. Resident #31 was on the floor with Resident #17 standing nearby. Resident #31 said Resident #17 pushed her down when she told Resident #17 to get off of her bed. The facility's conclusion of the internal investigation was the incident was substantiated. The facility's investigation summary revealed Resident #17 had one-on-one supervision from a previous incident in the last week. The interventions included continuing one-on-one supervision for at least one month, Resident #17 moved to a new room, a new medication was added to Resident #17's medication regimen and hospice increased nurse visit frequency. The facility's investigation revealed Resident #17 had two incidents with other residents prior to the incident with Resident #31 on 6/23/25 (see incidents above). The investigation revealed Resident #17 had one-on-one supervision from a previous incident. The conclusion of the internal investigation revealed there was a breakdown in the shift change system that led to substantiating the incident. Resident #17 had an incident on 6/19/25 and 6/22/25 with other residents. The intervention for the 6/19/25 incident was a medication review and 15-minute checks. The intervention for the 6/22/25 was one-on-one supervision. -Review of Resident #17 electronic medical record (EMR) and the facility incident investigation revealed the facility failed to have continuous one-on-one supervision, which led to the 6/23/25 incident.V. Resident #67 - victimA. Resident statusResident #67, age [AGE], was admitted on [DATE]. According to the 6/19/25 July 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (a chronic disease of the central nervous system), cerebral infarction (blood flow to a part of the brain is blocked), and memory deficit. According to the 6/12/25 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview mental status (BIMS) score of four out of 15. She required a wheelchair. She required supervision with oral hygiene and showering and required set-up assistance for eating and toiletingThe MDS assessment identified the resident had delusions and other behaviors on one to three days in the look-back period. The behaviors placed the resident at significant risk for physical illness or injury and significantly interfered with the resident's participation in activities or social interactions. The MDS assessment further revealed the resident's behavior had an impact on others, including putting others at significant risk for physical injury, significantly intruding on the privacy or activity of others and significantly disrupting the care or living environment of others. B. Record reviewThe 6/19/25 nurse note revealed the nurse went to assist and found three residents in a physical altercation. Resident #17 was hitting Resident #39 in the face and then pulled Resident #67's hair. The CNA and the nurse separated all three residents. The CNA told the nurse Resident #17 took Resident #39's walker. Fifteen minute checks were initiated. Cares and monitoring were ongoing. VI. Resident #39 - victim A. Resident statusResident #39, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included cerebral infarction and unspecified dementia. According to the 6/22/25 MDS assessment, the resident was severely cognitively impaired with a BIMS score of three out of 15. She required a wheelchair and wheelchair. She required supervision with eating, substantial assistance with oral hygiene, toileting and was dependent on staff for showering and personal hygiene. The MDS assessment identified the resident had physical behaviors towards others one to three days in the look-back period. The behaviors did not place the resident at significant risk for physical illness or injury and significantly interfered with the resident's participation in activities or social interactions. The MDS assessment further revealed the resident's behavior did not have an impact on others, including putting others at significant risk for physical injury, significantly intruding on the privacy or activity of others and significantly disrupting the care or living environment of others.B. Record reviewThe 6/19/25 physician's order revealed 15-minute checks for the victim of aggression from another resident every shift for three days. VII. Resident #36 - victimA. Resident status Resident #36, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnosis included Alzheimer's disease, chronic kidney disease stage three, psychotic disturbance, mood disturbance, anxiety and depression. According to the 6/5/25 MDS assessment, the resident was severely cognitively impaired with a BIMS score of three out of 15. She required set up assistance with eating, oral hygiene and was independent with toileting, dressing and personal hygiene. She required substantial assistance with showering. The MDS assessment did not identify the resident displayed behaviors during the assessment look-back period. B. Record review Review of Resident #36's physically aggressive care plan, revised 3/14/25 revealed the resident had the potential to be physically aggressive related to dementia. Interventions included anticipating the resident's need for food, thirst, toileting and comfort level. The 6/22/25 nurse note revealed the CNA said Resident #36 was in her room when another resident (Resident #17) entered her room and pushed her onto the floor. Resident #36 was assessed by a registered nurse (RN) for injuries. Resident #36 was noted to have a reddened area approximately three centimeters (cm) to her lower right side of back. The resident was able to move all extremities without difficulty. The 6/25/25 interdisciplinary team (IDT) note revealed Resident #36 received physical aggression on 6/22/25. The root cause was the aggressor (Resident #17) disregarded several verbal attempts to redirect. The intervention in place was one-on-one supervision for the aggressor. VIII. Resident #31 - victimA. Resident status Resident #31, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included atherosclerotic heart disease of native coronary artery (build up of fat, cholesterol and other substances in and on the walls of the heart arteries), type 2 diabetes mellitus with hyperglycemia (a condition of too much sugar in the bloodstream), tobacco use, dementia with anxiety, major depressive disorder, and mood disorder. The 5/21/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. She was independent with oral hygiene and toileting, required set-up assistance for eating, and was dependent for showering. The MDS assessment did not identify the resident displayed behaviors during the assessment look back period. B. Record review Resident #31's behavior care plan, revised 11/25/24, revealed the resident had the potential and history of becoming verbally aggressive and confrontational with staff and other residents. The resident preferred not to have visitors in her room and preferred to be alone at times in her room. Interventions included remaining calm and using a soft reassuring voice to prevent further escalation and offering to go for a walk or eat a snack. The 6/23/25 nurse note revealed Resident #31 said she was grabbed on her right arm by her roommate while sitting on her bed. The resident was heard yelling from her room. The resident was seen sitting on her floor with her roommate, Resident #17, standing nearby. Resident #31 said that Resident #17 pushed her down when she told her to get off her bed. The 6/24/25 IDT note revealed Resident #31 received physical aggression on 6/23/25. The root cause was the roommate had behaviors. The interventions in place were the resident's roommate (Resident #17) had one-on-one supervision, the roommate had a medication review from hospice and provider, the roommate moved rooms away from the resident and nursing staff were educated on one-on-one supervision hand-off procedures. IX. Resident #17 - assailant A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (a lung condition that makes it hard to breathe) and occlusion and stenosis of unspecified carotid artery (plaque buildup narrows the artery, potentially leading to stroke). The 6/9/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. She required partial assistance with toileting, supervision for oral hygiene and set up assistance with eating. The MDS assessment revealed the resident had delusions and had physical and verbal behavior symptoms towards others for one to three days during the look-back period. It revealed the behavior had an impact on the resident, including putting the resident at significant risk for physical illness or injury, significantly interfering with the resident's care and significantly interfering with the resident's participation in activities or social interactions. The MDS assessment further revealed the resident's behavior had an impact on others, including putting others at significant risk for physical injury, significantly intruding on the privacy or activity of others and significantly disrupting the care or living environment of others. B. Record review Resident #17's physically aggressive care plan, revised 6/24/25, revealed the resident had the potential to be physically aggressive. Interventions included one-on-one supervision, medication review and giving the resident as many choices as possible about care and activities.-However, the care plan failed to identify what triggered Resident #17's physically aggressive behaviors and include person-centered interventions in order to prevent further physically aggressive altercations from occurring with other residents.The 6/19/25 nurse note revealed the nurse went to assist and found three residents in a physical altercation. Resident #17 was hitting Resident #39 in the face and then pulled Resident #67's hair. The CNA and the nurse separated all three residents. The CNA told the nurse Resident #17 took Resident #39's walker. Fifteen-minute checks were initiated. Cares and monitoring were ongoing.The 6/23/25 nurse note revealed Resident #17 was sitting on her bed with a CNA. The resident held a towel to her left forearm and said she was bleeding. The nurse removed the towel and observed the resident's arm with a one-inch skin tear. The resident denied pain and did not remember the incident. The resident was easily redirected at this time. The resident sat with the nurse until she said she was ready for bed. One-on-one supervision was in place at this time, accompanying the resident at all times. The 6/24/25 IDT note revealed Resident #17 initiated physical aggression on 6/23/25. The root cause was aggressive behavior, Alzheimer's disease, hospice, past history of prior trauma. The treatment required was one-on-one supervision. X. Staff interviewsCNA #2 was interviewed on 6/23/25 at 10:05 a.m. CNA #2 said she was not present when Resident #17 had physical altercations with other residents. She said the resident's behavior escalated when staff and others moved fast or if she was around a lot of people. She said Resident #17 was de-escalated by removing the resident from the environment, offering a snack, providing one-on-one supervision and distracting the resident. CNA #2 said if she suspected abuse, she would protect the residents by separating the residents if it was a resident-to-resident altercation and she would tell the nurse and the director of nursing (DON) or the nursing home administrator (NHA). She said the nurse was responsible for writing an incident report and she would write a statement if she saw the incident. CNA #2 said the entire facility would be trained on what new interventions were put in place to prevent further abuse. Licensed practical nurse (LPN) #3 was interviewed on 6/23/25 at 10:20 a.m. LPN #3 said she was not present when Resident #17 had a physical altercation with other residents. She said if she suspected abuse, she would separate the residents to protect the residents and report the incident to the NHA. She said she started the incident report, wrote a progress note and notified the physician and the resident's representative. The resident aide was interviewed on 6/24/25 at 12:53 p.m. The resident aide said he was not present when Resident #17 had a physical altercation with other residents. He said if he suspected abuse, he would ask CNAs or nurses to come help him separate the residents. He said his main responsibility was providing one-on-one supervision to Resident #17. He said the purpose of one-on-one supervision was to help anticipate the needs of the resident, monitor the resident and report any behaviors to nursing. The NHA, the DON and the RCR were interviewed together on 7/23/25 at 3:39 p.m The NHA said the 6/19/25, 6/22/25 and 6/23/25 incidents involving Resident #17 as the aggressor were substantiated as physical abuse. He said after the 6/19/25 altercation, the interventions were a medication review and 15-minute checks for Resident #17. He said after the 6/22/25 altercation, the intervention was revised to one-on-one supervision of Resident #17. The DON and the RCR said the medication review and the 15-minute check interventions were not effective because Resident #17 was not on the new medication long enough to see the effects. The NHA said the one-on-one supervision intervention was not effective because staff did not follow the intervention, and there was a 90-minute gap in coverage. He said all nursing staff were trained on one-on-one supervision coverage, including education not to leave Resident #17 in order to prevent future altercations.

Based on observations, record review and interviews, the facility failed to ensure activities designed to support the residents' physical, mental and psychosocial well-being were provided for three (#17, #36 and #42) of four residents reviewed for activities out of 39 sample residents. Specifically, the facility failed to to offer and provide personalized activity programs for Resident #17, Resident #36 and Resident #42. Findings include: I. Facility policy and procedure The Activities policy, dated 4/11/25, was provided by the regional clinical regional clinical resource (RCR) on 7/24/25 at 5:12 p.m The policy read in pertinent part, “It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. “Each resident’s interest and needs will be assessed on a routine basis. Activities will be designed with the intent to: -Enhance the resident’s sense of well-being, belonging, and usefulness; -Create opportunities for each resident to have a meaningful life; -Promote or enhance physical activity; -Promote or enhance cognition; -Promote or enhance emotional health; -Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence; -Reflect resident’s interests and age; -Reflect cultural and religious interests of the residents; and, -Reflect choices of the residents. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for: -Residents who exhibit unusual amounts of energy or walking without purpose; -Residents who engage in behaviors not conducive with a therapeutic home like environment; -Residents who exhibit behaviors that require a less stimulating environment to discontinue behaviors not welcomed by others sharing their social space; -Residents who go through others’ belongings; -Residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of the day; -Residents who excessively seek attention from staff and/or peers; -Residents who lack awareness of personal safety; and, -Residents who have delusional and hallucinatory behavior that is stressful to themselves.” II. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer’s disease, chronic obstructive pulmonary disease (a lung condition that makes it hard to breathe) and occlusion and stenosis of unspecified carotid artery (plaque buildup narrows the artery, potentially leading to stroke). The 6/9/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. She required partial assistance with toileting, supervision for oral hygiene and set up assistance with eating. The assessment revealed the resident preferred reading books, newspapers or magazines, listening to music, being around animals such as pets, participating in favorite activities and spending time outdoors. The assessment revealed the resident did not refuse care. B. Resident’s representative interview Resident #17’s representative was interviewed on 7/21/25 at 9:53 a.m. The representative said staff told her activities were offered to Resident #17 but the resident refused. She said she thought the resident would participate in some activities. She said she would engage in watching old television shows. She said she wished the television in the resident’s room worked because it could help with the resident’s behavior. C. Observation During a continuous observation on 7/22/25, beginning at 1:51 p.m. and ending at 3:00 p.m., the following observations were made: The activities calendar in the secured unit revealed pet therapy was scheduled at 2:00 p.m. At 1:51 Resident #17 was in her room with the door closed. At 2:04 p.m. activity assistant (AA) #1 walked into the secured unit with a therapy dog. AA #1 went to multiple residents in the common area to see if they wanted to pet the dog. AA #1 sat down in the common area with residents sitting on both sides of her and across from her. At 2:53 p.m. AA #1 and the therapy dog left the unit. -However, the therapy dog was not directed to go into Resident #17’s room, despite the resident’s interest in dogs (see care plan below). At 3:06 p.m. Resident #17’s room was observed. There was a television above the foot of Resident #17’s bed. The television was not plugged in. There was no television remote in the resident’s room. Certified nurse aide (CNA) #7 was in the room and she said did not know where the remote was for the television. D. Record review Resident #17’s activities care plan, revised 6/12/25, revealed the resident loved dogs and she had two dogs when she lived at home. The resident and the dogs had sat together and birdwatched every afternoon. The care plan goal was for the resident to participate in two to three group activities per week until the next review. Interventions included assisting the resident to group activities if she chose to attend and inviting the resident to participate in activities of interest. A review of Resident #17’s electronic medical record (EMR) revealed the resident did not attend any emotional activities from 6/24/25 to 7/24/25 and she attended seven intellectual activities from 6/24/25 to 7/24/25. -There was no further documentation to indicate the resident had participated in or been offered the opportunity to participate in any other activities during the timeframe. III. Resident #36 A. Resident status Resident #36, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnosis included Alzheimer’s disease, chronic kidney disease stage three, psychotic disturbance, mood disturbance, anxiety and depression. The 6/5/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15. She required set up assistance with eating, oral hygiene and was independent with toileting, dressing and personal hygiene. She required substantial assistance with showering. The 12/17/24 MDS revealed it was somewhat important for the resident to have books, newspapers and magazines to read, to be around animals such as pets, and it was very important to do her favorite activities. B. Observations During a continuous observation on 7/22/25, beginning at 9:09 a.m. and ending at 11:01 a.m., the following observations were made in the facility’s secured unit: At 9:09 a.m. Resident #36 was observed in her room. At 10:07 a.m. AA #1 arrived at the unit. From 10:11 a.m. to 10:40 a.m. AA #1 engaged eight residents in the common area with a ball activity. At 10:14 a.m. an unidentified staff member said Resident #36 and her roommate were going to participate in the ball activity. At 10:15 a.m. Resident #47 interfered with Resident #36 walking towards the activity which caused Resident #36 to walk back to her room. -No staff members attempted to get Resident #36 to participate in the ball activity again. C. Record review Resident #36’s activities care plan, revised 6/8/25, revealed the group activities goal was for the resident to participate in activities two to three times a week. She likes to snack on cookies and chips, magazines with eye-catching pictures, reading a book, or reminiscing with activity staff. She enjoys lotion therapy, aromatherapy, working on simple puzzles, and word searches. She loves animals and really enjoys pet therapy. Her favorite activities are going out on the patio when the weather is warm and reminiscing with select residents and staff. Interventions included offering independent leisure activity materials, offering pet visits when in the building and visit three times a week for 20 to 30 minutes per week. -A review of Resident #17’s EMR revealed the resident did not attend any social activities from 6/24/25 to 7/24/25 and she attended six intellectual activities from 6/24/25 to 7/24/25. -There was no further documentation to indicate the resident had participated in or been offered the opportunity to participate in any other activities during the timeframe. IV. Staff interviews The nursing home administrator (NHA) was interviewed on 7/23/25 at 3:39 p.m. The NHA said if a resident had it on their care plan that they liked animals and the animal was part of the scheduled pet therapy, the activities staff should try to engage the resident with the pet therapy. He said he did not know when pet therapy was scheduled on 7/22/25 or why the pet therapy was not offered to Resident #17. He said he would talk to the activity director (AD) to ensure residents in their room were offered activities such as pet therapy. The AD was interviewed on 7/24/25 at 2:00 p.m. The AD said she had worked at the facility for the past year. She said she was fully staffed with herself, one full-time activities coordinator and two part-time activities staff. She said one staff member worked eight hours on Saturdays and AA #1 worked 15 hours per week, from 1:00 p.m. to 4:00 p.m. She said AA #1 was responsible for covering the activities in the secured unit. She said when AA #1 was not scheduled, she or the full-time staff covered the activities in the secured unit. The AD said if residents were in the secured unit at the dining room tables, the nursing staff should offer independent activity supplies. She said she had a closet full of activity supplies in the secured unit as well as crossword puzzles and other games next to the television. She said word searches, coloring and a sewing kit should be offered every day. She said the independent activities should be offered because residents in the secured unit could not express themselves so staff should offer individual activities. She said everyone should be invited and encouraged to participate in an activity. The AD said she documented if a resident attended or refused to attend the activity in the resident’s EMR under tasks. She said activities were important because activities could make a difference in residents’ lives and change how they felt about living in a facility. She said the residents needed to be in the facility so she wanted to make it fun for them. She said if a resident participated in pet therapy, it would be documented as an emotional activity in the resident’s chart and if it was a ball activity, it should be documented as a social activity. The AD said she was familiar with Resident #17. She said the resident was a really good artist and she liked fresh air. She said the resident liked to color and participate in pet therapy. She said she did not know that when pet therapy was an activity on 7/22/25 that Resident #17 did not get invited to participate. She said she did not know Resident #17’s activities participation record only documented that she participated in intellectual activities. The AD said she was familiar with Resident #36. She said the resident had her days when she did not participate in anything. She said sometimes she participated in activities in the main unit. She said if Resident #36 agreed to attend the ball activity and was distracted by Resident #47, staff should have attempted to invite her back to attend the activity. She said did not know Resident #36’s activities participation record only documented that she participated in intellectual activities. V. Resident #42 A. Resident status Resident #42, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 CPO, diagnoses included chronic respiratory failure, dementia, bipolar 2 disorder, borderline personality disorder, generalized anxiety disorder and depressive episodes. The 7/7/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. B. Resident interview and observations Resident #42 was interviewed on 7/21/25 at 10:15 a.m. Resident #42 said she wanted to start going to more activities. Resident #42 said she had gone to bingo one time but she could not see the numbers on the bingo cards. Resident #42 reiterated that she wanted to start going to more activities. On 7/22/25 at 3:07 p.m. AA #1 came into the facility with her dog. AA #1 went up and down Resident #42’s hallway and stopped into rooms to greet the residents with her dog and allow the residents to socialize with her dog. -However, AA #1 did not knock on Resident #42’s door or otherwise offer to socialize with Resident #42. Resident #42 was in her room at the time of the observation. On 7/23/25 at 2:20 p.m. an activity was being conducted in the main dining room. Resident #42 was in her room lying in her bed with no meaningful activity occurring. C. Record review The activity care plan, revised 1/2/25, revealed Resident #42 enjoyed independent activities and would participate in group activities if food or drinks were involved. Pertinent interventions included having care staff invite and encourage Resident #42 to participate in programs of interest such as food groups and to remind and encourage the resident to participate in group activities. The nutritional care plan, revised 3/28/25, revealed Resident #42 was at risk for nutritional problems due to her dementia. Pertinent interventions included inviting and encouraging Resident #42 to participate in physical activity and offer her activities of choice to help divert her attention away from food. Review of Resident #42’s one-on-one activity task log from 6/24/25 to 7/24/25 revealed the following: -No one-to-one activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s emotional activity task log from 6/24/25 to 7/24/25 revealed the following: -No emotional activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s outing activity task log from 6/24/25 to 7/24/25 revealed the following: -No outing activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s physical activity task log from 6/24/25 to 7/24/25 revealed the following: -No physical activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s social activity task log from 6/24/25 to 7/24/25 revealed the following: -No social activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s special event activity task log from 6/24/25 to 7/24/25 revealed the following: -No special event activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s spiritual activity task log from 6/24/25 to 7/24/25 revealed the following: -No spiritual activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s intellectual activity task log from 6/24/25 to 7/24/25 revealed the following: -On 6/26/25 at 3:49 p.m. Resident #42 participated in independent leisure. -On 6/27/25 at 1:42 p.m. Resident #42 participated in independent leisure. -On 7/1/25 at 2:41 p.m. Resident #42 participated in independent leisure. -On 7/7/25 at 3:07 p.m. Resident #42 participated in independent leisure. -On 7/22/25 at 8:20 a.m. Resident #42 participated in independent leisure. -On 7/23/25 at 3:43 p.m. Resident #42 participated in independent leisure. -On 7/24/25 at 11:53 a.m. Resident #42 participated in independent leisure. The intellectual activity task log did not document any refusals from Resident #42. E. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 7/23/25 at 2:56 p.m. CNA #4 said Resident #42 went to her birthday party activity in March 2025 and went to an activity two weeks prior. CNA #4 said Resident #42 had not left her room between those two activities. CNA #4 said the activities staff brought Resident #42 supplies for individual activities but Resident #42 did not want to leave her room. The AD was interviewed on 7/24/25 at 1:45 p.m. The AD said she visited every resident every day and invited and encouraged them to come to activities that day. The AD said refusals of each activity offered each day were documented in the residents’ EMRs under tasks. The AD said residents were assessed on admission to see what their life was like before they were admitted to the facility and see what their interests were. The AD said activities were important because they changed how the residents felt about being in a facility and allowed them to be comfortable and have fun. The AD said pet therapy, provided by AA #1, was considered an emotional activity. The AD said AA #1 should go to each resident’s room and usually went room to room with her dog. The AD said the facility provided three to four activities per day every day of the week. The AD said she tried to have residents attend activities at least twice per week. The AD said the activities assistants would document refusals for each resident in their tasks. The AD said she wanted the activities assistants to document refusals so she had proof the resident was invited to the activity. The AD said she had seen issues with the activities assistants’ documentation. The AD said she had tried implementing different color coding methods for charting.

Based on record review and interviews, the facility failed to ensure three (#47, #9 and #42) of five residents were free from chemical restraints were receiving the least restrictive approach for their needs out of 39 sample residents. Specifically, the facility failed to: -Ensure Resident #47 and Resident #9 behavior care plans included resident specific non-pharmacological care approaches;-Document consistent behaviors for Resident #47 and Resident #9 to justify the continued use of psychotropic medications; -Document resident-specific care approaches, to include medication specific target behaviors and person-centered intervention for Resident #47 and Resident #9's psychotropic medications; and,-Ensure gradual dose reductions (GDR) were attempted for Resident #42's psychotropic medications. Findings include: I. Facility policy and procedure The Use Of Psychotropic Medications policy, revised 4/28/25, was provided by the regional clinical resource (RCR) on 7/24/25 at 5:12 p.m. It read in pertinent part, “It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident’s medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. “A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. “The indications for initiating, maintaining, or discontinuing medications(s), as well as the use of non-pharmacological approaches, will be determined by evaluating the resident’s physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. “Non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. “The resident’s response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident’s medical record. “Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs.” II. Resident #47 A. Resident status Resident #47, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer’s disease, anxiety disorder, depression and cognitive communication deficit. The 7/23/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. She required set up assistance with eating, was dependent on staff for oral hygiene, toileting, showering, dressing and personal hygiene. The MDS assessment revealed the resident wandered on one to three days and exhibited physical behavioral symptoms, such as hitting, kicking, and pushing, directed toward others during the assessment look back period. B. Record review Resident #47’s dementia care plan, revised 12/30/24, revealed the resident had potential to be physically aggressive related to dementia. Interventions included analyzing times of day, place, circumstances, triggers and what de-escalated the resident’s behavior and documenting, assessing and addressing the resident for contributing sensory deficits, assessing and anticipating residents needs, monitoring any signs and symptoms of the resident posing a danger to self or others, offering ambulation for resident in hallway and redirecting the resident when she appeared to introduce in others’ space. Resident #47’s elopement care plan, revised 10/25/24, revealed the resident was a risk for wandering and elopement related to Alzheimer’s disease. Resident #47 wandered aimlessly, significantly intruding on the privacy or activities of others. -Review of Resident #47’s dementia and elopement care plans revealed there were no person centered non-pharmacological interventions. Review of Resident #47’s July 2025 CPO revealed the following physician’s orders: Ativan (antianxiety medication) 0.5 milligrams (mg). Take 0.25 mg by mouth at bedtime for anxiety, ordered 1/2/25. Ativan 0.25 mg. Take 0.25 mg by mouth in the afternoon for anxiety, ordered 1/2/25. Olanzapine (antipsychotic medication) 10 mg. Take 5 mg by mouth at bedtime for dementia, ordered 7/7/25. Trazodone (antidepressant medication with an off label use for insomnia) 50 mg. Take two tablets by mouth at bedtime for dementia with insomnia, ordered 12/26/24. Trazodone 50 mg. Take 25 mg by mouth twice a day for dementia and anxiety, ordered 1/8/25. Behavior monitoring - anti-depressants. Withdrawn, loss of appetite, crying, lack of interest, apathy, feeling of helplessness, feelings of worthlessness, suicidal ideations or insomnia. Interventions: document in progress note, ordered 3/4/25. Behavior monitoring - anti-anxiety. Document intervention attempted and effectiveness. Target behavior: avoidance and restlessness. Intervention: redirection, one-on-one, activity, low stimulation environment, toileting, offer snack, offer fluid, position change, assess pain or other intervention documented in progress note. Effective yes or no, ordered 3/4/25. -The behavior monitoring physician’s order failed to include Resident #47’s identified behaviors of physical aggression and wandering. -Resident #47’s physician orders did not include behavior monitoring for the resident’s antipsychotic medication. Review of Resident #47’s April 2025 (from 4/1/25 to 4/30/25) medication administration record and treatment administration record (MAR/TAR) revealed there was one incident of anti-depressant behavior documented on 4/9/25. It indicated the resident was withdrawn. -However, there was no documentation to indicate what intervention was offered and if the intervention was effective. The April 2025 MAR/TAR revealed there were two incidents where anti-anxiety behavior was observed for Resident #47 on 4/4/25 and 4/24/25. -However there was no documentation to indicate what behavior was observed, what interventions were offered and if the interventions were effective. -Review of Resident #47’s May 2025 (from 5/1/25 to 5/31/25), June 2025 (from 6/1/25 to 6/30/25) and July 2025 (from 7/1/25 to 7/23/25) MAR/TAR revealed there was no documentation to indicate the had resident exhibited antidepressant, antianxiety or antipsychotic behaviors during the month. -Review of Resident #47’s electronic medical record (EMR) from 4/1/25 to 7/23/25 revealed there was no documentation to indicate the resident exhibited any behaviors, if interventions were offered and if the interventions were effective. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE] . According to the July 2025 CPO, diagnoses included Alzheimer’s disease, rheumatoid arthritis (chronic autoimmune disease attacks the joints), atrial fibrillation (heart beats irregularly and often too fast) and insomnia. The 6/17/25 MDS assessment documented the resident was severely cognitively impaired with a BIMS score of zero out of 15. Resident #9 required set up assistance with eating, partial assistance with oral hygiene and substantial assistance with toileting and personal hygiene. She required a walker and wheelchair. The MDS assessment indicated the resident exhibited verbal behavior directed toward others on one to three days during the assessment look-back period. B. Record review Resident #9’s psychotropic medication care plan, revised 4/18/25, revealed the resident used a psychotropic medication, Risperdal. Interventions included monitoring for effectiveness every shift and monitoring and recording target behavior symptoms including pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards others and documenting, per facility protocol. Resident #9’s antidepressant medication care plan, revised 3/18/25, revealed the resident used an antidepressant medication, Trazodone. -Review of Resident #9’s psychotropic and antidepressant medication care plans revealed there were no person centered non-pharmacological interventions for the resident’s anti-psychotic and antidepressant medication use. Review of Resident #9’s July 2025 CPO revealed the following physician’s orders: Risperidone (antipsychotic medication) 0.25 mg. Take one tablet by mouth two times a day for Alzheimer’s disease, ordered 7/3/25. Trazodone 50 mg. Take 25 mg by mouth at bedtime for depression, ordered 6/15/25. Behavior monitoring - antidepressants. Withdrawn, loss of appetite, crying, lack of interest, apathy, feeling of helplessness, feelings of worthlessness, suicidal ideations, insomnia. Interventions: document in progress note, ordered 5/11/25. Behavior monitoring - antidepressants. Document interventions attempted and effectiveness. Intervention redirection, one-on-one, diversional activity, offering to call family or friend or other. Effective yes or no, ordered 5/11/25. -There was no physician’s order to monitor for behaviors related to Resident #9’s antipsychotic medications. -Review of Resident #9’s April 2025 (from 4/1/25 to 4/30/25), May 2025 (from 5/1/25 to 5/31/25), June 2025 (from 6/1/25 to 6/30/25) and July 2025 (from 7/1/25 to 7/23/25) MAR/TAR revealed there was no documentation to indicate the resident had exhibited antidepressant or antipsychotic behaviors during the month. The 6/20/25 nurse note revealed Resident #9 was awake and yelling at the top of her voice from 10:30 p.m. to 1:00 a.m. No matter what the staff did for the resident, she was not satisfied. -The progress note failed to include what interventions the staff attempted to use to redirect the resident’s behaviors. The 6/27/25 nurse note revealed the resident was up all day in the common areas for meals and was loud to other residents with unspecific meaning. The resident was easily redirected but only for a short time and then repeated again. -The progress note failed to include what interventions the staff attempted to use to redirect the resident’s behaviors. The 7/2/25 nurse note revealed Resident #9 called out for a specific person’s name after breakfast and was very loud and demanding to go see that person. The resident was redirected without difficulty and was quieter after that. -The progress note failed to include what intervention the staff used to effectively redirect the resident’s behaviors. The 7/19/25 morning nurse note revealed Resident #9 continued to call out “Help” and “I can not do this anymore.” The resident was swearing and disrupting other residents. -The progress note failed to include what interventions the staff attempted to use to redirect the resident’s behaviors. IV. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 7/24/25 at 11:36 a.m. CNA #2 said she knew what behaviors to monitor for residents based on their care plans. CNA #2 said she did not document what interventions were used and if the interventions were effective. She said she was familiar with Resident #47 and Resident #9. She said she did not know of any non-pharmacological interventions to use for Resident #47 or Resident #9’s behaviors. Licensed practical nurse (LPN) #3 was interviewed on 7/24/25 at 3:49 p.m. LPN #3 said she would document if she observed a resident’s behavior. She said she did not document if an intervention was used or if the intervention was effective. LPN #3 said was familiar with Resident #47 and Resident #9. She said the behavior Resident #47 had was pacing. She said she did not know what interventions worked Resident #47’s pacing behavior. During the interview, Resident #9 was yelling off and on in the common area in the secured unit. The resident yelled “I get so scared” and “help.” LPN #3 said the behavior Resident #9 had was being loud and wanting help. She said Risperdal, talking calmly and softly and coloring were effective interventions. She said food was not an effective intervention for the resident. The director of nursing (DON) and regional clinical resource (RCR) were interviewed together on 7/23/25 at 3:39 p.m. The RCR said the interdisciplinary team (IDT) determined what behaviors needed to be monitored for residents and social services was responsible for entering the behavior monitoring in the residents’ chart after the IDT discussion. The RCR said the IDT reviewed the incoming notes from the facility or hospital where the resident transferred from and from the 24-hour communication bar in the medical record. The DON said nursing staff knew what interventions to use for each resident based on the behavior tracking on the residents’ TARs. She said CNAs told the nurses when residents had behaviors. The DON said nursing staff entered a progress note or used the TAR. She said nursing staff should use the TAR and then document a progress note about the behavior. The DON said she knew what interventions worked for residents based on verbal reports from the nursing staff. The DON said if the interventions did not work, she would reach out to the resident’s physician and family. The DON said the residents’ families shared what worked for them. The social services director (SSD) was interviewed on 7/24/25 at 12:34 p.m. The SSD said at admission, she went through the admission paperwork for residents to see if there was any behavior to monitor. She said she knew what interventions to use for a resident because there was an IDT discussion about the behaviors. She said if there was an event where a behavior was exhibited, she worked with the IDT team to find out what triggered the behavior. She said non-pharmacological interventions were used prior to a resident starting a psychotropic medication. She said nursing staff was responsible for documenting if a resident exhibited a behavior, what interventions were used and if the intervention used was effective. She said she was not sure how nursing staff documented residents’ behavior monitoring. The SSD said she was familiar with Resident #9. She said the resident had auditory behaviors because she did not hear well. She said she yelled for her daughter. She said snacks and fluids were interventions that worked for her. -However, according to LPN #3, food was not an effective intervention for Resident #9 (see interview above). The SSD said she was familiar with Resident #47. She said the resident wandered. She said interventions that worked with her were specific redirection like talking to her about her past life, such as where she lived and about her career. The DON and the RCR were interviewed together again on 7/24/25 at 4:27 p.m. The DON said non-pharmacological interventions should be offered when residents’ behaviors were elevated. She said she was familiar with Resident #9 and said she yelled for her daughter. She said interventions that worked for Resident #9 were changing the resident to a different seat at a different table, a one-on-one conversation with the resident, coffee and a snack. -However, according to LPN #3, food was not an effective intervention for Resident #9 (see interview above). The DON and the RCR said the documentation of behavior monitoring, including what interventions to use could use improvement. V. Resident #42 A. Resident status Resident #42, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 CPO, diagnoses included chronic respiratory failure, dementia, bipolar 2 disorder, borderline personality disorder, generalized anxiety disorder and depressive episodes. The 7/7/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment indicated the resident had delusions. The assessment documented the resident had not had any other behavioral symptoms during the assessment look-back period. The MDS assessment documented a gradual dose reduction (GDR) had been attempted on 9/27/24. The assessment indicated a physician documented a GDR was contraindicated for the resident on 4/28/25. B. Resident interview and observations On 7/21/25 at 10:04 a.m. Resident #42 was talking with her physician in her room. Resident #42 said she did not want to take her Seroquel in the middle of the day because it made her so tired. -The physician’s response was not able to be heard. Resident #42 was interviewed on 7/21/25 at 10:15 a.m. Resident #42 said she had talked with her physician earlier and told them she did not want to be on so many medications because they made her so tired. Resident #42 said her physician told her as long as he was her doctor she had to take all of her medications. Resident #42 said she felt like she was on too many medications. C. Record review The antipsychotic medication care plan, revised 7/14/25, revealed Resident #42 took an antipsychotic medication for her bipolar disorder. Pertinent interventions included administering her medications as ordered and observing for side effects and effectiveness each shift, consulting with the pharmacy and physician to consider dose reduction when clinically appropriate for the resident at least quarterly, and discussing with the physician and family the need for ongoing medication use with the resident. The anxiety care plan, revised 7/12/24, revealed Resident #42 had an anxiety disorder. Pertinent interventions included moving Resident #42 to a calm, safe environment when conflict arose, allowing the resident time to answer questions and verbalize her feelings, and encouraging participation from the resident. The depression care plan, revised 7/14/25, revealed Resident #42 took an antidepressant medication for her depression. Pertinent interventions included administering her medications as ordered and observing for side effects and effectiveness each shift. The bipolar care plan, revised 11/8/24, revealed Resident #42 had bipolar disorder. Pertinent interventions included administering medications as ordered, assisting the resident to develop appropriate methods of coping and interacting, intervening as necessary to protect the rights and safety of others, and observing the resident’s behavioral episodes and attempting to determine their underlying cause. The cognitive care plan, revised 12/10/24, revealed Resident #42 had impaired cognitive function. Pertinent interventions included administering medications as ordered, cueing and reorienting the resident as needed, approaching the resident in a gentle friendly manner, and reviewing the resident’s medications and recording possible causes of cognitive deficits. Review of Resident #42's July 2025 CPO revealed the following physician's orders: Clonazepam 1 mg oral tablet, give one tablet by mouth at bedtime for bipolar disorder, ordered 9/26/24. Clonazepam 1 mg oral tablet, give one tablet by mouth in the afternoon for bipolar disorder, ordered 9/26/24. Clonazepam 1 mg oral tablet, give one tablet by mouth in the morning for bipolar disorder, ordered 9/26/24. Lamotrigine 200 mg oral tablet, give 200 mg by mouth at bedtime for bipolar disorder, ordered 11/21/24. Lamotrigine 200 mg oral tablet, give 200 mg by mouth in the morning for bipolar disorder, ordered 11/21/24. Melatonin 1mg oral capsule, give 1 mg by mouth at bedtime for insomnia, ordered 1/31/25. Seroquel 25 mg oral tablet, give one tablet by mouth in the afternoon for bipolar disorder, ordered 1/1/25 and discontinued 7/17/25. Seroquel 25 mg oral tablet, give one tablet by mouth in the morning for bipolar disorder, ordered 1/1/25 and discontinued 7/17/25. Seroquel 25 mg oral tablet, give one tablet by mouth in the morning for bipolar disorder, ordered 7/17/25. Seroquel 25 mg oral tablet, give one tablet by mouth in the afternoon at 2:00 p.m. for bipolar disorder, ordered 7/17/25. Seroquel 25 mg oral tablet, give four tablets by mouth at bedtime for bipolar disorder, ordered 1/1/25 and discontinued 7/17/25. Seroquel 25 mg oral tablet, give four tablets by mouth at bedtime for bipolar disorder, ordered 7/17/25. Venlafaxine 150 mg extended release oral tablet, give one tablet by mouth in the morning daily with breakfast for bipolar disorder, ordered 9/26/24. Review of Resident #42's MARs and TARs, from 3/1/25 to 7/24/25, revealed the following: The March 2025 (from 3/1/25 to 3/31/25) MAR/TAR revealed there was no documentation to indicate Resident #42 exhibited behaviors during the month. The April 2025 (from 4/1/25 to 4/30/25) MAR/TAR revealed there was no documentation to indicate Resident #42 exhibited behaviors during the month. The May 2025 (from 5/1/25 to 5/31/25) MAR/TAR revealed there was no documentation to indicate Resident #42 exhibited behaviors during the month. The June 2025 (from 6/1/25 to 6/30/25) MAR/TAR revealed there was no documentation to indicate Resident #42 exhibited behaviors during the month. The July 2025 (from 7/1/25 to 7/24/25) MAR/TAR revealed there was no documentation to indicate Resident #42 exhibited behaviors related to anxiety or depression during the month. A psychotropic meeting review form, dated 3/31/25, revealed Resident #42’s psychotropic medications were being reviewed by the medical director, the psychiatrist, the DON, the assistant director of nursing (ADON), the SSD and the NHA. The section on the form that asked if a GDR was contraindicated was marked as not applicable. The committee recommended Resident #42’s Seroquel be increased to 50 mg in the mornings and afternoons and 100 mg in the evenings. The committee further recommended the resident’s venlafaxine be decreased from 150 mg to 75mg. A progress note, dated 4/17/25 at 10:26 a.m., revealed the psychopharmacological medication committee recommended Resident #42’s Seroquel be increased and to decrease her venlafaxine. Resident #42’s physician was aware of the recommendation and was in disagreement with the recommendation. -However, the physician did not document a rationale for why changing Resident #42’s medications would not be recommended. The May 2025 pharmacy medication regiment review revealed Resident #42 was due for a GDR on her psychotropic medications. The pharmacy review documented if a GDR was contraindicated, the pharmacist recommended the physician document it as such in Resident #42’s EMR. A physician’s progress note, dated 5/30/25 at 5:45 p.m., revealed it was contraindicated for Resident #42 to undergo a GDR at that time as the resident was on the lowest effective dose of her medications for adequate symptom management. The note further documented that attempting a GDR at that time would place Resident #42 at high risk for symptoms decompensating to unmanageable levels. A psychotropic meeting review form, dated 6/30/25, revealed Resident #42’s psychotropic medications were being reviewed. The section on the form that asked if a GDR was contraindicated was marked as not applicable. The committee recommended Resident #42’s medications go unchanged and a GDR contraindication was signed by her physician. -However, the physician did not document a rationale for why changing Resident #42’s medications would not be recommended. A psychiatric follow-up note, dated 7/15/25 at 8:00 a.m., revealed Resident #42’s medications were reviewed by her physician. Resident #42 said she would like to GDR her Seroquel, and the physician recommended discussing her medications at the next psychopharmacological medication meeting. -However, according to Resident #42, the physician told her she had to take all of her medications (see resident interview above). D. Staff interviews The DON and the RCR were interviewed together on 7/24/25 at 2:42 p.m. The DON said for psychotropic medications, the nursing staff monitored the residents for side effects and efficacy. The DON said the IDT spoke about residents’ medication regimens during their psychopharmacological medication meetings. The DON said the pharmacy sent the facility recommendations and recommended GDRs and the physician would fill out risk/benefit forms as needed. The DON said Resident #42’s last GDR attempt was on 3/31/25. The DON said the facility attempted to GDR psychotropic medications every three months. The RCR said Resident #42’s venlafaxine was decreased from 150 mg to 75 mg per day on 3/31/25. -However, the decrease of the resident’s venlafaxine was the recommendation made by the psychopharmacological medication committee to the physician on 3/31/25, but the physician disagreed with the recommendation and the resident’s medication was not decreased (see record review above). The DON was interviewed a second time on 7/24/25 at 4:54 p.m. The DON said she found a progress note that documented Resident #42’s physician disagreed with the GDR recommended by the psychopharmacological medication committee on 3/31/25. The DON said Resident #42’s physician did not fill out any documentation to indicate the rationale for not changing the resident’s recommendations.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to assistance items for one (#49) of two residents reviewed for ADLs out of 39 sample residents. Specifically, the facility failed to ensure Resident #49, who was dependent on staff for care, received her preferred communication device during ADLs. Findings include: I. Resident #49A. Resident statusResident #49, age less than 65, was admitted prior to 2020. According to the July 2025 computerized physician orders (CPO), diagnoses included paraplegia (paralysis of the lower half of the body including the legs and sometimes the abdomen), muscle weakness, dysphagia (difficulty swallowing) and aphasia (difficulty speaking). The 5/8/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance for toileting hygiene, upper and lower body dressing, rolling, sitting to lying and lying to sitting, chair to bed transfers and toilet transfers. The resident was non ambulatory and was dependent on the use of a manual highback wheelchair.The MDS assessment indicated the resident used communication devices. B. Resident interview and observationsResident #49 was interviewed via her tablet on 7/21/25 at 3:46 p.m. Resident #49 said she used a communication board. She said the staff never gave her the communication board and she said that violated her rights. She said she could use her tablet but the typing took her longer. The resident's communication board was in a basket on top of her dresser and was not within reach for the resident.C. Resident observation During a continuous observation on 4/22/25, beginning at 8:30 a.m. and ending at 12:49 p.m., the following was observed:At 9:10 a.m. certified nurse aide (CNA) #1 entered Resident #49's room to inform her it was her shower day and she would come back later to give her her shower. CNA #1 did not utilize the communication device or offer it to the resident for use. At 9:45 a.m. CNA #1 assisted Resident #49 into the shower room. CNA #1 asked the resident to let her know if the water was too warm during her shower. The resident did not have a communication device in hand to inform CNA #1 if the resident was too warm or too cold. At 9:58 a.m. Resident #49 was assisted back to her room. CNA #1 told the resident she had to obtain the Hoyer lift (mechanical lift) to transfer her back to bed. At 10:02 a.m. CNA #3 entered Resident #49's room to assist CNA #1 with putting Resident #49 in her wheelchair. She was not provided the communication boardAt 10:16 a.m. CNA #1 asked Resident #49 what she wanted to wear. Resident #49 responded by nodding her head. -CNA #1 did not provide Resident #49 with a communication device. At 10:20 a.m. CNA #1 asked Resident #49 which color hair accessories she wanted. Resident nodded her head, CNA #1 picked a color. CNA #1 and asked what color glasses she wanted to wear. The resident nodded her head, CNA #1 picked a pair of glasses. -CNA #1 did not provide Resident #49 with a communication device. At 10:28 a.m. Resident #49 requested her tablet by pointing at it. CNA #1 gave her her tablet. CNA #1 did not offer her the communication board. At 10:57 a.m. all the staff left the room without giving Resident #49 her communication board. At 11:30 a.m. The resident was observed sitting in her wheelchair in her room watching television. Her communication board was observed on top of her dresser. At 12:30 a.m. The resident was sitting in her wheelchair in her room watching television. CNA #1 asked the resident if she needed anything. The resident did not respond. Her communication board was on top of her dresser. D. Record reviewThe care plan dated 10/21/15 identified the resident required substantial/maximal assistance with shower/bathing, and her preferred communication method was her tablet and communication board. Pertinent interventions included the resident requiring a communication board to communicate, ensuring the availability and functioning of adaptive communication equipment, the resident communicated well through email (initiated 10/21/15), evaluating the resident's dexterity/ability to use communication board,writing, use computer or use of sign language as alternate communication to speech (initiated 10/21/15), ensuring her adaptive equipment was provided, present, and functional including wheelchair and communication board (date initiated 9/26/23).II. Staff interviews CNA #3 was interviewed on 7/22/25 at 2:30 p.m. CNA #3 said she did not know how to communicate with Resident #49 and relied on the assistance of other staff. CNA #3 said she had not received any education from the facility about how to communicate with Resident #49. CNA #3 said Resident #49 has had a tablet that she used to play games on but did not use it to communicate with the nursing staff.CNA #1 was interviewed on 7/23/25 at 2:00 p.m. CNA #1 said the resident liked to use her tablet to communicate with the staff. CNA #1 said she only used yes or no questions when communicating with the resident. -However CNA #1 was observed using open ended questions regarding clothing choices and did not offer the resident her communication devices to reply to her questions (see observations above). Registered nurse (RN) #1 was interviewed on 7/22/25 at 2:00 p.m. RN #1 said there was no preferred communication method for Resident #49. RN #1 said she did not really communicate with Resident #49 because she just administered medications. RN #1 said there was no communication method in the resident medical record listed or her care plan. -However the residents comprehensive care plan indicated the resident preferred communication method was her tablet and communication board (see above). The director of nursing (DON) was interviewed on 7/23/25 at 1:15 p.m. The DON said Resident #49 had a tablet and a communication board available for the staff to use. She said the staff needed to use Resident #49's preferred communication device. The DON said the communication devices were listed on her care plan so that all staff were aware of how to properly communicate with Resident #49.

Based on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries from occurring or worsening for one (#14) of four residents reviewed out of 39 sample residents. Specifically, the facility failed to ensure staff provided consistent interventions to Resident #14, who had a pressure ulcer.Findings include:I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 7/29/25 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows:Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk).Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpableUnstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover' and should not be removed.Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.III. Resident #14A. Resident statusResident #14, age less than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included spinal stenosis (a condition where the spaces within the spinal canal narrow, putting pressure on the spinal cord and nerve roots), cerebral infarction (stroke), chronic pain and generalized muscle weakness. The 6/9/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident was dependent on staff for most activities of daily living (ADL). The assessment documented the resident was dependent on staff for rolling left and right in bed.The assessment indicated the resident was at risk of developing pressure ulcers. The assessment indicated the resident had a stage three pressure ulcer. The assessment indicated the resident was not on a turning or repositioning program.B. ObservationsDuring a continuous observation on 7/22/25, beginning at 1:19 p.m. and ending at 5:03 p.m., the following was observed:At 1:19 p.m. Resident #14 was lying on his air mattress on his back with his weight shifted partially to his right side. A pillow was placed under his left side and his legs were curled in slightly.At 2:46 p.m. the resident aide stepped into Resident #14's room briefly before retrieving an item from the nurses' station for Resident #14. The resident aide left the room immediately afterward. Resident #14 was lying in the same position.At 3:49 p.m. licensed practical nurse (LPN) #4 entered Resident #14's room to pass medications to the resident's roommate. Resident #14 was still lying partially on his right side with a pillow under his left side with his legs curled in slightly. LPN #4 left the room within three minutes of entering it and did not engage with Resident #14.At 4:01 p.m. certified nurse aide (CNA) #3 entered Resident #14's room and closed the door.At 4:02 p.m. CNA #3 left Resident #14's room. Resident #14 continued to lie partially on his right side with the pillow under his left side.-CNA #3 did not attempt to reposition Resident #14 during this time (see interviews below).At 4:35 p.m. Resident #14 continued lying partially on his right side with the pillow under his left side.At 5:03 p.m. CNA #3 entered Resident #14's room, removed the pillow from below the resident's left side and pulled Resident #14's body to the side slightly so he was lying completely flat. CNA #3 adjusted Resident #14's bed so he was sitting upright and prepared his bedside table to make room for his dinner tray.-Resident #14 was lying in the same position for almost four hours during the continuous observation.On 7/23/25 at 12:55 p.m. Resident #14's pressure injury was observed with LPN #6. The skin on Resident #14's coccyx was pink, intact and non-blanchable. Resident #14 did not express pain while Resident #14 applied the topical Triad cream.At 1:21 p.m. Resident #14 was lying in bed on his back with his weight shifted slightly to the right. Resident #14's legs were curled slightly inward and he had a pillow between his legs at his heels.C. Record reviewThe skin impairment care plan, initiated 12/27/24 and revised 6/11/25, revealed Resident #14 had potential impairments to skin integrity and had a stage three pressure injury to his coccyx. Interventions implemented on 12/27/24 included ensuring good nutrition and hydration, following facility protocols for treatment of injuries, identifying and documenting potential causative factors and eliminating them where possible and using caution during resident transfers. Interventions initiated on 5/12/25 included Resident #14 not wearing a brief while in bed.-The care plan did not include an intervention for frequent turning and repositioning of the resident.The ADL care plan, revised 12/27/24, revealed Resident #14 had an ADL self-care performance deficit. Pertinent interventions included ensuring Resident #14's air mattress was inflated and functioning. The care plan documented Resident #14 was totally dependent on staff for bed mobility and used a hoyer lift for transfers.Review of Resident #14's July 2025 CPO revealed the following physician's orders:Treatment to coccyx and left buttocks: clean with wound cleanser, pat dry, and apply Triad cream, ordered 7/1/25.ProSource oral liquid nutritional supplement, instructions to give 30 milliliters (ml) by mouth two times daily, ordered 7/3/25 and revised 7/17/25.Ensure air mattress is inflated and functioning with weight set at 200 to 210 lbs (pounds), ordered 4/10/25.No brief while in bed, only chux pads (incontinence pad), ordered 1/5/25.A Braden scale (pressure sore assessment risk) assessment, dated 3/11/25, revealed Resident #14 was at moderate risk for pressure ulcers with a score of 13 out of 18.A Braden scale assessment, dated 6/7/25, revealed Resident #14 was at risk for pressure ulcers with a score of 14 out of 18.A progress note, dated 5/6/25 at 8:49 a.m., revealed the wound care physician (WCP) found a stage three pressure injury on Resident #14's coccyx during wound rounds that day. The wound was cleansed and dressed and all responsible parties were notified.An interdisciplinary team (IDT) note, dated 5/7/25 at 7:31 p.m., revealed Resident #14 had a new pressure injury as of 5/6/25. The root cause was Resident #14 refusing to be repositioned at times due to the resident enjoying watching his television (TV). Treatments put into place included cleansing the wound with wound cleanser, patting dry, applying skin prep to the peri-wound area, applying a honey-based gel to the wound bed, and covering with border foam. Interventions put into place included Resident #14 not wearing a brief while in bed. The WCP visit note, dated 5/26/25, revealed Resident #14's coccyx wound was a stage three pressure ulcer. The wound measured 0.1 centimeters (cm) in length, 0.1cm in width and 0.1 cm in depth. Previous measurements, taken 5/12/25, revealed the wound had measured 0.3 cm in length, 0.3 cm in width and 0.1cm in depth. The wound bed was 50% granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and 50% epithelialization (a crucial part of wound healing, allowing the body to repair and close wounds by forming a new layer of skin or tissue). The wound was improving. Orders included cleansing the wound with wound cleanser, protecting the peri-wound skin with skin protectant, applying a honey-based gel to the wound bed and applying bordered foam three times per week and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently.-However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 6/2/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and moisture-associated skin damage (MASD) to the sacrum. The coccyx wound measured 0.1 cm in length, 0.1cm in width and 0.1 cm in depth. The wound bed was 90% granulation and 10% slough (a type of tissue that is not actively healing and can delay the wound healing process and typically appears as yellow or white, soft, and moist material in the wound bed). There was no change noted in the wound progression. The peri-wound area exhibited maceration (a condition where the skin becomes soft, white, and wrinkled due to prolonged exposure to moisture). Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently.-However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above). The WCP visit note, dated 6/9/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the sacrum. The coccyx wound measured 0.1 cm in length, 0.1cm in width and 0.1 cm in depth. The wound bed was 90% granulation and 10% slough. There was no change noted in the wound progression. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently.-However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above). The WCP visit note, dated 6/16/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the sacrum. The coccyx wound measured 0.1 cm in length, 0.1cm in width and 0.1 cm in depth. The wound bed was 50% granulation and 50% epithelialization. There was no change noted in the wound progression. The peri-wound area exhibited maceration. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 6/23/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx. The coccyx wound measured 0.2 cm in length, 0.2 cm in width and 0.3 cm in depth. There was a small amount of serous drainage (a thin, watery fluid, typically clear or pale yellow, that is a normal part of the wound healing process) noted. The wound bed was 100% epithelialization. The wound was deteriorating. Orders included cleansing the wound with wound cleanser and protecting the peri-wound area with skin protectant, packing the wound with iodoform packing and applying bordered gauze to the wound every day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 6/30/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the left buttock. The coccyx wound measured 0.2 cm in length, 0.2 cm in width and 0.3 cm in depth. There was a small amount of serous drainage noted. The wound bed was 80% granulation and 20% epithelialization. The peri-wound skin exhibited maceration. There was no change noted in the wound progression. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 7/7/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the left buttock. The coccyx wound measured 1.0 cm in length, 1.0 cm in width and 0.5 cm in depth. There was a small amount of serous drainage noted. The wound bed was 50% granulation and 50% epithelialization. The wound was deteriorating. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 7/14/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the left buttock. The coccyx wound measured 1.0 cm in length, 1.0 cm in width and 0.5 cm in depth. The wound bed was 100% epithelialization. There was no change noted in the wound progression. The peri-wound skin exhibited maceration. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 7/21/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the left buttock. The coccyx wound measured 1.0 cm in length, 1.0 cm in width and 0.5 cm in depth. The wound bed was 100% epithelialization. There was no change noted in the wound progression. The peri-wound skin exhibited maceration. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).Review of the CNA repositioning task records,from 6/25/25 through 7/24/25, revealed there were no refusals of repositioning documented for Resident #14 during the time period.IV. Staff interviewsCNA #3 was interviewed on 7/22/25 at 5:08 p.m. CNA #3 said she had entered Resident #14's room earlier that evening only to empty his catheter bag, as she had changed his brief earlier that day. CNA #3 said she had only emptied Resident #14's catheter bag and had not provided or attempted to provide any other care.CNA #1 was interviewed on 7/23/25 at 2:10 p.m. CNA #1 said Resident #14 was in pain. CNA #1 said Resident #14 was supposed to be up for every meal, so they assisted him up and into the dining room. CNA #1 said the nursing staff went in and repositioned Resident #14 every two to two and a half hours. CNA #1 said Resident #14 could move slightly and wiggle his limbs but could not fully reposition himself onto his side.-However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).CNA #1 said Resident #14 previously had a bad sore on his coccyx but it had gotten a lot better. CNA #1 said whenever the nursing staff went into Resident #14's room they also checked his incontinence brief. CNA #1 said they did not use an incontinence brief when Resident #14 was in bed when Resident #14 had the wound on his coccyx, but now the wound was better so he was able to wear a brief throughout the night.-However, the physician's order to not have Resident #14 wear briefs while in bed was in place as of 1/5/25 (see physician's orders above).CNA #4 was interviewed on 7/23/25 at 2:56 p.m. CNA #4 said Resident #14 was supposed to be up and out of bed for every meal. CNA #4 said Resident #14 was in pain all the time and it did not improve unless he was up. CNA #4 said Resident #14's bottom was raw and bled sometimes, but was not doing so as much as it used to. CNA #4 said she took Resident #14's brief off whenever he was in bed. CNA #4 said she applied Triad cream to his bottom whenever it was bleeding. CNA #4 said she was not sure if she was supposed to do that or if the nurses were supposed to do that, but Resident #14's bottom was dry and bleeding so she applied the Triad cream. CNA #4 said Resident #14 was not able to turn over on his own, so the nursing staff turned and repositioned him every two hours. CNA #4 said the nursing staff tried to put pillows under Resident #14 but he just fell back over, so he mostly laid on his back. CNA #4 said when the wound on Resident #14's bottom was bad he would fall back onto the wedge pillows and it looked as if he was never moved.Registered nurse (RN) #1 was interviewed on 7/24/25 at 9:06 a.m. RN #1 said Resident #14 liked to lean to the right and was supposed to be repositioned every few hours. RN #1 said repositioning residents every two hours redistributed their body weight. RN #1 said Resident #14 was not very mobile, so he would lie on his back all day if not repositioned by the nursing staff.-However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).LPN #5 was interviewed on 7/24/25 at 9:46 a.m. LPN #5 said the nursing staff were supposed to turn and reposition Resident #14 every two hours since he could not reposition himself. LPN #5 said Resident #14 did not have any skin issues that she knew of, but knew she applied cream to his hips. LPN #5 said repositioning Resident #14 changed the location of the pressure on his body so he would not get pressure ulcers.The WCP was interviewed on 7/24/25. The WCP said he did not have an exact timeframe for repositioning or turning frequency but said Resident #14 needed to be turned or repositioned at least every three hours. The WCP said Resident #14 had had wounds on and off since he started working at the facility. The WCP said the facility's interventions for Resident #14 included using Triad cream, as there were some macerations around his buttocks. The WCP said the facility staff had been turning Resident #14 and had been using wedge pillows, which were important to reduce heat and pressure on the skin. The WCP said sweat was a contributing factor for the wounds Resident #14 had at the time. The WCP said the nursing staff also used pillows between Resident #14's legs for comfort and positioning.-However, Resident #14 was not observed using wedge pillows during the survey process.The director of nursing (DON) was interviewed on 7/24/25 at 2:42 p.m. The DON said Resident #14 had a stage three pressure ulcer to his coccyx and MASD to his left buttock. The DON said the pressure ulcer on Resident #14's coccyx was first noted on 5/5/25. The DON said Resident #14's interventions at the time included using an air mattress and not wearing a brief in bed. The DON said she thought Resident #14 was also on a program for frequent turning/repositioning at the time but she was not sure. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above) and the care plan did not indicate the resident was on a turning/repositioning program (see record review above).The DON said Resident #14 was assessed to be at moderate risk for developing pressure ulcers on 3/11/25. The DON said Resident #14 was limited in his ability to self-reposition and could not roll onto his side independently but could move his arms and legs and readjust himself. The DON said Resident #14 was currently receiving the ProSource nutritional supplement twice a day and was being seen by the WCP. The DON said she thought Resident #14 was on a repositioning program but said she could not find any information about it in his electronic medical record (EMR). The DON said Resident #14 had been refusing repositioning, and refusal notes would be in his EMR.-However, review of Resident #14's EMR did not reveal any documentation about him refusing repositioning.

Based on record review and interviews, the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one (#18) of two residents reviewed for mobility out of 39 sample residents. Specifically, the facility failed to ensure Resident #18's hand splint was applied as ordered to help maintain the resident's limb function and mobility.Findings include:I. Facility policy and procedureThe Prevention of Decline in Range of Motion policy and procedure, undated, was provided by the regional clinical resource (RCR) on 7/24/25 at 5:21 p.m. It read in pertinent part, The facility will provide treatment and care in accordance with professional standards of practice. This includes appropriate equipment, including braces or splints. A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercises will be documented in the medical record.II. Resident #4A. Resident statusResident #18, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body), wound on the right ankle, contracture of muscles on the right lower leg, gait and mobility abnormalities and generalized muscle weakness.The 7/9/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. The resident was dependent on staff for most activities of daily living (ADL).B. Resident interview and observationsResident #18 was interviewed on 7/21/25 at 10:46 a.m. Resident #18 said he did not wear a splint for his hand. Resident #18's right hand had several fingers that were contracted and pointing downward.On 7/22/25 at 11:25 a.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand.At 11:57 a.m. licensed practical nurse (LPN) #4 left Resident #18's room after applying a dressing to his right ankle. -However, LPN #4 did not apply a splint to Resident #18's right hand.At 11:59 a.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand. Certified nurse aide (CNA) #3 entered Resident #18's room and gave him his lunch tray but did not apply a splint to the resident's hand.At 1:20 p.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand.At 3:25 p.m. Resident #18 was lying on his bed on his back. Resident #18 was not wearing a splint on his right hand.On 7/23/25 at 8:26 a.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand.At 1:10 p.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand.At 1:35 p.m. Resident #18 was lying on his back in bed. Resident #18 was not wearing a splint on his right hand.On 7/24/25 at 8:39 a.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand.On 7/24/25 at 9:55 a.m. LPN #5 entered Resident #18's room and asked him if he had a splint for his right hand, to which Resident #18 said he did. LPN #5 found a splint on Resident #18's bedside table and applied it to the resident's right hand.C. Record reviewReview of the comprehensive care plan, revised 7/22/25, did not reveal any care plan focus regarding Resident #18's hand contractures or therapeutic devices.Review of Resident #18's July 2025 CPO revealed the following physician's orders:Apply right upper extremity wrist cockup splint (a type of orthotic device designed to immobilize and support the wrist in a slightly extended (or cocked-up) position) and c-grip (a type of hand splint designed to support the wrist and encourage finger extension, particularly for managing contractures) hand splint daily as tolerated per restorative therapy, ordered 9/27/22. Resident will don (put on) right resting hand splint as tolerated per restorative, along with skin checks, sensation and movement, ordered 10/3/24.Review of the splint task documentation, which documented the amount of minutes Resident #18's splint was applied, revealed the resident wore his splint for 240 minutes on 7/24/25 (during the survey process). -However, there was no documentation to indicate Resident #18 had worn his splint from 6/24/25 through 7/23/25.D. Staff interviewsCNA #1 was interviewed on 7/23/25 at 2:10 p.m. CNA #1 said Resident #18 did not have any splints for his hands that she had seen.CNA #4 was interviewed on 7/23/25 at 2:56 p.m. CNA #4 said Resident #18 got out of bed first thing in the mornings and sat in his chair from morning until after lunch. CNA #4 said she did not think Resident #18 used any splints or restorative devices for his hands. CNA #4 said she thought she saw a splint for Resident #18's wrist at one point, but she said she was not told to do any restorative care for him. CNA #4 said if Resident #18 refused his splint, she would tell the nurse about the refusal.Occupational therapist (OT) #1 was interviewed on 7/23/25 at 3:45 p.m. OT #1 said Resident #18 was no longer on the occupational therapy caseload and was discharged from therapy on 1/10/25. OT #1 said Resident #18 had been on the therapy caseload for upper extremity management. OT #1 said Resident #18 had a resting hand splint with orders for the splint to be applied in his electronic medical record (EMR). OT #1 said Resident #18 was a little bit resistant to the resting hand splint and he was able to say whether he wanted the splint on or off. OT #1 said the resting hand splint was to maintain the functional grasp for his right hand for tasks, such as self-feeding or holding objects and to prevent further contracture of his hand. OT #1 said Resident #18 was not able to apply his resting hand splint himself and needed staff to do so for him. OT #1 said Resident #18's hand splint would be kept in his room. OT #1 said the nursing staff should have offered to apply Resident #18's hand splint for him. She said she had educated the nursing staff on applying the hand splint. OT #1 said the CNAs knew how to apply Resident #18's hand splint and should document his refusals.Registered nurse (RN) #1 was interviewed on 7/24/25 at 9:06 a.m. RN #1 said the therapy team left the nursing staff notes that indicated they needed to use a splint for residents with contractures. RN #1 said residents' splints were kept in their rooms. RN #1 said the nurses needed to make sure they followed the orders in the residents' CPO for when they needed to apply or take off the splints. She said hand splint application was typically marked in the treatment administration record (TAR).LPN #5 was interviewed on 7/24/25 at 9:46 a.m. LPN #5 said she had not seen Resident #18 wearing any splints. LPN #5 said she did not think Resident #18 would have enough nobility to don a hand splint by himself. LPN #5 said the CNAs applied residents' splints if they had them. LPN #5 said if Resident #18 refused any of his treatments she would mark the refusal in the TAR.LPN #5 was interviewed a second time on 7/24/25 at 9:55 a.m., after assisting Resident #18 with his splint (see observation above). LPN #5 said she usually checked to see if residents were wearing their braces or splints. LPN #5 said she had no idea Resident #18 had a splint and had never seen him wear it. The director of nursing (DON) was interviewed on 7/24/25 at 2:42 p.m. The DON said Resident #18 had a splint he wore on his right hand. The DON said the nursing staff should have been offering Resident #18 his splint each shift. The DON said Resident #18 could not don his splint by himself. The DON said offering of the splint and any resident refusals should have been documented in Resident #4's TAR or progress notes.-However, Resident #18 was not observed wearing a splint on his right hand during the survey period (see observations above).

Based on observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#7) of three residents reviewed for catheter care out of 39 sample residents.Specifically, the facility failed to:-Use privacy bag for Resident #7's catheter drainage bag;-Ensure Resident #7's catheter was placed appropriately to ensure the urine could flow freely; -Ensure Resident #7's catheter bag was emptied timely; and,-Consistently monitor Resident #7's intake and output per physician's orders. Findings include: I. Facility policy and procedure The Catheter Care policy and procedure, implemented 5/24/25, was provided by the regional clinical resource (RCR) on 7/24/25 at 9:11 a.m. It read in pertinent part, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Catheter care will be performed every shift and as needed by nursing personnel. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Privacy bags will be changed out when soiled, with a catheter change or as needed. Empty drainage bags when bag is half-full or every three to six hours. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. Document care and report any concerns noted to the nurse on duty. IlI. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, urinary tract infection (UTI), and obstructive and reflux uropathy (a condition where urine flow is blocked and urine flows backward from the bladder into the kidneys).The 6/23/25 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 dependent with toileting hygiene, bathing/showers, lower body dressing, personal hygiene and bed to chair transfers. He was non ambulatory and used a wheelchair for mobility.The MDS assessment indicated he had an indwelling catheter and was always incontinent of bowel and bladder.B. Resident interview and observationsResident #7 was interviewed on 7/21/25 at 1:48 p.m. Resident #7 said he had penis pain around his catheter insertion site. Resident #7 said he told the staff today (7/21/25) and they should be taking care of it. Resident #7 said he got the catheter put in while he was at the hospital prior to admission. Resident #7 said he was trying to increase his intake of water because he had been told he was dehydrated. During the interview the resident's catheter bag was hooked to the side of his bed. Resident #7 was interviewed on 7/22/25 at 3:15 p.m. Resident #7 said that his pain was much better and mostly gone today. He said the UTI medication was working. Resident #7 was resting comfortably in his bed and the catheter bag was hanging on the side of the bed. Resident #7 said the care staff had not emptied his catheter bag yet today. The resident's catheter bag was full or urine. On 7/22/25 at 3:44 p.m. certified nurse aide (CNA) #3 was in Resident #7's room. CNA #3 emptied dark yellow urine from Resident #7's catheter bag without donning (put on) gloves or a gown. On 7/23/25 at 1:23 p.m. CNA #1 and CNA #4 assisted Resident #7 with getting dressed, out of bed and into a wheelchair. The resident was assisted to the hallway. Resident #7's catheter bag was under his chair with no privacy bag covering the catheter bag. The catheter tubing was coming up and out of the top of Resident #7's pants at the waistband to the front right side. C. Record reviewThe indwelling catheter care plan, initiated 4/11/25 revealed the resident had a catheter. The interventions included monitoring for signs and symptoms of discomfort on urination and frequency, monitoring and documenting for pain/discomfort due to the catheter and monitoring/recording/reporting to medical doctor for signs and symptoms of a UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns.The EBP care plan, initiated 6/6/25, revealed the resident was on EBP to prevent the spread of multi-drug resistant organisms.The antibiotic therapy care plan, initiated 7/21/25 revealed the resident was on an antibiotic. Pertinent interventions included administering antibiotic medications as ordered by physician, monitoring/documenting side effects and effectiveness, monitoring/documenting/reporting as needed and adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat) and monitoring/documenting/reporting as needed any signs and symptoms of secondary infection related to antibiotic therapy: oral thrush (white coating in mouth, tongue), persistent diarrhea, and vaginitis/itchy perineum/whitish discharge/coating of the vulva/anus.-The antibiotic therapy care plan was not initiated for five days following the new UTI diagnosis on 7/16/25.-The care plans were not updated after the resident was diagnosed with a UTI on 7/16/25.The lab results, dated 7/15/25 at 7:12 p.m., revealed the resident had a UTI due to abnormal urinalysis (UA) results. The culture and sensitivity test revealed positive for Escherichia coli.The 7/16/25 nursing progress note documented at 11:09 a.m. revealed the primary care physician was aware of recent lab results, new orders for antibiotics.The 7/16/25 antibiotic monitoring note documented at 9:57 a.m. revealed the resident had his first dose of rocephin (injectable antibiotic) IM (intramuscular) on day shift. The 7/18/25 nurse practitioner (NP) note revealed the reason for the visit was follow-up on UTI. The UA was positive and white blood count was high. The note documented the resident had been on Rocephin IM for two days.The NP ordered Macrobid (antibiotic) 100 milligrams (mg) twice a day for seven days and may need to adjust based on sensitivity results.The 7/19/25 nursing progress note documented at 3:34 p.m. revealed in pertinent part that the resident was eating and drinking without difficulty. He had 800 mL (milliliters) of urine output that morning and oral fluids were being encouraged per orders. The 7/23/25 nursing progress note documented at 4:55 p.m. revealed in pertinent part that fluids were encouraged throughout shift today. The note documented that the resident had accepted two 600 ml containers of water during the shift, and accepted coffee this morning that was approximately 180 ml and approximately 240 ml of juice at lunch. The nurse drained 800 ml of urine from the foley catheter at this time. Review of the July 2025 CPO revealed the following physician's orders:Apply a dignity bag, check for placement each shift, ordered 4/8/25.Catheter bag to gravity drainage, every shift for foley catheter, ordered 4/8/25.16 French foley with 10 milliliter (ml) balloon to bedside drainage via gravity. Change every month, as needed leakage or dislodged every shift for foley catheter, ordered 5/29/25.Push 750 cubic centimeters (cc) water three times a day, three times a day for urinary issues, ordered 7/16/25.Macrobid Oral Capsule 100 mg (Nitrofurantoin Monohyd Macro). Give 1 capsule by mouth two times a day for UTI, for seven days, ordered 7/18/25.Encourage Oral Fluids, Monitor Intake and output, document urine characteristics, every shift for change of condition, ordered 7/19/25.-Review of Resident #7's electronic medical record (EMR) did not reveal documentation that the facility was consistently monitoring the residents intake and output of fluids (see interviews below).III. Staff interviews CNA #5 was interviewed on 7/23/25 at 2:00 p.m. CNA #5 said she had not received any catheter care training while at the facility but had learned about catheters during her CNA training. CNA #5 said when the catheter bags were emptied gloves and gown should be worn. CNA #5 said when getting a resident dressed who had a catheter the tubing went through the resident's pant leg so that it came out the pant leg at the bottom. CNA #5 said she would hook the catheter bag under the chair and put a privacy bag over the catheter bag.LPN #1 was interviewed on 7/23/25 at 2:06 p.m. LPN #1 said when completing catheter care, she checked that it was patent, unobstructed and draining properly. LPN #1 said she also checked that it was below the bladder level for proper draining. LPN #1 said she had received no catheter care training at the facility. LPN #1 said if a resident had a physician's order for monitoring fluid intake and output,the nurses would document how many cc‘s of fluid the resident consumed and the amount of urine that was output. LPN #1 said the nurses would also monitor the color and odor of the urine. LPN #1 said if there was a physician's order for monitoring intake and output the nurse was responsible for monitoring and documenting. LPN #1 said if there was a physician's order for monitoring input and output the nurse would document that information on the medication administration record/treatment administration record (MAR/TAR). LPN #1 said when the CNAs got a resident dressed that had a catheter, the catheter went down the pant leg and came out the bottom of the pant leg and then hook under the wheelchair. She said it was important to ensure the catheter did not touch the ground. LPN #1 said the catheter bag should always be covered with a privacy bag to ensure the resident's dignity. The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 7/23/25 at 3:17 p.m. The IP and the DON said it was important for staff to follow EBP to help prevent the development of UTIs. The DON said when there was a physician's order to monitor the resident's input, output and urine characteristics, the nurse would document that information in the progress notes. She said this would be something the nurses would assess. She said this would also be documented on the MAR/TAR since it was a physician's order. The DON said it was important to monitor the urine characteristics by looking at the color, odor and clarity to make sure there were no signs of infection. She said monitoring the resident's inputs and outputs could also signal hydration levels. The DON said when a resident got dressed the catheter bag went down the leg of the pants and came out the bottom and hooked under the chair, covered with a privacy bag, which was important for the resident's dignity. The DON said she found that the nurses were documenting the physician's order of monitoring the resident's input and output urine characteristics each shift (twice per day) in the progress notes. The DON said there should be two notes per day since the order started on 7/19/25 at 6:00 a.m. The DON said she checked the progress note and saw a note on 7/19/25 at 3:34 p.m. but said there was not a second note monitoring the resident. The DON said she checked the progress notes on 7/20/25 and 7//21/25 and said there was no documentation at all that day monitoring the resident. The DON checked the progress notes on 7/22/25 and said there was one note addressing urine characteristics but none that day addressing input and output. The DON said she checked the progress notes on 7/23/25 at 3:17 p.m. and there were no progress notes at all. The DON said the failure may be how the physician's orders were put in and made it difficult for the nurses to document. The DON said the urinalysis results said escherichia coli was the bacteria that caused Resident #7's UTI and not using gloves could have contributed to that or it could be improper perineal care. The DON said the catheter that was observed coming out Resident #7's waistband was improperly placed and could create a blockage and risk of not having the catheter drain properly with the tube coming up out of the pants. The DON said she would begin staff education on catheter care, EBP and perineal care today.

Based on observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#22) of two residents reviewed out of 39 sample residents.Specifically, the facility failed to ensure Resident #22's feeding tube was in place prior to administering a bolus feeding per physician's orders.Findings include: I. Facility policy and procedureThe Care and Treatment of Feeding Tubes policy and procedure, undated, was provided by the regional nurse consultant (RNC), on 7/24/25 at 5:34 p.m. It read in pertinent part, In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location. Tube placement will be verified before beginning a feeding and before administering medications.II. Resident statusResident #22, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 computerized physician orders (CPO), the diagnoses included hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) and dysphagia (difficulty swallowing).The 7/22/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview status (BIMS) score of ten out of 15. The resident required substantial to maximal assistance from staff with most activities of daily living (ADL).The assessment documented the resident had coughing or choking during meals or when swallowing medications. The assessment documented the resident was receiving 51% or more of her calories through a feeding tube and 501 cubic centimeters (cc) a day of fluid through a feeding tube. III. Resident observations and interviewResident #22 was interviewed on 7/21/25 at 9:23 a.m. Resident #22 said she was unable to eat, drink or take medications by mouth. Resident #22 said she received tube feeds five times per day. On 7/24/25 at 11:34 a.m. licensed practical nurse (LPN) #5 performed hand hygiene, donned (put on) a gown and gloves and entered Resident #22's room. LPN #5 removed a stopper from Resident #22's percutaneous endoscopic gastrostomy (PEG) tube, inserted the barrel of a syringe into the tube, poured a small splash of water from a plastic cup into the syringe and watched it drain into the PEG tube. LPN #5 then poured the entire contents of one 237 milliliter (ml) carton of Glucerna nutritional supplement into the syringe barrel slowly, allowing the contents to feed by gravity into the PEG tube. Once finished with the Glucerna, LPN #5 flushed the PEG tube again by pouring the remaining contents of the cup of water into the syringe barrel, disconnected the syringe and replaced the stopper.-However, LPN #5 did not check Resident #22's PEG tube to ensure it was placed and functioning properly prior to administering the bolus feeding and water flushes (see interviews below).IV. Record reviewThe nutrition care plan, revised 5/14/25, revealed Resident #22 was at a nutritional risk due to her dysphagia and had a PEG tube in place. Pertinent interventions included providing nocturnal feedings by administering Glucerna at a rate of 55 ml per hour over 12 hours, and flushing with 120 ml of water before and after feeding and every four hours.-However, the care plan did not reflect the updated physician's orders for Resident #22's bolus feeding amount and frequency.The gastrointestinal care plan, revised 5/25/25, revealed Resident #22 had an alteration in her gastrointestinal status due to her PEG tube. Pertinent interventions included avoiding snacks that aggravated her condition and administering medications as ordered.Review of the July 2025 CPO revealed the following physician's orders for Resident #22:-Enteral feed order: enteral tube placement will be checked each shift. Hold enteral feeding and notify physician if tube migration is suspected, ordered 6/28/25; and,-Enteral order: give 220 ml of 1.5 Glucerna bolus with 75 ml water before and after feeding five times per day, ordered 7/10/25.Review of the July 2025 treatment administration record (TAR) revealed the order to check Resident #22's enteral tube placement was marked completed twice daily from 7/1/24 through 7/24/25.V. Staff interviewsLPN #5 was interviewed on 7/24/25 at 11:34 a.m. LPN #5 said she used approximately 60 ml of water to flush Resident #22's PEG tube before her bolus and about 75 ml of water to flush after her bolus. LPN #5 said she measured it using a measuring cup at her medication cart and poured it into the plastic water cup, so she would pour about half of the cup before the bolus and a little bit over half of the cup after the bolus. LPN #5 said she did not know how to check to see if Resident #22's PEG tube was correctly positioned. LPN #5 said if Resident #22's PEG tube was migrating the facility staff would have to send her to the hospital.LPN #5 was interviewed a second time on 7/24/25 at 12:22 p.m. LPN #5 said she had checked Resident #22's PEG tube placement and marked it accordingly on the TAR as she saw the water flush went into Resident #22's PEG tube at an appropriate speed and her bolus feeding went in. LPN #5 said the physician's order to check PEG tube placement may have had something to do with aspirating the PEG tube but she would need to ask the director of nursing (DON) to clarify. LPN #5 reviewed Resident #22's CPO and said her enteral feed order specified she needed 75 ml of water flushed before and after each bolus feeding.The DON was interviewed on 7/24/25 at 2:42 p.m. The DON said for each bolus feeding, the nurse needed to have the resident's head of bed elevated and ensure their orders matched what feed they were going to administer. The DON said the nurse would then ensure the tube was placed correctly and was patent, flush the gastric tube with water, provide the feeding, flush again and clamp the tube. The DON said PEG tube placement was determined by visually examining the tube and making sure it looked secure, using a stethoscope to hear the air going into the stomach and making sure the site looked presentable and did not look infected. The DON said the PEG tube needed to be assessed to see if it was in place each shift and prior to each feeding. The DON said LPN #5 should have checked the placement of Resident #22's PEG tube prior to administering her feeding.

Based on observations, record review and interviews, the facility failed to ensure residents who displayed or were diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychological well-being for one (#47) of two residents reviewed for dementia care out of 39 sample residents. Specifically, the facility failed to develop and implement effective dementia management-focused interventions to prevent Resident #47 from wandering into other residents' rooms, shower rooms, the nurses' station and standing over the top of other residents. Findings include: I. Resident #47 A. Resident status Resident #47, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, anxiety disorder, depression and cognitive communication deficit. The 7/23/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired, with a brief interview for mental status (BIMS) score of two out of 15. She required set up assistance with eating, was dependent on staff for oral hygiene, toileting, showering, dressing and personal hygiene. The MDS assessment revealed the resident wandered one to three days and exhibited physical behavioral symptoms, such as hitting, kicking, and pushing, directed toward others during the look back assessment period. B. Observations During a continuous observation on 7/22/25, beginning at 9:09 a.m. and ending at 11:01 a.m., the following observations were made in the facility's secured unit: There were ten resident rooms and five of the ten rooms had their doors open. The doors of room [ROOM NUMBER], #24, #25, #27 and #29 were open. The shower room door was additionally open. Five residents were sitting at various dining tables in the dining room. Resident #47 was sitting in a chair across from the nurses' station, sleeping. At 10:04 a.m. Resident #47 woke up. At 10:11 a.m., activities assistant (AS) #1 started a ball activity with four residents at a dining table.From 10:13 a.m. to 11:01 a.m. Resident #47 was observed continuously walking up and down the one hallway in the secured unit. Resident #47 stood at the door to the main unit, standing over the top of residents who were sitting in their wheelchairs or chairs at the dining room tables and trying to push a resident in their wheelchair. -However, staff did not attempt to redirect or distract Resident #47 in order to reduce the resident's repetitive exit-seeking behavior, standing over the top of other residents sitting down and trying to push other residents in their wheelchairs. During a continuous observation on 7/23/25, beginning at 1:29 p.m. and ending at 2:54 p.m., the following observations were made in the facility's secured unit:Nine of the ten resident room doors were open. The doors of room [ROOM NUMBER], #21, #23, #24, #25, #26, #27, #28 and #29 were open. At 1:35 p.m. Resident #47 was observed entering room [ROOM NUMBER]. She closed the door once she entered the room.From 1:46 p.m. to 2:54 p.m., Resident #47 was observed standing over the top of a resident sitting in a chair at a dining table, walking in and out of room [ROOM NUMBER], looking at the door handles on the door to the facility's main unit and on the door to the facility's courtyard and touching a resident's wheelchair handles. -However, staff did not attempt to redirect or distract Resident #47 in order to reduce the resident's repetitive exit-seeking behavior, standing over the top of other residents sitting down and touching other residents' wheelchair handles. C. Record review Resident #47's elopement care plan, revised 10/25/24, revealed the resident was a risk for wandering and elopement related to Alzheimer's disease. Resident #47 wandered aimlessly, significantly intruding on the privacy or activities of others. The 2/1/25 nurse note revealed Resident #47was very agitated and restless. She continued to take food and drinks from other residents. She was unable to be redirected. The 2/8/25 nurse note revealed the resident was easily agitated when trying to redirect her. She continued to take other residents' drinks and snacks. The 2/11/25 nurse note revealed Resident #47 continued to ambulate, went into other residents' rooms and picked up other residents' belongings and moved furniture around. The 2/16/25 nurse note revealed the resident continued to ambulate up and down the hallway. She frequently stood over other residents and would attempt to squeeze into small spaces. She was difficult to redirect and became angry with the staff. The 2/18/25 nurse note revealed Resident #47 continued to ambulate up and down the hallway, going in and out of other residents' rooms. She was unable to redirect with offers of food, drink, activity, toileting. The 3/8/25 nurse note revealed the resident continued to ambulate up and down the hallways and in and out of other residents' rooms. She became angry when trying to redirect. The 3/9/25 nurse note revealed Resident #47 went into another resident's room, causing some aggravation to other residents. Fifteen-minute checks were started and no skin issues were noted. She continued to ambulate up and down the hallway with staff frequently redirecting. The 3/25/25 nurse note revealed the resident continued to go into other residents' rooms, going to the door whenever it opened, and was unable to be redirected. The 4/25/25 nurse note revealed Resident #47 was redirected multiple times because she was entering other residents' rooms, attempting to push other residents in their wheelchairs, attempting to move chairs and getting into the trash. Snacks, coloring books, cooking shows and reading a book were offered. The resident followed for a few minutes before getting up and needed to be redirected again. The 5/10/25 nurse note revealed the resident continued to ambulate up and down the halls and went into other residents' rooms. The resident was combative with staff when they tried to redirect the resident. The 6/21/25 nurse note revealed Resident #47 continued to wander and went into other residents' rooms, taking other residents' food and belongings. She continued to push other residents in their wheelchairs even though they did not want her to push them. -Review of Resident #47's progress notes revealed there was no consistent documentation regarding what interventions were used to redirect the resident and/or which interventions were effective when the resident's wandering was observed. Review of Resident #47's behavior monitoring and intervention task record, from 6/25/25 to 7/24/25, revealed the resident wandered, pushed, grabbed, and had repetitive movement. -There was no documentation in the behavior task record from 6/25/25 to 7/24/25 to indicate if interventions were used and if the interventions were effective. II. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 7/24/25 at 11:36 a.m. CNA #2 said she knew a resident wandered based on the resident's care plan. She said if she saw a resident wandered, she made sure the resident was safe by ensuring they wore the right footwear. She said she intervened if the wandering was not safe. She said wandering was not safe if the resident was exit seeking, tried to go into the nurses' station or tried to go into the shower room and other residents' rooms. CNA #2 said it was hard to keep the residents from going into other residents' rooms. She said some residents liked to lay in other residents' beds. CNA #2 said it was not okay for residents to stand close to other residents because it could escalate the other resident's behavior and she said she never knew what behavior might happen. She said interventions were important for the safety of the resident wandering and the other residents. She said she documented if the resident wandered in the resident's electronic medical record (EMR) under a behavior task. She said she did not document if she used an intervention and if the intervention was effective. CNA #2 said she was familiar with Resident #47. She said Resident #47 wandered everywhere including into the nurses' station, shower room and other residents' rooms. She said the resident also tried to leave the secured unit. She said Resident #47 got into another resident's space because she was unaware of other peoples' personal space. She said Resident #47 would sometimes get stuck and she did not know where to move. She said Resident #47 needed to be directed on where she needed to move. CNA #2 said successful interventions for Resident #47 included moving her away from other residents, talking to her about where she should go and letting her know that she was upsetting other residents. She said the resident liked the feeling of the handlebars on the wheelchairs and she needed redirection and reminders about her safety. CNA #2 said there were activities that had velcro and fabric for Resident #47 to use. She said Resident #47 had a short attention span and it was hard to find an activity to keep the resident engaged.Licensed practical nurse (LPN) #3 was interviewed on 7/24/25 at 3:49 p.m. LPN #3 said she knew a resident wandered based on a main communication board in the EMR system. She said she saw the communication board when she first logged into the EMR system. She said wandering was not safe if the resident was exit seeking, tried to go into the nurses' station, tried to go into the shower room, in other residents' rooms and in other residents' personal space. LPN #3 said if a resident wandered, she would redirect the resident to eating food, drinking fluid, listening to music or watching an animal show. She said she did not document if the resident wandered, if interventions were used or if the interventions were effective. She said interventions were important because it could alleviate anxiety, calm the resident down and reduce or eliminate aggressive behavior. LPN #3 said she was familiar with Resident #47. She said the resident wandered. She said it was important to keep the doors closed when leaving the secured unit because Resident #47 would try to leave the unit. She said she redirected the resident by telling the resident to walk a different direction and offer her something to do. She said a soft approach was an effective way to talk to the resident.The director of nursing (DON) was interviewed on 7/24/25 at 4:27 p.m. The DON said if a resident wandered, the resident had multiple interventions for nursing. The DON said the same intervention did not work every day for residents who had dementia. The DON said the resident's family helped develop the interventions. The DON said one-on-one, activities, board games, snack, rest and going outside were used to redirect the resident from what they were doing to something else like music therapy or socializing. The DON said moving the resident to a less stimulating area could also be effective. The DON said nursing should document if the resident was wandering more than what their baseline was and if their behavior changed. The DON said she was familiar with Resident #47. She said the resident wandered. She said the resident's baseline wandering was not documented. She said she did not know why the nursing staff was not documenting what interventions were used and what interventions were effective when Resident #47 wandered into other residents' rooms and the shower room or when the resident stood too close to other residents.

Based on record review and interviews, the facility failed to ensure drug regimens were free from unnecessary medications for two (#61 and #42) of five residents reviewed for unnecessary medications out of 39 sample residents. Specifically, the facility failed to ensure Resident #61 and Resident #42 were monitored for hours of sleep for insomnia (difficulty sleeping) medications.Findings include: I. Facility policy and procedureThe Use of Psychotropic Medications policy and procedure, revised 4/28/25, was provided by the regional clinical resource (RCR) on 7/24/25 at 5:08 p.m. It read in pertinent part, The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis and in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care.II. Resident #61A. Resident statusResident #61, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician's orders (CPO), diagnoses included anxiety disorder, insomnia, dementia and mood disorder.The 7/3/25 minimum data set (MDS) revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) assessment score of five out of 15.B. Record reviewReview of the comprehensive care plan, revised 7/10/25, did not reveal any focus related to Resident #61's insomnia or use of medications to treat his insomnia.Review of the July 2025 CPO revealed the following orders:-Melatonin 3 milligram (mg) oral tablet. Give 3 mg by mouth at bedtime for insomnia, ordered 1/23/25 and discontinued 7/11/25; and,-Trazodone HCl 50mg oral tablet with instructions to give 25mg by mouth in the evening related to insomnia, ordered 5/30/25.-However, there were no physician's orders to monitor or document the number of hours Resident #61 slept each shift.Review of the Resident #61's medication administration records (MAR) from7/1/25 through 7/23/25 revealed Resident #61 had been administered melatonin and trazodone as ordered each day throughout the period.Review of the resident's electronic medical record (EMR) did not reveal any documentation of the number of hours Resident #61 slept each day during that period.III. Resident #42A. Resident statusResident #42, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 CPO, diagnoses included chronic respiratory failure, dementia, bipolar 2 disorder, borderline personality disorder, generalized anxiety disorder and depressive episodes.-Resident #42 did not have a documented diagnosis of insomnia.The 7/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. B. Resident interviewResident #42 was interviewed on 7/21/25 at 10:15 a.m. Resident #42 said she had talked with her physician earlier and told them she did not want to be on so many medications because they made her so tired. Resident #42 said her physician told her as long as he was her doctor she had to take all of her medications. Resident #42 said she felt like she was on too many medications.C. Record reviewReview of the comprehensive care plan, revised 7/8/25, did not reveal any focus for Resident #42's insomnia or use of medications to treat insomnia.Review of the July 2025 CPO revealed a physician's order for melatonin 1 mg oral capsules with instructions to give one capsule at bedtime for insomnia, ordered 1/31/25.-However, there were no physician's orders to monitor or document the number of hours Resident #42 slept each shift.Review of the Resident #42's MAR from 3/1/25 through 7/23/25 revealed Resident #42 had been administered melatonin 1 mg each eveningReview of the resident's EMR did not reveal any documentation of the number of hours Resident #42 slept each day during that period.IV. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 7/23/25 at 4:47 p.m. LPN #4 said residents on psychotropic medications should be monitored for side effects and medication efficacy to see if they were effective. LPN #4 said for medications for insomnia, the nursing staff monitored the number of hours of sleep at night and if the residents were sleeping during the day. LPN #4 said the nursing staff monitored the hours the residents slept to see if the sleep medication was working or to see if they were taking too much medication and were too sleepy during the day. LPN #4 said she documented the number of hours slept in the TAR. LPN #4 said a physician's order was obtained to monitor the number of hours the resident slept whenever a resident was receiving insomnia medications.Registered nurse (RN) #1 was interviewed on 7/24/25 at 9:06 a.m. RN #1 said the nursing staff monitored behaviors and side effects for residents on psychotropic medications. RN #1 said insomnia medications could cause residents to appear drowsy or tired, so the nursing staff monitored the residents' number of hours slept and documented it in the TAR. RN #1 said there were also physician's orders to monitor hours of sleep for residents on insomnia medications. RN #1 said the nursing staff monitored the number of hours slept so they could ensure residents were not sleeping all day and that their medications were balanced. RN #1 said she reviewed the CPO for Resident #61 and said she found an order for trazodone for insomnia. RN #1 said she could not find a physician's order to monitor Resident #61's hours of sleep. RN #1 reviewed the physician's orders for Resident #42 and said she could not find a physician's order for sleep monitoring. RN #1 said she thought both residents had a physician's order to monitor their number of hours slept.LPN #5 was interviewed on 7/24/25 at 9:33 a.m. LPN #5 said she could not find a physician's order to monitor Resident #61's hours of sleep. LPN #5 said she reviewed the physician's orders for Resident #42 and said she could not find a physician's order for sleep monitoring. LPN #5 said she thought both residents had an order to monitor their number of hours slept.The director of nursing (DON) was interviewed on 7/24/25 at 2:42 p.m. The DON said residents receiving psychotropic medications were monitored for any potential side effects and the medication's efficacy. The DON said for residents receiving medications to treat insomnia, the nursing staff monitored the number of hours the residents slept each shift. The DON said if a resident slept through the whole day they were not receiving the proper medication dose, so sleep monitoring helped the facility staff find the correct insomnia medication and dose. The DON said there would be a physician's order for sleep monitoring and the number of hours slept would be documented in the TAR.The DON said she did not see any physician's orders for sleep monitoring for Resident #61. The DON said Resident #42 did not have a diagnosis of insomnia. The DON said she did not see any physician's orders for sleep monitoring in Resident #42's CPO but said she would obtain one.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease. Specifically, the facility failed to ensure the staff followed proper infection control procedures for Resident #7, who was on enhanced barrier precautions (EBP).Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 3/20/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part,Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities.EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status.II. Facility policy and procedureThe Catheter Care policy and procedure, implemented 5/24/25, was provided by the regional clinical resource (RCR) on 7/24/25 at 9:11 a.m. It read in pertinent part, Catheter care will be performed using EBP or additional precautions as directed. Perform hand hygiene. [NAME] (put on) gloves and gown.III. ObservationsOn 7/22/25 at 3:44 p.m. certified nurse aide (CNA) #3 was in Resident #7's room. CNA #3 emptied dark yellow urine from Resident #7's catheter bag without donning gloves or a gown.IV. Staff interviewsCNA #5 was interviewed on 7/23/25 at 2:00 p.m. CNA #5 said she had not received any catheter care training while at the facility. She said when she was emptying catheter bags, she should wear gloves and a gown. The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 7/23/25 at 3:17 p.m. The IP and the DON said CNAs needed to follow EBP when providing care to a resident with a catheter. The DON said this included when the CNAs were emptying the resident's catheter bag. The DON said it was improper for the CNAs to empty Resident #7's catheter bag without putting on a gown and gloves.

Based on interviews and record review, the facility failed to ensure residents had the right to choose his or her preferred attending physician for four ( #1, #2, #3 and #4) of six residents out of 12 sample residents. Specifically, the facility failed to assist residents to make an informed choice for selecting their attending physician when the facility changed medical provider groups. Findings include: I. Facility policy and procedure The Resident Rights policy, revised December 2016, was provided by the regional nurse consultant (RNC) on 10/16/24 at 2:48 p.m. It read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to be informed about his or her rights, be informed of, choose an attending physician, and participate in decision-making regarding his or her care. II. Resident interviews Resident #4, who was cognitively intact based on facility assessment, was interviewed on 10/16/24 at 1:12 p.m. Resident #4 said she was aware her attending physician had changed. She said she was not offered a choice for a new physician and did not recall the facility obtaining her consent to select the attending physician of her choice. Resident #4 said she was not informed she had the right to select her preferred attending physician and the facility had not informed her which physicians would be covered by her insurance. Resident #2, who was cognitively intact based on facility assessment, was interviewed on 10/16/24 at 1:24 p.m. Resident #2 said she was aware her physician had changed. She said she was offered a choice of a new physician but not the physician she preferred. Resident #2 said she was not informed she had the right to select the attending physician of her choice. She said she did not recall the facility notified which physicians would be covered by her insurance. III. Record review The electronic medical records (EMR) for Resident #1, #2, #3 and #4 were reviewed. There was an undated and unsigned provider choice document in each of the residents ' EMRs. The document read in pertinent part, We are proud to announce we have two new medical providers for you to choose from, please see below. Please let us know which provider you would like to have as your physician. I, (resident name), have decided I would like to have, one of the two physicians on the form, as my selected physician. Each of the forms were completed by the facility ' s social services director (SSD) and were not signed by the residents or the residents ' legal representatives. -The facility was unable to provide documentation the Residents #1, #2, #3, and #4 and/or their responsible parties had been informed about the change in attending physician and the residents' permission was obtained with informed consent to change the attending physicians. IV. Staff interviews The nursing home administrator (NHA) was interviewed on 10/17/24 at 8:20 a.m. The NHA said the previous facility owner contracted with a new medical group to provide primary care for the facility ' s residents around July 2024. The NHA said the previous owner would not allow residents to choose a physician outside of the newly contracted medical group. The NHA said the facility changed ownership on 9/1/24 and ended the contract with the previous medical group. The NHA said in September 2024, the facility arranged to have two new physicians assume primary care for the residents. The SSD was interviewed on 10/17/24 at 8:46 a.m. The SSD said in September 2024 she and her assistant met with each resident and assisted them in choosing a new attending physician. The SSD said, when she met with the residents, she told each resident they had a right to select a physician of their choice but did not include information for which physicians were covered by their insurance. She said if the resident was undecided which physician to choose, she reviewed the provider choice document with them and then the residents made their choice of one of the two listed physicians. The SSD said she completed the provider choice forms for each resident and the form reflected each residents ' choice for attending physician.

Based on interview and record review the facility failed to ensure one (#40) out of two residents received adequate supervision to prevent accidents out of 32 sample residents. Specifically the facility failed to ensure -Resident #40's fall interventions were implemented. The resident experienced two falls in one month, one which resulted in a right hip fracture. Additionally, the facility failed to investigate the falls, to determine the root cause. Findings include: I. Facility policy and procedure The Fall Management policy dated 3/10/23 was provided by the nursing home administrator (NHA) on 8/30/23 at 4:56 p.m. It read in pertinent part. The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. The fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the residents assessed needs. The following interventions may be considered after identification of root cause: Assess the environment and make appropriate changes, e.g. bed in lowest position, non-slip footwear. The call light and fluids should be within reach of the resident. Positioning devices (e.g. low bed, fall mat, defined perimeter mattress, bolsters, etc.) Notify Quality Mentor with frequent fallers and falls resulting in significant injury. Complete a thorough analysis of fall - time of day, location of fall, causative factors. Document in PCC (charting system) the resident ' s response to interventions and revise interventions if they are not successful. Falls review will include the following: Review the IDT (interdisciplinary team) risk management to ensure complete and appropriate interventions have been implemented. Review that a care plan has been initiated. Provide revisions to the plan of care as necessary after falls. II. Failure to ensure interventions were implemented for Resident #40 A. Resident status Resident #40, over age 65, was admitted [DATE], readmitted [DATE]. According to the August 2023 computerized physician orders (CPO) diagnoses include vascular dementia, senile degeneration of the brain, heart failure, muscle weakness, history of falling, and unspecified falls. The 8/8/23 minimum data set (MDS) assessment revealed the resident had severe cognitive disability with a brief interview for mental status (BIMS) with a score of zero out of 15. The resident required extensive two person assistance with bed mobility, transfers, and toileting. The resident required extensive one person assistance with dressing and eating. The resident was unable to walk and required a wheelchair for all mobility. B. Observations C. Record review The care plan for falls initiated 2/23/22 and revised on 7/7/23 documented the resident was a high risk for falls related to confusion, unaware of safety needs and poor safety awareness. The interventions included anticipate and meet the resident ' s needs, ensure the resident was wearing appropriate footwear when ambulating and to use a fall mat by the bed. Additional interventions were not put into place until the resident had suffered a second fall with a major injury. The 10/16/21 admission fall risk evaluation documented the resident had no history of falls however rexhibited a weak gait and was forgetful of own safety limits. The 4/11/23 fall risk evaluation documented the resident had a history of falls and a weak gait and required a cane or walker for ambulation. The facility failed to document a fall risk evaluation after the fall on 7/16/23. 1. Fall incident on 7/16/23 The 7/16/23 nursing note documented the resident suffered a fall while attempting to transfer to the wheelchair. The note failed to document if the fall was witnessed or unwitnessed. The care plan was not reviewed and no interventions were put into place. 2. Fall incident 8/3/23 The 8/3/23 nursing note documented at 2:34 p.m., the resident suffered a witnessed fall while walking in the bedroom. Resident was sitting on the floor and the right leg was shorter than the left. The note further documented at 5:00 p.m., the resident was having increased pain and swelling to the right hip and the resident was transported to the hospital emergency room . Nursing note dated 8/3/23 at 9:19 p.m. documented the resident was admitted to the hospital with a right hip fracture. Hospital note Hospital noted date of admission 8/3/23 documented the resident was admitted due to closed displaced right hip fracture with operative fixation of the right femur. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 8/31/23 at 9:32 a.m. The nurse said fall interventions should include a fall mat next to the bed, the resident should have the call light where they can reach it even when they are in their wheelchair, the bed should be in the lowest position so if a resident should fall it will not be as severe, and they should be checked on a lot. RN #2 was interviewed on 8/31/23 at 10:49 a.m. RN #2 said Resident #40 was declining and she would not call for help prior to ambulating. She said the interventions should include a fall mat next to the bed and the bed should be in the lowest position. She said Resident #40 liked to play with her bed remote and sometimes moved the bed. She said the resident should have their call light. She said the resident should be checked on. The social services director (SSD) was interviewed on 8/31/223 at 12:59 p.m. She said the IDT team meets for any fall, the team does a fall assessment and goes over what happened and try to determine the root cause. The SSD said the team discussed if there had been an injury, if the doctor had been notified, and if the family had been notified. The team would discuss if interventions were needed and put them into the care plan. The SSD said she would put interventions into the care plan. She said interventions include a fall mat, bolster mattress, refer to physical therapy, wheelchair anti-tips (small wheels on the back), non-slip socks, education on call light use or if the resident needs a pressure sensor call light or one with a night light in it. The director of nursing (DON) was interviewed on 8/31/23 at 2:04 p.m. The DON said Resident #40 fell on [DATE] due to a foot stub (stopping short) and her foot sticking to the floor while trying to walk. The DON said she had performed the assessment of the resident on 8/3/23 after the fall and noticed one leg was shorter than the other. The DON said the IDT team would meet to discuss falls to determine if interventions were appropriate and to determine the root cause of the fall. She said the team would look at the care plan to determine if it should be updated. The DON said the care plan for Resident #40 should have been reviewed to determine if there were any other interventions that should have been in place.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable, attractive and at the appropriate temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance. Findings include: I. Resident group interview A group interview was conducted on 8/29/23 at 3:26 p.m. with five cognitively independent residents (#29, #42, #44, #49, and #65). All the residents in the group interview said that the food was not palatable. Residents said the hot food came cold. II. Individual resident interviews Resident #62 was interviewed on 8/28/23 at 9:34 a.m. She said the meat served at dinner was sour and bland. She said the meat would have been better with salt and pepper. She did not know if there was salt and pepper served on the tray. Resident #42 was interviewed on 8/28/23 at 2:15 p.m. The resident said the meals were too salty. He said he did not ask for an alternative because it was too late to order an alternative. Resident #66 was interviewed on 8/28/23 at 2:23 p.m. He said the meat served was hard to slice and difficult to chew because it was tough. He said the food did not taste good and did not taste right. Resident #69 was interviewed on 8/28/23 at 2:27 p.m. He said if the menu said the cheese was supposed to be melted, the cheese was not melted. One example he gave was a tuna melt sandwich. He said the cheese was not melted. He said the pork loin served for lunch was overcooked. Resident #67 was interviewed on 8/28/23 at 2:49 p.m. The resident said the pork loin served for lunch was overcooked. Resident #49 was interviewed on 8/28/23 at 2:52 p.m. He said some meals were served with meat that was unidentifiable. He said his roommate and him called it mystery meat because neither of them knew what the meat was. He also said that the hot meals were served cold. Resident #29 was interviewed on 8/28/23 at 4:14 p.m. He said the French fries were served cold. He said he mentioned it to the facility management and the response was that fries were hard to serve warm and he was not the only resident who complained about cold fries. Resident #21 was interviewed on 8/29/23 at 9:14 a.m. He said he was one of the last residents served in his room, hot food was served cold and the food was not good. He was unable to explain further on what made the meals not taste good. He said the hot food was not served hot. Resident #41 was interviewed on 8/29/23 at 10:16 a.m. He said his meals were served in his room and the hot food was served cold. III. Meal service observations Meal tray pass was observed for one lunch in one unit. -The meal tray pass for the east unit was observed on 8/28/23 at 12:40 p.m. The dinner roll was served on the same plate with a dijon pork loin, scalloped potatoes and broccoli which made the roll soggy. The kitchen was observed for breakfast for all units. -The breakfast meal was observed on 8/29/23 at 7:28 a.m. The English muffins and toast were in a metal container on a shelf above the food steamers. The pureed bread was in a metal container on the same shelf as the English muffins and toast. There was not a mechanism to keep the food warm. IV. Test tray A regular diet test tray was evaluated on 8/29/23 at 12:22 p.m. by four surveyors. The menu was meat sauce, pasta noodles, Caesar salad, garlic bread and deluxe fruit salad. The following was observed: - All hot menu items were served on one plate with the garlic bread on top. - The meat sauce had too many green peppers and tasted like vinegar. It lacked Italian seasoning. - The pasta noodles were crunchy and not al [NAME]. - The toast was not toasted. It tasted like bread and there was no garlic flavor. - The Caesar salad was not Caesar salad but iceberg lettuce with an Italian dressing. V. Interviews The registered dietitian (RD) was interviewed on 8/30/23 at 3:04 p.m. The RD said there should be a heating mechanism for the toast, English muffins and pureed bread. The RD said toast and pureed bread should be served warm. She said biscuits, rolls and bread should not be served on the same plate as wet foods like spaghetti with meat sauce. She said that pasta noodles should be served al [NAME]. She said meat sauce should taste like garlic, oregano and basil. She said that pork loin should not be tough and if cheese was supposed to be melted, it should be served melted. The dietary director of operations (DDO) and nursing home administrator (NHA) were interviewed on 8/31/23 at 9:04 a.m. The DDO said toast should be served warm. The DDO said if the main meal was saucy, biscuits, rolls and bread should not be served on the same plate. She said pasta noodles should be served al [NAME]. The NHA said meat sauce should taste like tomatoes and Italian seasoning.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to: -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Ensure the correct items were served in accordance with the posted menu. Findings include: I. Facility policy and procedure The Meal Distribution policy and procedure, revised September 2017, was received from the Regional Clinical Consultant (RCC) on 8/31/23 at 3:39 p.m. It read in pertinent part, All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences. The dining services department staff will assemble the meal in accordance with the individual meal card. II. Failure to follow the correct portion sizes to ensure adequate nutrition was provided to the residents Observations and record review During a continuous observation during the breakfast meal tray line on 8/30/23 starting at 7:09 a.m. and ending at 8:40 a.m., cook #2 and dietary service aide (DSA) #1 did not follow the meal tickets in the following ways: -Meal tickets that said double portions had single servings of each breakfast item; and, -Meal tickets that said cold cereal were not measured and poured into a black round bowl. The menu revealed cold cereal should be one serving. III. Failure to ensure the correct items were served in accordance with the posted menu Observations and record review During a continuous observation during the breakfast meal tray line on 8/30/23 starting at 7:09 a.m. and ending at 8:40 a.m., cook #2 did not follow the meal tickets in the following ways: -Meal tickets that said regular diet received toast; and -Meal tickets that said CCD (calorie controlled diet) had regular jelly on their trays. The menu revealed residents who were prescribed regular diets should have received one English muffin. The menu revealed residents who were prescribed a CCD diet should have received diet jelly. IV. Staff interviews Cook #2 was interviewed on 8/30/23 at 8:40 a.m. He said that he ran out of English muffins. He said that was why some residents received toast. He said he kept the kitchen open for about 15 minutes after the last meal was served so that if residents wanted more, they would be open. The registered dietitian (RD) was interviewed on 8/30/23 at 2:17 p.m. She said the meal tickets indicated the diet ordered by the physician and must be followed. She said if the physician ordered double portions it was important to follow to prevent weight loss and help with wound healing and nutrition. The RD said that regular Welch's grape jelly was not considered a diet jelly and was not appropriate for CCD diets. The RD said one serving of cereal was the individual size cereal boxes or one half a cup. The dietary director of operations (DDO) was interviewed on 8/31/23 at 9:04 a.m. She said the kitchen manager was terminated two weeks ago but there was an assistant kitchen manager. She said the purpose of the meal ticket was so residents could get the nutrition they needed and if the physician ordered a CCD and double portions it should be followed. The DDO said she thought one serving of cereal was six ounces but she would double check. She said a double portion was considered twice the amount of each item listed on the menu. She said that the cook followed the facility's direction to provide a single serving to all residents regardless of what the meal ticket said and then the nursing staff would come back to ask for the second serving. The director of nursing (DON) and NHA were interviewed on 8/31/23 at 2:04 p.m. They said if there was a special diet ordered by the physician it should be followed. The DON said it was important to follow the CCD diet for diabetic residents because blood sugar levels could be affected either too high or too low. They said if a physician ordered double portions at meals it should be followed. The DON said it would be important for wound healing and to prevent weight loss.

Based on observations, record review and interviews, the facility failed to ensure residents had the right to be free from neglect and abuse for two (#4 and #8) of four out of 10 sample residents. Resident #4 was dependent on staff for most activities of daily living and transferred with a mechanical Hoyer (mechanical) lift by staff according to their Kardex (computerized overview of each resident's care summary information) and comprehensive plan of care. Resident #4 was transferred on 2/4/22 by a nurse and certified nurse aide using a gait belt, which resulted in a fall with a right femur fracture and associated pain. The facility neglected to transfer Resident #4 according to her plan of care. Resident #8, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #8 was in Resident #12's room doorway on 2/6/22 when she was pushed by Resident #12 out of her room. Resident #12 had a behavior problem of increased anxiety and paranoia related to her personal belongings with physical behaviors towards others. Due to the facility's failures of not appropriately addressing Resident #8's wandering behaviors, they failed to protect her from abuse which resulted in her sustaining a fall with a fracture to the right humeral neck (shoulder) as a result of being pushed by Resident #12. Findings include: 1. Facility policies and procedures The Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy, implemented on 10/2/21, was provided by the nursing home administrator (NHA) on 3/14/22 at 10:54 a.m. The policy revealed the facility was to report allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property were reported immediately to the NHA of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and service to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment, which resulted in physical harm, pain or mental anguish. This included the deprivation by an individual or caregiver, of goods or services that were necessary to attain or maintain the residents physical, mental and/or psychosocial well-being. Instances of resident abuse, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse was included hitting, slapping, pinching, kicking and any controlled behavior through corporal punishment. The facility would report all alleged violations and all substantiated incidents to the State Agency, to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation. The facility would analyze the occurrences to determine what changes were needed, if any, to policies and procedures to prevent further occurrences. Any owner, operator, employee, manager, agent, or contractor of the facility could report an allegation of abuse/neglect/exploitation to the abuse agency hotline without fear of retaliation. The director of nursing (DON), the NHA, or designee would notify the appropriate agencies immediately; as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than two hours after discovery or forming the suspicion. The NHA should follow up with government agencies, during business hours, to confirm the report was received and to report the final results of the investigation as required by state agencies. The Fall Prevention Program policy, copyright 2021, was provided by the nursing home administrator (NHA) on 3/14/22 at 12:33 p.m. The policy revealed each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A fall was an event in which an individual unintentionally came to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). The event may be witnessed, reported, or presumed when a resident was found on the floor or ground, and can occur anywhere. Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. Resident interventions would be monitored for effectiveness and the resident's plan of care would be revised as needed. When a resident experienced a fall, the facility would assess the resident, complete a post-fall assessment, complete an incident report, notify physician and family, review the resident's care plan and update as indicated. The facility would document all assessments, actions and obtain witness statements in the case of injury. II. Facility pain evaluation The Pain Evaluation form (not dated) was provided by the NHA on 3/16/22 at approximately 2:47 p.m. The Pain Rating Scale descriptions and the correlation of the Pain Faces Scale into a Pain Scale 0-10 numerical values revealed: 0 was no pain (comfortable), 1 to 3 was mild pain (bothersome, irritating, annoying, nagging), 4 to 5 was moderate pain (aggravating, upsetting, grueling, frustrating), 6 to 7 was severe pain (miserable, fierce, gnawing, piercing), 8 to 9 was very severe pain (dreadful, horrible, overwhelming, agonizing) and 10 was the worst pain possible (unbearable, crushing, devastating, excruciating). III. Resident #4 A. Resident status Resident #4, age 72, was admitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/10/22 minimum data set (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15 with no behaviors. The resident was totally dependent on staff for assistance with bed mobility, dressing, eating, personal hygiene and transfers with two plus persons ' physical assistance. The 2/21/22 minimum data set (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15 with no behaviors. The resident required extensive staff assistance for bed mobility, dressing, toileting and transfers (activity only occurred once or twice) with two plus persons ' physical assistance. The resident was totally dependent on staff for personal hygiene. B. Resident observations On 3/14/22 at 9:00 a.m., the resident was seated in a high backed wheelchair in her room. The resident's eyes were closed and a staff member was assisting the resident with a beverage using a straw. The resident had yellow non-skid socks on both feet. The wheelchair footrests had a black padded cushion with a padded divider. One foot was on either side of the divider. The resident was seated on a Hoyer lift sling and there was a Hoyer lift in the room, near the empty second bed. On 3/14/22 at 11:03 a.m. and at 12:57 p.m., the resident laid on her right side, on a low bed with a fall mat on the floor beside the bed. One side of the bed was against the wall. The resident had covers pulled to her chest. A Hoyer lift was in the room. On 3/16/22 at 8:30 a.m., the resident sat in her high backed wheelchair. She had non-skid socks on both feet and her feet were on either side of the food pedal padded divider. She was receiving care for a staff member. The resident sat on a Hoyer lift sling. At 9:30 a.m., the resident laid on her right side, on a low bed with a fall mat on the floor beside the bed. The resident had covers pulled to her chest. A Hoyer lift was in the room. C. Record review The facility substantiated an allegation of neglect that was reported to the State Survey and Certification Agency on 2/11/22 at 4:21 p.m. The description of the event revealed a nurse and a certified nurse aide (CNA) transferred the resident with a gait belt from the resident's wheelchair to the bed. The resident's wheelchair was not locked and the resident was lowered to the floor. The resident was care planned for the use of a mechanical lift with transfers. The resident was assessed by the nurse immediately after the incident. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse and the CNA were immediately disciplined and re-educated regarding proper/safe transfers and to review resident's care plans for appropriate transfers. The two staff members also received disciplinary action and education on proper transfers. Nursing staff were re-trained on transfer techniques and the importance of following the residents' care plan. -The facility substantiated neglect, however the initial report to the State Agency was not made until 2/11/22 which was eight days after the incident on 2/4/22 (cross-reference F609 reporting timely to State Agency). The care plan for assistance with activities of daily living related to dementia, [CONDITION(S)], legally blind, deaf, and multiple sites with joint pain was initiated on 4/29/15. One intervention was to use a full mechanical lift with two staff member's assistance for all transfers, which was revised on 10/1/21. The care plan for falls was initiated on 4/29/15. The plan revealed that the resident had the potential for safety and/or fall risk related to [CONDITION(S)], dementia with behaviors, blind, deaf, mute and joint pain. The resident had a fall on 2/4/22 with a major injury. One of the interventions was to use a mechanical lift for transfers that was initiated on 11/16/15. A nurse note dated 2/4/22 at 4:40 p.m., by registered nurse (RN) #2 revealed she prepared to transfer the resident to a wheelchair with the assistance of another staff member with a gait belt. The wheels on the wheelchair were not locked and they were unable to place the resident in the wheelchair. The resident was lowered to the floor. A pop sound was heard, coming from the resident's right knee, as the resident was lowered to the floor. The resident indicated there was pain by pointing to the right knee and right hip area. The eInteract situation, background, assessment and recommendation (SBAR) dated 2/4/22 at 4:45 p.m., by RN #2 revealed a change of condition reported for falls. Nursing observations, evaluation and recommendations were the resident was prepared to be transferred to a wheelchair with the assistance of two staff members with a gait belt. The wheels on the wheelchair were not locked. The staff were unable to place the resident in the wheelchair and she was lowered to the floor. A pop was heard coming from the resident's right knee area when the resident was lowered to the floor. The resident indicated she was in pain by pointing her finger to her right knee and also the right hip area. A nurse practitioner (NP) was notified and orders were obtained for STAT (urgent/immediate) x-rays for the resident's right knee and right hip. The resident was administered as needed Tylenol and the resident no longer indicated she was in pain. A weekly skin check note dated 2/4/22 at 4:45 p.m., by RN #2 (late entry) revealed the resident did not have any identified new skin concerns. The Morse Fall Scale dated 2/4/22 at 10:15 p.m., by RN #2 revealed a score of 55 or a high risk for falls. An interdisciplinary team (IDT) post fall review dated 2/4/22 at 10:17 p.m., revealed the resident had a witnessed fall on 2/4/22 at 4:30 p.m., with no injuries. The resident was in the process of a transfer to a wheelchair with two staff assistance using a gait belt. The resident's wheelchair was not locked and the staff were unable to place the resident in the wheelchair. The resident was lowered to the floor and a pop sound was heard coming from the resident's right knee area. The resident indicated there was pain, by pointing to the right knee and right hip area. The summary was to educate the staff on reviewing the resident's Kardex and to ensure the wheels on the resident's wheelchair were locked, prior to transferring the resident. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . From the date of the fall on 2/4/22 (day of the fall) through 2/28/22 the resident had the following 0-10 numerical pain scale levels that participated in the administration of pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 0 no pain = one time; 1 to 3 mild pain = 12 times; 4 to 5 moderate pain = 10 times; 6 to 7 severe pain = 13 times; 8 to 9 very severe pain = 18 times; and, 10 worst pain possible = four times. A nurse note dated 2/5/22 at 9:39 a.m., by a licensed practical nurse (LPN) revealed this nurse called the named mobile diagnostic and imaging service contractor regarding the STAT x-ray status and was informed that a technician would be in the facility before 11:00 a.m. A call was placed to the primary care provider. The on-call for the provider was updated on the resident's condition after an assessment. The resident's right leg was swollen and the resident pointed with her finger to her right hip and appeared uncomfortable. Orders were received and initiated for right hip pain. A radiology report electronically signed by a physician on 2/5/22 at 11:06 a.m., revealed the resident had a fracture involving the right distal femur with displacement. The right hip was in alignment and no fracture or dislocation was seen. A nurse note dated 2/5/22 at 12;24 p.m., by a LPN revealed a fax was sent to the primary care on-call provider with the results of the x-rays; awaiting orders. A nurse note dated 2/5/22 at 9:46 p.m., by a LPN revealed this nurse spoke with the pharmacy and the resident's [MEDICATION(S)]-Acetaminophen 5-325 mg tablet was on route and would be delivered. The resident was administered Tylenol for pain and was sleeping comfortably. A call was made to the on-call nurse practitioner (NP) for the primary care provider. This nurse was told that the NP had spoken with the family, it was decided not to send the resident to the hospital and because it was felt the resident was not a candidate for surgery, due to her condition. The resident was kept in bed and ate some dinner. The resident was quiet and not calling out at this time. The Morse Fall Scale dated 2/6/22 at 12:34 a.m., by RN #2 (late entry) revealed a score of 55 or high risk for falling. A nurse note dated 2/7/22 at 4:00 a.m., by a RN revealed the resident continued to complain of pain and discomfort related to a fracture of the right distal femur and right knee. The resident received pain medication at 1:00 a.m., and was quiet for the remainder of the shift. This RN would continue to monitor for pain, discomfort and any change in condition as the resident's family elected not to have any surgical intervention for the fracture. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP was going to call and get the x-ray radiology report for review. The on-call NP for the primary care provider spoke with the family and the family did not want the resident sent to the emergency department for revaluation. The resident's pain was currently controlled with [MEDICATION(S)]-Acetaminophen 5-325 mg. A call should be placed to an orthopedic outpatient clinic to get an appointment as soon as possible. The note also asked physical therapy if they had some type of immobilization brace for the resident's leg and to investigate the mechanism of the fall. The NP note dated 2/7/22 (signed on 2/9/22 at 10:14 a.m.) revealed this was an acute visit due to a fall the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . At that time a right hip and right knee x-ray were ordered which revealed a right distal femur fracture. The resident's power of attorney (POA) declined to have the resident sent to the emergency department. The on-call service provider ordered pain medication. The resident was examined today, resting in bed. There were no additional concerns. The diagnostic statement revealed a fracture of the lower end of the right femur; initial encounter for a closed fracture. The plan revealed the resident had an assisted fall on 2/4/22 with a subsequent right distal femur fracture with a displacement as demonstrated in the x-ray taken on 2/5/22. The resident would continue with [MEDICATION(S)]-Acetaminophen 5-325 mg tablet orally every six hours as needed and change the Tylenol from as needed to 1,000 mg orally twice a day. Continue to schedule the STAT follow-up with an orthopedic outpatient appointment. The NP would attempt right knee immobilization in the meantime and discuss the resident plan of care with the resident's primary physician; who agreed with the plan. The resident did not appear to be in pain today, but did have periods of pain as evidenced by increased calling out and pointing at her right knee. Nursing staff were to monitor the resident's pain level. The contingency plan was a comfort focused plan of care with no surgery and a possibility of considering hospice services. A typed note by the director of rehabilitation (DOR) on 2/7/22 (not timed) revealed the nurse practitioner (NP) for the resident's physician called the DOR for the facility and asked if the facility had stock orthotics such as a knee immobilizer for the resident. The DOR informed the NP that the facility did not have such a device in stock and the resident would need to be sent out of the facility for placement of a knee immobilizer. The NP was to send the resident to an orthopedic establishment to obtain the device. The note was hand-signed by the DOR. A nurse note dated 2/8/22 at 7:58 a.m., by a RN revealed the resident started making noises at 1:00 a.m., indicating she was experiencing pain. She was administered [MEDICATION(S)]-Acetaminophen 5-325 mg tablet with good results. This nurse would continue to keep the resident comfortable with positioning and medication. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interdisciplinary team (IDT) note dated 2/8/22 at 10:59 a.m., revealed the resident had a fall on 2/4/22. The resident was lowered to the ground and this was a fall with an injury. The resident had a fractured right knee. The family did not feel the resident was a good candidate for surgery. The resident's physician was working on getting a referral for an orthopedic consult to mobilize the resident. The resident's pain was being managed and her physician would continue to follow. A nurse note dated 2/10/22 at 10:51 a.m., by a LPN revealed the resident was transferred to an orthopedic clinic to repair the distal femur fracture. The resident's sister was present at the appointment and was aware of this plan of care and transfer. A nurse note dated 2/10/22 at 12:56 p.m., by a RN revealed the resident was hospitalized for further treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge placement note dated 2/10/22 revealed the resident's principal problem was a fall. The active problem was a fracture of the right femur; initial encounter for a closed fracture. The resident presented with a right femur fracture after a fall at her long-term care facility. After an extensive conversation with the resident's sister, the sister said she wanted the resident to be comfortable and would like to proceed with the surgery regardless of the risk because she felt this would provide the resident with the best quality of life. The sister understood if the resident did not improve or the resident's already compromised functional status declined further, that hospice services might be appropriate and the sister would be willing to transition to hospice services should the need arise. The plan was to proceed with the surgery as indicated and resume appropriate home medications. The trauma team would evaluate the resident as the fall mechanism was not clearly understood. The chief complaint was a fall with a right femur fracture. A nurse admission note dated 2/14/22 at 1:13 p.m., by a RN revealed a nursing assessment was completed this shift. The resident arrived at the facility on a stretcher and was admitted from the hospital due to surgery. A nurse note dated 2/14/22 at 1:15 p.m., by a RN revealed the resident arrived at the facility on a stretcher via an ambulance service from the hospital. A nurse note dated 2/15/22 at 6:00 p.m., by a RN revealed the resident slept until 4:30 a.m., and then indicated she was in pain. The resident was repositioned and administered [MEDICATION(S)] 5 mg orally for pain. The resident settled down and was able to go back to sleep. This nurse would continue to readjust the resident for comfort related to surgery on her right knee. A behavior note dated 2/15/22 at 10:23 p.m., by a RN revealed the resident was crying out loudly and frequently throughout the shift; especially after being changed. The certified nurse aide (CNA) was instructed to alert this nurse before physical movement, to see if the resident was eligible for any pain medication. The resident's pain medication appeared to offer good pain control. A nurse note dated 2/17/22 at 10:45 a.m., by a LPN revealed the resident had surgical intervention for a distal femur fracture on 2/11/22 that was sustained during a fall. The resident's Kardex and care plans have been updated with interventions. The resident returned to the facility on [DATE]. The resident had pain in the right lower extremity that was currently controlled. The resident had been ordered to undergo physical and occupational therapy services. The resident's surgical incision was well approximated and was clean, dry and intact. This LPN would continue to monitor the surgical site as well as pain control and progress with therapies. A nurse note dated 2/18/22 at 5:12 a.m., by a RN revealed the resident indicated she was in pain and was medicated twice this shift. There were no adverse effects observed from the pain medication. The surgical area to the right knee was clean, dry and the dressing was intact. This LPN would continue to monitor the resident. The Morse Fall Scale, dated 2/20/22 at 12:07 p.m., by the director of nursing (DON) revealed a score of 75 or high risk for falling. The resident's Kardex dated 3/15/22 revealed the resident required a full mechanical lift with two staff members for transfers at all times. -Per the NHA interview (see below), the resident's Kardex documented that she was a full mechanical lift with two staff members for transfers at all times prior to the incident on 2/4/22. D. Staff interviews The minimum data set coordinator (MDSC) was interviewed on 3/14/22 at 2:52 p.m. She said the resident's MDS dated [DATE] was correct. She said during the seven-day assessment period the resident was only transferred twice. She said since the resident was not transferred at least three times, the resident would not be coded as total assistance for transfers, but as extensive assistance with two plus persons' physical assistance. She said the transfer documentation would be entered into the resident's clinical record by the CNAs. The MDSC said the resident's MDS dated [DATE] was correct. She said during transfers, the resident offered little help five times during the seven-day assessment period. She said the resident needed to be transferred with two plus persons' physical assistance. She said the resident's care plan would reveal the need for the use of a mechanical lift. CNA #4 was interviewed by phone on 3/14/22 at 5:01 p.m. She said the resident did not fall. She said herself and RN #2 transferred the resident with a gait belt. The resident was also being supported under each arm. The wheelchair kept moving and they were unable to support the resident and they lowered the resident to the floor very gently. The resident's right knee was rotated and there was a big pop sound. She said she knew they were to use the mechanical Hoyer lift to transfer the resident and it was stupid of them not to use the lift. She said the resident yelled out in pain and the screaming was unbearable. She said RN #2 did an assessment before the resident was moved. She said a Hoyer lift was in the hallway, just outside the resident's room. She said she had access to the resident's Kardex and care plans. The NHA, DON and RNC were interviewed on 3/15/22 at 2:38 p.m. The NHA said RN #2 and CNA #4 came and told the DON immediately after the incident that they did not use a mechanical Hoyer lift, as they should have. The NHA said the resident's Kardex and care plan for transfers revealed the use of a mechanical Hoyer lift for all transfers. She said the RN #2 and CNA #4 were not following the resident's Kardex or care plans for transfers. She said the resident's Kardex and care plan for transfers were in place to prevent this type of incident from occurring. The NHA said at the time of the incident, there were no visible injuries and the resident did not hit her head when she was slowly lowered to the floor by staff. She said the facility used the non-verbal pain scale when the resident pointed her finger at her right knee and hip area. The NHA said RN #2 and CNA #4 were educated by the DON immediately to follow a resident's transfer status. The NHA said the resident had a STAT x-ray of the right knee on 2/5/22. The NHA said an unplanned change in elevation was considered a fall. The RNC said on 2/7/22 the facility did a Kardex audit of all the residents, to ensure their Kardex was up to date and matched their care plans. The RNC said the audit revealed that maybe two or three residents needed to have corrections made to their Kardex. RN #2 was interviewed on 3/15/22 at 4:03 p.m. She said the resident fell on [DATE]. She said herself and CNA #4 went to get the resident up from her bed for dinner. She said the resident was seated on the side of her bed and they placed a gait belt on the resident. She said she was on one side of the resident and CNA #4 was on the other side. She said they lifted the resident up and she was too heavy for them to lift high enough to get the resident into her wheelchair. They lowered the resident to the floor. The resident had contractures to her legs and as she was lowered, she went into a kneeling position and a loud pop sound was heard at the resident's knees. The resident yelled out in pain and at this time she did not point to any areas on her body. When the resident was placed back into bed, she pointed to her right lower extremity. She said they should have transferred the resident with a mechanical Hoyer lift. She said a Hoyer lift was available and was located in the hallway near the resident's room. She said after she did a full assessment of the resident before a Hoyer lift was used to remove the resident from off the floor to her bed. She said to review a resident's transfer status, she could look in a resident's Kardex or in their care plans. She said at the time of the incident, she had an idea that the resident required a mechanical Hoyer lift for transfers, however she did not look at the resident's care plan to make sure. She said, after the resident was in bed, she went immediately to the DON, told her what happened, that a gait belt was used during the transfer and that she heard a pop sound. She said she texted the resident's physician and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said after the fall, the resident had a pain scale of seven out of 10. She said the DON educated her (how to look at a resident's Kardex) and also wrote her up before she left the facility. She said lowering a resident to the floor was considered a fall. CNA #2 was interviewed on 3/16/22 at 9:45 a.m. She said to review a resident's transfer status, she would check the resident's Kardex. She said any changes in the resident's care plans would be reflected in the resident's Kardex. She said during shift change reports, she would learn about any changes in a resident's status and this would include any changes in transfer status. LPN #3 was interviewed on 3/16/22 at 10:50 a.m. She said to learn about a resident's transfer status, she would look at the resident's Kardex, the resident's care plans or talk with CNAs. She said she could also learn about any changes in a resident's status during the shift change reports and also by the nurse communication board. LPN #7 was interviewed on 3/16/22 at 3:58 p.m. She said to learn about a resident's transfer status, she would review the resident's Kardex. She said she could also learn about any changes in a resident's status during the shift change reports. The NHA, DON and RNC were interviewed on 3/16/22 at 4:40 p.m. The NHA said the resident's current Kardex intervention that required a full mechanical Hoyer lift with two staff members for transfers at all times was in place at the time of the incident. At 5:40 p.m., the NHA said all staff members received abuse training by 2/14/22 as part of the annual compliance (goal of an organization) for the facility. E. Facility staff training On 2/11/22 the NHA and the DON received training on timely reporting of allegations of abuse/neglect. RN #2 received abuse training on 2/1/22 and 2/5/22. CNA #4 received abuse training on 2/1/22 and 2/11/22. The NHA received abuse training on 10/26/21 and 2/4/22. The DON received abuse training on 10/20/22 and 2/7/22. A total of 54 staff members received training on Kardex, wheelchairs, gait belt and mechanical lifts from 2/8/22 through 3/16/22. IV. Resident altercation between Resident #8 and Resident #12 A. Resident #8 1. Resident status Resident #8, age 82, was admitted on [DATE]. According to the March 2022 computerized physician

Based on observations, record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (#8 and #12) of four out of 10 sample residents. Specifically, the facility failed to consistently provide person-centered approaches to Resident #12's dementia care services to address triggered physically aggressive behavior in order to prevent a physical altercation with Resident #8 on the memory care (secure) unit. The facility was aware Resident #12, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's aggressive behavior was escalated by others (residents) going through the resident's things. The care plan for Resident #12 revealed the facility staff were to intervene as necessary to protect the rights and safety of others. Staff were to divert the attention of the resident, remove the resident from a situation and to take the resident to an alternate location as needed. Staff were to minimize the potential for the resident's disruptive behaviors, aggression around personal items, by offering tasks which divert attention such as: taking the resident outside, especially to smoke and to socialize with others. The facility was aware Resident #8, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to consistently provide person-centered approaches to Resident 8's dementia care services to address her behaviors of wandering into other resident rooms to prevent resident to resident abuse. Furthermore, due to the facility's failures, Resident #12 pushed Resident #8 on 2/6/22. Resident #8 fell to the floor, which resulted in a right humeral neck (shoulder) fracture. Cross-reference F600 for resident to resident abuse. Findings include: I. Census and conditions demographic The 3/24/22 Census and Condition form documented that 86 residents resided at the facility. There were 47 residents with dementia and 11 residents with behavioral healthcare needs. The facility was designated with one long-term memory care unit with 19 residents residing in the unit. II. Failure to provide person-centered dementia care for Resident #12's triggered physically aggressive behavior A. Resident status Resident #12, age 86, was admitted on [DATE] and discharged on [DATE] to the hospital and did not return. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/11/22 minimum data set (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident had difficulty focusing her attention, such as being easily distracted or having difficulty keeping track of what was said. This behavior was present and fluctuated (comes and goes with changes in severity). The resident had disorganized thinking or was incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). This behavior was present and fluctuated (comes and goes with changes in severity). The resident had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). The behavior of this type occurred one to three days. The resident had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) this behavior type occurred one to three days. The resident required limited staff assistance for bed mobility, transfers, dressing, and toileting. The resident was totally dependent on staff for personal hygiene. The resident did not exhibit any wandering behaviors. B. Record review A care plan revised on 3/17/2020, revealed the resident resided on the Life Engagement Community secured unit with no need to question her return to the community on each assessment. The interventions were for the resident's discharge plan to be reviewed quarterly or as needed. The resident had no discharge date at this time. A care plan initiated on 1/27/2020 revealed the resident had a behavior problem of increased anxiety and paranoia related to her personal belongings, and communal living with dementia. Some of the interventions were to allow the resident to make choices within her decision making abilities. Staff were to anticipate and meet the resident's needs. Staff were to provide an opportunity for positive interaction and attention. Staff were to talk with the resident as they passed by the resident. Staff were to explain all procedures to the resident before starting and allow the resident time to adjust to changes. Staff were to intervene as necessary to protect the rights and safety of others. Staff were to approach/speak in a calm manner. Staff were to divert the attention of the resident, remove the resident from a situation and take the resident to an alternate location as needed. Staff were to minimize the potential for the resident's disruptive behaviors, aggression around personal items, by offering tasks which divert attention such as: taking the resident outside, especially to smoke and to socialize with others. The resident's triggers for aggression were: others going through her things; [CONDITION(S)] care; often feeling like her family left me here. The resident's behaviors were deescalated by positive encouragement; taking the resident out for a cigarette; going on a walk; and one on one conversation. The care plan did not reveal the resident did not like any other residents in her room and did not reveal she sometimes moved/pushed residents out of her way when walking down the hallway. -However, the facility did not revise or update the resident's care plans to protect other residents after the altercation on 2/6/22 (see below). C. Altercation 2/6/22 An interdisciplinary team note dated 2/8/22 at 11:18 a.m., revealed this was an at risk review. This resident was observed pushing another resident that caused the resident to fall to the ground. The resident was redirected from the area, until she was calm; while the other resident was being assessed. A nurse note dated 2/6/22 at 5:14 p.m., by licensed practical nurse (LPN) #2 said the resident was observed pushing another resident which caused the resident to fall to the ground. The resident was taken back to her room and kept there with a staff member, while the other resident was being assessed, monitored and redirected by a staff member. A situation, background, assessment and recommendation (SBAR) communication form and progress note dated 2/6/22 at 5:17 p.m., revealed a resident to resident interaction occurred on 2/6/22. Things that made it better were to keep residents from attempting to go into her room. The resident appeared agitated and was pacing. -The facility failed to consistently provide person-centered approaches to Resident #12's dementia care services to address triggered physically aggressive behavior in order to prevent a physical altercation with Resident #8 on the memory care (secure) unit. This altercation resulted in Resident #8 falling to the floor and sustaining a right humeral neck fracture. (cross-reference F600). D. Staff interviews The nursing home administrator (NHA), director of nursing (DON) and regional nurse consultant (RNC) were interviewed on 3/15/22 at 3:25 p.m. The NHA said Resident #12 and Resident #8 resided in the secure unit and both residents had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Certified nurse aide (CNA) #1 was interviewed on 3/15/22 at 4:49 p.m. She said Resident #12 and Resident #8 resided on the secure unit and both had dementia. She said Resident #12 was anxious at times and was also impulsive. She said Resident #12 did go into other resident's rooms, but she did not like any of the other residents coming into her room. She said when Resident #12 walked down the hallway, sometimes she did push other residents out of her way. Licensed practical nurse (LPN) #1 was interviewed on 3/15/22 at 4:28 p.m. She said Resident #12 had dementia. She said Resident #12 had a behavior of moving residents out of her way when she walked down the hall or if any residents were in her room. She said Resident #12 was impulsive in her actions and sometimes pushed residents or furniture out of her way, when she was walking. She said staff tried to redirect Resident #12 by keeping other residents away from her, when she walked down the hall. She said the staff tried to deescalate the resident with food, drinks or activities. CNA #2 was interviewed on 3/16/22 at 9:45 a.m. She said Resident #12 wandered into other resident's rooms but she did not want (tolerate) anyone in her room. She said Resident #12 would get mad and yell at any resident in her room. She said when Resident #12 walked down the hall, sometimes she was just in an aggressive mood and would push residents out of her way. She said Resident #12 was deescalated by offering her coffee, snacks, watching television in her room, music, dancing, to go smoke and talking with her daughter. LPN #2 was interviewed on 3/16/22 at 10:25 a.m. She said Resident #12 was moody and did not like to be bothered. She said Resident #12 had a tendency to get mad quickly. She said the resident wandered into another resident's room and tried to take things, but she did not like anyone coming into her room. She said the resident would get mad and try to push other residents out of her room. She said the resident was not easy to redirect. She said to deescalate Resident #12, the staff offered her coffee, to go smoke, watching television, reading books and talking with her daughter. The life engagement coordinator (LEC) was interviewed on 3/16/22 at 11:40 a.m. She said Resident #12 was anxious/agitated at times due to her placement at the facility by her daughter. She said to deescalate Resident #12, the staff would take her outside to smoke, talk with her on a one to one basis, play a poker game on her laptop, snacks, soda, watching old movies, listening to country music, talking about restaurants and food. She said talking with her daughter either decreased or increased her behaviors. LPN #7 was interviewed on 3/16/22 at 3:58 p.m. She said Resident #12's agitation occurred spontaneously and when she escalated she became more demanding in non-rational thoughts and questions. She said sometimes Resident #12 could not be redirected for long periods of time. She said Resident #12 was de-escalated by taking her out to smoke, snacks, juices, games, music, old movies and one-to-one staff conversations. III. Resident #8 A. Resident status Resident #8, age 82, was admitted on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/10/22 minimum data set (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident had difficulty focusing her attention as evidenced by being easily distracted or having difficulty keeping track of what was said. This behavior was present and fluctuated (comes and goes with changes in severity). The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The resident did not exhibit any wandering behaviors. B. Resident observations On 3/14/22 at 10:08 a.m., the resident was seated in a recliner in the common area on the secure unit. The television was on. Her eyes were closed and she had socks and shoes on both feet. On 3/16/22 at 9:40 a.m., the resident was seated in a recliner in the common television area on the secure unit by the fireplace. She had her eyes open. She had socks and shoes on both feet. She did interact with some staff when she was approached. C. Record review A care plan for elopement/wanderer related to exit seeking revealed the resident resided in the secured Life Engagement Community was initiated on 2/4/21. The pertinent intervention was to reorient/validate and redirect the resident as needed. A care plan for impaired cognitive function/dementia or impaired thought processes was initiated on 2/4/21. Some of the interventions were for staff to provide the resident with the necessary cues; staff were to stop and return if the resident was agitated. Staff were to cue, reorient and supervise the resident as needed. The resident understood consistent, simple and direct sentences. A care plan for the resident exploring when she entered other resident's rooms and forgot where she wanted to go was initiated on 3/11/21. The one intervention revealed to remind and redirect the resident when she entered another resident's room. A care plan for the potential/actual safety/or fall risk related to her disease processes and/or safety related to elopement, exit seeking behavior, and safety related to wandering was initiated on 3/12/21. The one intervention was to observe the resident frequently during increased wandering to ensure safety. -However, the care plans related to the resident's wandering behavior were not initiated until 3/11/22 and 3/12/22, which was more than a month after the incident on 2/6/22. The facility failed to identify and address the resident's behaviors of wandering to prevent the incident from happening on 2/6/22 and did not put additional measures in place after the incident to protect the resident. A care plan for being at risk for falls related to confusion, incontinence, psychoactive drug use and wandering was initiated on 4/6/21. Some of the interventions were to provide the resident with a safe environment with even floors free from spills and/or clutter; adequate glare-free lights; a working and reachable call light; place the resident's bed in the low position at night; handrails on the walls and personal items within reach. Staff were to review information on past falls and attempt to determine the cause of the fall and record possible causes. Staff were to alter and/or remove any potential causes if possible. An incident note dated 2/6/22 at 4:00 p.m., by a registered nurse (RN) revealed the resident was awake on the floor. The resident did not lose consciousness and was orientated times one with confusion. The resident had no wounds or hemorrhaging to her skin/body. The resident denied any pain and her hand grasps/foot pushes and pulls were equal and strong. The resident's neurological assessments were negative. The resident was assisted to a chair with a mechanical Hoyer lift. This note did not reveal the events that precipitated the resident being on the floor. A nurse note dated 2/6/22 at 4:38 p.m., by LPN #1 revealed the resident was observed on the floor on her back in the hallway. The resident was able to move all extremities with no complaint of pain. The resident did not have any observed redness or bruising at this time. The resident was assisted onto her feet and taken to the activity/dining room. The resident denied hitting her head. A message was left for her medical provider and her family. The resident's neurological assessments were within normal limits. This nurse would continue to monitor the resident. The resident continued to ambulate without assistance. The resident would be kept closer to the activity/dining room area. This note did not reveal the events that precipitated the resident being on the floor. A SBAR communication form and progress note dated 2/6/22 at 4:43 p.m., revealed the resident had a witnessed fall on 2/6/22. The resident had dementia with behaviors. A nurse note revealed the resident was observed on the floor in the hallway on her back. The resident was moving all of her extremities, denied hitting her head and denied having any pain. The resident was assessed by a RN with no obvious injuries observed at this time. The resident's medical providers and her family were notified. This note did not reveal the resident had a physical altercation with another resident that resulted in the witnessed fall. The IDT post fall review note dated 2/6/22 at 4:59 p.m., revealed the resident had a witnessed fall on 2/6/22 at 4:00 p.m., with no injuries. The resident was pushed (willful physical act) by another resident and fell backward onto her buttocks/back in the hallway. The resident was standing/walking with unassisted ambulation prior to the fall. The resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A SBAR dated 2/7/22 at 8:29 a.m., by the DON, revealed the resident had discoloration to the right shoulder and right upper arm related to an altercation with another resident. The resident was pushed to the floor by the other resident. Nursing staff would continue to evaluate the resident for any changes. An IDT note dated 2/8/22 at 11:12 a.m., by a RN revealed the resident had an altercation with another resident in the hallway on 2/6/22. The resident was pushed out of the way by another resident that caused the resident to fall onto her buttocks. The incident was witnessed and the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident continued to ambulate independently without difficulty, as was her usual. The staff would continue to monitor the resident's ambulation. A radiology report dated 2/10/22 that was electronically signed by a physician at 8:14 p.m., revealed the resident had a fracture involving the right humeral neck with modest displacement. D. Staff interviews The NHA, DON and RNC were interviewed on 3/15/22 at 3:25 p.m. The NHA said the facility protected Resident #8 from any behaviors from other residents, by having a higher staffing ratio on the secure unit. CNA #1 was interviewed on 3/15/22 at 4:49 p.m. She said Resident #8 had no behaviors and usually just walked around on the unit. She said the resident did walk in the hallway and did sometimes go into other resident's rooms. She said the resident had not done anything to any of the residents. LPN #1 was interviewed on 3/15/22 at 4:28 p.m. She said Resident #8 did not have any behaviors to her knowledge. She said the resident was very quiet and did not cause any problems. She said the resident did walk around on the unit. CNA #2 was interviewed on 3/16/22 at 9:45 a.m. She said Resident #8 was a very sweet person and had no bad behaviors. She said the resident was always smiling and did not cause any negative interactions with other residents. She said she never had to redirect the resident for any behaviors. LPN #2 was interviewed on 3/16/22 at 10:25 a.m. She said Resident #8 was a very easy resident to care for. She said the resident did not have any negative behaviors. She said the resident did sometimes pace up and down the hallway and at times did take one step into other resident's rooms. She said when the resident took the one step into another resident's room, she would then step out, and continued to pace. She said the resident was easy to redirect, usually by talking to her or by holding her hand. She said she had never seen the resident get mad at another resident. The social services director (SSD) was interviewed on 3/16/22 at 11:17 a.m. She said Resident #8 was a very sweet lady and did not have any behaviors. The LEC was interviewed on 3/16/22 at 11:40 a.m., and said Resident #8 did not have any behaviors. The resident was sweet and easy going. LPN #7 was interviewed on 3/16/22 at 3:58 a.m. She said Resident #8 did not have any behaviors, was very sweet and complainant. She said the resident did walk up and down the hall at a very slow pace. She said the resident was very redirectable; usually with only words or a gentle touch.

Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible. This had the potential to affect all of the residents residing in the facility, as the facility experienced a kitchen fire in the facility's only kitchen. Record review and interviews revealed the facility experienced a fire in the kitchen on 11/7/21, kitchen staff did not follow the facility policy and procedure for a kitchen fire, and instead attempted to extinguish the fire by throwing salt and flour onto the fire. Attempts to smother the fire were unsuccessful, and staff attempted to extinguish the fire with a fire extinguisher, but used the incorrect fire extinguisher. The kitchen fire was not extinguished until the local fire department arrived at the facility. These failures to follow the policies and procedures to extinguish a fire in the facility created the likelihood of serious adverse outcome for all of the residents in the facility. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy On 11/18/21, the facility confirmed there had been a fire in the only kitchen in the facility. The fire occurred on 11/7/21 and started on the gas stove while the cook was using grease to fry chicken. At the time of the fire, the cook (CK) and the dietary aide (DA), attempted to extinguish the fire by putting salt and flour onto the fire. When those attempts to extinguish the fire failed, the CK left the kitchen to get a nurse for assistance, and the DA called the dietary manager (DM), who was not in the facility at the time (see DM interview below). The nurse, licensed practical nurse (LPN) #1, called 9-1-1 on her personal cell phone, and went into the kitchen to attempt to put out the fire. LPN #1 also attempted to use flour to extinguish the fire, and when that was unsuccessful she used a class ABC fire extinguisher (not rated for grease fires). The local fire department ultimately extinguished the kitchen fire. At no time during the fire did staff follow the facility fire policy and procedure. This is to include but not limited to pulling the fire alarm to alert additional staff and residents of the fire, as well as the fire department. B. Imposition of Immediate Jeopardy Based on interviews and record review, which revealed policies and protocols were not followed to inform residents, staff and the fire department of a fire nor extinguish the fire properly the nursing home administrator (NHA) was informed on 11/18/21 at 1:54 p.m. The facility failures above created the likelihood of serious harm for all of the residents in the facility if the failures were not corrected immediately. C. Facility plan to remove Immediate Jeopardy On 11/18/21 at 5:28 p.m., the facility submitted a plan to remove the immediate jeopardy. The plan read: On 11/18/21, an attempt was made to reeducate the dietary employee who did not respond appropriately to a fire situation at the facility. After reeducation was attempted and the employee could not demonstrate competency, the employee was suspended pending her ability to retain the training. On 11/18/21, all dietary staff were retrained on fire safety procedures specific to pulling the fire alarm and the use of the class K fire extinguisher to include the RACE (Rescue/Alarm/Confine/Extinguish/Evacuate) and PASS (Pull/Aim/Squeeze/Sweep) fire safety procedures. Return verbal demonstration was accomplished. Beginning on 11/18/21 at the beginning of each shift the NHA (nursing home administrator) or designee, will educate all staff on RACE and PASS fire safety procedures to include appropriate fire extinguisher selection. Training will continue until all staff have received the education and demonstrated understanding. Upon hire and during facility orientation, SDC (staff development coordinator) or designee will train all new employees on the RACE and PASS fire safety procedures to include appropriate fire extinguisher selection. The hot plate in the kitchen currently being used for the stove was connected to an electrical outlet in the wall. The kitchen staff was educated on not using power strips. D. Removal of immediate jeopardy On 11/18/2021 at 5:28 p.m., the NHA and the senior vice president of operations (VPO) were notified the immediate jeopardy had been removed, based on the plan above. However, deficient practice remained at an F level, a pattern with the potential for more than minimal harm. II. Facility policy The NHA provided the facility's Emergency Response and Emergency Procedure: Fire on 11/22/21 at 3:11 p.m. It read in pertinent part: (The) facility will make preparations to help prevent fire in an effort to protect residents, visitors, employees, contractors, property, and confidential information. Fire drills must be treated as if they are real fire emergencies. A high level of confusion and anxiety may exist during a real emergency; therefore, staff must practice routinely to minimize confusion, anxiety, or other problems. Emergency directions: 1. The administrator calls the fire department immediately. 2. Staff ensures all exits are clear and free of equipment. Fire response- upon discovering fire or smoke: 1. Remove residents from immediate danger. 2. Call aloud 'Code Red' and the location of the fire. 3. Begin R.A.C.E. program. Rescue- remove residents to at least 20 ft. (feet) from the threatened area, preferably on the opposite side of the closest fire door. Alarm- activate the closest fire alarm. Even though automatic alarms may be activated, one person should be directed to dial 911. Confine- after removing the endangered residents, close the door(s) of the threatened area. Close smoke/fire doors behind you as you go. Extinguish/Evacuate- assess the fire threat to either attempt to extinguish the fire or evacuate residents from the affected area. If the area is evacuated, check that all (the) smoke/fire doors with sheets or towels to slow smoke penetration into the unaffected areas. Note: If the fire is small, it may be extinguished by smothering (covering) with sheets or clothes, or by using a portable fire extinguisher. You have only one attempt to extinguish the fire with a fire extinguisher. If unsuccessful, then confine the area of the fire and evacuate the residents and staff. No further access to the fire area should be allowed except fire department personnel. Do not attempt to go into areas where the electrical distribution panels are located. The local fire department will turn off the power and gas. Note: Do not call in additional personnel until the area has been cleared to avoid potentially placing additional staff in harm's way. III. Facility fire 11/7/21 and facility response A. Interviews with kitchen staff working 11/7/21 revealed the following: The cook was interviewed on 11/18/21 at 10:30 a.m. She said she was in the process of cooking the lunch meal, which was fried chicken. She said she was using a pot filled with oil to fry the chicken since the kitchen did not have a deep fryer. After she had finished cooking the chicken, the oil that had spilled under the burner had caught on fire. She said she tried to put the fire out with flour and salt, and that was not working so she left the kitchen to get an additional staff member to help. She said she told a nurse who came into the kitchen and used the red fire extinguisher to attempt to put out the fire, but that also did not work. The cook said she never pulled the fire alarm located in the kitchen or called 9-1-1. She said she was just very scared and did not know what to do when the fire would not go out. She said she had a similar kitchen fire about a year ago, and she also did not know what to do during that fire, but that fire eventually extinguished itself. The cook said she had received training following the fire on 11/7/21, but was unable to say or demonstrate what the education was or what she would do in the event of another kitchen fire. The dietary manager (DM) was interviewed on 11/18/21 at 10:37 a.m. She said she was not working the day of the fire, but did ask her staff what caused the fire. She said the cook had been frying chicken in a pot and some of the grease had splashed on the stove. The DM said when the cook began to cook the mashed potatoes for the meal, the grease caught on fire. The DM said the dietary staff had all been trained to throw flour or salt onto a kitchen fire, and that was what the cook and dietary aide had attempted to do. The DM said she was aware of the nurse (LPN #1) being called into the kitchen, and she had been told by the kitchen staff that the nurse had extinguished the fire, not the fire department. The DM said her staff should still attempt to extinguish a small kitchen fire with flour or salt, and if that did not work, they needed to use the kitchen rated fire extinguisher. The dietary aide (DA) was interviewed on 11/18/21 at 10:45 a.m. She said she had been working the day of the fire and she attempted to help the cook extinguish the fire by throwing salt on top of the fire. The DA said when that was not working she called the dietary manager on the phone, and the dietary manager told her to attempt to extinguish the fire again with the flour and salt. The DA said she never thought to pull the fire alarm located in the kitchen, and at the time of the fire she was unsure what fire extinguisher to use during the fire. She said she had since received training, and knew that she needed to pull the fire alarm located in the kitchen, and to use the kitchen silver fire extinguisher on grease fires. The DA said she would also attempt to put out a small fire with flour or salt. The DA said from the time she was aware of the fire to the time the fire department extinguished the fire was about 10 to 15 minutes. The city fire chief investigator (FC) was interviewed on 11/18/21 at 11:10 a.m. He said he had concerns with any training that would include attempting to extinguish any fire by throwing salt and/or flour onto it. The FC said not only is it very dangerous to attempt to smother a grease fire with anything, flour is actually flammable and could actually make the fire worse. The FC said he would only want staff to attempt to extinguish the fire with a kitchen rated fire extinguisher. The FC said it was also crucial for staff to pull the fire alarm, to not only notify the fire department but also to notify the staff in the building. The FC said had the kitchen staff pulled the fire alarm located in the kitchen, not only would the fire department have been timely notified, it would have activated the hood system located over the stove. He said the hood system located over the stove would have released a chemical and extinguished the fire, as well as turned off the electricity to the kitchen appliance which is crucial during a fire, to prevent further fires. The FC said the fire department received the 9-1-1 call on 11/7/21 at 9:36 a.m. and was to the facility by 9:44 a.m. to extinguish the fire. Licensed practical nurse (LPN) #1 was interviewed on 11/22/21 at 1:27 p.m. She said she was working on the hallway closest to the kitchen so she was the first person the cook encountered. She said she yelled out to a certified nurse aide (CNA) to move the residents who remained in the dining room following breakfast, but there were only a few residents since it was in between meals. The LPN said when she entered the kitchen she called 9-1-1 on her personal cell phone, and was placed on hold. She said while she was in the kitchen she attempted to put a little flour onto the fire, and that was not successful. She then grabbed the ABC fire extinguisher and attempted to extinguish the fire. She said the fire did go down a little, but then flared right back up and that was about the time the fire department showed up and extinguished the fire. The LPN said she was under pressure and did what she thought was best. She said she never had kitchen fire training, or training on what fire extinguisher to use for specific fires. The LPN said she did receive training after the fire regarding pulling the fire alarm, and using the correct fire extinguisher for grease fires. IV. Facility failures A. Facility failure to provide sufficient fire training and kitchen specific fire drills to staff. 1. The maintenance director (MTD) was interviewed on 11/18/21 at 11:23 a.m. he said he was responsible for providing fire training to staff in the facility, as well as facilitating the fire drills in the facility. He said he had never received formal training on what to train staff on, so he trained them on the facility fire policy as well as a brief description of the operating systems that activate during a fire alarm, such as the fire doors. The MTD said he was also responsible for completing the fire drills in the facility. He said those drills were completed monthly, and he would select a random location in the facility and would try to vary the time of day of the fire drill. The MTD said he had not done any training with the kitchen staff regarding kitchen/grease fires. He said their company was responsible for providing those training sessions. The MTD said none of the fire drills he had completed had taken place in the kitchen, and he was unsure the last time a fire drill had been conducted in the kitchen. The MTD reviewed the fire drills conducted in the facility for the past year, and said none of the fire drills had been completed in the kitchen. 2. On 11/18/21 at 11:35 a.m. the NHA said staff had been trained following the fire in the kitchen. The NHA said that training had been started on the day of the fire (11/7/21) and for a few days following. The NHA said staff were trained on the facility fire policy and procedure, which included following the acronym R.A.C.E(Rescue/Alarm/Confine/Extinguish/Evacuate). She said the training also included what types of fire extinguishers to use for specific fires. The NHA said all of the kitchen staff had been trained, as well as nursing staff, but she did not have documentation of what staff had received the training. On 11/18/21 at 12:25 p.m. the NHA said she had just completed re-education to the kitchen staff who had been present during the fire on 11/7/21. The NHA said she went over R.A.C.E and using the correct fire extinguisher for grease fires. The NHA said the dietary manager, and the dietary aide were able to verbalize understanding as well as provide a return demonstration. The NHA said the cook who had been working the day of the fire was present during the education, but she was unable to verbalize understanding or provide a return demonstration. The NHA said there was a language barrier with the cook, and she had utilized an interpreter, and the cook was still unable to verbalize understanding of what to do during a fire. The NHA said the cook had been suspended because of the safety concern in the kitchen. 3. On 11/22/21 at 2:25 p.m. the kitchen director of operation (KDOR) provided the fire training records for all of the kitchen staff. Those records documented that all of the kitchen staff had completed fire procedure and evacuation plan training on 9/15/21, and had completed grease fire procedure training on 10/20/21. When interviewing the kitchen staff, none had recalled any training they had received. The KDOR said the training was completed on the computer, which consisted of a video and a test. The KDOR said none of the kitchen staff had to demonstrate an understanding of the training or competencies. The grease fire procedure in service policy and procedure, undated, was provided by the KDOR on 11/22/21 at 2:29 p.m. It read in pertinent part: Purpose: To review the steps to take in the event of a kitchen grease fire including safety tips, dos and don'ts for kitchen grease fires, and steps to take in the event of a grease fire. If you are faced with a grease fire, follow these steps: 1. Turn off the source of the heat (for example, turn off the stove burner or heating element). 2. Do NOT pour water on the grease fire. 3. Cover the grease fire with a lid, pot, or baking pan - this will limit the fire's oxygen supply. 4. If covering does not extinguish the fire, pour baking soda or salt on it - this will work to limit the fire's oxygen supply. Do NOT use flour, baking powder, or cooking powders that might resemble baking soda or salt. These other powders have a different chemical makeup and could make the fire worse. If the above steps do not work to extinguish the grease fire, follow these Emergency Steps: 1. Use a Class K wet chemical fire extinguisher, if available. Though more effective for extinguishing large grease fires, these are generally only found in commercial settings. 2. Spray the fire with a Class B dry chemical fire extinguisher. Use this method if it is your only option, as the fire extinguisher will contaminate the food, dishes, and utensils. 3. Call 911 immediately if the fire is not quickly extinguished or if it grows too large to be controlled. The KDOR was interviewed on 11/22/21 at 1:15 p.m. She said her company is a contract company that supplies the kitchen staff to the facility. She said her company provided training to the kitchen staff, in addition to the facility training. She said it was not her company's policy to use salt, flour, or baking soda to extinguish a fire and she was unsure where the kitchen staff had received that information. She said it was dangerous to attempt to put out a grease fire because it would be too difficult to determine the size of the fire. The KDOR said she would have wanted the cook to first pull the fire alarm, and then use a kitchen rated fire extinguisher to attempt to extinguish the fire. She said her company did not complete fire drills with kitchen staff, and those drills were to be completed by the facility. The dietary manager (DM) was interviewed on 11/22/21 at 2:04 p.m. She said she had worked in the facility for several years, and she nor her staff had ever had hands on fire training, or kitchen fire specific training. She said her staff participated in the facility fire drills which always took place outside of the kitchen. The DM said she nor her staff had training on the difference between the two fire extinguishers in the kitchen, but did receive training following the fire on 11/7/21. The DM said the training she had received from her company had consisted of trying to put out a grease fire with salt, and she thought flour. The DM said all kitchen staff had received the same training, which instructed them to attempt to smother the fire with salt, flour, or baking soda. The DM said after she reviewed the grease fire procedure, she became aware that she should only use baking soda or salt. V. Facility follow-up plan The NHA was interviewed on 11/22/21 at 2:27 p.m. She said she was unaware of the difference in training provided by the facility and the contract kitchen company. She said moving forward the kitchen staff would only use the facility fire policy. The NHA said they were in the process of updating the fire policy to be more detailed, and to include kitchen fires. The NHA said all staff were currently being trained on the fire policy and procedure as well as what fire extinguisher to use in the event of a fire. The NHA said the facility would also begin fire drills for kitchen staff, as well as requirements for return demonstration training to ensure understanding.

Based on interviews and record review, the facility failed to ensure an allegation of abuse involving one resident (#97) of 20 residents reviewed of 35 sample residents was properly reported, timely investigated, and measures implemented to prevent further abuse. Specifically: Resident #97 reported to certified nurse aide (CNA) #8 that he had been sexually/physically abused by CNA #9, causing him to feel violated and humiliated. However, resident #97's abuse allegation was not reported to administration as expected per facility policy; staff interviews revealed the facility lacked an effective process to track and maintain concern forms where CNA #8 and the resident had purportedly documented the allegation of abuse. Investigation of the resident's allegation during survey revealed two other resident complaints of rough treatment by CNA #9. The findings included: I. Facility Policies In pertinent part, the facility's abuse and neglect prohibition policy, revised on 1/17, stated: -Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the administrator and/or the director of nursing. -The facility would protect residents from harm during the investigation. Any employee alleged to be involved in an instance(s) of abuse and/or neglect would be suspended immediately and would not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. -The facility would timely conduct an investigation of an alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin or misappropriated of resident property in accordance with state law. In pertinent part, the facility's incident/accident reporting for residents' policy, revised on 2/17, stated when an incident, accident or unusual occurrence was discovered, the employee making the discovery would notify their immediate supervisor or the administrator. The supervisor would notify the administrator timely. Review of facility records revealed the facility had conducted a staff training on abuse 3/21/17. II. Resident #97 A. Resident status Resident #97, age less than [AGE] years, was admitted on [DATE]. According to the face sheet, the resident had [DIAGNOSES REDACTED]. According to the 4/11/17 minimum data set (MDS) assessment, the resident had a brief interview for mental status (BIMS) score of 15 out of 15, which demonstrated the resident was cognitively intact. No mood or behavior symptoms were noted. The resident did not have a psychiatric/mood disorder diagnosis. The resident needed supervision for bed mobility, transfers, eating, and personal hygiene. The resident needed limited assistance for dressing. The resident was always continent in bowel and bladder. The resident had two unhealed pressure ulcers, which were classified as one unstageable pressure ulcer and one stage IV pressure ulcer. The activities of daily living (ADL) care plan was initiated on 1/25/17. The care plan documented the resident had a self-care performance deficit related to limited mobility. Pertinent approaches included providing supervision of one staff for twice-weekly bed bath/shower, dressing and for toilet use. B. Resident Interviews Interviews revealed the resident reported to CNA #8 that CNA #9 had violated him during care and described the alleged violation as abuse. Although CNA #9 was no longer allowed to care for him, the CNA continued to work at the facility and the resident said he was not approached by any staff about the incident until after the incident was reported to administration (assistant director of nurses) by the surveyors on 4/18/17 at 9:16 a.m. Resident #97 also said he had overheard the CNA verbally abusing other residents. The resident was interviewed on 4/18/17 at 8:54 a.m. and 4/19/17 at 8:40 a.m. During both interviews, the resident's report of the alleged abuse incident, his actions and the facility's response was consistent. The interviews with the resident revealed: -The resident stated he had been violated at the facility. The resident said CNA #9 violated him during a bed bath that was performed at around 10:00 a.m., at the end of January or beginning of February The resident explained that as CNA #9 washed between his buttocks, the CNA put her finger in his rectum. -The resident said he reported this incident to CNA #8 at around 10:30 p.m. that same day. The resident said he did not tell anyone until later that day (on the night shift) because he felt humiliated. The resident said when he reported the incident to CNA #8, CNA #8 got mad and said she was going to report it. The resident said he asked CNA #8 the next day if she had reported the incident and she said she had. The resident said CNA #8 told him she had filled out a concern form. The resident denied seeing this document and said no staff members, including the nursing home administrator (NHA) and director of nursing (DON), had discussed the incident with him until 4/18/17 (after the surveyor informed the assistant director of nursing (ADON) of the resident's concern at 9:16 a.m.). At that time, the NHA and a CNA came to speak with him about the incident and the NHA told him she was not previously aware of the incident. The resident said the NHA told him that if she had known about the incident, she would have suspended CNA #9 immediately. -The resident said CNA #8 must have reported the incident because the next morning CNA #9 was not allowed to come into his room. He said after the incident, CNA #9 did not work with him at all and knew to stay away from him. However, the resident said CNA #9 had not been removed from the facility at any time after the incident. -The resident said prior to CNA #9's violation of him, he often heard the CNA yell at residents or other staff members but he said he was not afraid of CNA #9. 4. Record review following facility notification of resident #97's allegation of abuse. The nursing home administrator was notified of resident #97's allegation of abuse on 4/18/17 at 9:30 a.m. after she was notified of the allegation by the assistant director of nursing. Although review of the clinical record on 4/19/17 at 10:00 a.m., did not identify any documentation involving the resident's allegation of abuse by CNA #9, interview with the DON and review of documentation submitted by administration revealed an investigation of resident #97's allegation of abuse was initiated on 4/18/17 at 9:30 a.m. The DON requested a written statement LPN #2, CNA #8's supervisor. The 4/19/17 written statement from LPN #2 revealed: -During the night shift near the end of January 2017, a CNA (CNA #8) advised the LPN resident #97 was verbalizing a complaint about another CNA (CNA #9). The resident told the LPN he felt CNA #9 inserted her finger in his anus. The resident said CNA #9 was wiping him hard during incontinence care. -This LPN advised the resident that due to the severity of the wound on his coccyx and the proximity of the wound to his anus, the pain might have made him feel as though the CNA had put her finger in his anus when she really did not. The LPN documented the resident said this explanation made sense to him; however, he still wanted to report the CNA for being too rough while performing incontinence care. -Because the resident did not want CNA #9 taking care of him anymore, when the day shift arrived the LPN had a conversation with CNA #9 to advise her she needed to be more gentle with incontinence care and to advise her that she was not to perform cares on resident #97. -The LPN provided the resident with a concern form and a pen. Two or three days after the incident occurred, the resident handed this LPN the concern form he had filled out and it was placed in either the NHA or the DON's box in the front hallway. The resident never again voiced concerns regarding this incident or the CNA in question to this nurse. 5. Facility failures a. Staff Interviews Interviews with the NHA and DON revealed staff (CNA #8 and LPN #2) did not follow procedure in reporting the known allegation of abuse. As a result, the allegation was not reported to administration and steps were not taken to prevent residents from abuse by CNA #9. Moreover, the concern forms written by CNA #8 and resident #97 (per their written statements above) which would have communicated the allegation to administration for follow up, could not be located. The NHA was interviewed on 4/18/17 at 10:00 a.m. after resident #97's allegations were reported to her by the surveyor. The NHA said she had no knowledge of the resident's allegation of abuse. Additionally, the NHA said DON and the charge nurse had no knowledge of the allegation. The NHA said CNA #9 had been suspended and a call had been placed to CNA #8. The NHA said an investigation would be started immediately. She said a call would be placed to the local police and a report would be initiated in the state reporting portal system. The NHA said she was going to see if the resident had attended the resident council meetings or had been a part of any other abuse investigation to see if he had ever mentioned this incident previously. The NHA and DON were interviewed on 4/19/17 at 10:38 a.m. The joint interview revealed: -The NHA said the investigation, initiated on 4/18/17 at 9:30 a.m., demonstrated CNA #8 reported the incident between the resident and CNA #9 to LPN #2, who was the direct supervisor. The NHA said LPN #2 did not document anything on this incident on any facility forms. The NHA said the moment the LPN heard there was an allegation of abuse, she should have immediately notified the NHA and started an abuse investigation. The NHA said none of this occurred. The NHA and DON said it was their expectation staff follow the abuse policy. -The DON said LPN #2 was interviewed (phone conversation) on the day (4/18/17) when she was first made aware of resident #97's allegation of abuse. The DON said LPN #2 commented she did not write down any documentation regarding the allegation of abuse. The DON said LPN #2 said CNA #8 told her CNA #9 was wiping the resident too hard during cares. LPN #2 said she talked with CNA #9 the following morning about being gentler and having a second staff member present during cares. The DON said she had LPN #2 write down a statement today (4/19/17) and she complied. -The DON said the facility investigation had identified two other residents who stated CNA #9 had been rough with them during cares. Neither of the two residents had reported their concern to staff. The DON said they would continue to interview other residents. At present, no residents reported other inappropriate behaviors/treatment from CNA #9. -The NHA said she was unable to find a concern form regarding the incident from CNA #8. The NHA said there was a staff member (terminated prior to survey) who was responsible for the concern forms. The NHA said the terminated employee could have misdirected or lost the concern form(s) documenting the resident's abuse allegation. The NHA said it concerned her the resident's concern form had not been found. The NHA said she believed a concern form had been filled out but it was never brought forth for review. b. Facility record review Although review of facility records revealed the facility had conducted a staff training on abuse 3/21/17, which was attended by CNAs #8 and #9, as well as LPN #2, there was no evidence from the written statements or administration interviews above that the training had triggered either CNA #8 or LPN #2 to communicate the allegation resident #97 had previously reported to them, to administration to ensure it had been addressed by administration. 6. Facility Follow-up The NHA and the DON were interviewed on 4/21/17 at 8:11 a.m. The NHA said the investigation had been concluded. She said 33 residents and 15 staff members had been interviewed. She said the allegation of abuse had meet the elements for reporting to the state and it had been reported. The police had an open investigation of the incident at this time. The NHA said all staff have been re-educated on abuse. The NHA said CNA #9 had been terminated as of 4/21/17 and would be reported to the licensing board. The NHA said LPN #2 had been re-educated on abuse and on timely documentation.

Based on observations, record review and interviews, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrated this was not possible for one (#93) of 24 sample residents. Specifically, the facility failed to: - Appropriately assess the resident's nutritional status and needs to prevent decline; - Appropriately and timely assess the resident's food preferences; - Provide appropriate assistance for the resident during meals; - Provide a variety of nutritional supplements to the resident to prevent weight loss; - Timely communicate with the resident's medical power of attorney/family, and - Timely address the resident's severe weight loss with the interdisciplinary team. The facility's failures contributed to the resident experiencing a severe 13 percent weight loss in three months. The findings included: Cross-reference F157, failure to notify family of the resident's severe weight loss 1. Professional Standards According to Pamela A. Fenstemacher MD and Peter Winn MD, Long Term Care Medicine, A Pocket Guide dedicated to the American Medical Directors Association (AMDA) staff (2011), chapter nine, Weight and Nutrition, by Todd H. Goldberg MD, CMD and Joel L. Levine MD, Chief of [MEDICATION NAME], West Virginia University, in pertinent part: As with persons of all ages, proper nutrition and maintaining a healthy weight are very important in elderly long-term care residents . -Optimal nutrition should ideally improve health, functioning, and quality of life and reduce the risk of morbidity, mortality, and complications such as weakness, impaired immunity . -Weight loss is a negative quality indicator and risk factor for poor outcomes - survival is markedly improved with appropriate and adequate nutrition . -Every resident has important and individual nutritional needs, but those with chronic illness and disability require extra attention to diet and nutritional assessment and need for assistance . -Serum [MEDICATION NAME] is the single most commonly used indicator of protein undernutrition and the level is correlated with mortality in older person . The laboratory tests should be ordered not only when problems are reported but perhaps considered periodically in all elderly residents at risk for poor nutrition, and are often abnormal in the elderly requiring changes in medications or supplements . -AMDA's Clinical Practice Guideline on Altered Nutritional Status; available from http://www.amda.com recommends that treatment should address underlying issues identified, tailoring meals/food to individual preferences and function, limiting unnecessary dietary restrictions, adding supplements, and as a last resort, tube feeding on an individual basis. Individuals at facilities must further be continually monitored for maintenance and improvement of nutrition . -It should be noted that caloric supplements optimally might need to be given between meals to minimize appetite suppression. 2. Facility policy According to the Weight/Hydration Management policy, revised August 2012, in pertinent part: As residents are weighed, staff can compare current weight to previous weight. Residents with weight variance are reweighed within 24 hours. Weight variance include: a. Weight change of 5 lbs b. Weight change of 3 lbs if weight less than 100 lbs Significant weight variance is defined as: 5% in one month (30 days) 7.5% in three months (90 days) 10% in six months (180 days) Those identified with significant weight change or insidious weight loss will be highlighted, underlined or circled on your weight change report .Meal intake records, supplement-nourishment/snack/fortified-food list with intake information, and diet order list will be brought to meeting by the Dietary Manager and/or Registered Dietician. Dietary Manager and/or Registered Dietician will visit with resident, family and care staff regarding weight status and acceptable interventions. Weekly At-Risk Review Meeting will be conducted on each resident with weight loss untll the IDT (interdisciplinary team) determines weight has stabilized and can discontinue from weekly review. The DON (director of nursing) and/or Dietary Manager will ensure communication to staff members on the changes to the interventions related to the weight status will be completed. 3. Resident status Resident #93, age 79, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 2/1/17 minimum data set (MDS) admission assessment, the resident had clear speech, usually made self understood and usually was able to understand others. She had short and long-term memory problems with moderately impaired cognitive skills for daily decision making. She had no hallucinations or delusions. Physical and verbal behaviors directed towards others and rejection of care were observed during the assessment period. -She required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and limited assist with transfers and eating. She was using a wheelchair and a walker for mobility. She was frequently incontinent of urine and occasionally incontinent of bowel. She had no swallowing disorder or nutritional approaches. Her weight was 112 pounds. She did not have an unhealed pressure ulcer. She did not receive insulin injections. She did not receive an antipsychotic, antianxiety, antidepressant or hypnotic medication. The care plan, initiated on 1/27/17 and revised on 3/30/17, identified potential nutritional problem related to dementia, diabetes mellitus, refusals of medications at times, refusals of supplementation, poor oral intake and significant weight loss. Interventions included meal assistance as needed, determination of individual likes and dislikes, fortified foods, registered dietician evaluation and diet change recommendations as needed, obtaining laboratory/diagnostic work as ordered, consistent carbohydrate diet, regular texture. 4. Record Review Record review revealed the registered dietician (RD) was aware of the resident's weight loss and had been documeting the unplanned weight change. Despite awareness of unplanned, severe weight loss, the facility did not take steps to identify a medical cause for the weight loss and did not evaluate the resident for protein calorie malnutrition. The facility did not timely evaluate the resident for approaches to mitigate the weight loss as evidenced by a delay in assessing resident food preferences, which were not obtained until 4/20/17, more than a month after severe weight loss of greater than five percent was known. Although the care plan addressed the resident's refusals of supplementation, record review revealed no protein supplements were prescribed to the resident since her admission to the facility despite significant weight loss. There was no other supportive documentation in dietary or nursing notes related to any protein supplementation trials with the resident who was insulin dependent diabetic to prevent the weight loss. A. Weight Records Review of the resident's weight record revealed severe weight loss as follows: 1/27/17 - 112 pounds 2/8/17 - 113 3/4/17 - 106 3/8/17 - 104 (8% weight loss in 30 days) 3/16/17 - 101 3/22/17 - 103 3/29/17 - 103 4/5/17 - 99 (12% weight loss in 60 days) 4/12/17 - 101 4/20/17 - 97 (13% weight loss in three months) B. Dietary Records Review of the RD notes revealed the following: Nutrition Data Collection dated 1/27/17: Rsd (resident) known to writer from stay at affiliated facility. Rsd has been refusing some wts (weights) s/p (status [REDACTED]. BMI WNL (body mass index within normal limitations). Intake appears adequate, but will f/u (follow up) pending current wt (weight) and intervene if warranted. -This nutritional assessment documented calorie needs of 1275-1530 and protein needs of 51-61 grams. There was no documentation of the resident's usual body weight, recent laboratory results, or food preferences. RD note dated 2/16/17: Rsd wt 113# (pounds), reflects slight gain of 1.2# since admission. BMI 22.1, WNL. Intake continues to appear adequate. Will monitor and f/u per protocol. RD note dated 3/2/17: ARR (at risk review) wt note: Rsd wt 106.2#, reflects sig(nificant) loss from admission. Will try offering fortified foods and monitor wt weekly. RD note dated 3/9/17: ARR Note: Rsd wt 104.8#, further 1.4# loss. Nsg (nursing) reports Rsd continues with very poor po (oral) intake and refusals of meds. NP (nurse practitioner) present today, reviewed wt hx (history), po intakes, and refusals of supplements with NP. Staff has also been alerted to Rsd wt loss and need for additional encouragement/cueing and possible different approaches at meals to assist with meal intake. MOST (Medical Orders for Scope of Treatment) indicates would accept short-term TF (tube feeding - artificially administered nutrition). Will continue to weigh weekly. RD note dated 3/16/17: ARR Note: Rsd wt 101.8#, further 3# loss. Staff continues to encourage intake with limited success. Rsd continues with c/o (complaints of) pain; also with increased behaviors over the past week. MD (physician) notified of wt loss, poor po intake, continued c/o pain, and increased behaviors. Also to consider possible TF. RD note dated 3/23/17: ARR Note: Rsd wt 103.8#, 2# desirable gain over the past week. [MEDICATION NAME] and [MEDICATION NAME] adjusted. Rsd with fewer behaviors and c/o pain. Will continue to monitor. RD note dated 3/30/17: ARR Note: Rsd wt 103#, .8# loss over the past week, had gained 2# the week prior. Will continue to monitor. RD note dated 4/13/17: ARR Note: Rsd wt 101.6#, reflects continued fluctuations, but no sig(nificant) change over 30 days from 101.8# 3/16/17. Staff report Rsd will only take meds when given with 'Dr. Pepper', they have been using diet d/t h/o DM, Rsd BG (blood glucose) appear adequately controlled, rec(recommended) change to regular Dr. Pepper for the additional calories. Will f/u on BGs. RD note dated 4/20/17: RD wt note: Rsd wt 97.6#, 3# further loss over the past week. Rsd h/o wt loss reviewed. Rsd has been being followed at ARR, NP and MD have been notified. Nsg has reported Rsd has had increased behaviors and had been refusing supplementation as well as medications. IDT discussed nutritional interventions and chose not to add oral supplement as team felt Rsd would view supplement as yet another medication and does not have the cognitive ability to understand why the supplement was ordered. Team decided to focus on increased assistance with meals and providing fortified foods that Rsd may be more familiar with and may accept more readily. Spoke with Nsg again this morning and Nsg reports Rsd accepted hot cocoa mixed with milk this morning and that she consumed all of her hot cereal when fed at Breakfast. Chart also reviewed for current labs. Rec offer chocolate nutritional shake TID, obtain CMP with [MEDICATION NAME], and continue to provide total assistance with meals. RD note dated 4/20/17: Dietary Manager contacted Rsd son and obtained food preferences. Copy of preferences placed in chart and Meal Tracker updated. Record review revealed the nurse practitioner failed to address resident's significant weight loss. There was no documentation related to the resident's physician visit since her admission to the facility three months ago. Record review failed to reveal any of the interdisciplinary team members presence and review of resident's #93 severe weight loss. C. Meal intake records Meal intake documentation was difficult to decipher and did not clearly demonstrate the meals or percentages the resident consumed. 5. Observations Observations of the resident revealed the resident did not attend meals consistently, at times remaining in bed missing meals. When staff provided feeding assistance, the resident was observed to accept bites of food. However, observations revealed staff did not consistently offer the resident feeding assistance. On 4/17/17 at 5:00 p.m., the resident was observed in her room, in bed, with eyes closed. Other residents were observed in the dining room, eating dinner. On 4/18/17 at 11:30 a.m., the resident was observed in her room, in bed, with eyes closed. Other residents were observed in the dining room participating in activities. The resident care advisor (CNA #10) was interviewed on 4/18/17 at 11:35 a.m. She said the resident did not get out of bed on 4/17/17 and she did not eat the whole day. She said the resident did not eat breakfast today either. The unit's medication nurse (LPN #1) was interviewed on 4/18/17 at 11:38 a.m. She said the resident did not eat yesterday and today. She said she would try to encourage the resident to get out of bed. On 4/18/17 at 12:00 p.m., the resident was wheeled in a wheelchair to the dining room and placed by the table. On 4/18/17 at 12:05 p.m., LPN#1 gave the resident a cup with chocolate milk and the resident took a few sips. LPN #1 said the resident liked to drink chocolate milk. On 4/18/17 at 12:15 p.m. a plate with lunch food was placed on the table, in front of the resident. CNA #7 was observed assisting another resident at the table with her lunch meal. The CNA said resident #93 did not require assistance. She said the staff would remind her to eat, but did not offer physical assistance. The resident was observed not eating. On 4/18/17 at 12:25 p.m., CNA #7 was asked if she could try to help resident #93 and see if she would accept the food. The resident did not resist and ate five spoons of lasagna, a few bites of dinner roll and some of the pudding. She consumed most of the chocolate milk. On 4/19/17 at 8:15 a.m., the resident was observed in the dining room, sitting at the table. LPN #1 was assisting/feeding the resident with breakfast. The resident ate all of her oatmeal and consumed some of the chocolate milk. On 4/19/17 at 1:00 p.m., the resident was observed in bed. LPN #1 and CNA #10 said the resident did not eat lunch. 6. Staff Interviews LPN #1 was interviewed on 4/20/17 at 9:20 a.m. She said she was not aware of the resident's significant weight loss. She said she had noticed the resident was not eating very well and she tried to give her chocolate milk once or twice a day. She said the resident did not have a physician prescribed nutritional protein supplement and she never offered one to the resident. She said since the resident liked to drink the chocolate milk, she could benefit from a chocolate flavor protein supplement. She said it was up to the dietician and physician to prescribe a nutritional supplement. CNA #10 was interviewed on 4/20/17 at 9:30 a.m. She said she did not know resident #93 required physical assistance with eating. She said the staff was trying to encourage to eat but never physically assisted her or fed her. She said the resident frequently stayed in bed the whole day and did not get up for meals. She said when staff was trying to help the resident get out of bed, she was screaming at them and the aides let her stay in bed. The RD was interviewed on 4/20/17 at 10:19 a.m. She said the last at risk review meeting (ARR) was on 4/13/17 and the resident's weight loss was addressed. The RD said she remembered the resident from her previous facility. She said the resident was eating very well and her weight was stable between 110 and 112 pounds. She said the resident was walking independent without assistive devices and did not exhibit any aggressive behaviors. She said she did not request protein supplementation because she thought it was a temporary adjustment to new facility. She said she did not realize that the pain due to the resident's [MEDICATION NAME] and lumbar vertebrae fractures would cause increased aggressive behaviors toward staff and refusing to eat. She said the resident's NP was notified of the resident's weight loss and meal refusals on 3/9/17. She said the NP was in the facility at that time. She said she did not understand why the NP did not take any medical approaches to prevent further weight loss. The RD said the resident's physician was notified on 3/16/17, over the phone, by the director of nursing (DON) about resident's weight loss, pain management and increase of aggressive behaviors. The RD acknowledged the resident's significant weight loss was not appropriately addressed. She said she relied on the nursing staff statements that the resident would refuse protein supplements as she was refusing to eat. However, the supplements were not prescribed nor there was documentation related to protein supplements being offered. She said she did not request laboratory work to check [MEDICATION NAME] or [MEDICATION NAME] levels for the resident, who had a [DIAGNOSES REDACTED].

Based on record review, and interviews, the facility failed to ensure residents on the secure unit, including five out five residents (#3, #2, #1, #4, #5) were free from accidents and injury. Specifically: The facility failed to ensure resident #3 and #2 received adequate supervision and behavioral assistance to prevent their abuse of residents on the secure unit as well as to prevent injury to themselves. Resident #3 bit several residents, at least one of whom, resident #4, required antibiotics secondary to an infection from the bite. Resident #2 attempted several elopements and exhibited behaviors that were aggressive and that angered and agitated other residents, placing resident #2 and other residents in the secure unit at risk for injury. The findings include: I. Facility Policies A. The Facility policy on the Secure Unit (no revision date) read in pertinent part: -A sufficient number of qualified staff is provided to meet the needs of residents in the secure unit. -Additional social work and activities staff are assigned to the unit to meet the social, emotional, and recreational needs of the residents and the social and emotional needs of their families in coping with the resident's Alzheimer's disease, related dementia and behaviors. B. The Facility policy on abuse and neglect prohibition (last revised 6/13) read in pertinent part: -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. -Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. II. Resident #3 Resident #3, age 73, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on the secured unit until 10/17/15 when she was transferred to the emergency room (ER). She was subsequently discharged from the facility on 10/20/15. A quarterly minimum data set (MDS) on 9/22/15 noted the resident had severe cognitive impairment. The resident required limited assist of one person for locomotion on the unit and supervision with set up only for walking in the corridor. The MDS also noted during the assessment period that the resident had wandered on one to three days; rejected care for one to three days; verbal behavior symptoms directed towards others for one to three days; physical behavioral symptoms directed towards others for one to three days; and was short-tempered and easily annoyed for seven to 11 days out of the observation period. A. Documentation of Physically Aggressive Behavior toward Residents on the Secure Unit - Resident to Resident Abuse 1. First Behavior (Bite) with Injury: Resident #3 and #1 Resident #1, was a [AGE] year old admitted on [DATE]. Her most recent MDS dated [DATE] identified the resident as having severe cognitive impairment and her [DIAGNOSES REDACTED]. A communication to the physician dated 9/12/15 noted, resident observed biting another resident (#1) on the shoulder. The corresponding facility report dated 9/12/15 at 2:30 p.m. noted resident #3 bit another resident (#1) in the secured unit. At the time of the incident, both residents were sitting together comfortably on a loveseat in the common area. Nurse saw resident (#3) lean over and bite resident (#1) on the left shoulder. Bruising in the shape of teeth marks noted upon initial assessment of resident (#1), skin not broken. Resident (#3) had a history of [REDACTED]. Resident (#3) on 1:1 supervision for the remainder of the day. It was also noted in the facility report that a second potential victim had reported later that day they, too, had been bitten on the arm by resident #3. 2. Second Behavior (Bite) with Injury: Resident #3 and Resident #5 Resident #5's MDS dated [DATE], revealed she was [AGE] years old with a [DIAGNOSES REDACTED]. A communication to the physician on 9/17/15 noted, The resident (#3) bite (sic) another resident (#5). Resident was sitting next to other resident and bite (sic) her at the left chest and witnessed. The corresponding facility report dated 9/17/15 noted, Resident #3 bit another resident on the left shoulder, breaking skin and causing bruising. At approximately 4:16 p.m. on the secure memory unit both residents were sitting on the same couch in the common areas next to each other. Resident (#3) leaned over and bit resident (#5) on the left chest/shoulder area. Bite measures 3 cm x 2 cm with red mark noted with 0.2 cm open area. Both residents immediately separated and 1:1 supervision provided. Changes that were made to the resident's care plan included to have 1:1 continuous supervision. 3. Third Behavior (Bite) with Injury: Resident #3 and resident #4 Record review revealed resident #4 was [AGE] years old. According to her CPO, her [DIAGNOSES REDACTED]. A communication to the physician dated 10/17/15 noted, Resident (#3) bit another resident (resident #4). Resident observed to be more difficult to redirect by staff, behaviors of sitting next to other residents and touching their legs and buttocks. Increase wandering, difficulty redirecting. treatment for [REDACTED]. The corresponding facility report dated 10/17/15, read, notified of resident (#3) in the secured memory neighborhood that bit another resident (third victim, resident #4) on the face, breaking skin and causing bruising. Both residents immediately separated and 1:1 supervision provided. At approximately 2:45 p.m. on the secure memory unit resident (#3) was in common area with 1:1 CNA/sitter and got up and started down hall. Sitter saw her starting to run with pants down and as sitter was following, she called her to pull pants up. Resident #3 turned and went into resident (#4's) room. Sitter called don't go into room and followed after her. By the time sitter got to the room, resident #3 was already on the bed and latched onto resident (victim). Sitter saw mouth open again and go for the arm, sitter called for help. Second CNA came really quick and it took both of them to unlatch from arm. Instead of tearing her mouth off the arm, they talked her down. A second narrative of the event on the same facility report stated: Resident (#3) was ambulatory and can run at fast pace. Resident was on 1:1 supervision and in her room alone at the time. Sitter was in hall in front of her door. Resident room is across hall from common area. Sitter turned to start DVD for other residents. Sitter heard resident (#3) come out of room, turned and saw her run at high speed, taking pants down. As sitter was following, she called her to pull pants up. Resident #3 turned, looked at sitter and went into resident (#4's) room. Sitter called don't go into room and followed after her. By the time sitter got into the room, resident #3 was already on the bed and latched onto resident (#4). The facility report further read that resident #4 was being observed being bitten by another resident (#3) to her left upper arm and near her left arm pit approximately 1.5 cm x 0.5 cm and 2 cm x 2 cm and a small laceration to her left eye (outer) corner. A physician monthly note for resident #4 on 10/19/15 stated bite by another resident on left cheek, left forearm and left chest near armpit on 10/17. An open wound on left chest about 3 x 3 cm, dirty wound. Tetanus vaccine given on 10/19. A progress note for resident #4 on 10/23/15 stated left chest wound noted to have scant drainage, redness around wound. Provider notified and came over to see residents. New orders received and carried out. A progress note on 10/24/15 stated resident has started on Keflex 500mg, three times each day for drainage to left chest wound. Dressing is CDI (clean, dry, intact). B. Resident #3 record review 1. Documentation of aggressive, potentially dangerous behaviors prior to 9/12/15 (first bite) and facility response A progress note on 7/1/15 stated that the resident was a new admission to the facility secured unit due to a high elopement risk. It noted, The resident had been refusing care and medications since the new admission, including those for anxiety, psychosis, and schizoaffective disorder. At risk for psych decompensation; if psych conditions decompensate, may need psych hospitalization . A monthly note on 8/10/15 stated, when other residents get close to her, she can be agitated and verbally abusive to the resident. Staff reported she hit other resident on arm on 8/8/15. She has been more combative and verbally abusive toward staff when staff offer care. A physician progress notes [REDACTED]. The resident was noted for refusing her antipsychotic medications. The physician noted that if dangerous behavior continues may need to send to ER to protect other residents. The physician noted that the administrator (NHA) and the nurse practitioner were attempting to find new placement. A care plan for behaviors was initiated 7/2/15 (and updated 9/23/15). It read in pertinent part: -Has behaviors related to co-morbid [DIAGNOSES REDACTED]. Walking through secured unit naked and not re-directable to re-dress, striking out at others. Being verbally and physically abusive towards staff and other residents. -The goals will be to not have weight loss or complications related to refusing food and that resident #3 will remain safe and free of infection/complications related to refusal of care. -Approaches included: Administer medications as ordered. Observe/document for side effects and effectiveness; increased and frequent monitoring of resident for whereabouts, as well as closeness to others in the common areas and rearrange seating, or redirect as able; obtain from family any tasks/interventions that have proved to be effective prior for compliance with cares; redirect resident as able to bedroom to assist with re-dressing as willing. 2. Documentation following first bite 9/12/15 and facility response - failure to provide adequate supervision and other interventions to ensure the safety of residents on the secured unit from resident #3's abusive behaviors. A monthly note on 9/14/15 stated she bit two residents at their shoulders on 9/12. (See above; only one resident was noted on the facility reporting.) -See above physician communication and facility report dated 9/12/15. There was no evidence that staff considered sending the resident to the ER as discussed in 9/9/15 physician progress notes [REDACTED]. A Post-Admission Level one update on 9/15/15 noted the resident has been physically violent to other residents (biting, hitting), striping (sic) clothes off to go through hallways, refusing meds and adls (activities of daily living) assistance. -This update was dated before the second and third biting incidents. There was no evidence of new interventions to protect residents on the unit from resident #3's aggressive behaviors. Likewise, there was no evidence of physician contact for review of the resident's violent behavior or consideration of transfer to the ER for dangerous behavior toward other residents. A progress note on 9/18/15 indicated that after resident #3 bit another resident, the facility attempted to send the resident to a psychiatric services facility but there was no bed availability. -Although resident #3's care plan was reviewed and revised on 9/23/15 following this incident (9/17/15), it failed to include reference to one to one supervision continuous as noted in the facility report dated 9/17/15, even though a social service progress note on 9/23/15 read that (resident #3) has a 1:1 staff member due to behaviors. Likewise, the care plan failed to include any other direction to staff regarding the level of supervision the resident required, detailed information on her behavioral triggers or resident-specific behavioral interventions to prevent a recurrent incident. A progress note on 9/23/15 stated the resident's care plan was reviewed and revised and would continue for the next 90 days or PRN (as needed). A progress note on 10/5/15 stated that, resident does not have a sitter at night. While CNA was helping someone else, this resident opened the door to the nurse's station and went in and opened the refrigerator and was eating the pudding and applesauce used for giving meds and was drinking the milk out of the milk jug. She was very difficult to redirect. Requires constant monitoring. -Although the facility identified (again) the resident's need for constant monitoring, this progress note revealed the resident was not constantly monitored. A monthly note on 10/16/15 documented that she often needs 1:1 care to prevent her from hurting others. -But see the facility report for 9/17/15, following the second biting incident that documented the resident would be on 1:1 supervision continuous(ly) not that this level of supervision would be employed often. See also the progress note on 10/5/15 (see above) that the resident required constant monitoring. A progress note on 10/17/15, prior to the third biting incident read, resident was observed to be sitting next to other residents. Resident would be moved to another chair away from other residents but she would then get up and continue to try and touch the other residents. She would leave, go to her room, and come out of her room with her pants down and no underwear on. Resident would then be redirected back to her room, redressed and the resident would repeat behavior. -There was no documentation the resident was supervised as she went down the hallway to her room to undress but rather that she was supervised afterwards to be redressed. Moreover, the facility report and narrative above dated 10/17/15, indicated the resident was not adequately supervised 10/17/15 as she was able to leave her room unsupervised and enter resident #4's room. C. Staff interviews Staff interviews confirmed resident #3 was not adequately supervised to prevent resident harm. On 12/11/15 at 8:00 a.m. CNA #1 stated resident #3 had behaviors. -The CNA said that after the resident bit the first resident, the facility NHA tried to get the resident transferred to a different facility but no one would take her due to the behaviors. The CNA said that after that, the resident tried to bite a second resident, but they were not sure if the second resident was completely bit or not. The resident then bit a third resident three times. -The aide stated resident #3 could really ambulate and it was hard to watch her. The CNA stated they had to be careful where resident #3 sat because if she sat next to another individual she would try to lean over and bite. The CNA said an additional aide was brought back to the secured unit to assist in watching the resident,, and was told to not take her eyes off of her. CNA #1 confirmed that the aide brought in to assist in watching resident #3 was not there full time. -CNA #1 stated that at some point, on 10/17/15, the additional aide was distracted and was assisting another resident. The aide was not watching resident #3. The resident was able to move quickly down the hallway unsupervised to the room of the victim. The CNA said that resident #3 had an interest in that specific room for some unknown reason, and they found her down in the room, having bit the victim three times. The CNA stated The bites were ugly. The aide added that the resident #3 had locked her jaws so tightly on the other resident staff had to use a plastic lid from a cup to place into the resident's mouth to get it to open just enough to have the resident release the bite. -The aide stated that resident #3 had other behaviors, and it was hard to watch resident #3 on the secured unit with only two regular CNAs as the additional CNA brought on to assist was not full time. On 12/11/15 at 10:47 a.m. a licensed practical nurse (LPN #1) stated that resident #3 had been discharged , but had displayed biting and behaviors problems while a resident at the facility. -The LPN said that after the resident bit someone the first time, she believed they put the resident on a one to one supervision by adding another aide. The LPN confirmed that the additional aide brought into the secured unit to monitor resident #3 was not full time and they did not have additional staff to monitor the resident every shift. The LPN added that the nurse would also watch out for resident #3 if the other aides were busy. -LPN #1 said resident #3 bit a third resident which required antibiotics when the bitten area began to get red after a few days. The LPN stated that the aide watching (resident #3) must have not seen the resident go to a room and bite someone, and all staff knew resident #3 liked to pace the hall. On 12/11/15 at 2:15 p.m. the DON and nursing home administrator (NHA) stated the social service director had attempted to find new placement for resident #3, but had not been successful. -The NHA confirmed the facility was actively trying to place the resident at a different facility after the initial incident on 9/12/15. The NHA stated that the physician had added some anxiety medication to be used as needed, and believed that it had helped improve the behaviors of resident #3. The DON and NHA said that the resident was on one to one at the time of the incident with the third victim, and that the incident was unexpected. She just turned and bit the resident in the face. - The DON and NHA confirmed that after this incident they felt they could not keep other residents safe due to the resident's propensity to bite and her unpredictable behavior. The first two bites were in a short time and then it seemed better. And we thought it was better. There was no additional behavior. She just ran down the hall, went into a room, and it took two aides to get her to stop the bite. They said the resident was discharged to the ER after that. The NHA added we thought our interventions were moving positively up until the third bite. III. Resident #2 Resident #2, age [AGE] years, was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS completed on 11/20/15 noted that the resident had a BIMS of five, indicating severe cognitive impairment. The resident was documented as requiring supervision with one person assist for walking in the corridor and locomotion on and off the unit. The resident was also noted during the last assessment period as having verbal behavioral symptoms directed towards others for one to three days; rejection of care for one to three days; and other behavioral symptoms not directed toward others for one to three days. A. Behaviors 1. Knowledge of resident behaviors shortly after admission - Facility response A Transfer History and Physical on 8/19/15 documented that the resident was being transferred from another facility. The resident becomes agitated easily and sometimes is very difficult to redirect. The resident had a history of [REDACTED]. Review of the care plan for resident #2 revealed the facility developed plans to address the resident's aggressive behaviors as well as risk for elopement. The plan read in pertinent part: (1) Is at risk for elopement or wandering and resides on the secured memory unit. -The goal is for the resident to remain safe within the facility and have no unplanned exits from the facility. -Approaches included: calmly redirect resident away from doors when she is exit seeking; monitor resident's whereabouts frequently to ensure resident safety. This care plan was initiated on 9/2/15 and last revised on 11/23/15. However, see below; the last documented elopement attempt was on 12/1/15. (2) Has a behavior problem such as episodes of being verbally aggressive, refusing care and asking repetitive questions related to recent admission and dementia diagnosis. -The goal is for the resident to have fewer episodes of verbal aggression, refusing care, and/or repetitive questions. -Approaches included: administer medications as ordered. Observe/document for side effects and effectiveness; allow choices within individual's decision making abilities. This care plan was initiated on 8/25/15 and was last revised on 8/25/15. 2. Documentation of behaviors after admission - failures in facility response Documentation revealed the resident successfully eloped at least three times and several times was documented as yelling, angering, agitating residents and striking other residents and staff. A progress note on 10/2/15 reported that at 9:00 p.m. the resident attempted to leave the building via the back skilled hall exit. Wanderguard alarm alerted staff, and staff prevented resident from leaving. Resident agitated, attempts at 1:1 and redirection were minimally effective. Any attempts to help steer resident down hall was met with striking out with hands. Resident did not successfully physically hit anyone. An additional progress note on 10/2/15 stated that resident became combative and continued to yell and wake up other residents. Resident went through the double doors on the end of north hall and got out the back door. Staff had to guide resident back in the building. A progress note on 10/17/15 stated that the staff in the secured unit heard the wander guard alarm sounding from the back/north side of building. When we assessed area we noted this resident outside in the driveway walking around. The resident was redirected back inside. A progress note on 11/20/15 reported that the resident was transferred to the secured unit. A progress note on 11/21/15 noted that the resident had escalated behaviors. A progress note on 11/21/15 also stated that the resident was yelling repetitively and staff was unable to redirect or offer anything to distract the resident. Other resident becoming angry and agitated with resident. A progress note on 11/22/15 stated that resident was continuously yelling, unable to redirect, and upsetting other residents. A note on 11/28/15 that resident #2 was observed striking another resident (#1) on the legs with an open hand. One observer noted that resident #2 was attempting to comfort and calm the other resident (#1) who was kicking a chair. No abuse was suspected. A second observer stated that resident #2 was observed hitting the resident's leg with an open hand. No injury was noted to either resident, and the residents were separated. A progress note on 12/1/15 noted that the resident got out of the building and into the courtyard at approximately 10:30 p.m. The resident was taken back inside by staff. A progress note on 12/4/15 revealed that resident #2 was screaming for five minutes, and another resident approached resident #2 and threw water on her. The resident was upset and stood up with her hand reached out attempting to slap the other resident. Staff were noted as able to stop both residents without any further incident. A note on 12/6/15 revealed resident #2 was observed striking a resident on the right leg with an open hand. The second resident (#1) was observed to be kicking a chair. Resident #2 yelled at the other resident to stop kicking and threatened to hit the resident if they did not stop kicking the chair. The resident did not stop and resident #2 slapped the other resident (#1). The residents were separated. Care plan review revealed no evidence staff had attempted to understand the resident's elopement behavior in an attempt to anticipate it and address it proactively. The resident's supervision needs were not defined even after her multiple elopement attempts. Moreover, the resident's care plan failed no include interventions to prevent her distressing nd aggressive behaviors toward other residents which put resident #2 as well as other residents in the secure unit at risk for harm. B. Staff interviews Staff interviews revealed difficulty providing resident #2 and other residents with behaviors adequate supervision. CNA #1 (see interview date above) said resident #2 could get upset and would yell for extend periods of time until other residents got worked up. The aide explained that with the care the residents need in the secured unit, it could be hard to make sure residents with behaviors are properly watched to prevent further incidents. The aide said that they tried to focus on activities for the residents in the secured unit. The CNA added that some residents on the secured unit required two-person assistance with care needs which made it very hard to watch for behaviors at the same time. CNA #1 (stated that the secured unit currently had 17 residents and only the two aides, and that many of the current residents had behaviors with five having major behaviors. She stated they had additional help at times during resident #3's stay, but had not had additional help after resident #3 was discharged . LPN #1 (see interview date above) stated the behaviors exhibited by resident #2 could be distracting and require additional time. The LPN confirmed resident #2 was a quick independent ambulatory resident, and had hit some other people; however, the nurse did not feel these behaviors were especially aggressive. LPN #1 (see interview date above) said there were currently four or five other residents in the secured unit that had behaviors that required supervision. The nurse also stated that there were a number of residents on the secured unit that required two-person assistance for their care needs, making it difficult for the staff to watch out for behaviors. The DON (see interview date above) added that the behaviors of resident #2 had started to improve in the secure unit; however, now that the resident was allowed to spend time in the facility main dining room for lunch with their spouse, the resident's behaviors had stopped improving. CNA #2, interviewed on 12/11/15 at 12:20 p.m. confirmed that there were still residents in the secured unit with behaviors and some of these resident were very mobile.CNA #2 confirmed that resident #2 could be very difficult to monitor. The aide added that other residents in the secured unit required both of the assigned aides to provide for their activities of daily living; this made it difficult for the two aides and the nurse to watch out for and prevent all resident to resident behaviors.

Based on observations, interviews and record review the facility failed to ensure that four (#37, #52, #66 and #63) of seven residents received the assistance to improve or prevent the decline of normal bladder function. Specifically, the facility failed to ensure that each resident received the care and assistance with toileting to remain clean and dry, and maintain continence to the extent possible. These failures contributed to resident incontinence, observations of residents sitting in incontinence for extended periods, and compromised resident dignity. The findings include: A. Facility Expectations In pertinent part the "Nursing Rounds/Licensed Staff" policy (revised 9/11) stated: -"Nursing staff routinely conducts rounds." -"The routine resident check involves entering the resident's room ...to ensure safety and comfort of the resident; to assist in continuity of care; to identify change in condition." -"Check resident every 2 hours." -"Observe for privacy, dignity and safety. Observe grooming and dressing-hair combed (men and women), oral care and lack of odor." B. Resident Failures 1. Resident #37 a. Resident Status Resident #37, age 82, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 12/3/14 quarterly minimum data set (MDS) assessment revealed: -The resident had problems with long and short term memory. -The resident did not know the season; location of her room; staff names and faces; or that she was in a nursing home. -The resident was severely impaired for decision making. -The resident exhibited fluctuating signs and symptoms of [MEDICAL CONDITION] that included inattention and disorganized thinking. -The resident did not exhibit signs and symptoms of [MEDICAL CONDITION]; behaviors; or rejection of care during the MDS observation period. -The resident did exhibit persistent wandering during the MDS observation period. -The resident required limited assistance with bed mobility; transfers; walking in the room and in the corridor; locomotion off the unit; and eating. -The resident required extensive assistance with locomotion on the unit; dressing; and personal hygiene. -The resident was not on a toileting program and was frequently incontinent of bladder. The 1/8/13 incontinence care plan, last reviewed 12/11/14, stated the resident was incontinent related to medications; functional impairments like impaired cognition; and pain from [MEDICAL CONDITION]. The goal was for the resident to have episodes of incontinence managed in a way that maintained skin integrity, urinary tract health and resident dignity. The approaches included: -Encourage fluids. -Provide perineal care daily and as needed. -Observe for incontinence episodes at regular and frequent intervals and as needed. b. Observations On 2/25/15 a continuous observation of the resident from 8:54 a.m. until 11:33 a.m., revealed: -The resident remained seated at the dining room with the back of her chair against the wall. -The dining room table was pushed up against the arms of the resident's chair. -Resident #52 was seated opposite the resident at the dining room table. -At 9:07 a.m., the resident made an attempt to stand but was unable to rise fully due to her positioning at the table. The resident returned to a fully seated position and began running her hand across the table top. -At 9:27 a.m., the resident again attempted to stand. A wet area had formed on the lap area of the resident's gray sweat pants. The resident returned to a fully seated position and began moving a coffee cup around the top of the table. -At 9:36 a.m., the resident remained seated as described above with resident #52 seated opposite her at the table. The resident was knitting her fingers together and her legs were fidgeting. -At 10:18 a. m., staff was passing doughnuts. The resident continued to sit at the table as described above with resident #52 seated across from her. -At 11:18 a.m., the resident continued to remain seated at the table as described above with resident #52 seated across from her. The resident was pursing her lips; her hands were folded on her lap. The resident was tapping her left foot quickly up and down. A urine odor was present and drying moisture could be seen on the right side of the resident's pants. -At 11:20 a.m., the resident continued to sit at the table as described above. The resident was squeezing her hands together and fidgeting her legs. The drying wetness was visible on the resident's chair. -At 11:33 a.m., the resident again attempted to stand. The seat of her pants had a drying wet stain and urine odor was present. Registered Nurse (RN) #2 directed Certified Nurse Aide (CNA) #7 to help the resident. CNA #7 moved resident #52 away from the table then pulled the table away from the resident. The resident immediately stood up and exited the table area. -CNA #16, who was also working on the unit, then directed the resident to the toilet in the nearby shower room. c. Staff Interviews: On 2/25/15 at 11:36 a.m., an interview with RN #2 revealed: -The RN acknowledged the drying urine that was visible on the front, back and sides of the resident's pants. -The RN acknowledged that the resident had been seated at the dining room table from breakfast time until she was assisted to the toilet at 11:33 a.m. -The RN stated that the resident walked independently and at times would be continent. -The RN stated that CNA staff should check and change the resident every two hours, but that this did not occur. -The RN stated it was important to provide timely incontinence care to the resident to prevent skin breakdown and urinary tract infections. On 2/27/15 at 1:34 p.m., an interview with the Director of Nursing (DON) revealed: -The DON stated that it was her expectation that each resident requiring toileting assistance receive such assistance at least every two hours. -The observation of resident #37 sitting in her wet pants from just over two hours was described to the DON. -The DON stated that staff did not meet her expectation for toileting the resident. d. Record Review: A review of the 2/15, 1/15, and 12/14 "Nursing Weekly/Monthly Summary" revealed: -12/14 the resident was incontinent of bladder and needed assistance to the bathroom. -1/15 the resident was incontinent of bladder. -2/15 the resident was incontinent of bladder. The quarterly 12/11/14 "Evaluation for Bowel and Bladder Training" stated: -The resident was incontinent daily. -The resident was independent with fluid intake. -The resident was independent to one assist for "functional status assist." -The resident had cognitive impairment. -The plan for managing incontinence was to assist the resident to the bathroom every two hours. 2. Resident #52 a. Resident Status Resident #52, age 90, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 12/4/14 quarterly MDS revealed: -The resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 0/15. -The resident did not exhibit signs or symptoms of [MEDICAL CONDITION] or [MEDICAL CONDITION] during the MDS observation period. -The resident did not exhibit behaviors, rejection of care or wandering during the MDS observation period. -The resident required extensive assistance with bed mobility; transfers; locomotion on and off the unit; dressing; eating; personal hygiene; and toilet use. -The resident was not on a toileting program and was always incontinent of bladder. The 3/20/13 incontinence care plan (last reviewed on 6/5/14) stated the resident had concerns with incontinence related to functional factors such as impaired cognition. The goal was for the resident to have episodes of incontinence managed in a way that maintained skin integrity, urinary tract health and resident dignity. The approaches included: -Encourage fluids. -Provide perineal care daily and as needed. -Observe for incontinence episodes at regular and frequent intervals and as needed. b. Observations On 2/25/15 a continuous observation of the resident from 8:04 a.m. until 8:44 a.m., revealed the resident was seated in her wheelchair at the table in the dining room table in the multipurpose area of the secure unit. The resident had a red blanket tucked around her from her lap up to her shoulders. There were bits of egg-like food debris on her lap. On 2/25/15 the continuous observation of the resident resumed at 8:52 a.m. and continued until 1:13 p.m. The following was observed: -The resident remained seated in her wheelchair at the table in the multipurpose area with the red blanket tucked around her. The egg-like food debris remained on her lap. -At 9:03 a.m., the resident was seated in her wheelchair at the table with her eyes closed. -At 9:36 a.m., the resident continued to sit at the table with her eye closed. No staff had offered to assist the resident to toilet. -At 10:18 a.m., the resident continued to sit with her eyes closed at the dining room table. No staff had offered to assist the resident to the toilet. -At 10:41 a.m., the resident continued to sit with her eyes closed at the dining room table. No staff had offered to toilet the resident. -At 10:55 a.m., the resident continued to sit in her wheelchair at the dining room table. The resident was now moving and shifting around in her wheel chair with her eyes open. A slight urine odor was present. -At 11:03 a.m., the resident remained seated in her wheelchair at the table. The resident continued to fidget in her wheelchair and was now yelling, "I want to leave!" -CNA #16 asked the resident where she wanted to go and the resident responded, "I want to go home." -CNA #16 told the resident she could go home after lunch. -The CNA did not offer to toilet the resident and did not remove her from the common area to complete a check and change. -At 11:05 a.m., CNA #7 has assisted the resident to the nurse's station. The CNA was sitting in a chair attempting to converse with the resident. The CNA did not offer to toilet the resident. -At 11:08 a.m., the resident was back at the table in the common area. The resident continued to move around restlessly in her wheelchair. -At 11:12 a.m., the resident was wiggling around in the seat of her wheelchair as she remained seated at the table. -At 11:14 a. m., the resident was demanding to "go home." CNA #16 removed the resident from the table, wheeled her down to the end of the hall and then returned her to the table. The CNA did not assist the resident to her room or to the bathroom for incontinence care. - At 11:20 a.m., the resident was seated at the table, moving around in the seat of her wheelchair. As the resident shifted positions, urine odor was detected. The resident continued to verbalize a desire to leave. - At 11:36 a.m., the resident was wheeled back from the table so that another resident could exit the table for toileting assistance. The resident was then immediately placed back at the table. -At 11:59 a.m., the resident remained seated in her wheelchair at the table. No staff had offered to assist the resident with toileting and urine odor was detected. -At 12:03 p.m., the lunch cart arrived on the unit. The resident remained seated at the table. Staff began passing lunch trays. -At 1:04 p.m., the resident had been seated at the table throughout the noon meal. The resident was not assisted to toilet. -At 1:22 p.m., CNA #7 approached the resident to remove her from the table. The CNA stated she was going to provide toileting. -The resident was escorted to the shower room where there was a toilet with more space available for maneuvering. -CNAs #16 and #7 were now both present in the shower room. -There was a very strong urine odor present. -A request was made to observe the resident's incontinence brief (see results below). c. Staff Interviews On 2/25/15 at 1:22 p.m., an interview with CNAs #7 and #16 revealed: -CNA #7 acknowledged the resident's brief was wet with urine. -CNA #7 acknowledged the resident's pants were wet, but stated she felt that happened when the resident was transferred to the toilet and the resident began to urinate again. -CNA #7 acknowledged the brief emitted a potent, stale urine odor. -Neither CNA #7 nor CNA #16 could state when the resident was last toileted. On 2/27/15 at 1:34 p.m., an interview with the Director of Nursing (DON) revealed: -The DON stated that incontinent residents should be checked and changed every two hours. -The observations of the resident were related to the DON. -The DON stated that resident #52 going without toileting assistance for more than four hours did not meet her expectations. d. Record Review A review of the 1/15, 12/14, and 11/14 "Nursing Weekly/Monthly Summary" revealed: -11/14 the resident was incontinent of bladder. -12/14 the resident was incontinent of bladder and was on scheduled toileting program. -1/15 the resident was incontinent of bladder. The quarterly 9/2/14 "Evaluation for Bowel and Bladder Training" (which was the most current available in the chart) stated: -The resident was occasionally incontinent of bladder. -The resident needed assistance with fluid intake. -The resident's "functional status" required assistance of one to two staff. -The resident had cognitive impairment. -The resident was not a candidate for a bowel and bladder program due to her unsteady gait, decreased safety awareness and confusion. 3. Resident #66, age 85, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident Status: The annual MDS assessment dated [DATE] documented the resident was impaired, with short/ long term memory deficits. On the BIMS, the resident scored six of 15, indicating the resident's cognition was severely impaired. The resident required limited assistance of one staff member with all ADLs except eating, transfers, or walking - supervision only. The MDS revealed the resident was frequently incontinent of bladder and bowel. The resident was not on any toileting program. It was very important for the resident how she was dressed and what she was wearing. The care plan, updated 10/8/14, revealed the resident had communication problems, was hard of hearing, had memory problems and thinking disorders due to dementia. She had [DIAGNOSES REDACTED]. She required extensive assistance of one staff member with all ADLs. -The resident was on a diuretic ([MEDICATION NAME] 40 mg twice daily) that affects continence and she was occasionally incontinent of bladder and bowel. -The approaches listed were: "Establish planned toileting program and assist to toilet upon rising, before and after meals and before bed. Provide perineal care daily and as needed. Observe for complaints of burning, frequency, noting color, amount and odor of urine. Observe for incontinence episodes at regular and frequent intervals and as needed." b. Observation and interviews: During the medication pass on 2/25/15 at 7:40 a.m. a strong urine odor inside the resident's room was detected. The odor was all over the hallway which was leading to the open large dining room. LPN #3 verified resident #66's room had a pervasive urine odor, and the smell was noticeable all the way down the hall to the dining room. -The director of nursing (DON) was notified immediately. She verified the odor was very strong and directed the bath aide to give the resident a shower and change her clothes. Then she asked that the room be cleaned and mattress changed. The DON added that the expectation was for staff to check the residents every two hours per facility policy (see above). CNA #15, interviewed on 2/25/15 at 8:00 a.m., said that the resident's bed and pillows were soaked from the night shift. On 2/25/15 at approximately 11:45 a.m., the maintenance director verified the mattress had a foul odor and was disposed of; and a new mattress was placed on the resident's bed. 4. Resident #63 a. Resident status Resident #63, age 57, was admitted to the facility on [DATE], with a brief hospitalization s on 12/19/14, and readmission on 12/24/14. [DIAGNOSES REDACTED]. According to her most recent MDS assessment dated [DATE] her brief interview for mental status (BIMS) was 13 out of 15 which indicated that she was cognitively intact. She was noted as having no behaviors and needing two staff assistance with all activities of daily living (ADL) except eating with which she required one staff assistance. Her pain was identified as moderate and occurring frequently with scheduled and prn (as needed) medication being the only interventions. She was noted as frequently incontinent and had not been trialed on a toileting program. b. Record review A care plan dated 7/31/13 and updated on 11/6/14 noted the resident had incontinence related to functional factors and pain. Approaches included hand washing before and after care, observe for incontinence episodes at regular and frequent intervals, observe resident for worsening mental or functional status, check and change before and after meals, at bedtime and as needed. A care plan dated 7/31/13 and rewritten on 1/30/15 noted the resident had actual pressure ulcers. An update noted 11/20/14 revealed the resident was admitted with a stage II pressure ulcer to the coccyx. An update note 1/30/15 revealed the resident had a current stage III pressure ulcer to the coccyx. Approaches included providing incontinent care after each incontinent episode. c. Observations On 2/25/15 at 1:31 p.m., the resident was heard crying. She was observed in her wheelchair in her room. On 2/25/15 at 1:36 p.m. two certified nurse aides (CNAs) #8 and #15 went to the resident's room stating they could help her now. They confirmed the resident had been up since lunch. After using a mechanical lift the CNAs started to perform incontinent care; however, the registered nurse (RN) #10 entered the room and instructed the CNAs to leave the resident and assist her with a different resident. After the nurse left the room the CNAs checked the resident's brief, stated that it was dry, situated the resident then left the room. On 2/2715 at 8:36 a.m. there was a strong odor of urine and bowel in the resident's room. The resident was in her bed crying out that she wanted to get up. On 2/27/15 at 8:59 a.m. two CNAs gave the resident care in her room. The resident was asked for permission to observe and requested she be cleaned first then talk. The resident was heavily soiled and her linens and clothes were changed after being cleaned. On 2/27/15 at 11:07 a.m. the resident was heard yelling from her room, her call light was not on. The resident was mostly unintelligible but could be heard from the nursing station. On 2/27/15 at 11:10 a.m. RN #3 entered with CNA #15 to change the resident's dressing. The resident consented to observation. The resident was heavily soiled with urine and was crying. d. Interviews On 2/27/15 at 8:36 a.m. CNA #13 was interviewed. The CNA stated the resident's linen was wet, and had not been changed since they got there at seven. The CNA stated that she had told her aides, but they were very busy and had not gotten to it. The CNA stated that this had been a common problem for their staff. On 2/27/15 at 11:30 a.m. after the observation noted above, the resident was interviewed. She stated that her sore hurt when she was wet and sitting up. She stated that it stung and after being changed it would still sting for a while then feel better.

Based on observations, interviews and record review, the facility failed to provide and deploy sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, the facility failed to ensure that sufficient nursing staff was in place to meet resident needs related to dignity, choices, pain management, grooming and hygiene, pressure ulcers toileting, range of motion services, accident prevention, nutrition and hydration. As a result, residents suffered pain, incontinence, pressure sores, dehydration, weight loss, range of motion decline, and falls. In interviews, residents expressed feeling painful, unclean and uncomfortable. Many of the facility residents were unable to speak for themselves, and some residents and family members requested anonymity for fear of retaliation (cross reference F165 - right to file grievances without fear of reprisal). The lack of sufficient nursing staff contributed to negative resident outcomes and had the potential to impact each resident in the facility. The findings include: Cross reference F221 - Physical restraints for facility failure to assess and ensure resident #37 was free from restraints. Cross reference F241 - Dignity for staff failures to ensure residents had dignified treatment related to toileting for resident #37, manner of dress for resident #21, permission to enter resident #53's room, and dining dignity for resident #20. Cross reference F242 - Choices for staff failures related to wake times for residents #31 and #52, bathing frequency for resident #53, and bed positioning for resident #63. Cross reference F244 - Grievances of the resident group related to failure to timely respond to resident council concerns related to delayed call light response. Cross reference F282 - Qualified staff related to facility failures to utilize qualified nursing staff for wound assessment/management and management of the restorative nursing program. Cross reference F309 - Highest practicable quality of care and services related to facility failures to assess, intervene and manage resident pain for residents #63, #84 and #29. Cross reference F312 - Assistance to maintain activities of daily living (ADLs) for failures to assist residents with wheelchair positioning for resident #14, eating and drinking for resident #20, bathing for resident #53; oral care for resident #50; and grooming and personal hygiene for residents #89 and #37. Cross reference F314 - Pressure ulcers for facility failures related to preventing development of new, and/or worsening of existing, pressure ulcers for residents #63, #20, and #59. Cross reference F315 - Maintain or restore bladder function and prevent urinary tract infections related to failure to provide timely toileting assistance for residents #37, #52, #66 and #63. Cross reference F318 - Treatment and services for limited range of motion for facility failure to provide range of motion and/or splint services to residents #20, #63, #49 and #64 who had contractures. Cross reference to F323 - Accident-free environment for facility failures to investigate, assess and implement strategies to prevent accidents for residents #51, #57 and #68; and for resident areas throughout the building. Cross reference to F325 - Nutrition for facility failures related to significant unplanned weight-loss for resident #49. Cross reference to F327 - Hydration for facility failures to provide adequate hydration for resident #63. A. Resident Population The Census and Conditions of Residents provided by the facility on 2/23/15 revealed: -The census was 66 residents. -60 residents required staff assistance with bathing; 31 residents were totally dependent on staff for bathing. -60 residents required staff assistance with dressing; 31 residents were totally dependent on staff for dressing. -47 residents required staff assistance with transfers; 16 residents were totally dependent on staff for transfers. -56 residents required staff assistance with toileting; 43 residents were dependent on staff for toilet use. -18 residents required staff assistance with eating; 11 residents were dependent on staff for eating. -Ten residents had contractures. -42 residents were either bedfast or in chair most of the time. -37 residents had dementia diagnoses. -34 residents had behavioral symptoms and 34 residents had a behavior management program. -41 residents were on a pain management program. -Six residents had significant unplanned weight loss/gain. B. Planned Staffing Patterns A review of 2/15 and 1/15 nurse schedules for the building revealed: -Four nurses were scheduled during the day. -Three nurses were scheduled during the evening. -Two nurses were scheduled over night. -The 2/15 nurse schedule showed there were two vacant nurse positions on the day shift and one vacant nurse position on the night shift. -The 1/15 nurse schedule showed there were two vacant nurse positions on the day shift. A review of the 2/15 and 1/15 certified nurse aide (CNA) schedule showed the facility planned: -Six CNAs, one bath aide, one restorative aide, and two part-time CNA/activity assistants on day shift. -Six CNAs for the evening shift. -Five CNAs for the night shift. -The 2/15 CNA schedule showed there was one vacant full time CNA position on days; one vacant part time position on evenings, and three vacant positions on the night shift. A review of the planned and actual nurse staffing for 2/15 and 1/15 revealed that the facility planned 1.2 hours per patient daily of licensed nurse care and typically provided 1.1 hours of licensed nurse care. Although planned and actual nurse aide staffing was requested from 12/1/14 to 2/22/15, the facility only provided nurse aide staffing from 12/1/15 to 1/15/15. Review of the planned and actual staffing revealed: -The building typically planned 1.88 hours per patient per day of nurse aide staffing. -On 16 days the facility did not meet planned nurse aide staffing. C. Observation On 2/24/15 at 7:50 p.m., an observation of the secure unit revealed: -No staff was visible on the secure unit as they were all in resident rooms. -Three residents (#31, #36, and #37) were wandering the hall. -Resident #36 began to lose balance and staggered backwards toward the wall. -A visitor to the unit, who was in the immediate vicinity, caught resident #36, and braced the resident against the wall preventing the resident's fall. -The visitor had to call for help as no staff was present. -RN #8 responded to the call and assisted the resident back to a fully standing position and then into a chair. -The RN thanked the visitor for catching the resident and preventing possible injury from a fall. D. Resident Interviews Seven residents, identified by the facility and by cognitive assessment as interviewable, stated during interviews that the facility did not provide sufficient nursing staffing to meet residents' care and service needs in a timely manner. Resident interviews, conducted throughout the facility, revealed the following: On 2/23/15 at 3:02 p.m., resident #27 was interviewed, and was asked if the facility had enough staff to ensure residents received the care they needed without having to wait a long time for assistance. The resident stated, "This is the best question yet. They don't have enough help. That's why we have a call system. If I need to go to the bathroom, I ring the bell. They don't come right away because (there is) not enough help. This is the main complaint that I have. It is worse in the evening time. I have to wait 45 minutes before they come help me. There is not enough help." On 2/23/15 at 3:38 p.m., resident #53 was interviewed. The resident said the facility did not have enough staff to ensure residents received the care they need without having to wait a long time. The resident explained waits for help were worse at shift change. The resident stated that the staff was always behind. On 2/23/15 at 4:06 p.m., resident #13 stated that he waited a while for assistance because the facility did not have the staff to assist in a timelier manner. On 2/23/15 at 4:18 p.m., resident #1 stated she required a mechanical lift for transfers, but often was transferred by one staff member instead of two. On 2/23/15 at 4:27 p.m., resident #50 said waits for assistance were usually 30 minutes and as much as two hours. The resident stated her unit had one CNA for 16 residents. The resident stated the "float" CNA often did not come to her unit resulting in her being transferred with a mechanical lift by one CNA instead of two CNAs. On 2/23/15 at 4:44 p.m., resident #84 said, "Go look at their shift schedule. There is only one nurse on staff at night after 6 p.m." The resident stated that there continued to be 30 residents on the unit after 6 p.m., so the need for two nurses remained. On 2/24/15 at 11:38 a.m., resident #57 stated, "I think they are in trouble as far as staff. When you go in the dining room there are not enough people to bring the food (CNAs assisted with meal service and resident assistance with dining). It is 30 minutes at least before you even get served. It takes a while to get help with the call light." E. Family Interviews Three of three family members interviewed in stage one of the survey process expressed concerns with facility staffing. On 2/23/15 at 12:31 p.m., an interview with a family member for resident #89 revealed: -The family member visited regularly. -The family member stated that the facility did not have enough staff to ensure that residents received the care and assistance they needed without having to wait a long time. -The family member stated there was "Not enough staff, for sure." -The family member stated, "Call lights beep, take forever to get answered." On 2/24/15 at 10:00 a.m., an interview with a family member for resident #25 revealed the facility did not have enough staff to ensure that residents get the care and assistance they need without having to wait a long time. On 2/24/15 at 11:09 a.m., an interview with a family member requesting anonymity revealed: -The family member stated there was not enough staff to assist residents with meals because staff had to "hop around" from resident to resident. -The family member stated s/he was not sure her/his family member received scheduled bathing because the resident often had oily hair. -The family member stated that s/he knew staff rushed with residents because her/his loved one had shoes on the wrong feet and clothes on backwards. -The family member stated the facility was so short staffed in the summer residents received only sponge baths. -The family member stated that resident wheelchairs were never cleaned because there was not enough staff to provide that service on the night shift. On 2/24/15 at 11:43 a.m., a family member, who requested anonymity for fear of retaliation, stated: -The facility did not have enough staff to ensure residents received the care and assistance they needed without having to wait a long time. -The family member stated the direct care staff was good, but that the facility was "incredibly understaffed." -The family member stated s/he once observed a CNA feeding 12 to 13 residents. F. Staff Interviews On 2/23/15 at 10:09 a.m., an interview with registered nurse (RN) #5 revealed: -The North unit had approximately 34 residents. -Two nurses staffed the day shift and one nurse was on the unit after 6:00 p.m. -There were two dedicated CNAs for the unit and one CNA that floated between the North and South units. -There was one bath aide shared between all units during the week. On 2/23/15 at 10:23 a.m., an interview with RN #2 revealed: -The RN had 16 residents on the secure unit. -The RN stated she worked with one CNA from 6:00 a.m. until 8:00 a.m., when the CNA/activity assistant arrived. -The RN stated that the CNA/activity assistant was "off today." On 2/23/15 at 10:31 a.m., an interview with RN #3 revealed: -The RN was the only nurse for 16 residents on the South unit. -The RN had one CNA to help her care for the residents. -The RN stated that the third CNA on the North unit was a "floater" that did come and provide some assistance on her unit. On 2/24/15 at 1:35 p.m., an interview with a staff member requesting anonymity for concerns of retaliation revealed: -The staff stated that the staffing in the building was "terrible." -The staff stated that there was not enough staff to meet resident needs because the building administration did not account for the acuity of the residents being served. -The staff member stated that two CNAs were not enough to meet the needs of 34 to 36 residents. On 2/24/15 at 7:31 p.m., an interview with RN #9 revealed: -The RN stated she currently had 17 residents to whom she was assigned nursing care. -The RN stated at 10:00 p.m., she took over nursing duties for the 16 residents on the secure unit as well. -The RN stated that one CNA was assigned to South with a CNA that floated over from North to help. -The RN stated that there were several residents that were extensive to total care with six residents that required mechanical lifts for transfer. -The RN stated that she often had to help the CNA complete the transfers. -The RN stated that from 10:00 p.m., until 6:00 a.m., the secure unit was staffed with one CNA. On 2/24/15 at 7:38 p.m., an interview with RN #4 revealed: -The RN stated she was the only nurse on duty for the 36 residents on the North unit from 6:00 p.m., until 6:00 a.m. -The RN stated she had two CNAs assigned exclusively to the North unit and one CNA that she shared with the South unit. -The RN stated she had eight residents on her unit that were "total care" and that she believed there were six residents on the South unit that were total care. -The RN stated the building did not have residents who were independent for all cares. On 2/24/15 at 7:44 p.m., an interview with RN #8 revealed: -The RN left the unit at 10:00 p.m., at which time the South unit nurse was responsible for the secure unit and South unit. -The RN had two CNAs until 8:00 p.m., and one CNA from 8:00 p.m., until 10:00 p.m. -The RN stated that they worked to have as many residents in bed by 8:00 p.m. as possible. On 2/25/15 at 9:17 a.m., an interview with a staff member requesting anonymity for concerns of retaliation revealed: -The staff member stated that the building was "extremely understaffed." -The staff member stated that the understaffing resulted in the compromise of resident safety because residents that used mechanical lifts were transferred by one, not two staff members. -The staff member stated that night nursing did not have time to do rounds with residents because there were so few of them that they were wholly occupied with resident call lights. -The staff member stated that s/he brought these concerns to building leadership but that "nothing had been done." On 2/26/15 at 4:09 a.m., an interview with RN #9 revealed: -The RN stated that she was the only nurse for the south unit and secure from 10:00 p.m., until 6:00 a.m. and that was the usual schedule for the building. -The RN stated there were two nurses in the buildings on the overnight shift. -The RN stated that if one unit had two emergencies, which she stated was known to have happened, the other nurse left her unit to assist. -The RN stated that if there were more than two or more urgent situations, then they would have to prioritize who received assistance. -The RN stated that the CNA on the secure unit had a cordless phone that she could use to call for help if there was an urgent/emergency situation on the unit. -The RN looked at the telephone cradle and then stated that the CNA was not currently carrying the cordless phone. On 2/26/15 at 5:10 a.m., an interview with CNA #21 revealed: -The CNA usually worked the night shift. -The CNA had not received any training on staff burn out but thought such training would be helpful. -The CNA was as needed (PRN) but often worked more than full time. -The CNA stated the night shift always seemed to be one or two people short. -The CNA worked occasionally on the secure unit, but received no special training for that population. On 2/26/15 at 5:18 a.m., an interview with CNA #2 revealed: -The CNA stated she had 17 residents to care for on her shift. -The CNA stated she could hear the call lights in both units. -The CNA stated that if there was an emergency, the staff would use their own cell phones to text each other, or they would hit the emergency call light and if it sounded for three minutes they would assume the other CNA needed help. On 2/27/15 at 9:06 a.m., an interview with a staff member requesting anonymity revealed: -The staff member stated that the facility was extremely understaffed. -The staff member stated that s/he had been working double shifts so that the facility could provide staffing coverage. -The staff member stated s/he recently worked alone for more than 30 residents because the facility was unable to find someone to fill for a vacant position. -The staff expressed frustration at not being able to meet the needs of residents because of low staffing. -The staff stated that resident #20 needed to be turned every two hours but was turned every five hours because there was so much work. On the afternoon 2/27/15, an interview with the director of nursing (DON) revealed that there should be two staff for all mechanical lifts per facility policy. On 2/27/15 at 4:24 p.m., an interview with the nursing home administrator (NHA), DON, and assistant director of nursing (ADON) revealed: -The NHA stated that the building staffing was good and was on par with any in the industry. -The NHA stated the building nursing department staffing rate was 3.1 hours per patient per day. -The NHA did not identify a need to staff to the acuity of the patients in the building. -The NHA stated the facility had a bath aide five days a week in addition to the CNAs assigned to work the floor. -The DON stated that the bath aide was to complete 16 baths or showers on her shift. -The DON stated that in addition to regular patient cares, each floor CNA on the day and evening shift was responsible for completing two baths.

Based on observations, record review, and resident/staff interviews, the facility failed to provide the care and services necessary to maintain the highest practicable physical well-being, for three of three residents (#63, #84, and #29). Specifically, the facility failed to ensure pain was assessed and managed for residents #63, #84, and #29. The facility failures contributed to resident #63 experiencing severe pain that caused her to cry, call out and sob per observation. The resident's pain, per resident and staff interview, increased in intensity during January and February 2015 without appropriate facility response to alleviate her pain. Additionally, resident #84 experienced "significant pain" when he did not receive regularly scheduled pain medications on 2/9 and 2/10/15 because the facility ran out of his pain medications; and resident #29 experienced back and abdominal pain "all the time." The findings include: -Cross reference F314: Resident #63 experienced pain from pressure ulcers, which the facility failed to prevent or treat appropriately. -Cross reference F318: Resident #63 experienced pain from lack of range of motion. 1. Facility Policy: a. According to the "Pain Management Overview," policy provided by the facility, with the last revision date of August 2012: "The facility recognizes the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to an impaired quality of life. The facility will evaluate and identify residents experiencing pain; evaluate the existing pain and the cause(s); determine the type and severity of the pain; and develop a Care Plan for pain management. The Care Plan is implemented and continually evaluated for its effectiveness; The Staff monitors and documents the resident's response to pain management interventions. -Pain screening is conducted upon admission using the Nursing Admission Assessment (Briggs). It is also conducted monthly using the Monthly Summary (Briggs), then quarterly, and annually thereafter using the Pain Evaluation Form. Residents who experience a change in condition or have a suspected new onset of pain are evaluated for pain. Residents are also evaluated for pain regularly by inquiring if they have pain and observation of the resident for signs and symptoms of pain. -The goal of the Pain Management Program is that pain is identified and treated effectively and consistently. Steps for Pain Management First Step: Evaluation for the Presence of Pain -Each time you complete the pain-related items on the Nursing Admission Assessment (Briggs) and the Monthly Summary (Briggs) you are screening for pain. Additionally, each time you complete the MDS (upon admission, quarterly, annually and with a significant change assessment) you will be screening for pain by looking for signs that a resident may be experiencing pain on an ongoing basis. Best Practice: All staff should inquire if resident is comfortable or uncomfortable during each interaction. Observe for any signs or symptoms of pain or discomfort. Second Step: In Depth Evaluation of Pain -For those residents who screen positive on the Nursing Admission Assessment (Briggs) the Monthly Summary (Briggs), or 'trigger' on the MDS, conduct an in-depth evaluation of their pain, including such things as the intensity and characteristics of pain, and the effectiveness of prior treatments. You also have to do an in-depth evaluation any time the resident has a new complaint of pain or when you suspect pain may be present. Third Step: Develop an Individualized Care Plan and Update the RCS Assignment Sheet/ Care Kardex (if appropriate) -Develop an Individualized Plan of Care for the resident related to their signs and symptoms of their pain. Remember that pain is whatever the resident states that it is. Interventions should be geared toward approaches that help to control their level of pain, whether it is by managing by pain medications or other approaches. Fourth Step: Putting the Plan into Action -To be successful your team must be consistent; everyone must provide the same type of care to that resident everyday, and be proactive to make sure that the resident achieves relief and remains free from pain. Monitoring the resident and communicating with each and every team member regarding the pain management for your identified residents is crucial. Fifth Step: Re-evaluate on a Regular Basis You need to re-evaluate the resident on a regular basis. This will be done each lime you administer a pain medication to the resident, evaluating the effectiveness of the medication and making changes if the medication or approach is not effective." b. According to the "Pain management start audit" policy, provided by the facility, with the last revision date of February 2010: "Explanation of tasks -The purpose of this Quick Start or Audit is to assist the facility to ensure that the program components are in place for the Pain Management Program. This quick start can also be used as an audit to ensure the program is being sustained within the facility. STEP 1 Nursing management will review the Systems material. DON arranges a meeting with nursing management and IDT (interdisciplinary team) to review the program material. To be included in the meeting: ·DON/designee ·Unit Manager/Charge Nurse ·RDMD or MDS Coordinator ·Restorative Lead/Representative ·Resident Care Specialists ·Activities/Social Services ·Rehab staff member STEP 2 Schedule an in-service on the Pain Management system for licensed Nurses, Resident Care Specialists, and the IDT and conduct the in-service. -After reviewing the program material, schedule a time to conduct the in-service. --It is recommended to hold an in-service on each shift and post at least 48 hours in advance. --Make sure the in-service is entered into the Training Tracking Database. --Obtain a list of all LNs and IDT members and check off as each attends. --If agency/contract staff is in the facility, be sure to review the Pain Management Program and expectations at facility orientation. STEP 3 Crosscheck the above results with current resident listing on an indentified Pain Management Program. -Put together two person teams. The number of teams depends on the size of the facility. As a guide, consider 30-40 residents per team. -Conduct an audit of charts of all residents identified to ensure all components are in place for compliance. -Crosscheck the above results with current resident listing on an identified Pain Management Program. STEP 4 Complete a follow-up of resident identified with pain. -Verify current MD orders for pain medications. -Ensure care plans are current, individualized, and appropriate. -Ensure RCS Assignment Sheets/Care Kardexes are updated as appropriate. -Keep all sheets together as part of the QA&A process and to ensure that each resident has been entirely completed. -Use the resident roster and check off/highlight as each resident is completed. STEP 5 -The IDT reviews residents on a daily basis with new onset of pain. STEP 6 -Set up a listing of all residents identified for the Pain Management Program. STEP 7 Conduct a Care Management Risk Review Meeting for residents identified with a Pain Management Program. STEP 8 During the review; ensure that each resident has all compliance components in place and that the medical record is reviewed. Review each resident's status and medical record against the pain management listing of residents. This process is followed for each resident and at each meeting until all components are in place and compliance. STEP 9 Document the results of the meeting in the Nurses Notes. Step 10 Bring to QA&A At least monthly, this information is reported to the QA&A team at the facility level." c. According to the "Pain Management' Practice Guidelines," provided by the facility, and last revised on August 2012: "Practice Guidelines 1. Upon admission, residents will be assessed for pain by using the Nursing Admission Assessment form 2. Residents will be screened for pain by using the Monthly Summary (Briggs) and the Pain Evaluation Forms quarterly, annually and with a significant change and/or new onset of pain. Also review the RADAR Report (an internal report) to identify residents at risk. a. Pain intensity and pain relief will be evaluated and re-evaluated at regular intervals. b. These evaluations will be used by the IDT (interdisciplinary team) to decide the appropriate therapeutic intervention, which may include pharmacological and non-pharmacological techniques. 3. Additionally, any resident report of inadequate pain control or identified with a new onset of pain, displays new signs or symptoms of pain, or identified through the RAI process or otherwise will have a full evaluation of the pain conducted using the Pain Evaluation Form. 4. Following the pain evaluation, notify the physician of the findings and document on the Change of Condition SBAR form (Briggs) Implement new orders as received. 5. Each resident identified for pain will have a Pain Management Care Plan. The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan should include both pharmacological and non-pharmacological pain management interventions. RCS Assignment sheet/ Care Kardex updated if appropriate. 6. The Licensed Nurse will implement a Medication Administration Record (MAR) for documentation of pain, medication, interventions and outcomes for all pain medication. 7. The Licensed Nurse will communicate any new onset or change of resident pain or change in resident pain through the 24 Hour Report process. 8. The IDT will discuss the new onset of pain or change in resident pain at the daily stand-up meeting and the IDT team conference. 9. The Pain Management Care Plan with interventions will be updated as indicated and discussed at the IDT stand up meetings as needed. 10. The staff will implement the Care Plan, monitor the resident, and administer therapeutic interventions for pain, if ordered. 11. The licensed nurse when administering scheduled or routine pain medications will record the drug administration and the following information on the MAR. -Pain level using the Wong-Baker FACES 0-10 scale -Administration of the routine pain medication. -Effectiveness of the routine pain medication. Note: Effectiveness of routinely scheduled pain medications may be documented on the back of the MAR or a brief note may be written each day in the nurses' notes. If the resident is case managed or receiving skilled services, the note can be written on the Nursing Daily Skilled Summary. 12. The Licensed Nurse, when administering PRN pain medications, will record the drug administration and the following on the MAR: ·Pain level using the Wong-Baker FACES (Trademark) 0-10 rating scale; ·Pharmacological interventions attempted; ·Non-pharmacological interventions attempted; ·Follow-up observations post intervention to determine the effectiveness of PRN pain interventions. If resident is asleep or resting, document as an observation. 13. At any time through the process of Pain Management, the IDT may conduct an At-Risk Review Meeting on the resident, in conjunction with other Risk areas reviewed. IDT referral to Rehab as needed. 14. If areas for improvement are identified, the Pain Management Program will be reviewed and discussed at the monthly Quality Assurance & Performance Improvement (QAPI) meeting." 2. Resident #63 a. Resident status Resident #63, age 57, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her most recent minimum data set (MDS) assessment dated [DATE], her brief interview for mental status (BIMS) was 13 out of 15, which indicated she was cognitively intact. She was noted as having no behaviors and needing two staff members assistance with all activities of daily living (ADLs), except eating with which she required one staff member's assistance. Her pain was identified as moderate and occurring frequently with scheduled and prn (as needed) medication being the only interventions. b. Record review A care plan, dated 7/31/13 and last reviewed 2/6/14, noted the resident had actual pain related to a recent fall, skin ulcer, joint pain, fracture and contracture, muscle spasms and [MEDICAL CONDITION]. Approaches included positioning, assistive devices, an exercise program/ stretching exercises, relaxation, administration of [MEDICATION NAME] as ordered, implementation of physician's orders [REDACTED]. Pain Evaluations: A pain evaluation dated 11/20/14 revealed the resident had a new onset of pain with pain in the joints and back. The resident was noted as having no pain present during the evaluation. The areas for pain interview, what relieved pain, description of pain, timing and contributing factors, manner of expressing pain and associated symptoms, whether pain interfered with any of the following, and interventions, were not completed. The assessment was documented by registered nurse (RN) #10. A pain evaluation dated 12/24/14 (after the resident was readmitted from the hospital) indicated the resident did not receive scheduled pain medication, but did receive prn pain medication. The pain interview indicated the resident had pain in the past five days frequently, which made it hard to sleep and limited her day to day activities. The location of pain was noted as her joints and bones of both lower extremities, with the potential cause being immobility and contracture. Interventions identified as relieving the pain were rest, massage, positioning, meditation, relaxation. The resident's manner of expressing pain was noted as verbalization, grimacing, groaning, frowning and clenching of jaw. Physician Orders: Review of the February computerized physician order [REDACTED]. -[MEDICATION NAME]/[MEDICATION NAME] (pain medication) 5mg/325mg. One tablet by mouth (PO) Q4hr (every four hours) prn for pain (start date 12/31/14) -[MEDICATION NAME] 25 mcg/hr patch 72 hour. One patch [MEDICATION NAME], remove old patch at 8:00 p.m. apply new patch at 8:00 p.m. every 72 hours, rotate sites (Start date 1/6/15) -Apply Biofreeze (over the counter topical pain cream/spray) BID (twice daily) to bil (bilateral) knees and feet BID 0800 (8:00 a.m.) 2000 (8:00 p.m.) (Start date 1/6/15) - Pain scale assessment rate 1-10 assess and rate pain Q (every) shift (start date 12/31/14) -Apply warm moist heat pack(s) QD (every day) prn: Apply heat or ice to left shoulder QD PRN for comfort (Start date 8/2/13) -Apply sling on in AM (morning) and off at HS (hour of sleep): Apply sling to left arm for comfort (Start date 8/2/13) -Nudexta 20mg (given for uncontrollable crying) BID Medication Administration Records (MARs): Review of the January 2015 MAR revealed the resident received prn [MEDICATION NAME]/[MEDICATION NAME] 18 times in 31 days; however, the prn pain medication administration record revealed the resident had only received 12 doses of prn pain medication in 31 days. When documented the result was noted as effective with a pain rating of 0; however, the medication was not consistently documented and the prn pain medication administration record had conflicting effectiveness from the nurse's medication notes. Review of the February 2015 MAR revealed the resident received prn [MEDICATION NAME]/[MEDICATION NAME] 29 times in 26 days; however, the prn pain medication administration record revealed the resident had received the medication 36 times in 26 days. When documented the result was noted as effective with a pain rating of 0 until 2/24/15-2/26/15 when five administrations were noted as not relieving pain; however, the medication was not consistently documented and the prn pain medication administration record had conflicting effectiveness from the nurse's medication notes. Review of MARs for the previous three months revealed the resident was never noted as receiving warm/moist heat packs. Review of the MARs for the previous three months revealed the resident was noted as receiving a sling for comfort as ordered each shift (see observations below of no sling being present and interviews with nursing staff regarding no sling or brace being present). physician progress notes [REDACTED]. Review of physician's progress notes and telephone orders revealed the following: -A physician's progress note dated 9/10/14 documented, "She hurts if she stays up in her WC (wheelchair) more than a couple hours usually." -The resident was receiving [MEDICATION NAME] 75mcg every 72 hours prior to 12/10/14. A physician's progress note dated 12/10/14 detailed, "Decrease [MEDICATION NAME] to 50mcg. Monitor pain and adjust med prn. treatment of [REDACTED]." -A physician's progress note dated 1/16/15 read, "Chronic pain due to multiple joints/muscle contracture and OA ([MEDICAL CONDITION]). Cont (continue) current meds, [MEDICATION NAME], decrease [MEDICATION NAME] to 25mcg and replace [MEDICATION NAME] gel with biofreeze cream, she denied pain today. Monitor pain and adjust med prn. treatment of [REDACTED]." -A physician's progress note dated 1/16/15 only noted the resident's pain in reference to musculoskeletal exam noting, "She has bilateral knee contractures with pain w/ attempted ROM (range of motion) testing. Upper extremities have adequate ROM w/o (without) pain." The physician's progress notes made no reference to the resident's increased complaints of pain. Nursing Notes: A nursing note dated 2/25/15 for the day shift (no time of entry noted) read: 1300 (1:00 p.m.) c/o (complaint of) pain to BLE (bilateral lower extremities). Medicated at 0800 (8:00 a.m.) 1200 (12:00 p.m.) with some relief. Crying out loudly and yelling loudly to be laid down directly after lunch. Calm when staff enters room but will then start to cry out again to be laid down, "I hurt!" although medicated before. Once in bed resident will remain calm and quiet. Wound care done, is to see wound doctor on Friday. Does not c/o pain during wound care. Excoriated area healing c+a (unknown). Resp (respirations) even and unlabored. BS (+) x4. Abd (abdomen) soft and nontender. Repositioned frequently while in bed." (See observation below of same timeframe.) Review of nursing notes from 11/14-2/15 revealed the resident had increased reports of pain including pain to her coccyx and wound. There was no documentation indicating the resident's increased complaints of pain were reported to the physician. Review of the MAR revealed pain ratings assessed every shift were from zero to six until 2/13/15, when they increased to rating of six to ten on average. c. Observations On 2/23/15 at 5:16 p.m., resident #63 was observed in the dining room. The resident had a contorted expression with her jaw clenched and her eyes closed. The resident was crying loudly, and sobbing. The resident was approached for an interview. The resident stated that her left leg hurt. Numerous residents were in the area and staff members were passing food. On 2/23/15 at 5:17 p.m., the resident was approached by the licensed practical nurse (LPN) #2. The LPN stated that they had the situation under control and that they would take the resident to her room and use some Biofreeze (a topical over the counter pain spray) on the leg. (Biofreeze was ordered twice daily at 8:00 a.m. and 8:00 p.m.-see orders above.) On 2/25/15 at 1:31 p.m., the resident was heard crying. Her sobbing could be heard by the doors to the special care unit. The resident was in her room in her wheel chair. The resident stated she was in pain. The resident's face was contorted again with a clenched jaw. On 2/25/15 at 1:32 p.m., the registered nurse (RN) #10 was approached at the medication cart and was in ear shot of the resident who was still crying. When asked if she was aware the resident was in pain, the RN stated the resident had something at 11:00 a.m. although later review of the medical record revealed no documentation for pharmacological or non pharmacological pain treatment at 11:00 a.m. -The RN did not offer to assess the resident and did not offer to find something else to help the resident's pain. The nurse returned to her activity without further comment. On 2/25/15 at 1:33 p.m., two certified nurse aides (CNAs) #8 and #15 went to the resident's room stating that they could help the resident now. The two CNAs prepared the resident for a two person mechanical lift and tried to calm the resident by speaking to her. The resident told the two CNAs that she was in pain and needed to lie down because of her leg. The resident was sweating heavily, she was grimacing, and her hands were clenched in fists. On 2/25/15 at 1:35 p.m., RN #10 came into the room, looked at the CNAs, did not address or look at the resident, stated she had to 'give her something,' and then left the room. On 2/25/15 at 1:36 p.m., the resident was lifted to her bed and immediately stopped crying. Her body and face relaxed and she became conversational with the CNAs and said, "Thank you. That is much better." On 2/25/15 at 1:39 p.m., RN #10 entered the resident's room as the CNAs were preparing to do incontinent care on the resident. The CNAs stated that they were almost finished; however, the nurse instructed them to remove the mechanical lift sling and leave the resident and come back later because she needed assistance in another room. Both CNAs stated that they would be finished momentarily with the resident. The nurse left the room without further comment or checking on the resident. The CNAs completed their incontinent care and situated the resident prior to leaving the room. The resident was then interviewed (see interview below). On 2/25/15 at 3:10 p.m., the resident was observed in her bed in her room. She was calm and watching television with no signs or symptoms of pain. On 2/27/15 at 11:07 a.m., the resident was heard yelling from her room. Her call light was not on. The resident was mostly unintelligible but could be heard from the nursing station. A staff member, RN #1, entered the room and asked the resident what was going on. The resident cried, and then the staff member told her to take a breath and tell her what was causing her to cry. The resident was heard saying that it was her bottom. The staff member immediately notified the unit CNAs that the resident needed assistance. On 2/27/15 at 11:10 a.m., RN #3 entered with CNA #15 to change the resident's dressing. The resident consented to observation. The resident was heavily soiled with urine and was crying. As they moved her she stated that her knee hurt. After removing the soiled dressing CNA #18 came in and CNA #15 left the room. Once the resident was cleaned and the dressing was changed she was no longer in pain and was not calling out (see interview below). On 2/27/15 at 1:53 p.m. the resident could be heard down the hall yelling. The social services director (SSD) went into the resident's room and the resident said she needed help, The SSD turned on the call light and went to get a CNA. Two CNAs went into the resident room to assist the resident with positioning. They repositioned the resident and the resident immediately stopped calling out and crying. The resident was not observed wearing a splint during any of the above observations. The nurses were not observed asking the resident to rate her pain on a scale of one to ten. d. Resident Interviews On 2/25/15 at 1:45 p.m., after observation of the resident reporting pain and being transferred to bed, the resident was interviewed. When asked where her pain was, she stated it was in her left leg. She stated that since she was in bed it felt much better. On 2/27/15 at 11:30 a.m., after the observation of wound care noted above, the resident was interviewed a second time. She stated that her pressure sore hurt when she was wet and sitting up. She stated that it stung, and after being changed, it would still sting for a while then feel better. When asked what made her pain better, she started to cry and said that she wanted her range of motion to be done again. Her range of motion was not being done and had not been done for weeks. She said she had requested her range of motion, but they would not do it. She also had not had her arm brace on for weeks and she did not know why the staff was not helping her with range of motion or her splint. She added that the cream they used on her legs did not seem to do anything for her pain. e. Staff Interviews On 2/26/15 at 5:02 p.m., RN #10 was interviewed regarding the resident's pain. The nurse stated the resident had frequent pain in her knees. She was "kind of contracted and probably atrophied." She had her pain pill ([MEDICATION NAME]) every four hours and Biofreeze to her feet. Things that would help the resident with pain were, "If you go and talk to her one on one, positioning, reassurance and massage: Mainly repositioning." -The nurse identified the resident's pain as a behavio, adding that she could give her a pill, but the resident would still cry out wanting to get out of bed. The RN stated that she did not deny the resident had pain, but felt a lot of the issue was a behavior that would go away when she had one on one attention. -RN #10 stated that the resident had the same level of pain with the [MEDICATION NAME], and the resident used to have [MEDICATION NAME] cream, but for insurance reasons they had to change that to Biofreeze. The RN thought the resident had no pain from her wound when she was getting treatment, but maybe when she was sitting on it. When asked if she thought the resident had an increase in pain she stated that, after thinking of it, she had given the resident a prn pain medication three times a day for the past two days, which was more than usual. She stated that maybe after a week she would let the physician know if pain medication was not working. On 2/27/15 at 11:34 a.m., certified nurse aide (CNA) #18 was interviewed regarding the resident's care. The CNA had worked with the resident for eight months. The CNA stated that he did the restorative program on the weekends, but the resident was not on a restorative program at this time. The resident's right arm had a contracture and was supposed to have a splint, but they were working on getting another one (the previous one was not available). The CNA stated that the resident's pain was in her legs and bottom. When asked if the resident had behaviors, the CNA stated that the resident did have frequent crying; however, she (resident) was able to state that it was a complaint of pain. On 2/27/15 at 11:40 a.m., RN #1 was interviewed regarding the observation (noted above) with the resident. She stated that she had not worked with the resident before, but it was common sense to ask a resident to try to identify their pain. On 2/27/15 at 2:04 p.m., an interview was conducted with the director of nursing (DON) regarding pain. She stated nurses should monitor pain with a form inside the chart, and should be asking residents if they had pain during rounds and during med passes. If a prn was given, the nurse should document on the MAR and sign off on the back of the MAR as well as get a rating of the pain from the resident or use the Wong Baker scale for nonverbal signs and symptoms of pain. The nurses should be going back to ask the resident if the medication was effective. If it was not effective the nurse would re-medicate or would need to call the doctor. The facility should be calling the doctor if the resident had increased instances of unrelieved pain. It was the facility's responsibility to make sure pain was under control. -When addressing issues with resident #63 specifically, the DON stated that she was aware the resident had pain issues in her hip and knee. She believed that when sitting in the wheelchair, the resident's hip was not aligned right so they would try to reposition her. The DON added that she was aware that they had also recently increased the dose on the resident's [MEDICATION NAME], although (see above; orders indicated the dose was being decreased. The observations above were relayed to the DON. She stated that if the resident was saying she was in pain it was not a behavior or Pseudobulbar affect (PBA - emotional lability), but an articulate statement of pain. Based on the observations the DON stated the resident would need to be repositioned or the nurse would need to address it. -The DON stated the facility needed to do a lot of in-servicing on pain. 3. Resident #84 a. Resident Status: Resident #84, under age 55, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 12/29/14 MDS admission assessment revealed the resident was coded with a BIMS of 15/15, which indicated the resident was cognitively intact. The resident was coded with no [MEDICAL CONDITION], behavioral symptoms or rejection of care. The resident required supervision of one person for bed mobility, transfers, locomotion on the unit, dressing and toilet use. The resident required setup assistance only with supervision for eating. The resident was independent with personal hygiene, walking in the room and corridor. The resident had frequent pain of nine on a 0-10 scale, making it hard to sleep at night. Review of the new patient History and Physical, dated 12/30/14, revealed the resident stated he was used to taking narcotics as he had broken his clavicle, scapula and right shoulder, along with seven ribs in a vehicle crash in the past. Review of the care plan, updated 1/6/15, revealed the resident had recent surgery due to a fracture from a gunshot wound to the left foot. The facility staff would administer [MEDICATION NAME] as ordered and implement a pain management flow sheet. The facility would monitor the resident for signs and symptoms of pain every shift. The facility would notify the physician if interventions were not consistently effective. b. Resident Interviews and Observations: On 2/23/15 at 4:35 p.m., the resident was interviewed and stated several weeks ago the facility did not administer pain medication for a day and a half and he had experienced significant pain during this time. The resident stated he had not received enough pain medication during this time to manage his pain. On 2/25/15 at 9:30 a.m., the resident stated he had called a facility regional director regarding the lack of pain medication administration and then the issue was fixed right away. c. Record Review: Review of the 1/6/15 Nurse Practitioner Progress Note revealed the resident was status [REDACTED]. The resident had a pre-operation appointment today related to pins and screws in his foot. The facility nurses had heard the resident tell a physician that he had given half of his pain medication to someone else at another facility. The resident complained he did not have enough pain medication; however the staff had noted he was able to close his closet door with his wounded foot with no observed increased pain. Review of the 2/13/15 medical laboratory report for a specimen collected on 2/10/15 at 1:15 a.m. revealed the resident's [MEDICATION NAME] was out of range and low at a three, with a reference range of 10-100. A handwritten note by LPN #2 on the lab report indicated the resident "did not have [MEDICATION NAME] from 2/9/15 in the a.m. until 2/10/15 in the p.m." Review of the 2/15 CPO revealed the resident received [MEDICATION NAME] five mg tablet and to administer three tablets totaling 15 mg total dosage by mouth for pain every four hours around the clock at 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m., 12:00 a.m. and 4:00 a.m. (start date 1/22/15). Review of the 2/9/15 Physician Telephone Order (TO) revealed to discontinue the previous [MEDICATION NAME] order (tablets); and, administer [MEDICATION NAME] 5 mg/5 milliters (mL) (liquid) totaling 15 mL every four hours around the clock at 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m., 12:00 a.m. and 4:00 a.m. Review of the 2/15 MAR revealed the following: -Tablet O

Based on observations, interviews, and record review, the facility failed to provide care and services for three (#63, #59, and #20) out of five residents reviewed with wounds out of 57 sample residents, that prevented the development or worsening of pressure ulcers. Specifically: --Resident #63 acquired an unstageable pressure ulcer to the coccyx, and a stage II pressure ulcer to the right buttock while at the facility (1/9/15) which the facility failed to appropriately monitor and treat, and which caused the resident pain; -Resident #59 developed two stage II pressure ulcers - one to the heel and one to the sacrum - while at the facility, which the facility failed to appropriately monitor; and -Resident #20 developed unstageable pressure ulcers to her heel for which the facility failed to appropriately document, treat, or consistently use appropriate and planned interventions. The findings include: I. Professional Reference The National Pressure Ulcer Advisory Panel, "NPUAP Pressure Ulcer Stages/Categories" 2014, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stages-categories (2/2015), read in part: NPUAP Pressure Ulcer Stages/Categories The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. International NPUAP-EPUAP Pressure Ulcer Definition A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages/Categories Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones and may indicate "at risk" persons. Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanguinous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss and may include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. Suspected Deep Tissue Injury - depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. II. Facility policy According to the 'Skin Management' policy provided by the facility, in pertinent part, last revised 8/12: Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Practice Guidelines - Newly admitted Residents: 1. Upon admission, all residents are assessed for skin integrity by completing a head to toes physical assessment of skin condition and completing the Braden Scale for predicting pressure sore risk. 2. Following admission, the Braden Scale- for predicting pressure sore risk will be completed weekly for 3 (three) additional weeks (for a total of 4 (four) weeks including admission), quarterly, annually, and with a significant change of status for their risk for development of pressure ulcers. 3. Appropriate preventative surfaces of beds, wheelchairs, etc. will be implemented on all residents identified at risk (score of 18 or less on the Braden Scale- for predicting pressure sore risk). And the interventions documented on the care plan. 4. Residents admitted with skin impairments will have: a. Appropriate interventions implemented to promote healing; b. A physician's orders [REDACTED]. c. Wound location and characteristics documented in the Nursing Notes; d. Referral to rehabilitation Services e. Their family notified of presence of skin impairment 5. In addition, the following forms are completed and placed with the resident's Treatment Record (TAR): a. Pressure Ulcer: Weekly Pressure Ulcer Record; b. Low Extremity Ulcer: Non-Pressure skin condition record; c. Skin tears and all other significant skin impairment; Non-Pressure skin condition record. 6. A care plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment and the interventions implemented to promote healing and prevent further breakdown. The care plan should address, but is not limited to: - Hydration -Nutrition -Preventative devices -Pain -Positioning requirements -Proper body alignment 7. Wounds are tracked as acquired (developed in house or admitted with) and are assessed and documented on the Weekly Pressure Ulcer Record. These records are maintained in the resident's treatment record while in use. 8. The licensed nurse will document daily monitoring of all pressure ulcers on the treatment administration record (TAR). 9. A physician's orders [REDACTED]. 10. The licensed nurse will record: a. Plus sign (+) if there are no observed abnormalities or changes to the dressing, skin or pain associated with the wound. b. Minus sign (-) if abnormalities or changes to the dressing, skin or pain associated with the wound are present/observed. If any abnormalities are observed, document a descriptive note of findings and the licensed nurses response in the nurses notes section of the resident's medical record. 11. The licensed nurse will record his/her initials on the TAR to reflect the monitoring of each wound regardless of the findings. 12. A nutritional evaluation will be completed within 7 (seven) days of admission on all residents identified at risk or with the compromised skin integrity. 13. A Registered Dietitian will assess all residents identified with skin impairment for nutritional status in a timely manner. 14. Ongoing monitoring and continuous quality improvement will be achieved by the interdisciplinary Team (IDT). 15. At risk review meetings will be conducted weekly to review/discuss: a. New admissions; b. Review facility RADAR report to identify residents at high risk or with decline based on the most recent MDS (minimum data set); c. Residents with any skin changes; d. Treatment modalities and interventions with Resident/Family; and e. Recommendations based on interdisciplinary evaluation. 16. Skin assessments a. "Weekly Skin Check" will be transcribed onto the Treatment Record including the day and shift on which the check will be conducted. b. Completion of the weekly skin assessment will be noted on the TAR with the licensed nurse's initials. c. Skin assessment findings will be documented weekly on the Head to Toe Skin Check form. d. A change of condition form is to be completed and new physician's orders [REDACTED]. e. It is recommended that skin assessments be completed when a resident will be out of the facility for more than 4 hours. Findings and follow-up, if needed, are to be documented in the nurses' notes. 17. The nurse will assure treatments, interventions, care plan, and the appropriate skin documentation records are initiated in a timely manner according to practice guidelines. 18. Pressure ulcers are measured and staged weekly in accordance with the practice guidelines. 19. The DON (director of nursing)/designee will distribute follow up assignments to the IDT following the at-Risk Review meeting. 20. The assigned IDT member will ensure communication to other staff of the results of the review and any changes to the plan of care. III. Resident #63 a. Resident status Resident #63, age 57, was admitted to the facility on [DATE], with brief hospitalization s from 11/16 to 11/20/14 and 12/19 to 12/24/14, and most recently readmitted on [DATE]. According to the face sheet her [DIAGNOSES REDACTED]. According to her most recent minimum data set (MDS) assessment dated [DATE], her brief interview for mental status (BIMS) was 13 out of 15 indicating that she was cognitively intact. She was noted as having no behaviors and needing two staff assistance with all activities of daily living (ADL) except eating, with which she required one staff assistance. Her pain was identified as moderate and occurring frequently with scheduled and prn (as needed) medication being the only interventions. She was frequently incontinent. -A discharge assessment dated [DATE] noted the resident had one stage II pressure ulcer, and that she was always incontinent. b. Record review A care plan, dated 7/31/13 and rewritten on 1/30/15, noted the resident had actual pressure ulcers. -An update noted 11/20/14 revealed the resident was readmitted with a stage II pressure ulcer to the coccyx. -An update noted 1/30/15 revealed the resident had a current stage III pressure ulcer to the coccyx. -Approaches included a pressure reduction mattress to the bed, a pressure reduction cushion to wheelchair, repositioning in chair frequently for comfort and pressure reduction, turning and repositioning while in bed frequently for comfort and pressure reduction, providing incontinent care after each incontinent episode, measuring and staging pressure ulcers weekly on the pressure ulcer healing assessment form, completing a full body check weekly, and wound doctor to see patient on each wound round. Review of the monthly computerized physician's orders [REDACTED]. -Juven Powder (a supplement for wound healing) one packet BID (twice daily) for wound healing (start date 1/7/15) -[MEDICATION NAME] ointment Q (every) shift for excoriation. Apply Q shift and prn (as needed). (Start date 12/16/14) -Clean buttock wounds with NS (normal saline), pat dry, apply thin coat of barrier cream, Q shift and prn (start date 1/9/15) -Apply Hydroguard cream to peri-area, labia, Q-shift and prn, d/t (due to) incontinence Q shift (start date 12/24/14) -Mattress: Air. Q-shift check placement/function (start date 12/31/14) -Skin: Weekly head to toes skin assessment + intact, - not intact. Weekly skin checks on Fri. 6p-6a (night shift) (start date 12/31/14) -Apply heel booties Q-shift check placement/function. Remove Q-shift for skin check only, dx (diagnosis) skin integrity (start date 10/7/13) -Topical 6a-6p for wound treatment, apply Santyl ([MEDICATION NAME] ointment) to sacrum and Rt (right) buttocks wounds, cover with calcium alginate sheet, cover with dry gauze, change QD and prn for displacement (start date 1/16/15, discontinued 1/23/15) -Cleanse coccyx/sacral wounds/buttocks wound with NS, pat dry. Apply Santyl and TAO (triple antibiotic ointment). Cover with border gauze QD and prn (start date 1/23/15) Nutritional Status Reviews - The facility failed to inform the registered dietician of skin integrity issues after new wounds were noted on 1/9/15, resulting in no dietary intervention until 1/29/15 (see below). -A nutritional status review dated 11/26/14 noted the resident had returned from the hospital and had a pressure ulcer prior to hospitalization . A stage II was noted. Juven was recommended for wound healing support. -A nutritional status review dated 12/31/14 noted that per nursing the resident's skin breakdown was almost healed. Juven was determined as unnecessary due to wounds being healed. (However, see orders - Juven started 1/7/15) -A nutritional status review dated 1/29/15 noted the resident had two decubitus ulcers to the coccyx. The resident was recommended Juven, one packet BID, and fortified cereal. Wound care specialist evaluations (WCSE) - WCSE were performed by an outside group and were not a part of the resident's clinical record. They were requested and were not readily accessible. -A WCSE dated 12/2/14 revealed the resident was seen for a stage II pressure wound of the coccyx. The wound care physician (WMD) recommended house barrier cream once daily and prn, and to off load the wound, repositioning the resident per facility protocol. -A WCSE dated 12/12/14 noted the resident was seen for a stage II pressure ulcer to the coccyx measuring 0.4 x 0.2cm identified as site 2. Site one (noted 12/2/14 was not documented on the evaluation.) -A WCSE dated 12/19/14 noted the resident was seen for a stage II pressure wound of the coccyx. It noted the wound (site 2) was resolved with the anatomic location of the previously existing wound examined and [MEDICATION NAME] and resolved. -A WCSE dated 1/9/15 noted the resident was being followed for a right buttock wound (site 3). It was identified as a stage II wound. It was measured at 10 x 3 cm and the recommendation was skin prep daily, a gel cushion to chair, a group two mattress, off loading of the wound, repositioning of the resident per facility protocol, and to avoid the use of a wedge. A second wound (site 4) was observed as unstageable pressure ulcer to the sacrum. The wound was measured at 6 x 6 cm and the recommendation was to apply barrier cream once daily and prn, foam and calcium alginate once daily and prn. It was noted to off load the wound, reposition per facility protocol, and keep stool from the area as much as possible. -A WCSE dated 1/16/15 noted the resident had a stage II pressure ulcer (site 3) on the right buttock measuring 2 x 2.5 cm. A Pressure ulcer of the sacrum (site 4) was noted as unstageable measuring 6 x 6.5 cm. -A WCSE dated 1/23/15 noted the resident had a stage II pressure ulcer of the left buttock (site 3/ noted now as left buttock, not right) measuring 3.5 x 4 cm and had deteriorated. Recommendations included adding a Roho for the wheelchair. A second wound (site 4) was noted to be an unstageable pressure ulcer to the midline central wound sacrum measuring 6 x 3.5 cm. -A WCSE dated 1/30/15 noted a stage II pressure ulcer of the left buttock (site 3) measuring 3 x 3 cm. Recommendations included a gel cushion to chair, off load wound, and reposition. A second wound (site 4) was documented as unstageable to the sacrum measuring 3 x 0.5 cm. -A WCSE dated 2/6/15 noted a stage II (site 3) pressure ulcer to the left buttock measuring 1.5 x 0.8 cm. A second wound (site 4) was identified as unstageable on the sacrum measuring 3.7 x 0.5 cm with a macerated peri wound. -A WCSE dated 2/13/15 identified a stage II pressure ulcer (site 3) measuring 1.2 x 0.4 cm. A second wound was identified as unstageable (site 4) to the sacrum measuring 3.2 x 0.5 x 0.3 cm. The wound was debrided. -A WCSE dated 2/20/15 identified a stage II pressure ulcer (site 3) pressure ulcer on the left buttock that was resolved (but see observation of current wound on left buttock). A second wound was noted (site 4) as an unstageable pressure ulcer measuring 4 x 0.8 x 0.3 cm. Medication Administration and Treatment Administration Records (MARs) and (TARs) - Weekly head to toe skin checks were not documented, and wound care was not documented as performed on 1/10/15 through 1/12/15. February 2015 -Review of the February 2015 TAR revealed the resident was receiving treatment to wounds as follows: Cleanse wounds on buttocks with wound cleanser, apply hydrogel gauze to wound on L (left) buttocks, apply alginate to wound on coccyx area, cover with border gauze Q day and prn. The treatment was started on 2/6/15 and was not documented as completed as ordered on [DATE] or 2/22/15. -Prn treatments were documented 11 times; however, no explanation or documentation of the wound was provided for the prn treatments. -Weekly skin assessments were not signed as completed on 2/6/15 or 2/13/15 (see interview with RN below). January 2015 -Review of the January 2015 TAR revealed Juven (ordered 1/7/15) was not administered and noted as, "not available," from 1/22/15 through 1/29/15 (13 doses). Review of the nursing notes of the same dates revealed there was no documentation of the physician or family being notified of the Juven not being administered as ordered. -1/8/15 a treatment was initiated to cleanse coccyx wound with wound cleanser. Apply medi-honey to wound, cover with Alginate, covered by bordered gauze. Change Q day and prn dx coccyx wound. It was not documented as done on 1/8/15 and was discontinued on 1/9/15. -1/9/15 a treatment was initiated to cleanse coccyx/sacral wound, buttocks wounds with NS and pat dry. Cover sacral wound with Alginate and border gauze Q day and prn. The order was not signed off until 1/12/15 and discontinued on 1/16/15. No treatment was documented for the resident's wounds for four days in the treatment record. It was documented as changed four times on 1/9/15 in nursing notes (see nurse's notes below). -1/8/15 a treatment order was initiated to apply thin coat of barrier cream to all other areas of the buttocks Q shift and prn. -1/16/15 a treatment was initiated to cleanse coccyx/sacral wounds buttocks wound with NS pat dry, apply Santyl, cover with calcium Alginate sheet and dry gauze Q day and prn. The order was discontinued on 1/23/15. -1/23/15 a treatment was initiated to cleanse coccyx/sacral wounds buttocks wound with NS pat dry, apply Santyl and TAO cover with border gauze Q day and prn. -Review of the TAR revealed the weekly skin assessment was not documented as done on the scheduled days of 1/16/15, 1/24/15 and 1/30/15. December 2014 -A telephone order dated 12/26/14 noted a wound treatment for [REDACTED]. It read to cleanse with wound cleanser, apply collagen hydrogel gauze, and cover with bordered gauze Q day and prn. The treatment was not performed until 1/7/15. physician progress notes [REDACTED]. A physician progress notes [REDACTED]. Complete skin exam per facility protocol. No wounds on feet. On 11/20/14 a readmission (from the hospital) physician's note documented the resident was readmitted with one new 3 x 5cm stage II pressure ulcer on the coccyx. The physician ordered foam gauze daily and prn and a consult with the wound doctor the next week when he was at the facility. On 11/21/14 in the doctor's progress notes he ordered a daily wound change with medi-honey. On 12/2/14 a monthly physician's progress note documented a stage II pressure ulcer at the coccyx acquired during hospitalization . The wound measured 0.2 x0.3 cm. On 12/10/14 a physician's readmission note (resident was readmitted from a brief stay at the hospital) noted the resident had a stage II pressure ulcer of the coccyx acquired during hospitalization , and a new stage II pressure ulcer at the coccyx measuring 0.2 x 0.3cm. On 12/26/14 a physician's readmission note (the resident was hospitalized [DATE]-12/24/14) identified the resident had a stage II pressure ulcer (no measurements noted). On 1/16/15 a monthly physician's progress note read the resident had a stage II pressure ulcer; the coccyx that worsened after hospitalization then gradually improved. It also noted the resident had a stage II pressure ulcer on the buttock (coccyx) that worsened during hospitalization , which was gradually healing and smaller in size. It was noted to do dressing change daily and prn with collagen, hydrogel gauze, and to continue with air mattress and skin check per facility protocol. (See WCSE dated 1/16/15 identifying the wounds as larger and one being unstageable.) Head to toe skin checks On 11/21/14 (the day after the resident returned from the first hospitalization ) there was no head to toe skin check completed by the nurse. On 12/24/14 the resident was readmitted to the facility from a hospital stay (12/19/14 to 12/24/14). The nursing admission assessment documented the resident had a 3 x 2cm open wound to the coccyx. -A telephone order was written on 12/24/14 on readmission to do a weekly skin check each Wednesday. On 12/26/14 a nurse's note documented the resident had an open area on the coccyx 3.5 cm long x 0.5 cm wide with tunneling at the base of the 3 cm area (this was signed by an LPN). Weekly Pressure Ulcer Records (WPUR) - Only one WPUR noted below was completed by a qualified registered nurse (RN). All others were completed by a licensed practical nurse whose scope of practice does not include assessment or staging of wounds. (Cross reference F282 failure to provide qualified staff) - A weekly pressure ulcer record was not available on 11/20/14 when the resident was readmitted from the hospital with a wound. -A WPUR dated 12/2/14 noted a stage II wound to the coccyx measuring 0.5 x 0.3 cm with no depth. It was noted as improved. The nurse noted the wound was seen by the wound doctor and to apply barrier cream Q day and PRN. An additional WPUR dated the same date contained the same information but was completed by a licensed practical nurse (LPN). -A WPUR dated 12/12/14 noted the resident had only one wound on the coccyx measuring 0.4 x 0.2 cm and to continue with barrier cream QD and prn. It was completed by an LPN. (The physician's readmission noted two wounds on 12/10/14.) - A WPUR dated 1/9/15, completed by an LPN, noted wound rounds were completed with the WMD. A sacral wound was measured at 6 x 6 x 0.5 cm with 10% yellow, 40% granulation, 50% skin stage III. The right buttock was measured at 6 x 2 cm stage II with 10% granulation and 90% skin. A right buttock 'cluster' was measured as 10 x 3 cm. The sacral treatment was noted as alginate with border gauze, and the buttocks was noted as barrier cream. -A WPUR dated 1/23/15 noted wound rounds were done and a right buttock wound measured 6 x 3.5 cm and a left buttock wound measuring 3.5 x 4 cm. (The assessment was not complete and was not signed. See interview with LPN below.) -A WPUR dated 2/13/15 noted wound rounds were done. A right buttock wound measured 1.2 x 0.4 cm. A coccyx wound was noted as 3.2 x 0.5 x 0.3 cm. (The assessment was not complete or signed.) -A WPUR dated 2/20/15 noted a sacral wound measuring 4 x 0.8 x 0.5 cm and a sacral wound measuring 1.3 x 1.3 cm. (The assessment was not complete or signed.) SBAR (situation, background, assessment, and request) Communication form -An SBAR dated 1/4/15 noted the resident had skin breakdown to the coccyx. It documented a night certified nurse aide (CNA) reported breakdown and redness to the left buttocks near the fold of the thigh and buttocks. Collagen and hydrogel gauze were applied and covered with border gauze. -An SBAR dated 1/9/15 noted a new coccyx wound (five days later). The nurse documented the CNA alerted the nurse that the resident needed a dressing change, and a half dollar size area of bleeding was noted next to the current coccyx wound. The area was cleansed and the dressing to the coccyx was changed. Nurse's Notes - A nurse's note dated 1/8/15 documented the resident had new orders for a wound treatment to cleanse wound with wound cleanser and apply medi-honey to wound bed then cover with Alginate, covered by bordered gauze. The nurse made no note of performing the treatment. - A nurse's note dated 1/9/15 identified a new open area noted next to the current wound. The wound care was completed. Later that day another nurse noted changing the dressing three times. - A wound care skin integrity evaluation, on a form not included in the resident's active record, but provided by the facility, dated 2/13/15, noted a right buttock wound with an onset of 2/13/15. It was noted as a stage II pressure ulcer measuring 1.2 x 0.4 x 0.2 cm and was noted as hospital acquired. (However, the resident had returned from the hospital on [DATE].) A second wound was noted as sacrococcygeal with an onset of 12/2/14 (hospital acquired). It was noted as unstageable and measured 2.2 x 0.5 cm. It did not match any other form of documentation provided, and had no signature of any facility representative. c. Observations On 2/25/15 at 1:31 p.m., the resident was heard crying. Her sobbing could be heard by the doors to the special care unit. The resident was in her room in her wheel chair. The resident stated she was in pain. The resident's face was contorted with a clenched jaw. On 2/25/16 at 1:33 p.m., two certified nurse aides (CNAs) #8 and #15 went to the resident's room stating that they could help the resident now. The two CNAs prepared the resident for a two person mechanical lift and tried to calm the resident by speaking to her. The resident told the two CNAs that she was in pain and needed to lie down because of her leg. The resident was sweating heavily, she was grimacing, and her hands were clenched in fists. On 2/25/15 at 1:36 p.m., the resident was lifted to her bed and immediately stopped crying. Her body and face relaxed and she became conversational with the CNAs and said, "Thank you. That is much better." On 2/27/15 at 8:36 a.m., the resident was observed in her room crying out to get up. The room had a strong odor of urine and feces. On 2/27/15 at 8:59 a.m., two CNAs gave the resident care in her room. The resident was asked for permission to observe and requested she be cleaned first, then talk. The resident was heavily soiled and her linens and clothes were changed after being cleaned. The resident was rolled on her right side exposing her backside that had a dressing on the coccyx/ buttock area that was intact and dated 2/26/15 at 5:30 p.m. On 2/27/15 at 11:07 a.m., the resident was heard yelling from her room; her call light was not on. The resident was mostly unintelligible but could be heard from the nursing station. A staff member, RN #1, entered the room and asked the resident what was going on. The resident cried, and then the staff member told her to take a breath and tell her what was causing her to cry. The resident was heard saying that it was her bottom. The staff member immediately notified the unit CNAs that the resident needed assistance. On 2/27/15 at 11:10 a.m. RN #3 entered with CNA #15 to change the resident's dressing. The resident consented to observation. The resident was heavily soiled with urine and was crying. As they moved her she stated that her knee hurt. After removing the soiled dressing, CNA #18 came in and CNA #15 left the room. The RN donned the same pair of gloves from the beginning of the wound care to the end, and did not change her gloves or wash her hands between removing the soiled dressing and applying the new dressing. -The resident was observed to have two wounds: One on the coccyx area had slough on the wound bed and was unstageable. One wound was observed on the left buttock exposing a red wound bed. Both wounds were wiped with wound cleanser by the RN, she then applied skin prep to the area (not included on the order). She then removed the hydrogel from the packet and it touched the resident's bedside table which did not have a clean field. The nurse continued the dressing and applied the contaminated hydrogel dressing. The nurse finished applying the dressing of alginate and bordered gauze, with the same gloves she had worn while touching the resident's bed, soiled dressings, and wound dressing packet. She treated both wounds at once and failed to avoid potential contamination and cross contamination. On 2/27/15 at 1:53 p.m. the resident could be heard down the hall yelling. The social services director (SSD) went into the resident's room and the resident said she needed help. The SSD turned on the call light and went to get a CNA. Two CNAs went into the resident room to assist the resident with positioning. They repositioned the resident and the resident immediately stopped calling out and crying. d. Interviews On 2/25/15 at 1:45 p.m., after observation of the resident reporting pain and being transferred to bed, the resident was able to be interviewed. When asked where her pain was, she stated it was in her left leg. She stated that since she was in bed it felt much better. On 2/26/15 at 5:02 p.m., RN #10 was interviewed. The RN said she thought the resident had no pain from her wound when she was getting treatment, but maybe when she was sitting on it. When asked if she thought the resident had an increase in pain, she stated that after thinking of it, she had given the resident a prn pain medication three times a day for the past two days, which was more than usual. She stated that maybe after a week she would let the physician know if pain medication was not working. On 2/27/15 at 9:27 a.m., an interview with RN #3 revealed the nursing staff was responsible for doing weekly head to toe skin assessments and weekly pressure ulcer documentation. They would document in the MARs on the head to toe skin checks. When shown the incomplete skin checks on the 2/6/15 and 2/13/15, she stated that they should have been done by the nurse working the shift. Review of the schedule revealed the RN was on duty on 2/6/15. The RN stated they were not aware of why they would have missed the skin assessment. She confirmed the MAR/TAR was the only place skin assessments would be documented. On 2/27/15 at 11:30 a.m., after the observation of wound care noted above, the resident was able to be interviewed. She stated that her pressure sore hurt when she was wet and sitting up. She stated that it stung, and after being changed, it would still sting for a while, then feel better. On 2/27/15 at 8:36 a.m., CNA #13 confirmed

Based on observation, record review and interview, the facility failed to ensure four of four residents (#63, #49, #64, and #20) received appropriate treatment and services to increase range of motion and/or to prevent a further decrease in range of motion. Specifically: -Residents were not provided a restorative program that was reviewed monthly by a designated registered nurse (RN); -Resident #63 experienced a decrease in lower extremity range of motion (ROM) while not receiving referred restorative services; -Resident #49 was not offered her left hand splint to address finger contractures; -Resident #64 was discharged from therapy with a contracture but was not referred to restorative for splint management; and -Resident #20 was not observed with a hand device, as ordered. The findings include: Cross reference F282 - Qualified staff including restorative registered nurse 1. Resident #63 a. Resident status Resident #63, age 57, was admitted to the facility on [DATE], with a brief hospitalization on [DATE], and a readmission on 12/24/14. [DIAGNOSES REDACTED]. According to her most recent minimum data set (MDS) assessment dated [DATE], her brief interview for mental status (BIMS) was 13 out of 15 indicating that she was cognitively intact. She was noted as having no behaviors and needing two staff assistance with all activities of daily living (ADLs), except eating with which she required one staff assistance. Her pain was identified as moderate and occurring frequently with scheduled and prn (as needed) medication being the only interventions. -The discharge MDS dated [DATE] noted the resident had last received occupational therapy on 12/10/14. She was not noted on the quarterly or discharge assessment to be on a restorative program. -The 10/24/14 quarterly MDS revealed the resident had limited range of motion on one upper extremity and both lower extremities. -The 7/29/14 annual MDS revealed the resident had limited range of motion on one upper extremity, and only one lower extremity. b. Record review A rehab to restorative transition record dated 2/19/15 noted the resident was referred by therapy to the RNA (restorative nurse aide). The goals of intervention were listed as maintenance or improvement of passive and active range of motion of both upper extremities, and to maintain the passive range of motion for both lower extremities. An additional goal to have the resident wear a left upper extremity splint 2-4 hours a day was noted. Review of the restorative care book including minutes for all residents revealed there were no co-signatures from an RN, and no monthly summary or updates from a restorative nurse coordinator (RNC). c. Observations -On 2/25/15 at 1:31 p.m. the resident was observed without a splint. -On 2/27/15 at 8:36 a.m. the resident was observed without a splint. -On 2/27/15 at 8:59 a.m. the resident was observed without a splint. -On 2/27/15 at 11:10 a.m. the resident was observed without a splint. -On 2/27/15 at 1:53 p.m. the resident was observed without a splint. d. Interviews On 2/27/15 at 11:30 a.m. the resident was interviewed and said she had pain. -When asked what made her pain better, the resident started to cry and said that she wanted her range of motion to be done again. Her range of motion was not being done and had not been done for weeks. She had requested her range of motion but they (facility staff) would not do it. She also had not had her arm brace on for weeks and she did not know why the staff were not helping her with range of motion or her arm brace. Interview with the restorative aide (RA) at 1:22 p.m. on 2/27/15 revealed he had been in the position for three years. The RA stated that there was no restorative nurse. He stated the occupational therapist had given him a referral for the resident on 2/19/15; however, the resident had requested not to work with the RA so her program had not been started. He stated that certified nurse aide (CNA) #18 did the restorative program on the weekends, but he had not informed the CNA of the referral, so the CNA would not know about it. The RA stated that floor staff could be trained to do ROM exercises, but they would get busy and likely not complete them. He did not know where the resident's splint was currently. The RA stated that the weekend CNA that did restorative was often pulled to cover shifts where they were short, and was not always able to finish programs on the weekend. (Cross-reference F353 - Sufficient nursing staffing) On 2/27/15 at 11:34 a.m., CNA #18 was interviewed regarding the resident's care. The CNA stated that they did the restorative program on the weekends. The CNA stated the resident was not on a restorative program currently, and no longer had the splint available. On 2/27/15 at 2:04 p.m., an interview was conducted with the director of nursing (DON). She stated the restorative program was run by the RA and he was working with the resident. She stated referrals came from therapy and went to the RA. She stated that the RA was the only CNA responsible for restorative and they did not have another person. She was not aware that the resident had requested to not have the RA care for her, and did not know how the restorative program would be completed with that situation. She stated that the facility did not have a designated restorative nurse and she was not aware of the requirements. She stated that if a resident had a contracture she would expect them to be in restorative, and other CNAs would be able to do things like apply braces and splints. 2. Resident #49 Resident #49, age under [AGE] years, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the annual MDS assessment dated [DATE], the resident's BIMS score was 14 out of 15, which indicated that the resident was cognitively intact. The resident did not receive any passive, active, and splint or brace assistance for the past seven calendar days of the assessment period. a. Discharge Status and Recommendations from Occupational Therapy (OT) Review of the OT's discharge and recommendations, the resident's baseline, dated 12/24/14, was to increase active range of motion of the left shoulder, wrist and hand. The resident had a contracture of the fourth and fifth digits. The orthotic management recommendation for the resident on 12/9/14 was a resting hand splint for the left hand and digit splints. The summary of care, dated 12/9/14, showed that the resident and restorative nurse had received training for splint wearing and coordination to use the left upper extremity. The resident was discharged from the program due to achieving the "highest practical level" and had "made fair progress toward short term goals however seems to be plateauing. Will establish RNP (restorative nursing program)." The occupational therapist recommendation was for the resident to remain in the long term care facility and to participate in the restorative nurse program. The summary of care dated 2/9/15 showed that the resident and staff had received ongoing training for encouragement to use the left upper extremity in activities, and awareness/management of the left side of the body. The resident was discharged from occupational therapy on 2/9/15 due to lack of follow through with the room exercise program and inconsistent attendance. b. Care plan and record review There was not a care plan for range of motion services. On 2/15 the computerized physician orders [REDACTED]. "Order date: 10/7/14: Therapy Evaluation and Treatment: Occupational. Evaluate and treat for contractures." There was not a physician order [REDACTED]. d. Resident Observations On 2/25/15 at 11:44 a.m., 2/26/15 at 9:01 a.m., 2/26/15 at 2:49 p.m., and 2/27/15 at 8:30 a.m., the resident was observed lying in bed without a splint on her left hand. e. Resident Interview On 2/27/15 at 8:30 a.m., the resident was interviewed. The resident said she had a splint for her left hand, but had not worn it in months. She said the splint was uncomfortable. When asked if staff encouraged her to wear the splint she responded "no." f. Staff interview On 2/27/15 at 8:20 a.m., the OT was interviewed. The OT said that the resident was discontinued from services due to lack of follow through. The OT also said the resident was previously on restorative, did not wear her splint on her left hand, frequently took it off and misplaced it. The OT confirmed that no other preventive devices have been offered to the resident. On 2/27/15 at 1:23 p.m. the restorative aide (RA) was interviewed. The RA confirmed that the resident had a splint for her left hand and he only saw her wearing it some of the time. The RA said that the other CNAs were supposed to assist and encourage the resident to wear the splint. The last time the RA worked with the resident was six or seven months prior to the interview for walking assistance. On 2/27/15 at 2:24 p.m. the DON was interviewed. The DON said that if a resident was refusing to wear splints, then after a month alternative preventative devices needed to be put into place. The DON also said if a resident was refusing to wear the preventive device the expectation would be for the nurses to contact the physician, and the resident to be reevaluated by therapy to find out the reasons why the device was causing discomfit or pain. 3. Resident #64 Resident #64, age 87, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the annual MDS dated [DATE], the resident's BIMS score was ten out of 15, which indicated that the resident was moderately cognitively impaired. The resident did not receive any passive, active, and splint or brace assistance for the past seven calendar days for a minimum of 15 minutes. The resident's start date for physical therapy was 5/28/14 and end date for physical therapy was 6/24/14. a. Discharge Status and Recommendations from Physical Therapy The resident's baseline dated 12/16/14 was for the resident to increase the right knee extension from negative 15 degrees to negative seven degrees, to improve the range of motion and reduce risk for contractures and improve functional transfers. The discharge recommendation on 2/21/14 was for the resident to remain in the long term care facility with staff assistance. However, the restorative nurse program on 2/21/14 did not have any restorative orders. The resident was discharged from physical therapy on 2/12/15 due to goals being met on 1/28/15. b. Care plan and record review According to the care plan, last revised on 8/28/14, for activities of daily living the resident was total care utilizing one staff member. On 2/15 the CPOs documented the following, in pertinent part: "Order date: 12/11/14: Therapy Evaluation and Treatment: Physical." c. Resident Observations On 2/26/15 at 4:21 p.m. and 2/27/15 at 8:40 a.m. the resident was observed lying in bed without a knee brace on. d. Resident Interview On 2/27/15 at 8:40 a.m. the resident was interviewed. The resident confirmed that she had a contracture in her shoulder and in her right knee. She said the nurses gave her a knee brace but she did not wear it. e. Staff interviews On 2/27/15 at 8:20 a.m. the OT was interviewed. The OT said that the resident was discontinued from therapy services without restorative nursing and without splints in place. On 2/27/15 at 1:23 p.m. the RA was interviewed. The RA confirmed that the resident was never on a restorative program but could have benefited from the restorative program. On 2/27/15 at 2:24 p.m. the DON was interviewed. The DON said the expectation was that the resident would be discharged with restorative nursing if there was a contracture present and that there would be a physician order [REDACTED]. 4. Resident #20 Resident #20, age 72, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent MDS assessment, dated 10/31/14, indicated that the resident had a limited range of motion on one side in both the upper and lower extremities. The resident was non-interviewable. a. Observations: -- On 2/24/15 at 8:26 a.m., the resident was observed in her bed. The resident's right arm and hand were contracted. There were no splints or cones in place. -- On 2/27/15 at 8:36 a.m., the resident was observed. The resident's hand did not have any splints or cones in place. b. Record Review A computerized physician's orders [REDACTED]. The device was to be checked for placement and function daily. A review of the TAR for January indicated that as of 1/23/15, the resident was to wear a carrot at all times in her right hand. There were no initials from 1/23/15 to 1/31/15 to demonstrate that this had been done. The TAR for February was not provided. A review of the nursing notes from 1/23/15 to 2/27/15 did not reveal any notes that the resident had refused treatment. c. Staff Interviews: On 2/24/15 at 10:22 a.m., RN #3, who was the resident's charge nurse, was interviewed. The RN stated that the resident had contractures to her right arm. The RN stated that range of motion services had been discontinued since the resident was on hospice, but that she had a splint for her hand as a comfort measure. On 2/27/15 at 8:36 a.m., CNA #13, who was familiar with the resident, was interviewed. The CNA confirmed by observation that the resident did not have a device in place in her right hand, and stated that she was supposed to have one even though she was on hospice. On 2/27/15 at 8:50 a.m., CNA #15, who was assigned to the resident for that day, was interviewed. The CNA stated that the resident was supposed to have a carrot in place for her right hand because the hand was contracted to the point that her fingernails were digging into her skin. On 2/27/15 at 2:23 p.m., the DON was interviewed. The DON stated that if a resident had a contracture, they would be in the restorative program. The DON stated that although the RA was the only restorative CNA, other CNAs would be able to apply and check braces, including carrots, and that this was her expectation.

Based on observations, record review, and resident and staff interviews, the facility failed to provide and monitor fluid intake to maintain proper hydration and health for one of four residents reviewed for hydration issues (#63). Specifically: The facility failed to ensure fluids were accessible and monitored for a resident identified as at risk for dehydration and electrolyte imbalance. Resident #63 was hospitalized in November and December 2014 with dehydration, electrolyte imbalance, and acute [MEDICAL CONDITION]. The findings include: A. Professional Reference regarding Hydration According to Mayo Clinic Staff, "Diseases and Conditions: Dehydration," 2/12/14, http://www.mayocliniclorg/diseases-condtions/de hydration/basics/definition/con- 056 (December 2014): "Dehydration occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions. If you don't replace lost fluids, you will get dehydrated ...Anyone may become dehydrated, but young children, older adults and people with chronic illnesses are most at risk. You can usually reverse mild to moderate dehydration by drinking more fluids, but severe dehydration needs immediate medical treatment. The safest approach is preventing dehydration in the first place ...Anyone can become dehydrated if they lose too many fluids. But certain people are at greater risk, including: ...older adults. As you age, you become more susceptible to dehydration for several reasons: Your body's ability to conserve water is reduced, your thirst sense becomes less acute, and you're less able to respond to changes in temperature. What's more, older adults, especially people in nursing homes or living alone, tend to eat less than younger people do and sometimes may forget to eat or drink altogether. Disability or neglect also may prevent them from being well nourished. These problems are compounded by chronic illnesses such as diabetes, dementia, and by the use of certain medications ...Dehydration can lead to serious complications, including: ...kidney failure. This potentially life-threatening problem occurs when your kidneys are no longer able to remove excess fluids and waste from your blood. Coma and death: When not treated promptly and appropriately, severe dehydration can be fatal ...Treating severe dehydration: Children and adults who are severely dehydrated should be treated by emergency personnel arriving in an ambulance or in a hospital emergency room , where they can receive salts and fluids through a vein (intravenously) rather than by mouth. Intravenous hydration provides the body with water and essential nutrients much more quickly than oral solutions do - something that's essential in life-threatening situations. To prevent dehydration, drink plenty of fluids and eat foods high in water such as fruits and vegetables ...Fluids can be obtained not just from water but also from other beverages and foods." B. Resident status Resident #63, age 57, was admitted to the facility on 7/14/13, with brief hospitalization s from 11/16 to 11/20/14 and 12/19 to 12/24/14 with readmission on 12/24/14. [DIAGNOSES REDACTED]. diabetes, [MEDICAL CONDITIONS], chronic pain, vitamin D deficiency, depressive disorder and late effect [MEDICATION NAME] cognitive deficit, according to the face sheet. According to her most recent minimum data set (MDS) assessment dated [DATE], her brief interview for mental status (BIMS) was 13 out of 15, which indicated she was cognitively intact. She was noted as having no behaviors and needing two staff members assistance with all activities of daily living (ADLs), except eating with, which she required one staff member's assistance. Her pain was identified as moderate and occurring frequently with scheduled and prn (as needed) medication being the only interventions. A discharge assessment dated 12/19/14 revealed the resident had one stage II pressure ulcer. C. Record review - Review of the resident record revealed there was no care plan for hydration. -A physician's readmission note, dated 11/20/14, read in pertinent part, "During hospitalization she was found to [MEDICAL CONDITION] and possible constipation. She received IV [MEDICATION NAME] (an antibiotic) during hospitalization . BMP (basic metabolic panel) showed dehydration, BUN (blood urine nitrogen) 41, and creat (creatinine) 1/93 on 11/18." - An SBAR (situation, background, assessment, and recommendation) communication form dated 11/16/14 revealed the resident appeared to be hypovolemic (decrease in blood volume) related to dehydration. - A hospital record dated 12/20/14 noted, "Most likely has systemic [MEDICAL CONDITION] response syndrome from infection stemming from a urinary tract infection as well as dehydration with azotemia (an elevation of blood urea nitrogen (BUN) and serum creatinine levels) from the dehydration with ACE inhibitors on board. Plan: Admit her, IV (intravenous) fluid hydration." -A telephone order (TO) dated 12/26/14 (the resident was readmitted from an acute hospital stay on 12/24/14) noted to "monitor urine output by changing diaper frequently BM (bowel movement) until 1/1/15." -A TO dated 1/2/15 noted a "stat (immediate) UA (urinary analysis) with CNS (culture and sensitivity) due to decreased urine output." -A SBAR dated 1/2/15 noted the resident had a dry brief due to dehydration. -Review of the nursing notes from 12/26/14 to 1/2/15 revealed there was no documentation regarding the resident's brief or output. -Labs drawn on 1/2/15 revealed the resident had lab values within normal limits. -A physician's monthly progress note dated 2/16/15 read in pertinent part: "She drinks lots of fluid if CNA (certified nurse aide) filled up her water bottle about 5000 to 7000 ml per day. The last ... hospitalization in Dec was related to electrolytes/fluid imbalance. Plan is to give her IV (intravenous) hydration at facility if she does not drink 2000 ml in day shift ... past two times of hospitalization most likely due to dehydration, plan to give her IV hydration at facility if oral fluid intake < (less than) 2000 ml." -Labs drawn on 2/21/15 revealed the resident had an elevated BUN of 29 mg/dl, low potassium at 3.4 and low calcium at 7.9. (All lab values noted had been within normal limits on 1/2/15.) -A TO dated 1/27/15 revealed the resident was to have skilled nursing record the resident's oral fluid intake for four days (through 1/30/15). -An intake and output record dated 1/27/15-2/3/15 noted the resident had between 2500 and 8200ml of oral fluid intake documented per day. -A TO dated 2/20/15 noted the resident was to have intake and output monitored, labs, IV hydration of 2 L (liters). -A TO dated 2/21/15 ordered to discontinue the IV-no further orders were written to the date of survey exit (2/27/15). -A request was made on 2/27/15 for any fluid intake records for the resident. The document noted above was produced a second time with an additional intake and output record. The record was dated 1/31/15-2/20/15. There was partial documentation (fluid intake amounts) on 2/1/15-2/11/15, and no documentation on 2/12-2/19/15, and a partial documentation of only one shift on 2/20/15. No other intake documentation was available or provided during or after the survey. D. Observations -On 2/25/15 at 1:31 p.m. the resident was observed with her fluid out of reach. -On 2/27/15 at 8:36 a.m. the resident was observed with her fluid out of reach. -On 2/27/15 at 8:59 a.m. the resident was observed with her fluid out of reach. -On 2/27/15 at 11:10 a.m. the resident was observed with her fluid within reach. The certified nurse aide (CNA) #18 positioned the resident in bed and placed her filled water bottle on the bedside table that he positioned within arm's reach of the resident. -On 2/27/15 at 1:53 p.m. the resident was observed with her fluids out of reach. (See MDS above - the resident needed staff assistance to eat and drink.) E. Resident Interview On 2/27/15 at 11:30 a.m., after observation of the resident receiving care, the resident was interviewed. She stated the fluid was often not within her reach. Since they had moved the position of her bed, her dresser was not next to her head and she could not reach anything set on it. She stated that she was always thirsty, but did not want to bother the staff by calling for assistance. Cross reference F242 - Failure to honor resident choices related to bed positioning Cross reference F312 - Failure to provide assistance with eating and drinking for dependent residents F. Staff Interviews On 2/27/15 at 11:34 a.m., CNA #18 was interviewed regarding the resident's care. The CNA stated the resident needed her water bottle filled and placed within reach in order to drink. She was not able to move herself and needed assistance with positioning and set up. He was not aware of the need to document the resident's intake. On 2/27/15 at 2:04 p.m., an interview was conducted with the director of nursing (DON). She stated the facility did not monitor intake or output on residents. On 2/26/15 at 5:02 p.m., registered nurse (RN) #10 was interviewed. She stated that they did not monitor intake on residents in the facility. On 2/27/15 at 10:57 a.m., an interview with the registered dietitian (RD) revealed she was not involved in fluid monitoring. The RD said that was left up to the physician and the facility staff.

Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible and failed to ensure eight (#11, #17, #20, #50, #52, #56, #58 and #61) of 38 sample residents received adequate supervision and assistance devices to prevent accidents. Specifically: -The facility failed to ensure residents #11, #17, #20, #50, #52, #56, #58 and #61 were safe from falls. Resident #58, known to be at high risk for falls and to be unsteady with transfers, fell and sustained a laceration and fell again, sustaining a hip fracture. Resident #61, also known to be at high risk for falls, fell and sustained a hip fracture. And resident #20, also known to be at high risk for falls, sustained a cervical fracture. -The facility failed to keep potentially hazardous chemicals inaccessible to residents. The findings include: A. INDIVIDUAL RESIDENT FAILURES 1. Resident #58, age 74, was admitted to the facility on [DATE] with diagnoses, according to the facility admission face sheet, of Alzheimer's disease, esophageal reflux, hypertension, seizure disorder, bi-polar disorder, anxiety, chronic headaches, insomnia, a history of having a cardiovascular accident (CVA), a history of falls and a history of having a fracture of the right distal radial head. Resident Status: The 10/18/12 MDS assessment indicated the resident was unable to participate in the BIMS. Staff assessed the resident as having moderate impairment of cognitive ability and indicated she required cueing and supervision. The MDS documented the presence of delusions and verbal behavior symptoms. -The assessment described supervision/oversight was needed by the resident for bed mobility, transferring, walking and toilet use. Limited assistance was noted for dressing and extensive assistance was noted for personal hygiene. The MDS also noted the resident was able to stabilize her balance only with assistance from others for moving from a seated to a standing position, walking, turning around and facing the opposite direction while walking, moving on/off toilet and for surface to surface transfer. No function limitation of range of motion noted. -The assessment indicated the resident had occasional incontinence of bowel and frequent urinary incontinence. The assessment also indicated the resident did not participate in a toileting program. -The MDS noted a history of falls with injury. The 11/29/12 Computerized Physician order [REDACTED].? tablet (tab) at hour of sleep (QHS), ferrous sulfate 325 mg QD, vitamin C 500 mg QD, Depakote (anticonvulsant) 125 mg three times each day (TID), Norco (narcotic analgesic) 5 mg-325 mg give ? tab four times each day (QID) and give ? tab Q4 hrs and as-needed (PRN), Senna 8.6 mg QHS, vitamin D 3 50,000 units (ui) on the 15th and 28th day of the month and Voltaren 1% Gel (anti inflammatory) applying 2 grams (G) to each knee BID. Known Fall Risk - Falls - Facility Response - Failures in Facility Response: See MDS and CPO above; the resident was known to have a history of falls and to need assistance from others to stabilize with transfers. She also was on a number of medications with potential central nervous system side effects. The 12/15/12 Nursing Care Plan (NCP) for transfers and for falls included an approach to encourage the resident to ask for assistance. The 12/15/12 NCP for falls did not include the use of a call light. The 12/11/12 NCP included an approach to encourage the resident to call for help, placing the call light within reach. A 10/3/12 nurse's notes documented a fall at 2:15 a.m. by the resident, resulting in a laceration of the outer aspect of her left eye. An Interdisciplinary Post Fall Review was completed on 10/3/12 for the fall occurring on 10/3/12 and indicated the resident fell and suffered a laceration of the outer aspect of her left eye. The review summary stated staff should remove the resident's Ted hose and apply gripper socks at night. Upon request, the facility was unable to provide a copy of the incident report or investigation related to the 10/3/12 fall. A 10/8/12 nurse's note documented the receipt of an order for [REDACTED]. A 10/22/12 Fall Risk assessment documented the resident received a score of 18, indicating a high risk for falls. A 11/3/12 nurse's note indicated the resident had an incident where she walked into the legs of another resident who was seated. The resident fell to her knees. A telephone order (TO) given on 11/15/12 indicated monitoring of landing strips was discontinued. A neuropsychology report received by the facility on 11/29/12 noted concern over the effect Klonopin use had on steadiness, given the resident's history of falls. The report included a recommendation to consult with the resident's physician regarding the concern. A review of nurse's notes, physician's progress notes, CPO and TO, after 11/29/12 to present, did not reveal the facility had contacted the physician regarding the 11/29/12 concern over the effect of Klonopin use. A nurse's note written on 12/10/12 at 9:45 a.m., indicated the resident was found with her RLE hanging off the side of the bed. The resident complained of pain in the RLE and the nurse reported it was warm to the touch. According to the 9:45 a.m. nurse's note, the nurse attempted to assist the resident to the toilet, but the resident was unable to stand and began crying her leg hurt. The nurse administered a PRN pain medication and then called the resident's physician to request a venous doppler (to check for deep vein thrombosis). Further review of nurse's progress notes provided no other indication the resident received assistance going to the bathroom between 12/10/12 at 9:45 a.m. and 12/11/12 at 1:30 a.m. There was no acute care plan regarding the resident's painful right leg and inability to stand or plans to ensure the resident's safety; there was no instruction to staff to increase resident supervision. Another nurse's note written at 12/10/12 at 3:15 p.m., described an unwitnessed fall by the resident. The resident was found on the floor. According to the 3:15 p.m. nurse's note, the resident's RLE continued to be red in color, swollen and warm to the touch. A 12/11/12 nurse's note, written at 1:30 a.m. indicated the resident was assisted to the bathroom through the use of a wheelchair. The note indicated the resident was unable to bear weight on her right leg. The nurse described the resident's right leg as rotated outward with bruising of the right hip. According to a nurse's note written on 12/11/12 at 5:10 p.m., an x-ray confirmed a fracture of the resident's right hip and she was transported to the hospital at 5:30 p.m. A review of the incident report completed for the 12/10/12 fall included a description of the resident's location and position when discovered on the floor, a description of an initial assessment of her condition, documentation of notification and a description of action taken. The incident report did not include documentation of the investigation of the fall and did not identify possible factors that may have contributed to the fall. The Interdisciplinary Post Fall Review completed on 12/13/12 for the fall occurring on 12/10/12 did not include discussion of the possible factors that may have contributed to the fall. The review indicated the resident was wearing shoes at the time of the fall. Another Interdisciplinary Post Fall Review completed on 12/11/12 for the same fall on 12/10/12 indicated the resident was wearing socks at the time of the fall and noted the resident's RLE was swollen and painful and may have contributed to the fall. Interviews: The Registered Nurse (RN) was interviewed on 12/19/12 at 12:40 p.m. The RN stated the resident was able to transfer with supervision prior to her fall. The RN confirmed the resident was having difficulty transferring and walking on 12/10/12 because of the pain she was experiencing. The RN also confirmed the resident fell while trying to ambulate. -The RN confirmed the call light from the resident's room had been removed and was not aware of a specific determination the resident was not able to use the call light. The RN stated she was unsure whether the resident might be able to use the call light for assistance. -The RN said it was possible the resident fell because she attempted to ambulate but could not because of the pain she was experiencing. The RN also indicated a wheelchair should have been used to transfer the resident to the bathroom any time she needed to void. An interview was conducted with the Director of Nurses (DON) on 12/20/12 at 12:20 p.m. The DON agreed the pain and edema in the resident's RLE may have contributed to the fall and she expected the resident would be assisted to the bathroom. An interview was conducted with the Nursing Home Administrator (NHA) and the Corporate Consultant of Clinical Services (CCCS) on 12/13/12 at 1:15 p.m. -The NHA stated the facility's process for reviewing an accident was to complete and incident report, conduct an investigation and, in the event of a fall, convene a Post Fall Committee review of the incident within 72 hours. At the time of this interview, the NHA and CCCS stated the incident reports for the 10/3/12 and 12/10/12 falls could not be located though the documents might be in office of the DON. The NHA and CCCS were asked on 12/19/12 at 4:15 p.m. to provide copies of the 10/3/12 and 12/10/12 incident reports and investigations. The 12/10/12 incident report was located (see above); however, the NHA and CCCS stated the incident report for the 10/3/12 fall and investigation follow-up for both incidents were still missing. 2. Resident #52, age 86, was admitted to the facility on [DATE] with diagnoses, according to the facility admission face sheet, of vascular dementia with delusions, chronic pain, spinal stenosis, degenerative joint disease, type II diabetes mellitus, anxiety, depression, [DIAGNOSES REDACTED], chronic kidney disease, gastroesophageal reflux disease, [DIAGNOSES REDACTED], coronary atherosclerosis, anemia and chronic urinary tract infection. Resident Status: The 9/6/12 Minimum Data Set (MDS) assessment indicated the following: -The resident was not able to complete the Brief Interview of Mental Status (BIMS) because the resident was rarely understood. Staff assessed the resident's cognitive status as moderately impaired, requiring cueing and supervision to make safe decisions. The assessment also noted the presence of delirium identified as inattention, disorganized thinking, altered level of consciousness and psychomotor retardation. The assessment indicated the resident experienced hallucinations and delusions and demonstrated physical behavior symptoms. -The resident required extensive assistance for Activities of Daily Living such as bed mobility, transferring, walking, locomotion, dressing, eating, toilet use and personal hygiene. The resident required assistance from others to balance and stabilize when transitioning and walking. -The resident did not participate in a toileting program but experienced frequent urinary incontinence and occasional incontinence of bowel. No therapies or restorative nursing services were noted in the assessment. The 11/29/12 Computerized Physician order [REDACTED].) every day (QD), polyethylene glycol 17 grams (g) QD, and Lantus 100 unit/millileter(ui/ml) give 15 ui QHS. The CPO also included orders to provide a bed alarm pad, chair alarm, a low bed and TED hose (i.e., Thrombo-Embolic Deterrent) in place each morning and removed HS. Known Fall Risk and Facility Response: See MDS above regarding the resident's cognitive status and assistance needs. The 12/10/12 Nursing Care Plan (NCP) for falls included approaches to encourage the resident to ask for assistance, ensure the resident has proper footwear such as gripper socks or shoes, encourage resident to ask for assistance/use call light, offer assistance to toilet frequently and as accepted and provide a low bed with a fall mat. The 9/27/12 NCP included a goal for incontinence with the approach to prompt voiding every 2-3 hours and PRN. The 10/30/12 CPO included an order for [REDACTED]. The Resident Care Cardex noted the resident sometimes refused to wear TED hose. Staff were instructed to keep the resident's bed in a low position with use of a fall mat as well as encourage the resident to ask for assistance. On 11/07/12, a nurse's note documented an unwitnessed fall. The resident was noted to have gripper socks on and had her walker. An Interdisciplinary Post Fall Review was completed for the 11/07/12 fall. The fall was not witnessed and the resident was found sitting on her buttocks. The Fall Review summary indicated staff should encourage the resident to use her call light and call for assistance. The 11/09/12 nurse's note indicated the bedside mat was discontinued because the resident was noted to walk on it causing her to become unsteady. The note also indicated the resident's pressure pad alarm sounds when the resident attempts to leave her bed, but staff are unable to get to the resident's room as quickly as she gets out of bed. The note indicated staff would continue to monitor for safety. A Progress Note dated 11/9/12 included the Physician's Assistant (PA) agreement to discontinue the fall mat because it presented a tripping hazard for the resident. And a physician's Telephone Order (TO) dated 11/9/12 instructed staff to discontinue using the fall mat because it was no longer warranted. Another TO subsequently discontinued the chair alarm as the resident was independent. A review of nurse's notes, therapy notes and records did not indicate the facility provided further assessment, evaluation or recommendation to replace the fall mat with a suitable alternative or to further address the resident's unchanged risk for falling. Failure to implement planned measures for resident safety: On 12/12/12 at 3:25 p.m., the resident was observed standing in the middle of her bedroom, holding her walker with the bed pressure alarm sounding. A Certified Nurse Aide (CNA) approached the room and entered the room next door, not responding to the alarm. The resident stated repeatedly she had to go to the bathroom. The resident was not wearing shoes. The CNA responded several minutes later and assisted the resident to the toilet. On 12/12/12 at 3:25 p.m., the resident was observed leaving her room pushing her walker in her bare feet. The resident was stopped half way up the hall and returned to her room. On 12/12/12 at 3:50 p.m., the resident was observed pushing her walker up the hall in her bare feet. Her polyester pants were dragging on the ground and were tucked under both of her heels. A CNA stopped her and then left the resident to walk up the hall as the CNA went to retrieve the resident's shoes. On 12/17/12 at 4:48 p.m., the resident was observed walking to the bathroom in her room. The resident was pushing her walker in her bare feet. Interviews: A CNA was interviewed on 12/19/12 at 1:15 p.m. The CNA stated it was difficult to get to the resident's room because it was at the end of the hall. She indicated the resident often tries to go to the bathroom after rising from a nap and will not wait for assistance. A Registered Nurse (RN), familiar with the resident's care, was interviewed on 12/19/12 at 12:40 p.m. The RN stated the resident will get up from a nap and will not wait for assistance. The RN indicated there were no call lights in the room because the lights were removed from the secured unit some time ago. The RN stated assessments were not completed to determine if specific residents were able to use call lights. The RN also indicated the resident must wear proper footwear at all times and noted gripper socks could be placed over the resident's TED hose. An interview was conducted with the Director of Nursing (DON) on 12/20/12 at 12:20 p.m. The DON expressed her expectation for the resident to wear appropriate footwear when ambulating. She agreed staff should have escorted the resident to a safe place to sit before leaving her to retrieve the resident's shoes. 3. Resident #61, according to the facility face sheet, was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent MDS, dated [DATE], revealed the resident needed extensive assistance of one staff for transfer, toileting, dressing, and hygiene. She needed limited assistance in walking. She used a walker and a wheelchair. The resident had long- and short-term memory problems. She demonstrated disorganized thinking and inattention. The resident had one fall with minor injury. Known Fall Risk - Falls - Facility Response - Failures in Facility Response: See MDS above; the resident required extensive assist, demonstrated disorganized thinking and inattention and had a fall history. The resident's most recent fall risk evaluation dated 10/26/12, revealed the resident had a score of 14. (Total score of 10 or more represented high risk for falls.) Record review revealed the resident had falls on 1/12/12, 3/12/12, 4/27/12, 6/5/12. There were neurological checks to indicate a fall on 11/6/12, but no documentation of a fall. Further record review of nurses' notes on 8/17/12 at 8:30 p.m. revealed the resident was on neurological checks status [REDACTED]. -The resident was alert and confused (baseline). She had bruising and swelling at the left side of her chin and the right side of her chin. A change of condition form revealed the resident was found on the floor by her bed at 2:30 a.m. She had swelling and bruising on her left jaw and two bruises on her left upper arm. -The problem was thought to be that the resident had tried to go to the bathroom by herself. Record review revealed the resident fell with injury 12/4/12. -Nurses' notes on 12/4/12, revealed the resident was found on the floor of her room at 8:30 p.m. Her bed alarm was inaudible until inside her room and it was noted to be closed inside her bottom dresser drawer. She was lying on her right side. She verbalized severe localized pain approximately four inches distally of the right greater trochanter. Right hip femur x-ray ordered. Right hip and leg immobilized as much as possible. -Post fall review 12/4/12 revealed the resident was found in her room between the bed closet and room door lying on her right side. The bed alarm was not heard until in the room. The alarm was noted to be in a drawer. Unable to determine (cause) other than resident got up from her bed, fell to floor. The bed alarm was not in place at the time. Past interventions included self-releasing seat belt discontinued, high low bed discontinued on 10/26/12. The Summary of the Interdisciplinary Team (IDT) was review of current interventions in place, education to staff regarding placement of alarms. -A portable x-ray on 12/5/12 revealed an acute hip fracture. Review of the resident's care plan for falls revealed the most recent intervention for falls was dated 4/3/12. The intervention was to initiate self releasing seat belt, hi/low bed with fall mat. Physician's progress note on 6/7/12 revealed the physician spoke with the resident's family member who was concerned that the resident had a lap-belt that the resident could release herself and that she repeatedly did release it; she had a fall two days ago and hit her head. Record review revealed there was no assessment of the possible causes for the resident's falls, i.e. toileting issues, call light availability, medications, hunger or thirst. No new interventions were in place or reassessment of effectiveness of current interventions or need for new interventions. Observations: On 12/18/12 at 8:30 a.m., the resident was observed in bed sleeping. She was alone in the room. Her fall mat was at the foot of her bed. Her breakfast tray was on the over-bed table. The Hospice certified nurse aid (CNA) entered. The facility CNA also entered room. He stated that resident's fall mat was moved because the resident was being fed. He stated the resident can no longer move herself in bed. Interviews: On 12/19/12 at 4:00 p.m., the Nursing Home Administrator (NHA) and Corporate Consultant for Clinical Services (CCCS) were interviewed. When asked regarding interventions assessed and initiated for the resident's falls after 4/3/12, there was no response. 4. Resident #17, according to the facility face sheet, was admitted on [DATE] with [DIAGNOSES REDACTED]. The most current MDS dated [DATE], revealed a BIMS score of 15, indicating the resident had no long- or short-term memory loss. The resident had no behaviors. The resident needed total assistance of two staff for transfer and toileting. The resident had range of motion impairment on the upper extremity on one side. The resident used a wheelchair for mobility. The resident had an indwelling catheter. The resident was frequently incontinent of bowel and was not on a toileting program. The resident had additional [DIAGNOSES REDACTED]. Known Fall Risk: The resident's interdisciplinary care plan revealed a problem/need for risk for falls, identified 5/7/08 and last reviewed 8/23/12. The risk was related to history of previous falls, balance problems, history of fracture, psychotropic medications, and assistive devices, including a front wheel walker and wheelchair. The care plan revealed the approach of using the Hoyer lift for transfers. Observations - Lack of Adequate Supervision: On 12/13/12 at 10:30 a.m., the resident was observed in the shower room in a shower chair with two CNAs. On 12/13/12 at 10:35 a.m., one of the CNAs was observed in the resident's room, and the second CNA was observed in the hallway getting linen. When questioned about the whereabouts of the resident, the CNA stated she was in the shower room. The CNA used the key combination to open the shower room door, and the resident was alone in the room. The only emergency call device in the room was several feet away from the resident and per observation, did not work when activated. The CNA stated that she shouldn't have left the resident alone, but she needed to get the lift and another staff to help her with the lift. On 12/13/12 at 11:00 a.m., the CNA said she thought the resident would be safe alone because she had not fallen in the shower. The CNA stated the resident would not have been able to recover her position by herself if she slipped, and would not be able to reposition herself in the chair without help. The CNA stated she did not know the call light in the shower room did not work because she didn't try it. -At 11:15 a.m. the CNA stated she sent a work order for the shower room call light, and called maintenance. -At 2:00 p.m., the NHA was informed of the resident being left unattended in the shower room. The NHA immediately initiated an inservice for staff. 5. Resident #50, according to the facility face sheet, was admitted [DATE] with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. The resident was prescribed oxygen at 2 liters/minute. The most current MDS dated [DATE], revealed the resident was described as having long- and short-term memory problems and moderate impairment in daily decision-making. She was also described as having problems with inattention and disorganized thinking. The resident needed extensive assistance of one staff for bed mobility, transfer, toileting, dressing, and personal hygiene. The resident was coded as having no falls in the prior assessment period. Known Fall Risk: The resident's interdisciplinary care plan revealed a problem/need for risk for falls, identified on 8/2/12. The risk factors included recent fall, balance problems, decreased muscle coordination, and as needed use of narcotics. Approaches included that the resident was placed on the falling star program, and to encourage the resident to ask for assistance. A care plan for alteration in behavior dated 8/3/12, revealed the behavior was manifested by the resident deciding to get out of bed without assistance stating she crawled out of bed because she wanted to take a shower. The resident had an unwitnessed fall. The resident's Fall Risk Assessment sheet dated 10/15/12 revealed a score of 17 (high risk for falls). Failure: The facility fall incident report for the resident's fall on 8/2/12 revealed the resident fell at 8:00 a.m. The information from the nurse's note on the fall was rewritten on the incident report. No additional information was given in the investigation of the fall. There was no signature of the person completing investigation, or administrative signature. Past interventions were blank on the form. A physical therapy screen was recommended, and the resident was instructed to use call light for staff assistance. Observations and Interviews: On 12/12/12 at 1:50 p.m., the resident was observed sleeping in her wheelchair in the dining room. The resident had food debris on her clothing. There was no nursing staff observed in the dining room. The resident was using oxygen. Housekeeping and dietary staff were in and out of room. One dietary staff was interviewed. Dietary staff stated sometimes CNAs took sleeping residents to bed. On 12/12/12 at 2:00 p.m., a visiting corporate Director of Nursing (DON) came into the dining room and asked the resident if she would like to go to her room and go to bed. The resident responded that she thought she was in her room. When asked how he knew the resident was sleeping and unattended in the dining room, the visiting DON stated that he was told by administration to check the dining room for residents who needed to be returned to their room. On 12/13/12 at 1:05 p.m., the NHA and CCCS were interviewed. The CCCS stated they knew incidents and accidents were a problem. They knew the system was broken. The problem was first identified on 12/3/12. They reported that: -If there was an incident, it was reported followed by a post fall review, and investigation sheet. Starting 12/12/12, DON notification also was required. -The Interdisciplinary Team (IDT) has a fall meeting and should be doing the investigation, care plan, and interviews, including an interview with the CNA and nurse on duty. They should look at the room, look at the bathroom. -Close monitoring was not an intervention. They do not have a set standard monitoring, but it should be continuously, either a nurse or CNA should always be on hall. -The fall investigations were incomplete. When asked if the identification of the problem and action was timely considering the findings including falls with injuries since 12/3/12 (see above), the CCCS stated it should have been done sooner. The Interim NHA stated she started in the middle of September. The incident report recommendations to prevent falls looked like their process was to flip flop interventions, not assessment for new interventions. She agreed that there was no new information on the investigation form regarding resident #50's fall, just a repeat of the nurse's note. The CCCS stated she had prepared a fall packet on 12/3/12. The CCCS reported the packet included how to fill out the incident report, to call the physician timely, to fill out the first part of the post fall review and give it to the DON that same day, or call on the phone. The IDT was to meet the next day, update the care plan, and complete the second page of the post fall review. -The CCCS said they didn't have a specific form for staff interview, but they need to interview the nurse and CNA or whoever found the resident. They didn't have this written up as a policy. -The CCCS said they will be adding a charge person who will be responsible for filling out reports. They haven't looked at staffing as an intervention to decrease falls. The new job description for charge person will be duties added to existing staff. They didn't plan to add staff. 6. Resident #20, an [AGE] year old male, was admitted on [DATE] with the [DIAGNOSES REDACTED]. Resident Status: Review of the MDS dated [DATE], showed resident #20 had a BIMS score that was not completed. Functional status denoted the resident needed extensive assistance with all activities of daily living (ADLs). The resident needed one person assist for all ADLs except transferring, which required two people. The resident utilized a wheelchair for mobility. On 10/22/12 the telephone orders stated, "D/C (discontinue) alarm belt on W/C (wheelchair). Hoyer Lift d/t (due to) inconsistency with stand lift." Signed by the Physical Therapist (PT) and physician. On 10/23/12 the telephone order stated, "D/C bed and chair alarm signed by the LPN (licensed practical nurse) and physician. The transfer care plan noted to use a mechanical lift for all transfers. Known Fall Risk: The resident was care planned for falls. Review of the fall care plan dated 10/22/12, revealed it included the following approaches: -Falling star program, encourage resident to ask for assist, Interdisciplinary approval of physical therapy and occupational therapy, orient resident to room/environment, provide assistive devices wheelchair/footrests as indicated and accepted and foot support, place call light within reach, observe for potential patterns of falls to identify possible causes, offer/assist to toilet frequently and as accepted, assist with acquiring items, place frequently used items within reach, observe for potential medication related causes, and low bed with floor mat. -The most recent intervention was completed on 12/13/12, adding an approach for a one-to-one sitter PRN. Fall 11/3/12 with injuries: On 11/3/12 following a fall, there was a change of condition form completed that stated: 1. The sign/symptom/change I am calling about is: a fall from the wheelchair. 2. Things that make the problem/symptom worse are: no seat belt on chair. 3. Things that make the problem/symptom better are: alarmed seat belts. The assessment section noted a laceration to left orbital upper and lower and a skin tear. There are corresponding neurological status checks. However: -There were no Interdisciplinary Post Fall Review in the chart for the incident on 11/3/12. -There were no updates regarding safety interventions after this fall to the fall care plan (see below ED instructions). The nurses note from 11/3/12 stated the measurements of the laceration were 3 cm across his left upper orbital, a 1.5 mm laceration across his left lower orbital, and a skin tear to his left posterior wrist. The return nurses note stated he received seven stitches above the eye, and three below the eye, and he also had a cervical collar in place that was not to be removed according to the hospital Emergency Department (ED) physician. The ED physician sent patient visit information stating that read the r