Every finding on record at Colorado State Veterans Nursing Home - Rifle

Based on observations, interviews, and record review, the facility failed to protect three (#1, #3, and #2) out of seven residents from physical abuse out of 12 sample residents.Specifically, the facility failed to:-Protect Resident #2 and Resident #1 from physical abuse from each other; -Protect Resident #3 from physical abuse by Resident #1; and,-Protect Resident #2 from physical abuse by Resident #1. Findings include:I. Incident of physical abuse between Resident #2 and Resident #1 on 9/12/25The facility investigation, dated 9/12/25, documented Resident #2 was agitated and verbally aggressive towards staff around 7:30 p.m. All attempts to redirect Resident #2 were unsuccessful and his aggressive behaviors continued to escalate. Staff attempted to administer his evening medications; however, he refused. Staff continued to monitor and de-escalate Resident #2's aggressive behaviors.Around 8:00 p.m. Resident #2 and Resident #1 were in the dining room together. Staff were not present in the dining room and the incident had to be viewed on the facility's video surveillance system to determine what happened as the incident began.The investigation documented the nursing home administrator (NHA) viewed the video surveillance and documented the incident. The NHA documented the following events; Resident #2 approached Resident #1, in response, Resident #1 then kicked Resident #2's walker. Resident #2 then pushed his walker into Resident #1's knees. Staff separated the two residents. The investigation documented the staff utilized therapeutic neck massages to de-escalate Resident #2. Staff said that this intervention was successful as no additional incidents occurred that evening.Resident #1 and Resident #2 were both assessed to have severe cognitive impairment and were non-interviewable. The nursing assessment after the incident revealed neither resident had any physical injuries and did not appear afraid.The facility investigation revealed Resident #2 was not given his morning antipsychotic medication because he was asleep and the nurse did not want to wake him up to administer the medications. Additionally, at the time of the altercation, Resident #2 was ordered to be on line-of-sight supervision when out of his room due to his aggressive behaviors. Line of sight was defined as staff being able to continually observe the resident to ensure his safety and the safety of other residents.-However, in an interview with CNA #6 on 11/19/25 at 12:30 p.m. revealed the majority of the dining room cannot be viewed by staff from the nurses' station or the common area lounge just outside of the dining room (see staff interviews below). CNA #6 was interviewed as part of the facility investigation. CNA #6 said that it was important for Resident #2 to receive his scheduled medications to reduce his agitation. She said aside from administering his medications as ordered, she could not think of any additional interventions staff could have used to prevent the altercation from occurring.CNA #9 was interviewed as part of the facility investigation. CNA #9 said that aside from making sure that Resident #2 took his scheduled medications, she did not have any other suggestions on how the altercation could have been prevented.-The facility concluded that physical abuse did not occur because neither resident sustained major injuries or unreasonable confinement.-However, physical abuse occurred due to Resident #1 and Resident #2 willfully hitting and kicking each other. II. Incident of physical abuse by Resident #1 toward Resident #3 on 10/6/25The facility investigation, dated 10/6/25, documented registered nurse (RN) #4, who witnessed the resident-to-resident physical altercation was interviewed. She said that on the evening of 10/6/25, Resident #1 was very agitated and difficult to redirect despite the staff's attempts to de-escalate him. Around midnight, Resident #1 was in the dining room and looked like he needed assistance. When RN #4 offered Resident #1 assistance, he struck out at her and hit the pitchers that she was carrying. RN #4 reported that after he attempted to hit her, she left him alone. The investigation documented 20 minutes later, Resident #3 was headed into the dining room when Resident #1 postured and blocked the entrance to the dining room. Resident #1 then swung and hit Resident #3 in the chest. Staff separated the two residents. RN #4 said Resident #1 continued to have aggressive behaviors towards staff for the remainder of the evening until he went to sleep.RN #4 assessed both residents and determined that neither had sustained any physical injuries or psychosocial harm.Resident #3 was interviewed as part of the investigation. Resident #3 denied being involved in the altercation.-However, Resident #3 was diagnosed with dementia and determined to have severe cognitive impairment.As part of the facility investigation, CNA #10, who witnessed the altercation was interviewed. CNA #10 said Resident #1 was agitated and tried to hit all of the staff members that evening. She said that he eventually used the restroom, and calmed down after using the bathroom. CNA #10 said she suspected Resident #3's irritability was caused by needing to use the toilet. CNA #10 said she was not sure what the staff could have done differently to prevent the altercation.The facility concluded that physical abuse did not occur because neither resident sustained major injuries or unreasonable confinement.-However, abuse occurred due to Resident #1 willfully hitting Resident #3 in the chest.III. Incident of physical abuse by Resident #1 toward Resident #2 on 10/13/25The facility investigation, dated 10/14/25, documented Resident #1 approached Resident #2, who was napping in a chair in the common area, and unprovoked struck Resident #2 on the side of the face with his hand. Additional staff were called to help control the situation. The residents were then separated.CNA #7 was interviewed as a part of the facility's investigation. CNA #7 witnessed the physical altercation and said observed Resident #1 walk towards Resident #2 and thought the resident was just walking around. Then before she could respond she witnessed Resident #1 hit Resident #2 in the face. CNA #7 said the incident was unprovoked and there was no clear trigger to the event. The investigation documented the nursing staff assessed Resident #2 after the incident; resident #2 was found to have no injuries and denied any fear for his well-being.RN #4 was interviewed as a part of the facility investigation. RN #4 said Resident #1 was sitting in a recliner and threw his socks across the room, then got up out of his recliner as if to go pick up the socks, but continued walking towards Resident #2. Resident #1 appeared to be looking at the wall beside Resident #2 before struck Resident #across the face. RN #4 said after they separated the residents, Resident #1 said that Resident #2 was upsetting him. The facility concluded that physical abuse did not occur because neither resident sustained major injuries or unreasonable confinement.-However, abuse occurred due to Resident #1 willfully hitting Resident #2 in the face. IV. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the November 2025 computerized physician's orders (CPO), diagnoses include dementia of unspecified severity, with other behavioral disturbance, and aphasia (difficulty speaking).According to the 9/28/25 minimum data set (MDS), the resident was unable to participate in a brief interview for mental status (BIMS) exam. The staff assessment revealed the resident had short and long-term memory problems and severe cognitive impairment.2. Record reviewResident #1's behavior care plan, initiated on 5/23/2, revealed the resident had the potential to display aggressive behaviors.Pertinent interventions included: talking and interacting with Resident #1 on his interests, such as sports, swing music, and feeling helpful, and try to help him have a sense of purpose (initiated 10/6/25) and placing the resident on line of sight while out of his room and redirect him with one-on-one time, activities, snacks, and drinks (initiated 8/7/25).V. Resident #2A. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the November 2025 CPO, diagnoses include dementia of unspecified severity, with other behavioral disturbance, and mood disorder.The 9/11/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of seven out of 15.B. Record reviewResident #2's behavior care plan, initiated, 6/15/25, revealed the resident had the potential to display physical and verbal aggression. Pertinent interventions included: keeping the resident in line of sight and engaging the resident with activities that he preferred. VI. Resident #3A. Resident statusResident #3, age [AGE], was admitted on [DATE] and discharged from the facility on 10/16/25 to inpatient hospice. According to the October 2025 CPO, diagnoses included alcohol dependence with alcohol-induced persistent dementia, abnormalities of gait and mobility, and dementia of unspecified severity, with other behavioral disturbance.The 10/14/25 MDS assessment revealed the resident was unable to participate in a BIMS exam. Staff assessment of the resident revealed the resident had short and long term memory problems. VII. Staff interviewsThe activities director (AD) was interviewed on 11/20/25 at 9:40 a.m. The AD said if residents were aggressive or combative, the activities staff would not interact with the residents. She said staff would try to reapproach the resident at a later time in the day to engage the resident in activities. The AD said residents who socially isolate or have behavioral concerns would be placed on the friendly visit program or on individual activity sessions. She said that despite Resident #1's aggressive behaviors, he did not receive friendly visits or one-to-one activities. The AD said Resident #2 was on the friendly visit program due to his aggressive behaviors; the activities department would meet with him three times a week for individual visits.The NHA, social services director (SSD) and director of nursing (DON) were interviewed together on 11/20/25 at 10:00 a.m. The SSD said the staff were expected to know the resident's care plans so they could appropriately intervene if a resident becomes aggressive. The SSD said that staff were encouraged to respond to aggressive residents by intervening in the situation, distracting the aggressor, and ensuring a safe environment for other residents.The SSD said that one staff member was expected to monitor the day room at all times to ensure resident safety. She said some residents have care plan orders to be line of sight in common areas for behavioral concerns. The NHA said if staff were needed in many places at once, the staff should use their best judgment to determine which situation needs their attention first or call for a manager to provide additional supportCNA #4 was interviewed on 11/19/25 at 9:13 a.m. CNA #4 said she did not know what was on Resident #1's care plan nor could she identify his specific behavioral triggers or interests. She said that he might become more agitated in the evening and in response to care assistance, but she wasn't sure. She said that if he became agitated, she would try to have one staff person interact with him, try to decrease stimuli, and notify the nurse. CNA #6 was interviewed on 11/19/25 at 12:30 p.m. CNA #6 said she had worked with Resident #1 for a while. She said that when he was agitated, she would try to de-escalate him. CNA #6 said an example was when Resident #1 was grumpy and kept trying to get out of his chair in the day room, she would encourage him to stay seated because he was a fall risk. She said he would calm down when she got him a snack. CNA #6 said that her other strategy for interacting with aggressive residents was to physically stand in the way to protect another resident. CNA #6 said Resident #2 used to become agitated frequently. She said that when he became agitated, she would offer him a snack and encourage him to watch television. CNA #7 was interviewed on 11/19/25 at 4:11 p.m. CNA #7 said she saw Resident #1 hit Resident #2 on 9/12/25.RN #3 was interviewed on 11/19/25 at 12:15 p.m. RN #3 said she had a lot of experience working with Resident #2. She said he needed a lot of redirection. She said sometimes, she would offer him a snack or a drink if he became irritable. She said it was often difficult to figure out why he was agitated and that sometimes she was able to help him and sometimes she was not.RN #3 said sometimes she would redirect him by encouraging him to sit in a recliner in the dayroom. She said that when it came to his specific likes and dislikes, she thought he might like western movies, but was not sure.

Based on interviews, observations and record review the facility failed to provide necessary respiratory care and services, for one (#11) one resident out of 12 residents reviewed for oxygen therapy.Specifically the facility failed to:-Provide Resident #11 oxygen therapy as ordered; and,-Ensure the physician's order for Resident #11's oxygen therapy included the prescribed liter flow, method of delivery and duration of use. Findings include:I. Professional referenceAccording to the American Lung Association, Oxygen Therapy, updated 4/15/25, retrieved online 12/3/25 from https://www.lung.org/lung-health-diseases/lung-procedures-and-tests/oxygen-therapy Oxygen is a gas that is vital to human life. It is one of the gases that is found in the air we breathe. If you have a chronic lung disease, you may need additional (supplemental) oxygen for your organs to function normally.II. Facility policy and procedureThe Oxygen Therapy policy and procedure, reviewed on 12/16/24, was provided by the nursing home administrator (NHA) on 11/20/25. The facility policy read in pertinent part, It is the policy of the (Colorado State Veterans Nursing) that oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician. Oxygen is administered under orders of a physician, except in the case of an emergency. In such a case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Personnel authorized to initiate oxygen therapy include physicians, licensed nurses, and respiratory therapists. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to:-The type of oxygen delivery system.-Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered.-Monitoring for complications associated with the use of oxygen.III. Resident # 11A. Resident statusResident #11, age greater than 65, was admitted to the facility on [DATE]. According to the November2025 computerized physician's orders (CPO), diagnoses included diabetes, chronic kidney disease and chronic atrial fibrillationThe 10/6/25 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 12 out of 15. The MDS did not indicate that the resident was oxygen dependent. -However, the resident was prescribed oxygen therapy on 11/18/25.B. ObservationsDuring a continuous observation on 11/18/25,from 1:40 p.m. to 3:20 p.m. Resident #11 was observed without oxygen, sitting in a recliner in the common area lounge. Certified nurse aide (CNA) #1 approached Resident #11 at 3:20 p.m., one hour and 40 minutes after the resident was first observed without oxygen and asked the resident where his oxygen was. CNA #1 then proceeded to leave the common area room and down the hall to the residents room. CNA #1 returned back to the common area and was looking around the area. CNA #1 assisted the resident with a transfer to the wheelchair with the assistance of CNA #2 and took the resident to his room. At 3:22 p.m. CNA #1 came back to the common area lounge to search for the resident's oxygen concentrator. After finding the resident oxygen concentrator in the common area CNA #1 rolled it down to the resident's room. At 3:40 p.m. CNA #1 assisted the resident to apply his oxygen by nasal cannula. Resident #11 was observed in bed with nasal cannula on.The resident was observed taking labored breaths between speaking his words. C. Record reviewThe resident's comprehensive care plan. initiated 6/27/23 and revised on 11/13/25, revealed no interventions for oxygen therapy. The November 2025 CPO revealed a physician's order for oxygen therapy: Oxygen therapy, titrate to keep oxygen saturation level above 90 percent, (normal blood oxygen levels are between 90 to100 percent, measured by a device placed on the finger) start date 11/18/25 at 7:00 a.m. -The order failed to include the prescribed liter flow, method of delivery and duration of use.V. Staff interviewsCNA #2 was interviewed on 11/18/25 at 3:42 p.m. CNA #2 said Resident #11's oxygen therapy order was new this morning as a result of the resident presented with poor respiratory status and low oxygen levels. CNA #2 said she was not aware of how many liters of oxygen was ordered. She said the resident did not refuse oxygen therapy. She reported residents who were oxygen dependent were checked on frequently to check for portable oxygen fill needs and to ensure they are on oxygen. CNA #1 was interviewed on 11/18/25 at 3:50 p.m. CNA #1 said Resident #11 only had night time oxygen and often refused day time oxygen. He reported the resident was without his oxygen during the observation to provide transfer assistance and reported he was unaware if daytime oxygen was needed. Registered nurse (RN) #5 was interviewed on 11/20/25 at 10:20 a.m. RN #5 said all oxygen orders should include a prescribed oxygen liter flow, method of delivery and duration of therapy. RN #5 said if the order did not provide all applicable details the floor nurse was to reach out to the prescribing physician to get a corrected order following the facility's template for required details of the order. The director of nursing (DON) was interviewed on 11/20/25 at 12:00 p.m. The DON said she contacted Resident #11's physician to obtain a corrected oxygen order with the proper ordered information included. She said the new physician's order read Oxygen: 2 LPM (liters per minute - oxygen flow) via nasal cannula, monitor oxygen saturations every shift and notify the physician if unable to maintain oxygen saturation greater than 90 percent.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistive devices to prevent accidents. This failure affected one discharged resident (#61) and 22 current residents (#34, #31, #22, #14, #46, #35, #2, #33, #45, #17, #21, #42, #47, #54, #4, #7, #58, #18, #43, #52, #40 and #29) out of 41 sample residents. Specifically: TRANSFER POLES On [DATE], Resident #61, severely cognitively impaired and with a history of falls, was discovered stuck between the bed and his transfer pole. The facility failed to complete a safety risk assessment for Resident #61 before placing the transfer pole and, after the incident on [DATE], failed to investigate how the resident got stuck between the transfer pole and his bed. Record review and interviews revealed the facility failed to complete safety risk assessments for all 17 current residents (#34, #31, #22, #14, #46, #35, #2, #33, #45, #17, #21, #42, #47, #54, #4, #7 and #58) who had a transfer pole, to ensure resident safety. These failures created a situation of immediate jeopardy for serious harm that required immediate corrective action. FALLS The facility failed to prevent multiple falls, complete assessments after falls, investigate falls, and timely update fall care plans for Resident #18, Resident #43, Resident #52, Resident #4, and Resident #40. SMOKING and OXYGEN The facility failed to ensure Resident #29 did not smoke with his oxygen cannula on his face and hunched over his portable oxygen tank. Findings include: I. IMMEDIATE JEOPARDY A. Situation of Immediate Jeopardy Resident #61 was admitted on [DATE] with a history of falling. The resident was identified as severely cognitively impaired. The resident was ordered a vertical transfer pole to help with self-transfers on [DATE]. The facility failed to complete a safety risk evaluation for the use of the vertical transfer pole. On [DATE], Resident #61 was discovered by a certified nurse aide (CNA) stuck between the transfer pole and his bed. The CNA triggered the resident's emergency call light because she was unable to reposition the resident without assistance. The nurse responded and found the CNA trying to remove the resident from between the transfer pole and bed. The nurse noted the resident displayed agonal breathing (gasping), his eyes were open but he was not blinking and he had no pulse. The CNA and nurse repositioned the resident on his bed and did not start cardiopulmonary resuscitation (CPR) because the resident had an order for do not resuscitate. The nurse applied oxygen and emergency medical services (EMS) was called. When EMS arrived, the resident had begun breathing on his own. The facility failed to complete a safety risk assessment for Resident #61 after the incident on [DATE]. On [DATE], the facility completed a physical restraint assessment; however, the restraint assessment did not include a safety assessment. On [DATE] at 7:20 p.m., the nursing home administrator (NHA) was notified the failure in the facility's response to the incident on [DATE] and the failure to conduct safety risk assessments for all of the 17 current residents with transfer poles created a situation of immediate jeopardy that required immediate corrective action. B. Plan to remove Immediate Jeopardy On [DATE] at 6:05 p.m., the facility submitted the following plan to remove the immediate jeopardy situation: On [DATE] physical therapy (PT) staff completed evaluations for each resident with access to a transfer pole. Evaluations included proper placement (bed height, proximity to wall and/or toilet, distance from transfer surface) as well as resident conditions that may affect transfer, any risks for entrapment for all residents with access to transfer pole i.e. shared bathrooms. Assessments included: General assessment: fall risk, cognition, transfer ability and other comorbidities that may affect ability to safely use assistive or transfer devices by PT; Bedside: to include transfer ability with multiple assistive devices to determine safest option for individual resident need. PT to establish the distance from bed to appropriate assistive device and determine safest distance based on individuality of the resident and manufacturer's recommended use to 'make sure the product has sufficient space to allow user(s) to walk between the pole or handle and any other stationary object.' Assessment will include mechanics of the bed, including possible mattress and wheel shift; Placement considered safe and appropriate by PT from beside and bathroom individual evaluation as evidenced by distance deemed safe and beneficial through multiple transfer trials with PT to determine the resident's specific body habitus. 15-minute checks performed by direct care staff on shift until evaluation or assessment is completed by therapy and further determination is made. Evaluation or assessment to be completed by the end of business day [DATE]. Education of nursing staff will be provided by director of nursing (DON), infection preventionist (IP) or lead CNA prior to staff's next scheduled shift. Lead CNA educated by DON. Education includes: 15-minute checks and resident safety for residents for increased fall risk and for the residents that still have access to a transfer pole. If a new transfer or assistive device is implemented, the above staff will continue to educate front line staff, housekeeping and maintenance. Beds will be marked and staff educated to ensure appropriate placement. Will monitor placement of device installed in relation to the mattress, if the device is at bedside, an order obtained from PT every shift by nursing, daily safety rounds by restorative and quarterly by therapy and as needed. Resident's bed and any furniture in close proximity to the device will be marked on the floor to ensure proper replacement of furniture should it need to be temporarily moved. Will continue to encourage call light use. For those residents whose transfer pole was removed, staff have been educated to provide 15-minute checks, offer transfer assistance and encourage call light use education provided to direct care staff to continue with 15-minute checks until the interdisciplinary team (IDT) determines they are no longer needed to ensure safety. Encourage residents to use call light to request assistance and staff to provide transfer assistance as indicated. Any new transfer pole request will not be ordered or initiated until therapy completes and evaluation to determine appropriateness. C. Removal of Immediate Jeopardy Based on a review of the facility's plan, observations, and record review, the NHA was informed the immediate jeopardy situation was removed on [DATE] at 6:05 p.m. However, the deficient practice remained at a G level, isolated, actual harm. II. TRANSFER POLES A. Resident #61 1. Resident status Resident #61, age greater than 65, was admitted on [DATE] and passed away on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included heart failure, abdominal aortic aneurysm without rupture (swelling in the artery in the stomach), chronic kidney disease, osteoarthritis of the left knee, and abnormalities of gait and mobility. The [DATE] minimum data set (MDS) assessment revealed Resident #61 had a severe cognitive impairment with a brief interview of mental status (BIMS) score of three out of 15. Resident #61 was documented to have an impairment to both lower extremities and used a wheelchair. The resident had no restraint devices documented. 2. Record review Resident #61's activities of daily living (ADLs) care plan documented a vertical transfer pole as an intervention on [DATE]. Resident #61 had a physician's order for a vertical transfer pole dated [DATE]. On [DATE], a progress note documented in Resident #61's electronic health record (EHR) revealed: -At approximately 12:45 p.m., the nurse responded to the resident's emergency call light. The nurse discovered the CNA was attempting to remove the resident from in between the transfer pole, his bed, and a chair where the resident appeared to be stuck. The resident was noted to be bent over in a crumpled-up position with his foot stuck in between the transfer pole and his bed. -The resident was unresponsive with agonal breathing and his eyes were open and not blinking. The nurse attempted to assist the CNA by keeping the resident upright while two other CNAs moved the bed to free the resident's foot. The staff moved the resident flat on his bed into a Trendelenburg position (feet placed higher than the resident's head). -Resident #61 was not responding to verbal stimuli or a sternal rub. The nurse was unable to feel the resident's pulse. The nurse sent a CNA to get the physician and another CNA to call 911 and check the resident's code status. The resident was a do not resuscitate (DNR) and CPR (cardiopulmonary resuscitation) was not provided. The physician verified there was a cessation of heartbeat during the assessment of the resident. EMS arrived and Resident #61 began breathing more at a regular rate within several minutes of being in Trendelenburg and applying oxygen. The resident was making nonsensical statements. When EMS arrived the resident was able to speak and a transfer to the hospital was not necessary. A review of the resident's record revealed no evidence the facility had completed a safety risk assessment for Resident #61 before placing the transfer pole and, after the incident on [DATE], no evidence the facility completed a safety risk assessment or investigated how the resident became stuck between the transfer pole and his bed. On [DATE], a physical restraint evaluation was completed for Resident #61 and the transfer pole. However, the evaluation did not include a safety risk assessment. In addition to the failures above for Resident #61, the facility failed to review the use of transfer poles by 17 current facility residents (see below). B. Resident #34 1. Resident status Resident #34, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included osteoarthritis in an unspecified hand, fibromyalgia, dementia, pain in the right hip, generalized muscle weakness, and lack of coordination. The [DATE] MDS assessment revealed Resident #34 had a severe cognitive impairment with a BIMS score of six out of 15. Resident #34 used a walker and a wheelchair. The resident had no restraint devices documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #34 had a vertical transfer pole next to her bed. 3. Record review Resident #34 did not have a physician's order for a vertical transfer pole. Resident #34 did not have documentation in her care plan for a vertical transfer pole. Resident #34 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #34 was a high fall risk. C. Resident #31 1. Resident status Resident #31, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included chronic kidney disease, mild cognitive impairment, and Guillain-Barre Syndrome (a neurological disorder where the nervous system attacks the peripheral nervous system). The [DATE] MDS assessment revealed Resident #31 had a severe cognitive impairment with a BIMS score of six out of 15. Resident #31 had no impairments to his extremities and used a cane or crutch to walk. The resident had no restraint devices documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #31 had a vertical transfer pole next to his bed. 3. Record review Resident #31 did not have a physician's order for a vertical transfer pole. Resident #31 did not have documentation in his care plan for a vertical transfer pole. Resident #31 did not have a safety risk assessment for a vertical transfer pole A fall risk assessment completed on [DATE] revealed Resident #31 was a high fall risk. D. Resident #22 1. Resident status Resident #22, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included seizures, epilepsy, traumatic brain injury with loss of consciousness, macular degeneration (a disease that damages the eye), and mild cognitive impairment. The [DATE] MDS assessment revealed Resident #22 had a severe cognitive impairment with a BIMS score of six out of 15. Resident #22 had no impairments to his extremities and used a wheelchair. The resident had a motion sensor alarm used daily but no other restraints were documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #22 had a vertical transfer pole next to his bed. 3. Record review Resident #22 did not have a physician's order for a vertical transfer pole. Resident #22 did not have documentation in his care plan for a vertical transfer pole. Resident #22 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #22 was a high fall risk. E. Resident #14 1. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included psychotic disorder with delusions, osteoarthritis, age-related macular degeneration, dementia, and Parkinson's disease. The [DATE] MDS assessment revealed Resident #14 was unable to participate in the assessment because he was unable to be understood. The staff assessment revealed the resident had short-term and long-term memory problems. Resident #14 had an impairment to his lower extremities and used a walker and wheelchair. The resident had no restraint devices documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #14 had a vertical transfer pole next to his bed. 3. Record review Resident #14 did not have a physician's order for a vertical transfer pole until [DATE] (during the survey). Resident #14 did not have documentation in his care plan for a vertical transfer pole until [DATE] (during the survey). Resident #14 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #14 was a high fall risk. F. Resident #46 1. Resident status Resident #46, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included bipolar disorder, abnormalities of gait and mobility, abnormal involuntary movements, and neuroleptic-induced Parkinsonism (Parkinson's disease caused by antipsychotic medications). The [DATE] MDS assessment revealed Resident #46 had a moderate cognitive impairment with a BIMS score of nine out of 15. Resident #46 had impairments to his lower extremities and used a walker and a wheelchair. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #46 had a vertical transfer pole next to their bed. 3. Record review Resident #46 had a physician's order for a vertical transfer pole on [DATE]. Resident #46 did not have documentation in his care plan for a vertical transfer pole. Resident #46 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #46 was a high fall risk. G. Resident #35 1. Resident status Resident #35, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included dementia, stage three chronic kidney disease, osteoarthritis, and bilateral low-tension glaucoma. The [DATE] MDS assessment revealed Resident #35 had a severe cognitive impairment with a BIMS score of five out of 15. Resident #35 had impairments to one side of his lower extremities and used a wheelchair. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #35 had a vertical transfer pole next to his bed. 3. Record review Resident #35 did not have a physician's order for a vertical transfer pole. Resident #35's fall care plan revealed the resident had a transfer pole as a fall intervention on [DATE]. Resident #35 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #35 was a high fall risk. H. Resident #2 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included altered mental status, repeated falls, bilateral primary osteoarthritis of the knee, Parkinson's disease with dyskinesia (involuntary movements), Parkinson's disease without dyskinesia, bilateral age-related nuclear cataract (an eye disease that causes blindness) and muscle wasting and atrophy. The [DATE] MDS assessment revealed Resident #2 was cognitively intact with a BIMS score of 15 out of 15. Resident #2 had impairments to his lower extremities and used a wheelchair. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #2 had a vertical transfer pole next to his bed. 3. Record review Resident #2 did not have a physician's order for a vertical transfer pole. Resident #2 did not have documentation in his care plan for a vertical transfer pole. Resident #2 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #2 was a high fall risk. I. Resident #33 1. Resident status Resident #33, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included stage two chronic kidney disease, peripheral vascular (eye) disease, restless legs syndrome, and cellulitis (infection) in her lower extremities. The [DATE] MDS assessment revealed Resident #33 was cognitively intact with a BIMS score of 15 out of 15. Resident #33 had impairments to her lower extremities and used a walker and a wheelchair. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #33 had a vertical transfer pole next to her bed. 3. Record review Resident #33 did not have a physician's order for a vertical transfer pole. Resident #33 did not have documentation in her care plan for a vertical transfer pole. Resident #33 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment was not completed for Resident #33. However, Resident #33's fall care plan revealed she was a moderate risk for falls. J. Resident #45 1. Resident status Resident #45, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included chronic kidney disease and osteoarthritis. The [DATE] MDS assessment revealed Resident #45 was cognitively intact with a BIMS score of 13 out of 15. Resident #45 had no impairments to his extremities and used a walker. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #45 had a vertical transfer pole next to his bed. 3. Record review Resident #45 did not have a physician's order for a vertical transfer pole. Resident #45 did not have documentation in his care plan for a vertical transfer pole. Resident #45 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #45 was a moderate fall risk. K. Resident #17 1. Resident status Resident #17, age lower than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included mild cognitive impairment, osteoarthritis, and dementia. The [DATE] MDS assessment revealed Resident #17 was cognitively intact with a BIMS score of 14 out of 15. Resident #17 had no impairments to his extremities and used a walker. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #17 had a vertical transfer pole next to their bed. 3. Record review Resident #17 did not have a physician's order for a vertical transfer pole. Resident #17 did not have documentation in his care plan for a vertical transfer pole. Resident #17 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #17 was a moderate fall risk. L. Resident #21 1. Resident status Resident #21, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included osteoarthritis of the hip, diastolic (congestive) heart failure, bilateral osteoarthritis of knees, age-related macular degeneration, and fatigue. The [DATE] MDS assessment revealed Resident #21 was mildly cognitively impaired with a BIMS score of nine out of 15. Resident #21 had no impairments to his extremities and used a walker. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #21 had a vertical transfer pole next to his bed. 3. Record review Resident #21 did not have a physician's order for a vertical transfer pole. Resident #21 did not have documentation in his care plan for a vertical transfer pole. Resident #21 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #21 was a moderate fall risk. M. Resident #42 1. Resident status Resident #42, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included age-related osteoporosis, dementia, history of falls, systolic (congestive) heart failure, and abnormalities of gait and mobility. The [DATE] MDS assessment revealed Resident #42 moderate cognitive impairment with a BIMS score of seven out of 15. Resident #42 had no impairments to her extremities and used a wheelchair. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #42 had a vertical transfer pole next to her bed. 3. Record review Resident #42 did not have a physician's order for a vertical transfer pole. Resident #42 did not have documentation in her care plan for a vertical transfer pole. Resident #42 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #42 was a high fall risk. N. Resident #47 1. Resident status Resident #47, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included chronic diastolic heart failure and glaucoma (eye disease). The [DATE] MDS assessment revealed Resident #47 cognitively intact with a BIMS score of 14 out of 15. Resident #47 had no impairments to her extremities and used a walker. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #47 had a vertical transfer pole next to her bed. 3. Record review Resident #47 did not have a physician's order for a vertical transfer pole. Resident #47 did not have documentation in her care plan for a vertical transfer pole. Resident #47 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #47 was a high fall risk. O. Resident #54 1. Resident status Resident #54, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included chronic pain syndrome, muscle wasting and atrophy, generalized muscle weakness, and abnormalities of gait and mobility. The [DATE] MDS assessment revealed Resident #54 cognitively intact with a BIMS score of 15 out of 15. Resident #54 had impairment to one side of her lower extremities and used a walker and a wheelchair. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #54 had a vertical transfer pole next to her bed. 3. Record review Resident #54 did not have a physician's order for a vertical transfer pole. Resident #54 did not have documentation in her care plan for a vertical transfer pole. Resident #54 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #54 was a moderate fall risk. P. Resident #4 1. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included chronic pain syndrome, stage three chronic kidney disease, abnormal involuntary movements, mild cognitive impairment, tremors, repeated falls, and muscle wasting and atrophy. The [DATE] MDS assessment revealed Resident #4 moderate cognitive impairment with a BIMS score of 12 out of 15. Resident #4 had no impairments to her extremities and used a walker and a wheelchair. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #4 had a vertical transfer pole next to her bed. 3. Record review Resident #4 did not have a physician's order for a vertical transfer pole. Resident #4 did not have documentation in her care plan for a vertical transfer pole. Resident #4 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #4 was a high fall risk. Q. Resident #7 1. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included dementia, stage three chronic kidney disease, and chronic pain syndrome. The [DATE] MDS assessment revealed Resident #7 moderate cognitive impairment with a BIMS score of eight out of 15. Resident #7 had no impairments to her extremities and did not use assistance devices for ambulation. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #7 had a vertical transfer pole next to her bed. 3. Record review On [DATE] (during the survey) Resident #7 had a physician's order for a vertical transfer pole in the bathroom. Resident #7's ADL care plan had an intervention to use a transfer pole in the bathroom to assist with standing up from the toilet on [DATE] (during the survey). Resident #7 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #7 was a high fall risk. R. Resident #58 1. Resident status Resident #58, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included stage two chronic kidney disease, bilateral osteoarthritis of knees, low back pain, and generalized muscle weakness. The [DATE] MDS assessment revealed Resident #58 was cognitively intact with a BIMS score of 15 out of 15. Resident #58 had no impairments to his extremities and did not use assistive devices for ambulation. The resident had no physical restraints documented. 2. Observations On [DATE] at approximately 2:00 p.m., observations revealed Resident #58 had a vertical transfer pole next to their bed. 3. Record review On [DATE] (during the survey) Resident #58 had a physician's order for a vertical transfer pole in the bathroom. Resident #58's ADL care plan had an intervention to use a transfer pole in the bathroom to assist with standing up from the toilet on [DATE] (during the survey). Resident #58 did not have a safety risk assessment for a vertical transfer pole. A fall risk assessment completed on [DATE] revealed Resident #58 was a moderate fall risk. S. Resident interviews Resident #45 and Resident #33 were interviewed together on [DATE] at 6:00 p.m Resident #45 said he and his wife had transfer poles next to their beds. He said his pole was removed by staff and the staff told him he could not have a transfer pole. Resident #33 said her husband used her transfer pole more than she did. Resident #45 said when he got out of bed he had to reach across the gap between his and his wife's bed to use her transfer pole to make it easier for him to get up. He said it was a large gap since each bed was placed against different walls. He said he feared falling but needed to use Resident #33's transfer pole to continue being independent. T. Staff interviews 1. The staff development coordinator (SDC) was interviewed on [DATE] at 6:07 p.m. The SDC said the therapy department placed vertical transfer poles and sometimes they were placed by the maintenance team. The SDC said there needed to be an indication for a resident to need the transfer pole. She said once there was a need identified, the resident needed to be assessed for safety and a physician's order was needed. She said the restorative registered nurse (RRN) completed almost everything the resident needed to get a transfer pole. The SDC was unsure how staff checked for the proper placement of the transfer pole and where the transfer pole needed to be placed. She said the assessment was supposed to make sure the resident would not get entrapped or cause injury. She said she was unsure how she would know if a transfer pole was safe for a resident. The SDC said the incident with Resident #61 was not investigated and her statement was never taken by leadership. The SDC said she was informed the resident was found stuck and unconscious. 2. Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 6:07 p.m. LPN #2 said a resident was assessed by the nurse and therapy before a transfer pole was installed. She said the RRN placed the transfer poles and sometimes maintenance placed the transfer poles. She said the transfer poles were documented in each resident's care plan and the resident needed to be reassessed periodically for safety. LPN #2 said she had not received education about the transfer poles and she was unsure where the poles were supposed to be placed or how to know if the transfer poles were right for the resident. 3. CNA #7 was interviewed on [DATE] at 6:07 p.m. CNA #7 said she was the staff member who discovered Resident #61 on [DATE]. She said the resident attempted to self-transfer and got stuck between his bed and the transfer pole. CNA #7 said Resident #61's knees were stuck and he was facing the head of the bed but he was bent backward toward the foot of the bed. She said she triggered the resident's emergency call light and tried to get his knees unstuck. CNA #7 said the resident was breathing but very slow and weird when she found him. CNA #7 said Resident #61 was with me but he was not with me. She said she was unable to recall when the resident was last seen before the incident. She said she was not interviewed about what happened. 4. CNA #8 was interviewed on [DATE] at 6:07 p.m. CNA #8 said if[TRUNCATED]

Based on observations, record review and interviews, the facility failed to provide care and treatment to prevent the development and worsening of pressure injuries for one (#54) of two residents reviewed for pressure injuries out of 41 sample residents. Resident #54 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, history of toe amputation, osteomyelitis (bone infection) and neuropathy. On 9/26/24, after not wearing her podiatry ordered offloading boots due to a red area on her heel, potentially from the podiatry offloading boot and/or a screw located on her wheelchair foot pedal, Resident #54 developed a blister on her left heel which progressed into an unstageable pressure ulcer. Resident #54 had physician's orders for the offloading pressure relieving boots and the boots were care planned, however, the resident did not consistently wear the boots as ordered. The resident's refusals to wear the boots were not documented or refusals were not care planned and there were no care plan interventions directing staff what to do if the resident refused the boots. Resident #54 was able to identify why she did not consistently wear the pressure relieving boots but the facility did not ask the resident her reasoning or implement interventions to address the resident's concerns with the pressure relieving boots. Due to the facility's failures to ensure effective interventions were put in place and monitored for compliance and effectiveness, Resident #54 developed a blister to her left heel which worsened to an unstageable pressure ulcer. Additionally, Resident #54 was identified on 11/13/24 to have a potential second pressure wound developing to her right lateral foot. 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 from https://www.internationalguideline.com on 12/3/24, Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) 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/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 Loss. 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 blister. Presents as a shiny or dry shallow ulcer without slough or bruising. The Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss. Full 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 Loss. Full 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 ulcer can extend into muscle and/or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown. Full 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) on 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 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 and procedure The Wound Management policy, revised on 8/7/24, was provided by the corporate consultant (CC) on 11/22/24 at 10:02 a.m. The policy read in pertinent part, To promote wound healing and decrease the risk of developing various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and provider orders. Wound treatment should be provided in accordance with provider orders, including the cleansing method, type of dressing and frequency of dressing change. Implement appropriate interventions to decrease risk of recurrence as applicable. Treatments should be documented on the MAR (medication administration record) or TAR (treatment administration record). The effectiveness of treatments should be monitored through ongoing assessment of the wound. The resident's comprehensive care plan should be kept up to date. III. Resident #54 A. Resident status Resident #54, age greater than age 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included diabetes mellitus due to underlining condition with diabetic autonomic (complication of diabetes), acute kidney failure, osteomyelitis (bone infection), unspecified open wound of unspecified toe and other abnormalities of gait and mobility. The 10/11/24 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 did not exhibit rejection of care behaviors and used a wheelchair for mobility. According to the MDS assessment, the resident was at risk for developing pressure ulcers and had an unhealed stage one or greater pressure ulcer. The MDS assessment revealed the resident had an unstageable pressure ulcer. IV. Resident interview and observations Resident #54 was interviewed on 11/18/24 at 3:48 p.m. Resident #54 was sitting in a wheelchair in her room. She said she developed a blister on her left foot that turned into a wound. She said she did not have a lot of feeling in her foot but the boot she received (from the podiatry physician) had bothered her foot. The resident said she developed the blister shortly after being admitted to the facility. Resident #54 said she had a boot she should have been wearing but she had not put it on for the day (11/18/24). She said she was supposed to wear the boot when she was up and out of bed. She said she could put the boot on herself but staff could help her if she asked them too. Resident #54 said she should currently be wearing the soft form heel protective boot for her left foot, but the boot would get tangled up in her wheelchair and so she did not like to wear it. On 11/20/24 at 10:04 a.m. Resident #54 was laying in bed. The resident wore socks on her feet, however she was not wearing her heel protective boots. Resident #54's heels were resting directly on the bed. Resident #54 was interviewed a second time on 11/20/24 at 1:54 p.m. Resident #54 was in her wheelchair and wore a heel protective boot on her left foot. The resident's feet were both on the wheelchair foot pedals. She said she just got back from a podiatry appointment and said the wound on her left foot would be slow to heal. On 11/21/24 at 8:42 p.m. the resident was in bed. She had two soft foam heel protective boots by her walker which she was not wearing. On 11/22/24 at 9:03 a.m. Resident #54 was sitting on her bed. She did not have her heel protective boots on. The resident said she did not like wearing boots in bed because she needed a pillow between her knees for comfort, and the pillow and the boots were too much together. Resident #54 said her soft form boots were too bulky to wear in bed and with her wheelchair. She said her wheelchair foot pedals were not comfortable with the boots on. She said there was a screw that held the back strap on the foot pedal that was causing some rubbing on her foot. She said the screw was removed but the foot pedals, the size of her wheelchair and the boots together did not feel comfortable. She said no one had looked at her foot pedals or her wheelchair to determine if there could be an adjustment made to create a better fit when she wore her foam heel protective boots. V. Wound care observations and interview On 11/20/24 at 1:40 p.m. wound care was observed with the physician (PHY). Resident #54 wore a heel protective boot over a sock on her left foot. The PHY said the wound to her left foot was started by a podiatry shoe. He said the shoe caused a blister so the resident stopped using the shoe. The PHY said the podiatry shoe had a plastic insert in the heel that could not be removed and that caused the pressure to the resident's heel. The PHY said the facility had had difficulty with the local podiatry specialists and had had to watch their recommendations and devices closely over the last few months. Resident #54's left heel had eschar (dead tissue) throughout the wound. The wound measured 3.5 centimeters (cm) by 4.2 cm x 0.1 cm. The PHY said the wound was unstageable. The PHY said the wound was avoidable because of the shoe from the podiatrist, but was also unavoidable because her blood sugars were out of control when the injury occurred. The PHY placed Iodosorb (wound treatment) around the edges of eschar and a large heel dressing was placed on the resident's heel. A sock and a blue heel protective boot were placed on the resident's left foot. VI. Record review The 7/18/24 Braden Scale assessment (a tool for predicting pressure ulcer risk) identified Resident #54 was at risk for developing pressure sores The skin integrity care plan, revised 11/7/24, indicated Resident #54 had a potential/actual impairment to skin integrity to her bilateral feet related to diabetes type 2 neuropathy, fragile skin and a current chronic non healing wound. The care plan identified the resident had a recent surgical toe amputation and a history of osteomyelitis and cellulitis. The care plan interventions on 7/22/24 included directing staff to document weekly treatment to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, educating the resident/family/caregivers of causative factors and measures to prevent skin injury, encouraging good nutrition and hydration in order to promote healthier skin, following facility protocols for treatment of injury, identifying and documenting potential causative factors and eliminating/resolving where possible, monitoring/documenting location, size and treatment of skin injury and reporting abnormalities, failure to heal and signs and symptoms of an infection or maceration to the physician. The care plan interventions initiated on 10/21/24 included using caution during transfers and bed mobility to prevent striking the resident's arms, legs, and hands against any sharp or hard surface, using bilateral foot pedals on the resident's wheelchair for offloading and using offloading boots when the resident was seated and lying down. -Review of Resident #54's care plan did not identify the resident refused her offloading heel protective boots. -The care plan did not identify interventions to try if and when the resident refused to wear her heel protective boots. The skin/wound note, dated 9/26/24 at 6:17 p.m. documented Resident #54 informed the registered nurse (RN) there was an issue with her left foot. The RN assessed the resident's foot and identified the resident had a large blister covering the majority of the edge of her heel. According to the note, the blister was not present earlier during the shift when the RN changed the dressing to the resident's hallux (toe) on the same foot. The note identified the resident was not wearing her heel protective boot on 9/26/24 by choice. The RN notified the wound care nurse (WCN). A second skin/wound note, dated 9/26/24 at 9:31 p.m. documented Resident #54 had a large 3 cm by 2 cm serous (clear, liquid part of the blood) filled blister. The blister was drained and treated per the recommendations of the PHY. Resident #54 was unsure of how the blister formed but said she had noticed a red area on her left heel prior to the formation of the blister. The note identified the lack of the resident not wearing her boot could have contributed to the blister. The resident said the bottom area of the blister was sore but the pain was relieved once drained. The podiatry report dated 10/2/24 documented Resident #54 had a blister on her left heel. The resident had been using a wheelchair which had a screw on it and the resident believed the blister began due to the rubbing of the screw and the boot she was wearing had a hard area inside it. The blister had increased in size from the size of a quarter to a half dollar. The podiatry note further documented Resident #54 developed a blister on the left heel likely due to pressure from a screw on the wheelchair and from a hard boot. The blister had been drained and dressed regularly. The wound was not deep but continued wound care was necessary to prevent it from becoming deeper. The physician note dated 10/2/24 identified Resident #54 had a deep tissue pressure injury persistent and non blanchable pressure injury acquired on 10/2/24. The initial wound measured 4.5 cm width by 0.2 cm depth with a small amount of serous drainage. The physician recommended offloading and floating the resident's heels in bed and directed staff to check on the resident's feet and lower extremities every shift and ensure proper footwear. Review of the November 2024 CPO revealed the following physician's orders: Use of offloading boots (heel protective boots), ordered on 10/21/24. Wound care: change the left inner heel dressing daily. Cleanse with wound cleanser soaked gauze, remove and allow it to dry. Apply Iodosorb around the wound edges, cover with foam heel dressing and notify the provider and/or wound RN of concerns, ordered on 10/23/24. -The October 2024 medication administration record (MAR) and the treatment administration record (TAR) did not identify the active order for the use of heel protective boots. -The October 2024 MAR and TAR did not identify the tracked administration and use of the ordered heel protection. -Review of Resident #54's October 2024 electronic medical record (EMR) did not identify Resident #54 was offered and refused the physician ordered heel protective boots. The skin/wound note dated 11/6/24 documented the resident's left inner heel wound was an unstageable pressure wound measuring 3 cm by 3 cm by 0 cm. The 11/9/24 podiatry consultation report documented Resident #54 had a podiatry appointment on 11/20/24 at 11:00 a.m. The report identified Resident #54 should wear offloaders (heel protective boots) to both feet when she was not ambulating. -However, observations during the survey revealed Resident #54 was not consistently wearing her heel protective boots (see observations above). The skin/wound note, dated 11/13/24, identified the resident's right lateral foot was red but the skin was intact. The right foot would be monitored daily during wound care to the left foot and staff was to place a foam dressing if necessary and notify podiatry at the 11/20/24 appointment per the PHY. According to the wound note, the resident should be encouraged to wear foam heel protective boots for increased protection and offloading. -However, observations during the survey revealed Resident #54 was not consistently wearing her heel protective boots (see observations above). The note further documented Resident #54 left inner heel dressing was removed revealing an increased maceration (breakdown of the skin due to prolonged exposure to moisture) to 360 degrees surrounding the wound's edges due to the dressing not covering the entire site of the wound. The wound measured 3.3 cm by 4.2 cm by 0.3 cm. The podiatry report, dated 11/20/24, identified Resident #54 was seen by the podiatrist on 11/20/24. The report documented the resident reported her heel dressing was changed daily, however the dressing had not been changed before the 11/20/24 (at 11:00 a.m.) appointment. The report identified the resident's left medial heel had eschar measuring 4 cm by 3 cm with a small amount of drainage at the wound edges. According to the report, the resident did not have an offloading heel protective boot and an offloading heel boot was provided to the resident to relieve pressure. In addition, the podiatry report identified Resident #54 had a stage 0 pressure ulcer at the base of her right fifth metatarsal (a bone in the foot). The skin/wound note, dated 11/20/24, documented the resident returned from her podiatry appointment. The left heel wound measured 1.5 cm by 1 cm by 0.5 cm with 100% dry stable eschar to the wound site without drainage or odor. According to the note, the resident was to wear offloading heel protective boots to bilateral feet when she was not ambulating. -However, observations during the survey revealed Resident #54 was not consistently wearing her heel protective boots (see observations above). -The November 2024 MAR and TAR did not identify the active order for the use of heel protective boots. -The November 2024 MAR and TAR did not identify the tracked administration and use of the ordered heel protection. -Review of Resident #54's November 2024 EMR did not identify Resident #54 was offered and refused the physician ordered heel protective boots. VII. Staff interviews The WCN and the DON were interviewed together on 11/21/24 at 1:20 p.m. The WCN said Resident #54 had an unstageable pressure ulcer to her left inner heel. The WCN said on 9/26/24, Resident #54's nurse notified her that the resident had a serous filled blister on her left heel. She said the resident wore an offloading boot she received from the podiatrist as ordered on 8/1/24. The WCN said the resident told the nurse the offloading boot was giving her a red mark so she did not wear the boot on 9/26/24, potentially resulting in the blister to her heel. The WCN said the resident had been wearing the boot since shortly after her facility admission (7/18/24). She said Resident #54 had not complained of the boot bothering her before 9/26/24 and a red mark was not observed on her heel. She said the offloading boot the podiatrist provided had a piece of plastic near the heel of the boot as part of its design. She said Resident #54 went to the podiatrist after the blister developed and was provided with the soft foam heel protective boots. The WCN said Resident #54 should have been wearing the heel protective boots all the time unless she was transferring from surface to surface. She said the staff should be reminding and encouraging the resident to wear the soft foam heel protective boots to both of her feet and use her wheelchair foot pedals when she was using her wheelchair. The WCN said the staff should be documenting any refusals of the heel protective boots in the MAR and TAR. The WCN said she had not care planned that Resident #54 did not consistently use and/or refused her physician ordered heel protective boots. The WCN said the resident did not feel and or understand that she should be wearing the heel protective boot of her right foot for pressure relief along with the left foot. She said she had not care planned that the resident did not want to use the right boot either. The WCN said Resident #54 felt she only needed the boot worn on her left foot to cover the wound. The WCN said she had not care planned interventions regarding what staff should do when the resident refused the heel protective boots. The DON said she had seen Resident #54 wear the left heel protective boot but not the right. She said she had not asked the resident why she did not wear the boots consistently. The WCN said the soft foam heel protective boots were bulky but she was not aware the resident felt the boot got tangled up with her wheelchair. The WCN said the resident told her the boots were uncomfortable in bed so she suggested Resident #54 try to prop a pillow under her legs, but she said she needed to evaluate if the pillow would be comfortable to her as an intervention. The WCN said Resident #54 was at risk for additional concerns because she had lost a toe (related to osteomyelitis) and did not want the same concern to happen to her foot. Certified nurse aide (CNA) #6 was interviewed on 11/22/24 at 9:15 a.m. CNA #6 said he frequently worked with Resident #54. He said he usually saw Resident #54 wearing a heel protective boot on her left foot when she was out of her room. He said she could put the boot on herself. He said the resident did not need or use a heel protective boot on her right foot. He said she only needed a heel protective boot to cover the left foot wound. CNA #6 said he was not sure if the resident should wear the heel protective boots in bed. -However, the resident had a physician's order to wear the heel protective boots and instructions from the physician to wear them except when she was ambulating (see record review above) The DON and the NHA were interviewed together on 11/22/24 at 2:12 p.m. The DON said pressure ulcers were reviewed with the IDT. She said the team reviewed the residents that currently had pressure ulcers, identified if the pressure ulcers were improving, what treatments were provided and received insight from the medical director. The DON said the staff spoke to Resident #54 on 11/21/24 (during the survey) and learned that the resident did not always wear her foot pedals as she should and the facility would be following up with her on her concerns with the foot pedals. The DON said the facility needed to work on improving documenting refusals of interventions, increasing observations of the resident and addressing concerns with the resident.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to implement an effective system to identify and address multiple concerns related to quality of care, including accidents/hazards, in which the facility failed to conduct safety risk assessments for residents with transfer poles which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely. Findings include: I. Facility policy The Quality Assurance Performance Improvement (QAPI) policy, updated 9/30/24, was provided by the nursing home administrator (NHA) on 11/18/24 at 1:21 p.m. The policy documented in pertinent part, It is the policy that the facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life. Develop and implement appropriate plans of action to correct identified quality deficiencies. Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. The QAPI plan should address the following elements: -Design and scope of the facility's QAPI program and QAA (Quality Assessment and Assurance) committee responsibilities and actions; -Policies and procedures for feedback, data collection systems, and monitoring; and, -Process addressing how the committee should conduct activities necessary to identify and correct quality deficiencies. Key components of this process include: -Tracking and measuring performance; -Establishing goals and thresholds for performance improvements; -Identifying and prioritizing quality deficiencies; -Systematically analyzing underlying causes of systemic quality deficiencies; -Developing and implementing corrective action or performance improvement activities; and, -Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. The facility takes actions aimed at performance improvement as documented in QAA committee meeting minutes and action plans. Performance/success of the actions should be monitored and documented in subsequent QAA committee or sub-committee meetings. To ensure improvements are sustained, the effectiveness of performance improvement activities should be monitored in QAA committee meetings in accordance with the QAPI plan, but no less than annually. II. Cross-referenced citations affecting quality of care identified during the facility's recertification on 11/22/24 Cross-reference F689: The facility failed to ensure the resident environment remained as free of accident hazards as possible. The facility failed to complete a safety risk assessment before placing resident transfer poles and failed to investigate after a transfer pole accident. Additional accident/hazards failures were identified related to fall prevention and smoking while wearing a nasal cannula and a turned off oxygen tank. The deficiency was cited at a K scope and severity, immediate jeopardy, pattern. Cross-reference F686: The facility failed to prevent a resident from developing a pressure ulcer and failed to ensure interventions were consistently in place to prevent the pressure ulcer from worsening. The deficiency was cited at a G scope and severity, actual harm, isolated. Cross-reference F880: The facility failed to maintain an effective water management plan. The deficiency was cited at a F scope and severity, potential for more than minimal harm, widespread. Cross-reference F600: The facility failed to protect residents from physical abuse. The deficiency was cited at a D scope and severity, potential for more than minimal harm, isolated. Cross-reference F761: The facility failed to maintain appropriate temperatures in the medication refrigerator and the vaccine refrigerator. The deficiency was cited at an E scope and severity, potential for more than minimal harm, pattern. Cross-reference F677: The facility failed to provide bathing per resident preferences. The deficiency was cited at a D scope and severity, potential for more than minimal harm, isolated. Cross-reference F908: The facility failed to use medically rated blood pressure cuffs to obtain residents blood pressures. The deficiency was cited at a D scope and severity, potential for more than minimal harm, pattern. Cross-reference F805: The facility failed to ensure residents were served food in a form designed to meet residents' needs per physician's orders. The deficiency was cited at a D scope and severity, potential for more than minimal harm, isolated. III. Staff interviews The NHA and the director of nursing (DON) were interviewed together on 11/22/24 at 2:12 p.m. The NHA said the QAPI committee met monthly to continuously improve processes and meet standards. The NHA said all managers, the medical director, the pharmacist and the licensed social worker from a sister facility participated in the monthly QAPI meetings. The NHA said during the meetings, each manager reviewed their department reports and as a team, the committee tried to identify concerns, problem solve as a group and discuss how the facility would address the concern in attempts to resolve it. The NHA said the QAPI committee received additional insight from line staff, resident council, care conferences and morning nurse reports. The DON said each department would determine the root cause of their department concern. She said the department managers would bring their department concerns to the QAPI committee if they felt they needed to expand the discussion and analysis. The NHA said the QAPI committee created and implemented performance improvement projects/plans. She said the QAPI committee reviewed the implemented plans, made the determination if the identified concern was resolved and if the facility was able to effectively sustain system change. The NHA said if the plan did not produce a sustaining resolution to the concern, the committee would attempt to adjust the plan in efforts to resolve the concern. The DON said the QAPI committee reviewed falls monthly in the QAPI committee meeting. She said the committee looked at the number of falls in each month, whether the falls were witnessed or not, residents with multiple falls and where the falls occurred. The DON said if the facility had a resident fall several times in one month, the committee discussed the nature of the falls in an effort to gain additional insight and perspective that may not have already been identified. The DON said part of the root cause analysis was to identify if staff were properly educated and understanding why the falls happened. The DON said the process failed because the committee did not recognize what needed to be documented and not enough questions were asked to determine the full factor/cause of the falls. The NHA said the QAPI committee did not review smoking with a nasal cannula on or smoking near a turned off oxygen tank as a QAPI concern because the staff had not seen or reported to management that it was a concern. She said the resident involved in the situation was usually good about taking his oxygen off before he went outside to smoke. The DON said the QAPI committee did not review the residents' transfer poles and lack of safety assessments. The DON said the QAPI committee did not identify the assessments were not completed prior to the installation of the transfer poles. The NHA said pressure ulcers were reviewed in the QAPI committee meetings. The DON said pressure ulcers were reviewed during QAPI committee meetings. She said the team reviewed the residents who currently had pressure ulcers, identified if the pressure ulcers were improving, what treatments were being provided and received insight from the medical director on the pressure ulcers. The DON said the facility needed to work on improving documenting refusals of interventions, increasing observations of the resident and addressing concerns with the resident. The NHA said food textures were not reviewed in QAPI meetings. She said menus were reviewed but the committee had not discussed if the residents received the appropriate textured diets. The DON said diet order education with the kitchen staff had been discussed in the care concern at-risk meetings. The NHA said the registered dietitian (RD) had a weekly report of everyone with weight concerns and choking hazards. The NHA said the RD discussed any related concerns with the IDT, speech therapy and the kitchen staff and offered her recommendations. The DON said there had been a lot of confusion related to mechanical soft textures and she would like to look at new text diet texture processes and education. The DON said the use of medical grade blood pressure cuffs was not reviewed in QAPI meetings. The DON said she was not aware there was a problem with the blood pressure cuffs the facility was using. The NHA said residents' bathing preferences and choices had not been identified as a concern in QAPI meetings. She said residents did not usually address bathing preferences as a concern. She said the bathing preferences concern may have been addressed under the grievance process but the QAPI committee had not identified this as a concern. The NHA said resident-to-resident altercations were reviewed in QAPI committee meetings. She said the social services director (SSD) reviewed every occurrence identified in the previous month. The NHA said the QAPI committee discussed the occurrences to help identify trends that needed to be addressed. The NHA said the committee tried to find the root cause of the concern, looked at what caused each incident and tried to determine what could be put in place to prevent the incident from happening again. She said for resident-to-resident altercations, the team looked at interventions to help separate residents when needed and de-escalate the situations. The NHA said staff to resident physical abuse was discussed in QAPI meetings but the committee had not identified the concerns as a facility trend. The NHA and the DON said the facility had not looked at the lack of education provided to the temporary traveling staff. The DON said she recently requested the education the contract agency provided to the traveling staff. The NHA said refrigerator temperatures were reviewed in QAPI meetings, but not recently. She said in the past, audits identified concerns with consistent tracking of the temperature in the kitchen but refrigerators storing medications and vaccines had not been reviewed in QAPI committee meetings or identified as a concern. The NHA said the water management plan in relation to Legionella had not been reviewed in the QAPI meetings or identified as a concern. The NHA said the facility would look at all the identified concerns addressed and would relook at the facility's QAPI committee process, add additional audits and review how the QAPI committee analyzed facility concerns.

Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to implement an effective water management plan. Findings include: I. Professional reference According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, last reviewed 3/15/24, was retrieved on 11/26/24 from https://www.cdc.gov/control-legionella/php/toolkit/potable-water-systems-module.html It read in pertinent part, Operation, maintenance, and control limits guidance: Monitor temperature, disinfectant residuals, and pH frequently based on Legionella performance indicators for control. Adjust measurement frequency according to the stability of performance indicator values. For example, increase the measurement frequency if there's a high degree of measurement variability. Hot water: Store hot water at temperatures above 140 F (60 C). Ensure hot water in circulation does not fall below 120 F (49 C). Recirculate hot water continuously, if possible. Cold water: Store and circulate cold water at temperatures below the favorable range for Legionella (77-113 F, 25-45 C). Legionella may grow at temperatures as low as 68 F (20 C). Flushing: Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Ensure disinfectant residual is detectable throughout the potable water system. Clean and maintain water system components, such as thermostatic mixing valves, aerators, showerheads, hoses, filters, and storage tanks, regularly. Consider testing for Legionella in accordance with the routine testing module of this toolkit. II. Facility policy and procedure The Legionella water management program policy was provided by the nursing home administrator (NHA) on 11/20/24 at 11:14 a.m. It documented in pertinent part, It is the policy of the Veterans Community Living Centers (VCLCs) to establish water management plans for reducing risk of legionella and other opportunistic pathogens in the facility's water systems. It is also the policy of the VCLCs to establish primary and secondary strategies for the prevention and control of legionella infections. C. Record Review The water management plan documentation was provided by the director of maintenance (DOM) on 11/20/24 at 12:43 p.m. The plan documented the facility had completed a legionella test on 7/18/24 which was negative. -The facility failed to document the flushing of dead legs and low-flow piping runs on all three hallways where residents resided. An email was received from the director of nursing (DON) on 10/22/24 at 9:54 a.m. The DON documented that seven rooms available for resident use had been vacant for seven contiguous days or more between 9/23/24 and 11/22/24. D. Staff interviews The DON and the NHA were interviewed together on 11/20/24 at 12:43 p.m. The DOM said all empty rooms in the facility had hot water run though all dead legs and low-flow piping runs of empty resident rooms in the facility every two weeks. The NHA said the facility flushed water in empty rooms every other week. The DOM and the NHA both said flushing the water every two weeks was sufficient to prevent the growth of legionella. The DOM said the facility tested for legionella annually. The infection preventionist (IP) and the DON were interviewed together on 11/22/24 at 9:03 a.m. The IP said she was not directly involved in the water management plan because that was the responsibility of the maintenance department in the facility. The IP said she thought water had to be flushed weekly to prevent the spread of waterborne pathogens such as legionella. The DON said she also thought water had to be flushed weekly in dead legs to prevent legionella growth. The IP and the DON both said they were not aware the facility practice was to flush water in dead legs and low-flow piping runs every two weeks.

Based on record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards in two of three medication storage refrigerators. Specifically, the facility failed to maintain a medication refrigerator temperature log for the facility vaccine refrigerator and the medication refrigerator. Findings include: I. Professional reference According to the Centers for Disease Control (CDC), Handle with Care: Protect your Vaccine, Protect Your Patients, (revised on 3/19/24) was retrived on 11/26/24 from https://www.cdc.gov/vaccines/hcp/admin/storage/downloads/vaccine-storage-temperatures.pdf Keep your storage units and vaccines within the appropriate temperature ranges. Check and record storage unit min/ma (minimum/maximum) temperatures at the start of each workday. II. Facility policy and procedure The Medication Storage policy, revised on 1/25/24, was provided by the nursing home administrator (NHA) on 11/21/24 at 2:43 p.m. It documented in pertinent part, All drugs and biologicals will be stored in locked compartments (medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. II. Record review The vaccine and medication refrigerator temperature log records from 10/1/24 to 11/19/24 were provided by registered nurse (RN) #1 on 11/20/24 at 2:16 p.m. Out of 50 days of documentation opportunities, vaccine refrigerator temperatures were documented on 16 of those days. Out of 50 days of documentation opportunities, medication refrigerator temperatures were documented on 24 of those days. III. Staff interviews RN #1 was interviewed on 11/20/24 at 2:16 p.m. RN #1 said the medication and vaccine refrigerator temperatures should be logged every night by night shift nurses. RN #1 said many days had not been documented in the medication and vaccine refrigerator temperature logs. RN #1 said it was important to ensure medications were safely stored at the correct temperature so they could be safely administered to residents. The director of nursing (DON) was interviewed on 11/22/24 at 10:27 a.m. The DON said that all floor nurses were responsible for recording medication refrigerator temperatures. The DON reviewed the medication and vaccine refrigerator temperature logs between 10/1/24 and 11/19/24. The DON said many days had not been documented in the temperature logs. The DON said the vaccine and medication refrigerator temperatures should be documented daily. The DON said that if these refrigerators were not monitored by staff, then medications could expire or not work correctly for residents.

Based on observation, record review and staff interviews, the facility failed to ensure three (#12, #26 and #52) of seven residents reviewed for abuse out of 41 sample residents was kept free from abuse. Specifically, the facility failed to: -Protect Resident #12 from physical abuse from a staff member; and, -Protect Resident #26 from verbal abuse from Resident #52. Findings include: I. Facility policy and procedure The Abuse policy, revised 9/19/24, was provided by the nursing home administrator (NHA) on 11/18/24 at 1:21 p.m. The policy read in pertinent part, It is the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent mistreatment, abuse, neglect, and exploitation (MANE). The facility will take necessary precautions to prevent resident abuse by anyone including staff members, other residents, volunteers, contracted staff, family members, resident representatives, visitors, and any other individuals. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The facility employees and contractors will be educated on MANE during initial orientation. Existing staff will receive annual education and as needed. Training topics should include: -Types of abuse; -Prohibiting and preventing all forms of MANE; -Identifying what constitutes MANE; -Recognizing signs of MANE, such as physical or psychosocial indicators; and, -Reporting process for MANE, including injuries of unknown sources. Understanding behavioral symptoms of residents that may increase the risk of MANE such as: -Aggressive and/or catastrophic reactions of residents; -Wandering or elopement-type behaviors; -Resistance to care; -Outbursts or yelling out; and, -Difficulty in adjusting to new routines or staff. II. Allegation of physical abuse of Resident #12 from certified nurse aide (CNA) #2 A. Allegation of physical abuse on 11/11/24 The 11/11/24 alleged abuse incident report was provided by the director of nursing (DON) on 11/20/24 at 1:49 p.m. Resident #12 alleged that a male CNA (CNA #2) held/grabbed his arms during care that the resident did not want done. The resident reported the allegation to the DON and the lead CNA on 11/11/24 at 1:38 p.m. Resident #12 reported that the male CNA (CNA #2) held/grabbed his arms so another staff member could change him when he refused wanting to be checked and changed. According to the incident report, the resident was alert and oriented and immediately assessed for injury. The assessment of the resident's right hand identified Resident #12 had a small crescent moon shaped bruise on the back side between his thumb and his first finger. He had multiple red marks on his left arm that the resident said were bruises, however, the marks were consistent with various red age spots on both his arms. According to the incident report, the facility started an investigation after the allegation of the abuse. The NHA provided the 11/11/24 alleged abuse occurrence investigation packet on 11/19/24 at 4:25 p.m. According to the alleged abuse occurrence investigation, Resident #12 reported CNA #2 entered his room on 11/11/24 at 3:00 a.m. and held him down to change his brief. The alleged abuse occurrence investigation documented the alleged assailant was placed on administrative leave pending the investigation, a skin assessment was completed for Resident #12 and other staff and residents were interviewed. The 11/11/24 interview with Resident #12 documented Resident #12 reported to the DON two staff members requested to change the resident's brief. Resident #12 declined the request which prompted CNA #2 to hold the resident's arms while the other CNA changed his brief. According to the documented interview, Resident #12 was yelling out as his arms were held and his brief was changed. The 11/11/24 interview with CNA #2 documented CNA #2 said he entered Resident #12's room and the resident was yelling at him and told him to leave his room. CNA #2 said he left the room and reported the interaction to the night shift nurse. According to the documented interview, CNA #2 said he later returned to the room with CNA #3 to change Resident #12. CNA #2 reported the resident became physically and verbally aggressive. The 11/11/24 documented interview with CNA #2 further revealed CNA #2 said he grabbed Resident #12's arm to prevent him from hitting CNA #3. CNA #2 said he did not leave the room when the resident was upset because he was told by CNA #3 that Resident #12 needed to be changed on the last rounds, no matter what. The documented interview indicated CNA #2 and CNA #3 received education from the night shift nurse to leave the situation next time and report the resident's refusal to the nurse. The 11/11/24 documented interview with CNA #3 identified CNA #3 witnessed CNA #2 grab Resident #12's arms to prevent the resident from hitting her face. The 11/11/24 alleged abuse occurrence investigation packet identified four other residents and three other staff members were interviewed as part of the initial investigation. A staff interview with CNA #4 documented another resident (Resident #37) told her CNA #2 was a bit rough in his approach and felt he could benefit from some additional training. The summary of the investigation included in the 11/11/24 alleged abuse occurrence investigation packet documented Resident #12 was combative and struck CNA #3 when she was providing cares so CNA #2 held his arm back to prevent her from being hit. According to the summary, CNA #3 felt there was no malicious intent of CNA #2 with his actions, no other residents expressed fear or experienced injury from a staff member and Resident #12 had no behavioral changes after the incident. The summary of the investigation indicated the documentation following the incident did not identify Resident #12 had new bruises or injuries consistent with the allegation noted to his arms following the incident. According to the summary, the resident had a small one centimeter (cm) bruise in between his thumb and index finger where he would normally grip his wheelchair. The summary of the investigation documented the facility did not determine physical abuse occurred because there were no injuries or bruising on the resident's arms consistent with the allegation and the resident had a noted history of prejudice. According to the summary, CNA #2 was asked to return to the facility and his contract was terminated. -However, abuse occurred because CNA #2 willfully held Resident #12's arm down while CNA #3 changed the resident. B. Resident #12 1. Resident status Resident #12, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included mild cognitive impairment of uncertain or unknown etiology, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. The 10/10/24 minimum data set (MDS) assessment documented Resident #12 had moderate cognitive impairment deficits with a brief interview for mental status (BIMS) score of 12 out of 15. He did not have inattention, disorganized thinking, hallucinations or delusions. Resident #12 used a wheelchair for mobility. According the MDS assessment, Resident #12 did not have physical or verbal behavioral symptoms directed at others or rejections of care. 2. Resident observation and interview Resident #12 was interviewed on 11/18/24 at 4:09 p.m. Resident #12 said a little over a week ago, a large male CNA (CNA #2) entered his room in the middle of the night and wanted to change Resident #12's brief and bed pad. The resident told CNA #2 he was comfortable and did not want to be changed at that time. Resident #12 said CNA #2 left the room but returned with a female CNA (CNA #3) a few minutes later. He said the CNA #3 tried to forcibly remove his underwear while CNA #2 held him down by his arms. He said both CNAs left the room after he was changed. Resident #12 said he was bruised as a result of the incident. Resident #12 pointed out small red spots on both forearms/wrists and a fading purple bruise approximately the size of a quarter, on the back side of his right hand. between his thumb and index finger. He said he had reported the incident to staff on the same day as the incident. He said he had not seen CNA #3 since the incident and had heard CNA #2 was terminated. He said he had not had any concerns with other staff. Resident #12 was interviewed a second time on 11/20/24 at 1:45 p.m. Resident #12's bruise was slightly lighter in color. He said he was not fearful of anyone. 3. Record review The cognitive impairment care plan, initiated 4/14/24, identified Resident #12 had mild cognitive impairment and needed reduced distractions during interactions. The care plan was updated on 11/11/24, after the incident, to include the following interventions: -Reminding Resident #12 he was safe in his environment; -Explaining provided tasks/care in short simple sentences; -Allowing Resident #12 time to process information and respond; -Leaving the room if Resident #12 resisted a staff provided task, making sure the resident was safe and asking a different team member to approach the resident again in a timely manner; and, -Respecting Resident #12's right to decline. The psychosocial well-being care plan, initiated 4/22/24, identified Resident #12 experienced loss of his spouse in May 2024 and loss of his home of [AGE] years. The care plan directed staff to allow Resident #12 time to answer questions and to verbalize his feelings, perceptions and fears and validating his concerns and feelings. The activity of daily living (ADL) care plan, initiated 10/7/24, directed staff to provide the resident with supportive care, assistance with mobility and encourage him to use the call light for assistance. According to the care plan, staff should allow Resident #12 sufficient time for dressing and undressing. -The review of progress notes and skin assessments prior to 11/11/24 did not not identify a bruise on Resident #12's hand. The 11/12/24 nurse progress note documented Resident #12's arms were assessed on 11/11/24 and 11/12/24 to ensure safety following the (11/11/24) occurrence investigation. The note identified a small crescent moon shaped bruise on his right hand between his thumb and first finger and red marks which were consistent with age spots. According to the note, there were no behavioral changes following the incident, the resident felt he was doing well and spent time with staff and family. The note documented staff would continue to monitor the red spots on his left arm. -The note did not identify the staff would continue to monitor the bruise on his hand. The 11/13/24 nurse progress note documented the nurse met with the resident on 11/13/24. According to the note, Resident #12 had no new bruising and the spots on the left arm continued to be consistent with age spots and there were no changes in shape or color. He continued to deny pain, there were no changes in his behavior and the resident felt he was doing well. -The note did not identify the staff would continue to monitor the bruise on his hand. The Personal Care: Dressing Dependent Resident training, conducted with staff on 5/14/24, was provided by the corporate consultant (CC) on 11/26/24 at 12:17 p.m. The training identified staff should never forcefully pull or tug on clothing to assist a resident while dressing because it could cause injury. -The review of the training did not identify CNA #2 or CNA #3 had attended the training. The Competency Fair staff training, conducted on 10/15/24 and 10/16/24, was provided by the CC on 11/26/24 at 12:17 p.m. The training reviewed facility policies, such as abuse training. -The review of the Competency Fair attendance sheet, identified CNA #2 and CNA #3 did not attend the training. The Emergency Response Plans staff signature sheet, dated between 1/16/24 and 11/21/24, and the facility's onboarding packet was provided by the DON on 11/22/24 at 9:34 a.m. The packet included the abuse policy and the resident rights policy. The resident rights policy identified residents had the right to be free of verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. According to the policy, the residents had the right to make choices regarding their care, including schedules, activities, healthcare providers or health care services. -The review of the Emergency Response Plans staff signature sheet revealed CNA #2 did not sign that he had received the emergency response plans and onboarding packet. C. Staff interviews The DON was interviewed on 11/20/24 at 4:10 p.m. The DON said if there was a new bruise on a resident, staff should try to determine what was the cause of the bruise. She said staff would interview the resident and notify the physician. She said the facility would make sure the resident was safe and the bruise was not caused by another person. She said the bruise would be documented in the risk management assessment. The DON said if the cause of the bruise was not known, then she would start an investigation and interview staff. The DON said the bruise on the right hand of Resident #12 was found during a skin assessment after a reported incident on 11/11/24. The DON said Resident #12 alleged, on 11/11/24, that a staff member grabbed his arms and held him. She said the resident reported the incident to her and the lead CNA. She said the CNA (CNA #2) was an agency/travel staff member. She said CNA #2 and CNA #3 were interviewed. The DON said both CNAs said Resident #12 attempted to hit CNA #3 so CNA #2 grabbed his arm to stop him. She said CNA #2 reported he grabbed the resident's left arm. The DON said the agency CNA #2 worked for was notified and CNA #2 was suspended, pending the investigation. The DON said Resident #12 did not have a bruise on his left arm. She said the bruise on the back of his right hand was in the shape of a half moon and in between his index finger and his thumb. The DON said the bruise was not identified before the 11/11/24 incident. She said she thought the bruise might have been caused by his wheelchair. She said the bruise matched up to where he would put his hand on the wheelchair. She said she was not aware of any incidents or observations which indicated that the resident injured himself from use of his wheelchair. She said it was possible the resident's bruise was caused during the 11/11/24 incident. The DON said the facility decided not to have CNA #2 return to the facility because another resident felt the CNA was rough with care. She said the term rough could be a trigger word for potential abuse. The DON said the other residents were not fearful of CNA #2 and said he was just a little rough. The social service assistant (SSA) was interviewed on 11/21/24 at 10:07 a.m. The SSA said she assisted with abuse investigations when they were reported to her. She said she was a nurse and would conduct a head to toe assessment when needed, by use of the weekly assessment form if there was a bruise that was unexplained or an allegation of abuse. The SSA said she interviewed residents anytime that there was a potential abuse allegation, including verbal and physical abuse, including a resident to resident altercation. She said if a resident was not able to answer the questions, she and the staff would make observations of their behaviors and complete an assessment for non-interviewable residents. The SSA said the social services department would report their piece of the investigation findings to the interdisciplinary team (IDT) and the NHA would make the determination if abuse was substantiated or not. The NHA was interviewed on 11/21/24 at 10:33 a.m. The NHA said she reported all allegations of abuse to the State Agency and then the social services department started the investigation with a skin assessment to check for injuries and interviews with staff. She said if a resident had a high BIMs score, they would be interviewed. She said staff should attempt to interview pertinent residents even if they had a lower BIMS score. She said if the resident was not interviewable, a non-interviewable form would be completed. The NHA said there needed to be enough information gathered to make the determination if abuse occurred. The NHA said to substantiate abuse, she needed to confirm elements of abuse occurred, such as injury and or fear, depending on what type of abuse was alleged. She said she did not determine the allegation of physical abuse towards Resident #12 was substantiated after the investigation because the resident said it was his arms that were grabbed and the bruise was found on his hand. The NHA said CNA #2 said Resident #12 kicked CNA #3 but he did not make contact with her with his hand. The NHA said Resident #12 did not indicate fear and there was no injury to his arms where he said he was grabbed. The NHA said CNA #2 was preventing the resident from striking CNA #3. She said CNA #2 was asked not to return to the facility after the incident because another resident said he was a bit rough with care. The NHA said the term rough could be a trigger word indicating potential abuse. She said the facility started an investigation when a resident alleged potential abuse. The DON was interviewed a second time on 11/21/24 at 10:54 a.m. She said CNA #2 and CNA #3 were educated by the night nurse after the incident. CNA #2 and CNA #3 were told they should have not performed ADLs after Resident #12 refused and should have informed the nurse of the refusal. The DON said both CNAs were temporary traveling staff. She said before they started working independently with the residents, they had to shadow another staff member and sign off on a packet of facility expectations and policies. She said the abuse policy was included in the packet the CNAs had to sign off on that they would have received. -However, record review revealed CNA #2 did not sign the receipt of the facility's packet that included the abuse policy. The DON was interviewed on 11/22/24 at 9:34 a.m. She confirmed CNA #2 did not sign the facility policies and expectations when he was on boarding The CC was interviewed on 11/22/24 at 12:10 p.m. The CC said the facility would make sure all temporary and current staff had reviewed and signed off on the facility policies and expectations after it was identified CNA #2 did not sign that he received the packet that included the abuse policy. The DON and the CC were interviewed together on 11/22/24 at 12:13 p.m. The CC said bruises should be monitored for 72 hours after the bruise was identified. The DON said the documentation in Resident #12's EMR did not clearly indicate the bruise to his hand was monitored. She said she recently looked at it and it was looking much better then when it was first identified on 11/11/24. The DON said Resident #12 had not made allegations towards staff before 11/11/24. The CC said restraining a resident's movement would be considered abuse. The NHA and the DON were interviewed together on 11/22/24 at 2:12 p.m. The NHA said the facility reviewed every occurrence/incident every month, including allegations of abuse and resident-to- resident altercations to identify possible trends and areas the facility needed to address. The NHA said the interdisciplinary (IDT) team tried to find the root cause of the concern, looking at what caused the incident and what could be put in place to prevent the incident from happening again. She said for resident-to-resident altercations, the team looked at interventions to help separate residents when needed and de-escalate the situation. The NHA and the DON said the facility had not looked at the lack of education provided to the temporary traveling staff. The DON said she recently requested the education the contract agency provided to the traveling staff. The DON said the facility did not have evidence that CNA #2 received and reviewed the facility's policy on abuse. The DON said, moving forward, all traveling staff were to sign the policies in person on the day of their first shift at the facility. She said the facility had created a form to verify that staff had received and understood the abuse policy going forward. 50314 III. Incident of physical abuse on 8/29/24 between Resident #52 and Resident #26 A. Facility investigation The facility's investigation of the incident on 8/29/24 between Resident #52 and Resident #26 was provided by the DON on 11/19/24 at 4:01 p.m. A statement written by CNA #4 on 9/3/24 documented Resident #52 and Resident #26 were observed attempting to elope from the Bookcliff hallway on 8/29/24 at approximately 5:45 p.m. CNA #4 said the door alarm went off and she responded in an attempt to redirect Resident #52 and Resident #26. CNA #4 said Resident #26 asked for keys to leave the facility and CNA #4 told Resident #26 she did not have them. CNA #4 said Resident #26 began yelling at her and Resident #52 told Resident #26 not to yell at CNA #4. CNA #4 said Resident #26 threatened to hit Resident #52. CNA #4 said Resident #52 put her hand on the back of Resident #26's neck and said she would like to see Resident #26 try. CNA #4 said Resident #26 then attempted to uppercut Resident #52 with only her index finger connecting to Resident #26's chin. CNA #4 said Resident #52 pushed Resident #26 and Resident #26 pushed Resident #52 back in response. CNA #4 said she was able to intervene and separate Resident #52 and Resident #26. A statement written by the NHA on 8/29/24 documented observations of facility camera surveillance footage between 5:30 p.m. and 6:00 p.m. on 8/29/24. The observation documented that Resident #52 and Resident #26 were observed attempting to elope through the Bookcliff stairwell exit door. The statement documented that when a staff member approached the residents, Resident #52 went into her room briefly and then returned. The statement documented that Resident #26 was observed to be tapping Resident #52 on her chin. The statement documented Resident #52 then pinched or poked Resident #26 and Resident #26 poked Resident #52 in response. The statement documented neither resident was observed to stumble or fall. The investigation documentation included new recommendations for Resident #52's medication regimen to address her anxiety and restlessness. The investigation documented the facility updated care plans for Resident #26 and Resident #52. The facility documented that the attending physician, the NHA, the DON and the social services department were notified of the incident on 8/29/24 within two hours of the event occurrence. The facility documented that the police department and adult protective services were notified at 6:45 p.m. on 8/29/24. The state health department, veteran's affairs, and the ombudsman were also notified of the event on 8/29/24. The summary of the investigation documentation, not dated, was provided by the DON on 11/19/24 at 4:01 p.m. It read in pertinent part; Abuse is unsubstantiated. Element of bodily injury or unreasonable confinement or restraint not met. Element of fear not met for verbal abuse as both residents remain at baseline prior to incident. -However, CNA #4's statement documented that Resident #26 attempted to hit Resident #52 in an uppercut motion and the statement further documented Resident #26 and Resident #52 pushed each other. -Furthermore, the NHA documented she observed via the camera footage, that Resident #26 intended to hit Resident #52 with her hand and the NHA documented Resident #52 and Resident #26 pinched and poked each other (see NHA statement above and interview below). B. Resident #52 1. Resident status Resident #52, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included dementia, unspecified mood disorder and unspecified depression. The 9/12/24 MDS assessment documented the resident was severely cognitively impaired with a BIMS score of five out of 15. The resident required moderate assistance with oral hygiene, dressing and toileting hygiene. The assessment documented Resident #52 was independent with all other aspects of daily mobility. The assessment documented that Resident #52 exhibited wandering behaviors on a daily basis which put her at a significant risk for her to get to a potentially dangerous place. The assessment documented that Resident #52 had exhibited physical and verbal behavioral symptoms directed towards others on one to three days during the assessment period. The assessment documented Resident #52's physical and verbal behaviors created a significant risk of causing herself physical illness or injury, significantly interfered with her care and put others at significant risk for physical injury, intruded on the safety or privacy of others and disrupted the care environment. The assessment documented that Resident #52's behaviors were getting worse. 2. Resident #52's representative interview Resident #52's representative was interviewed on 11/20/24 at 10:07 a.m. The representative said Resident #52 had severe dementia and elopement behaviors. The resident's representative said he thought Resident #52 and Resident #26 were friends. He said he had seen Resident #52 and Resident #26 arguing in the dining room, however, Resident #52 was known to argue with others around her for years even before she received her dementia diagnosis. The resident's representative said he was notified that Resident #52 and Resident #26 hit each other on 8/29/24 after trying to elope from the facility together. He said Resident #52 was not known to be physically aggressive before the event on 8/29/24. 3. Record review The elopement plan of care, initiated and revised 9/3/24, documented that Resident #52 was a high elopement risk because of her cognitive deficits. The plan of care documented the goal was for Resident #52 to be at a reduced risk of injury and elopement through the review period. The plan of care documented interventions including redirecting Resident #52 to other activities of interest when she was wandering, to keep Resident #52 within line of sight of staff members when outside of her room and to reassure Resident #52 that the animals were fed and her kids were safe. A social services quarterly note, dated 10/2/24, documented that Resident #52 was a high elopement risk and the resident needed to be within staff line of sight when outside her room. A behavior monitoring note, signed 8/30/24 by LPN #4, documented that Resident #52 and Resident #26 were observed attempting to elope on 8/29/24 after dinner. The note documented that Resident #52 punched Resident #26 in her neck. It documented that immediately thereafter, both residents were separated and placed on frequent checks. C. Resident #26 1. Resident status Resident #26, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included dementia, unspecified depression and anemia. The 8/22/24 significant change MDS assessment documented Resident #26 was severely cognitively impaired with a BIMS score of six out of 15. The resident required supervision with upper body dressing and oral hygiene and moderate assistance with personal hygiene. The assessment documented that Resident #26 was independent walking 50 feet, but required a helper to provide verbal cues when walking 150 feet. The assessment documented Resident #26 was independent with all other aspects of daily mobility. The assessment indicated Resident #26 experienced hallucinations and delusions but did not exhibit physical or behaviors directed towards herself or others. The assessment documented that Resident #26 exhibited wandering behaviors on one to three days during the assessment period, but the wandering behavior did not place the resident at risk of getting to a potentially dangerous place. 2. Record review The elopement plan of care, initiated 5/2/24 and revised 7/12/24, documented that Resident #26 was at a high risk of elopement because the resident would often be looking for her husband and children, and experienced increased confusion. The facility documented her elopement plan of care goal was to keep her safe through the current review period. The facility documented interventions included keeping Resident #26 within line of sight when she went upstairs to the office or visited with other residents, to offer distractions to decrease wandering behaviors, and to reassure the resident that her family was fine because Resident #26 was often confused about where she was at. A social services quarterly assessment, dated 7/17/24, documented Resident #26 did not have a history of wandering behaviors. The assessment documented Resident #26 did not have elopement precautions and Resident #26 was not at risk for elopement. -The social services quarterly assessment failed to accurately document Resident #26's wandering behaviors. An elopement assessment, dated 11/12/24, documented that Resident #26 had no history of wandering behaviors. The assessment documented Resident #26 was a moderate risk for elopement. -The elopement assessment failed to document the elopement behaviors witnessed by the facility staff on 8/29/24. D. Staff interviews Registered nurse (RN) #1 was interviewed on 11/20/21 at 9:51 a.m. RN #1 said Resident #26 and Resident #52 were both known to wander in the facility, but it was usually rare for Resident #26 to wander while it was often a daily occurrence for Resident #52 to wander. RN #1 said Resident #52 was known to help other residents and the resident would wander around to look for other residents who needed help. RN #1 said Resident #52 was easily redirected when she was observed to be wandering where she was not supposed to be. RN #1 said she had heard Resident #52 and Resident #26 hit each other a few months ago. Nursing assistant (NA) #2 was interviewed on 11/21/24 at 10:41 a.m. NA #2 said she was present in the building on 8/29/24. NA #2 said at the time, she was in the role of a student observer on the upstairs floor. NA #2 said she was not interviewed as part of the investigation between Resident #52 and Resident #26. NA #2 said she did not see anything occur that day since she was on the second floor and the event occurred on the first floor of the building. NA #2 said Resident #52 was known to wander in other resident rooms and all nursing staff knew to look out for her whenever she was moving in the building to ensure she was not going somewhere she was not supposed to. RN #2 was interviewed on 11/21/24 at 3:21 p.m. RN #2 said she heard Resident #52 and Resident #26 hit each other several months ago while trying to elope through the stairwell door. RN #2 said she was not working in the building on 8/29/24. RN #2 said when she worked downstairs she kept a close eye on both residents. RN #2 said she had not observed either Resident #52 or Resident #26 exhibit aggressive behaviors in September 2024, October 2024 or November 2024. RN #2 said care staff had to redirect Resident #52 from her wandering behaviors on a daily basis. RN #2 said she had observed Resident #26 exhibit wandering behaviors on only one occasion in the last few months. The NHA was interviewed on 11/22/24 at 11:32 a.m. The NHA said she reviewed the camera footage of the physical altercation that occurred between Resident #52 and Resident #26 on 8/29/24 but said she did not witness the original event occur. The NHA said the camera footage revealed Resident #52 approached Resident #26 from behind and placed her open hand on the back of Resident #26's neck. The NHA said she then Resident #26 brushed the chin of Resident #52. The

Based on observations, record review and interviews, the facility failed to ensure resident choices for one (#213) of two residents reviewed for activities of daily living (ADL) out of 40 sample residents. Specifically, the facility failed to provide bathing assistance for Resident #213 per her preference. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy, revised 6/6/24, was received from the corporate consultant (CC) on 11/22/24 at 1:33 p.m. It documented in pertinent part, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. II. Resident #213 A. Resident status Resident #213, age less than 65, was admitted on [DATE]. According to the November 2024 computerized physician order (CPO), diagnoses included paraplegia (loss of function in the lower legs), congestive heart failure,and generalized muscle weakness. According to the 11/14/24 minimum data set (MDS) assessment Resident #213 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment documented Resident #213 was dependent on staff for toileting, hygiene, dressing, chair and toilet transfers. The assessment did not document the amount of assistance Resident #213 needed with bathing. B. Resident interview and observations Resident #213 was interviewed on 11/19/24 at 9:35 a.m. Resident #213 said she was admitted to the facility earlier in the month and had only received one bed bath since her admission on 11/7/24. Resident #213 said she hoped to receive two baths per week. Resident #213 said she was paraplegic and had no feeling below the level of her waist. Resident #213 said that she knew her care took more time and staff, since she was unable to move or control the lower half of her body. Resident #213 said she could not sense if the lower half of her body was not clean. Resident #213 said her hair was difficult to comb because it had not been washed recently. Resident #213 said she felt sad that she required extensive assistance with bathing because she perceived her extensive ADL care needs would reduce the help other residents received on her bath days. Resident #213's hair was greasy. She was attempting to comb through it, but was struggling to do so. On 11/20/24 at 9:12 a.m., the restorative registered nurse (RRN) was discussing the daily plan to get Resident #213 out of bed and into the wheelchair with another unidentified staff member. The RRN said Resident #213 required three person assistance with a hoyer lift to get her out of bed and into the wheelchair. III. Record review The ADL/mobility plan of care, initiated on 11/15/24 and revised on 11/15/24. The plan of care documented Bathing/Showering level of assistance: Independent; set-up assistance; supervision; minimal assist; extensive assist; dependent. -A review of the resident's comprehensive care plan did not reveal documentation indicating Resident #213's bathing preferences or the level of assistance Resident #213 required with bathing. The Bathing/shower preference documentation was reviewed between 11/7/24 and 11/21/24. The facility documented Resident #213 was unavailable for bathing preference discussions on 11/18/24 and bathing preference discussions were not applicable on 11/8/24, 11/11/24 and 11/15/24 (see interviews below). The facility point of care bathing documentation was reviewed for 14 days (11/7/24 to 11/21/24). It documented Resident #213 had received two baths out of four opportunities. IV. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 11/21/24 at 1:41 p.m. CNA #3 said it was normal for residents to receive two baths per week or by the resident's preference. CNA #3 said if a resident refused a bath the nurse would be told and the resident refusal would be documented in the electronic medical record (EMR). Registered nurse (RN) #2 was interviewed on 11/21/24 at 1:55 p.m. RN #2 said the residents received two baths per week on their chosen days unless the resident had a more specific preference. RN #2 said it was important to bathe residents to reduce infection risk and also because it felt nice to be clean. The director of nursing (DON) was interviewed on 11/22/24 at 10:27 a.m. The DON said she reviewed Resident #213's bathing documentation between 11/7/24 and 11/21/24. The DON said Resident #213 received two baths in the review period. The DON said Resident #213 did not receive enough baths. The DON said the residents should receive two baths per week or by their stated preference. The DON said Resident #213's bathing preference and assessment documentation did not make sense and should not have been documented as not applicable.

Based on observations, record review and interviews, the facility failed to ensure two (#43 and #14) of seven residents received food and fluids prepared in a form designed to meet their needs per speech therapy recommendation, physician's orders and the resident's care plan out of 41 sample residents. Specifically, the facility failed to ensure Resident #43 and Resident #13, who were prescribed a mechanically altered diet texture, were served food in the correct form. Findings include: I. Facility policy and procedure The Therapeutics Diets policy, revised on 6/7/24, was provided by the corporate consultant (CC) on 11/21/24 at 1:33 p.m. It read in pertinent part, Each resident has a specific food and beverage preparation detailed on a tray card so accurate diets are served. Therapeutic diets are prepared and served according to written orders from the provider and are planned and served with supervision from the dietary manager (DM) or registered dietician (RD). Specific diets and textures are referenced in the diet manual with specific content and preparation. A current diet manual is available for reference to attending physicians, nursing service and dietary staff. Residents and/or their power of attorney (POA) may refuse the recommended diet. In this case the facility must provide education, provide and ask for a signature on a dietary waiver and increase monitoring at meal times. II. Facility's diet manual The Diet Manual, revised August 2015, was provided by the nursing home administrator (NHA). It read in pertinent, Dysphagia mechanically altered: This level consists of foods that are moist, soft textured and easily formed into a bolus. Meats are ground or minced no larger than one-quarter-inch pieces: they are still moist with some cohesion. This diet is a transition from the pureed textures to more solid textures. Chewing ability is required. The textures on this level are appropriate for individuals with mild to moderate oral and/or pharyngeal dysphagia. Breads: Soft pancakes well moistened with syrup or sauce. Pureed bread mixes, pregelled or slurried breads that are gelled through entire thickness. Avoid all other breads. Vegetables:All soft, well-cooked vegetables should be smaller than half-an-inch and easily mashed with a fork. Avoid cooked corn and peas, broccoli, cabbage, brussels sprouts, asparagus or other fibrous non-tender or rubbery cooked vegetables. III. Facility recipes A. Salisbury steak Mechanical soft: Grind portions needed from regular prepared recipe into one eighth inch pieces. B. Garlic cheese biscuit It is recommended to serve pureed bread/biscuit or gelled bread for dysphagia diets, but if the speech language pathologist (SLP) at your facility signs and approves regular breads on an individual basis, chop regular portions. Make sure all particles are no more than half-an-inch by half-an-inch. -The facility served cooked biscuits with a slice of American cheese melted over the top (see observations below). IV. Resident #43 A. Resident status Resident #43, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician order (CPO) diagnoses included dementia, acute cough and dysphagia (difficulty swallowing). The 11/4/24 minimum data set (MDS) assessment revealed Resident #43 t had long-term and short-term memory problems and was severely cognitively impaired per staff assessment. The MDS assessment indicated Resident #43 required a mechanically altered diet. B. Record review A review of the November 2024 CPO revealed the resident had a physician's order that indicated the resident was prescribed a mechanical soft diet and was to be served his food on a lipped plate, ordered on 10/14/24. A review of Resident #43's electronic medical record (EMR) did not reveal a dietary waiver indicating the resident was able to consume regular textured food cut-up (see interview below). C. Observation The following was observed on 11/21/24 at 11:44 a.m.: Resident #43 was served a Salisbury steak and a dinner roll both were cut into bite-sized pieces. -The facility failed to serve theSalisbury steak ground and puree or gel the dinner roll as indicated on the recipe (see recipe above). V. Resident #14 A. Resident status Resident #14, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO diagnoses included dementia, Parkinsonism (degenerative disease that causes involuntary movements) and dysphagia. The 10/12/24 MDS assessment revealed Resident #14 t had long-term and short-term memory problems and was severely cognitively impaired per staff assessment. The MDS assessment indicated Resident #14 required a mechanically altered diet. B. Record review A review of the November 2024 CPO revealed the resident had a physician's order that indicated the resident was prescribed a mechanical soft diet and nectar thick liquids, ordered on 8/20/2020. A review of Resident #14's EMR did not indicate a dietary waiver that indicated the resident was able to consume regular textured food cut-up. The resident had a dietary waiver in place to consume thin liquids versus nectar thick (see interview below). C. Observations The following was observed on 11/21/24 at 11:44 a.m.: Resident #43 was served a regular textured Salisbury steak and a dinner roll both were cut into bite-sized pieces. -The facility failed to serve the Salisbury steak ground and puree or gel the dinner roll as indicated on the recipe (see recipe above). VI. Staff interviews Dietary aide (DA) #3 was interviewed on 11/21/24 at 11:50 a.m. DA #3 said Resident #43 and Resident #14 had waivers in place to eat regular or bite-sized textured foods. DA #3 said if a resident's plate looked like the wrong texture she would send it back to the kitchen to be fixed. DA #3 said she was unaware bread needed to be pureed or slurried on a mechanical soft diet. -However, review of the resident's EMR did not indicate dietary waivers were in place for the residents to receive regular textured food (see record review above). The cook (CK) was interviewed on 11/21/24 at 11:50 a.m. The CK said Resident #43 and Resident #14 were allowed to have bread and the Salisbury steak was the correct texture. The CK said she was unaware the bread needed to be pureed or gelled for residents who were prescribed a mechanical soft diet. The NHA, the CC and the registered dietitian (RD) were interviewed together on 11/21/24 at 12:57 p.m. The RD said the facility had not implemented the International Dysphagia Diet Standardisation Initiative (IDDSI) program yet. She said the facility modified resident's diets based on what the SLP recommended. The NHA, the CC and the RD said they were unaware the facility's diet manual indicated the mechanically soft texture required the bread to be pureed or slurried. The RD said although the Salisbury steak was made from ground beef it should not have been formed into a steak shape and cut into bite-sized pieces. The RD said the residents should have been served ground beef with the gravy.

Based on observations, record review and interviews, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition. Specifically, the facility failed to ensure facility staff used blood pressure cuffs rated for medical use. Findings include: I. Professional reference According to the [NAME] Advantage for Basic Nursing handbook, third edition, retrieved on 11/25/24 from Treas, [NAME] S., et al. [NAME] Advantage for Basic Nursing: Thinking, Doing, and Caring. F. A. [NAME] Company, 2022., Blood Pressure - Practical Knowledge, Electronic blood pressure monitors may be less accurate than those with an aneroid monitor (a manual blood pressure measuring device). To ensure accuracy, you should auscultate (listen to) a baseline blood pressure before initiating automatic monitoring. Ensure devices are rated for medical use. The width of the blood pressure cuff bladder of a properly fitting cuff will cover approximately two-thirds of the length of the upper arm for an adult, and the entire upper arm for a child. Alternative sites you can use are the forearm, thigh, or calf. However, systolic pressure may be 20 to 30 mmHg (millimeters of mercury) higher in the lower extremities than in the arms, but diastolic pressures are similar. Abnormally high or low blood pressure readings should be rechecked by the provider. II. Facility policy The Medical Equipment policy, revised 7/1/24, was provided by the corporate consultant (CC) on 11/22/24 at 1:39 p.m. It documented that all durable medical equipment (DME) to be used for resident assessment and monitoring would be deemed medically rated for use in health care facilities. III. Observations On 11/20/24 at 8:52 a.m., licensed practical nurse (LPN) #1 was observed using a Veridian Healthcare model 01-574 model wrist type blood pressure cuff to take Resident #213's blood pressure. -LPN #5 did not use a blood pressure cuff rated for medical use to obtain Resident #213's blood pressure (see professional references above and interview below). On 11/20/24 at 10:23 a.m., registered nurse (RN) #4 was observed taking Resident #33's blood pressure using a W1101L wrist type blood pressure cuff. -RN #4 did not use a blood pressure cuff rated for medical use to obtain Resident #33's blood pressure (see professional references above and interview below). IV. Record Review On 11/20/24 at 11:57 a.m., the director of nursing (DON) said (via email) that she could not find manufacturer's instructions for the W1101L wrist type blood pressure cuff or the Veridian Healthcare model 01-574 model wrist type blood pressure cuff that documented either device was rated for medical use. The DON said both blood pressure cuffs had been removed from use in the facility on 11/20/24. V. Staff interviews LPN #1 was interviewed on 11/20/24 at 8:55 a.m. LPN #1 said she enjoyed using the Veridian Healthcare model 01-574 model wrist type blood pressure cuff to obtain blood pressures on residents. LPN #1 said she did not know if the blood pressure cuff was rated for medical use. LPN #3 was interviewed on 11/21/24 at 1:17 p.m. LPN #3 said she had used both the Veridian Healthcare model 01-574 model wrist type blood pressure cuff and the W1101L wrist type blood pressure cuff to obtain resident blood pressure readings. LPN #3 said the blood pressure cuffs were stored in a protective case on each medication cart to use whenever nurses needed to. LPN #3 said she did not know if the devices were rated for medical use. The DON was interviewed on 11/22/24 at 10:27 a.m. The DON said she had obtained the blood pressure cuffs from a medical supply company but did not verify if the blood pressure cuffs were rated for medical use. The DON said she was surprised to learn the Veridian Healthcare model 01-574 model wrist type blood pressure cuff and the W1101L wrist type blood pressure cuff were not rated for medical use. The DON said it was important for the facility to use blood pressure cuffs rated for medical use to ensure residents' vital signs were accurate. The DON said residents could receive blood pressure medications when they were not needed if the facility relied on the accuracy of a non-medically rated device to obtain resident blood pressures.

Based on interviews, observations and record review, the facility failed to ensure one (#1) of five residents out of 13 sample residents was free from significant medication errors. On 5/16/24, when Resident #1 was no longer able to swallow oral medication prescribed for pain relief, registered nurse (RN) #1 consulted with the resident's hospice provider and primary care practitioner for alternative medication orders. Nurse practitioner (NP) #1 called in a prescription for liquid morphine sulfate 20 milligrams (mg)/5 milliliters (ml), give 3.75 ml (which equaled 15 mg) and entered the new order into the resident's electronic medical record (EMR). RN #1 obtained a bottle of liquid morphine sulfate solution from the facility's emergency stock medication supply and proceeded to administer the medication to RN #1. RN #1 failed to perform a dosage check on the bottle of morphine sulfate solution obtained from the facility's backup medication stock and compare it to the order written by NP #1. RN #1 drew up and administered 3.75 ml of the morphine sulfate solution and gave the medication to the resident. -However, the dosage of the morphine sulfate solution obtained from the facility's backup medication stock was 20 mg/1 ml, which resulted in Resident #1 receiving five times (75 mg) the amount of morphine sulfate ordered by NP #1. RN #1 failed to follow professional standards of nursing practice and perform the seven rights of medication administration to ensure safe and effective care and treatment of a resident in her care. As a result of RN #1's failure to complete a dosage check on the medication before administering the prescribed medication, Resident #1 received an excessively high dose of morphine sulfate solution (five times the prescribed dose of medication), which likely caused the acceleration of the resident's passing away. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 6/3/24 to 6/6/24, resulting in the deficiency being cited as past noncompliance with a correction date of 5/26/24. I. Situation of serious harm The facility failed to ensure Resident #1 was administered the correct dose of morphine sulfate solution when RN #1 failed to perform the seven rights of medication administration and check the medication label to confirm the dosage of the medication obtained from the facility's backup medication stock was the same dosage ordered by NP #1. RN #1's failure to follow NP #1's prescribed order for pain medication led to Resident #1 being given an excessively high dose of morphine sulfate on 5/15/24. Record review and interviews during the complaint investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance at the time of the survey from 6/3/24 to 6/6/24. II. Facility plan On 6/3/24 the nursing home administrator (NHA) provided the facility's investigation, report of findings and records of corrective action related to the morphine sulfate solution overdose incident. The incident occurred on 5/15/24 at 7:07 p.m. On 5/16/24 an investigation was initiated upon discovery of the incident and remained ongoing pending a determination of the nurse's employment status. The facility initiated several corrective action measures including: On 5/16/24 the pharmacy consultant alerted the facility that Resident #1 was prescribed morphine sulfate solution in a concentration that was higher than the dose the facility had in its emergency backup medication stock. The pharmacy consultant recommended the facility perform a dosage check to ensure the nurses were aware of the difference in the dosage concentration of the morphine sulfate solution that was ordered by NP #1 versus the dosage concentration of the medication that was in the facility's backup medication stock. At the time of the pharmacy alert, the resident had already passed away. On 5/16/24 the facility's administration immediately interviewed RN #1, who had administered the first and only dose of the newly prescribed morphine sulfate. On 5/16/24, upon verification that RN #1 had administered an incorrect dose of morphine sulfate, RN #1 was immediately suspended, pending the outcome of the investigation. On 5/16/24, immediately upon the discovery that RN #1 had made a significant medication error, the facility administration took the following measures to place corrective actions to prevent future errors in the administration of liquid morphine sulfate. On 5/16/24 the facility conducted an audit of all residents receiving liquid morphine sulfate solution to ensure the medication orders were accurate and matched the liquid morphine sulfate medication provided by the pharmacy for each resident. On 5/16/24 the facility reported RN #1's performance was reported to the State Licensing Board for review, The licensing board opened an investigative case on 5/21/24. On 5/16/24 the facility's administration reviewed the facility's policy for Medication Administration for accuracy. No changes were required to the policy. On 5/17/24 the facility contacted hospice providers and other prescribers to educate the prescribers about the availability of the liquid morphine sulfate solution concentration that the facility had in the emergency backup medication stock. The facility requested the prescribers to prescribe effective medication dosages for morphine sulfate solution in concentrations of 20 mg/1 ml (the dosage concentration that was in the facility's backup medication stock). On 5/17/24 The facility contacted the pharmacy to ensure there was a system in place for the pharmacy to perform a medication check on all morphine sulfate solution orders to ensure accurate dosing of the initial physician's order of liquid morphine sulfate to a resident. On 5/20/24 the facility contacted Resident #1's hospice provider for guidance and other resources for the accurate administration of liquid morphine sulfate. The hospice nurse provided the facility with a resource for morphine sulfate solution conversions. The resource provided a conversion chart for various dosage concentrations of morphine sulfate solution to the dose that the facility had on hand (20 mg/1 ml) in their backup medication stock. The resource further provided instructions on how to administer and calculate dosage per medication concentration for accurate administration. By 5/26/24 all licensed nurses were educated and provided instructions on the proper administration of liquid morphine in various concentrations, including how to calculate the proper dosage of the medication if the medication on hand was not the concentration ordered by the prescriber. In addition, the nurses were instructed in methods of proper medication administration, including following the seven rights of medication administration. The facility would discuss the incident and monitor the corrective actions in the Quality Assurance and Performance Improvement meetings to determine if further corrective actions were needed. Interviews and record reviews during the complaint investigation from 6/3/24 to 6/6/24 revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained corrections were in place. III. Professional reference According to the Food and Drug Administration (FDA) Highlight of Prescribing Information Morphine Sulfate Oral Solution - Scheduled II controlled substance, retrieved on 5/10/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022195s002lbl.pdf, Morphine oral solution is available in 10 mg per 5 ml, 20 mg per 5 ml and 100 mg per 5 ml (20 mg/ml) concentrations. Take care to avoid dosing errors due to confusion between different concentrations and between mg and ml. Warnings and Precautions: Risk of Medication Errors: Use caution when prescribing, dispensing, and administering to avoid dosing errors due to confusion between different concentrations and between mg and ml, which could result in accidental overdose and death. Respiratory depression: Increased risk in elderly, debilitated patients, those suffering from conditions accompanied by hypoxia, hypercapnia, or upper airway obstruction. Elderly patients (aged [AGE] years or older) may have increased sensitivity to morphine sulfate. Acute overdose with morphine sulfate is manifested by respiratory depression, a decrease in respiratory rate and/or tidal volume (airflow through the lungs), Cheyne-Stokes respiration (fast shallow breathing followed by slow heavier breathing and no breath), and cyanosis (shortage of oxygen in the blood and bluing of the skin), extreme somnolence progressing to stupor or coma, skeletal muscle flaccidity (condition of being soft and limp), cold and clammy skin, constricted pupils, and, in some cases, pulmonary edema, bradycardia (slowing heart rate), hypotension (low blood pressure), cardiac arrest and death. IV. Facility policies and procedures The Medication Administration policy, revised on 10/20/23, was provided by the NHA on 6/3/24 at 1:13 p.m. The policy read in pertinent part, It is the policy of (facility name) that medications are administered by licensed nurses as ordered by the licensed provider and in accordance with professional standards of practice, in a manner to prevent errors, contamination, and/or infection. The nurse is responsible for following the seven (7) rights of medication administration: -Right resident; -Right medication; -Right dose; -Right time; -Right route; -Right documentation; and, -Right to refuse. Review the medication administration record (MAR) to identify the medication to be administered. The MAR is used to reflect current orders for administration of medications and as documentation of medication administration. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. Refer to drug reference material if unfamiliar with the medication such as the mechanism of action or common side effects. V. Significant medication error A. Resident status Resident #1, over the age of 65, was admitted on [DATE] and passed away on 5/15/24. According to the May 2024 computerized physician orders (CPO), diagnoses included congestive heart failure, atrial fibrillation, aortic stenosis, pulmonary hypertension and chronic pain. The 4/15/24 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The assessment documented the resident was receiving opioid and antidepressant medications. The assessment documented the resident was receiving hospice care. B. Record review The facility investigation, dated 5/16/24, documented the following: On 5/16/24 at approximately 12:45 p.m., the consultant pharmacist (CP) alerted facility staff that there could have been a potential discrepancy between a medication order for morphine sulfate and the actual medication administration of the resident because the facility did not have the morphine sulfate dosage concentration that was ordered available at the facility in the emergency back up medication stock and the pharmacy had not yet delivered the ordered dosage concentration to the facility. Facility leadership initiated an immediate investigation and attempted to reach RN #1, who was the nurse who signed as having administered the resident's medication immediately after the prescriber placed the order. As a part of the investigation, RN #1 was interviewed by the director of nursing (DON) and NHA on 5/16/24 at 4:06 p.m. RN #1 was asked to explain the administration of liquid morphine sulfate prescribed to Resident #1 on 5/15/24. RN #1 said she administered a total of 3.75 ml of the liquid morphine sulfate from the 20 mg/ 1 ml dosage concentration bottle she had obtained from the facility's emergency backup medication stock. The NHA asked RN #1 to explain in detail how she measured out the dose of liquid morphine and RN #1 said she drew up the medication from the available morphine sulfate backup medication stock using a one ml syringe. RN #1 said she filled the syringe four times until she measured out 3.75 ml and poured each syringe full of liquid medication into a cup for administration. During the interview the DON read the morphine sulfate solution order from the MAR (20 mg/5 ml, give 3.75 ml), pointing out that was not the concentration the facility had in the backup medication stock. When the DON informed RN #1 that giving 3.75 ml of the facility's available dosage concentration meant that Resident #1 received 75 mg of morphine versus the prescribed dose of 15 mg that was ordered, RN #1 said she did not even notice that the order read 20 mg/5ml and assumed that the prescriber wrote the order for the standard dose that the facility had in the emergency backup medication stock. RN #1 was interviewed a second time on 5/16/24 at approximately 4:15 p.m., by the NHA, DON and a higher level of the administrative staff. RN #1 gave the same interview information and said she did not read the order or perform a dosage check and she instead assumed that the order was for morphine sulfate at a dosage concentration of 20 mg/1 ml because that was what the facility had available in the backup medication stock. Immediately following the interview, RN #1 was placed on administrative leave pending investigation. A review of Resident #1's EMR revealed the following information: A medical provider note, dated 5/15/24 at 10:59 a.m., revealed the resident was seen by NP #1 on 5/14/24, at the request of the resident's son, to evaluate and manage acute concerns when the resident reported she did not feel well. Resident #1 reported nausea after eating lunch but denied cough, congestion or breathing difficulties. The resident was using oxygen continuously at a flow rate of 3.5 liters per minute (LPM). Resident #1 was seen again by NP #1 on 5/15/24 after breakfast and continued to complain of not feeling well and not wanting to get out of bed. NP #1 recommended lab work to assess changes in condition. The resident was taking several medications for pain relief including MS Contin (morphine sulfate) oral tablet extended release15 mg two times a day for pain, duloxetine oral capsule delayed release 60 mg one time a day for chronic pain, lidocaine external patch 4 percent for pain relief of an affected area, naproxen sodium oral tablet 220 mg two times a day for arthritis pain and hydrocodone-acetaminophen oral tablet 5-325 mg every six hours as needed for pain. The physical exam revealed the resident was alert with no apparent distress and poor memory, her pupils were equal size and there was no jugular vein distention noted. The resident had normal respiration effort in the left lung but had crackling sounds in the right lung and an irregular cardiac murmur (a whooshing sound made by rapid, choppy blood flow through the heart). The resident had fluid retention in both lower extremities and both lower extremities were pale and cool to the touch. The resident's other skin areas were warm and dry. The resident's mood was euthymic (calm and tranquil). A medical provider note dated 5/15/24 at 7:01 p.m. documented RN #1 called NP #1 and informed her the patient was unable to safely take MS Contin oral tablets related to her current condition. NP #1 documented a change in morphine orders to give the resident a one-time dose of liquid morphine sulfate solution that evening and then, beginning the next day, orders for liquid morphine sulfate solution 15 mg twice a day. The May 2024 MAR documented an order for morphine sulfate solution entered on 5/15/24 at 6:59 p.m. by NP #1 and confirmed by RN #1 at 7:01 p.m. The order read, Morphine sulfate oral solution 20 mg/5 ml. Controlled drug. Give 3.75 ml by mouth one time only for chronic pain until 5/16/24. The May 2024 MAR displayed a black box warning that read in pertinent part, To reduce the risk of respiratory depression, proper dosing and titration of morphine are essential. Risk of medication errors (oral solution). Ensure accuracy when prescribing, dispensing, and administering morphine sulfate oral solution. Dosing errors due to confusion between mg and ml, and other morphine solutions of different concentrations, can result in accidental overdose and death. A nursing note, dated 5/15/24, read in pertinent part, At approximately 8:45 p.m., the certified nurse aide (CNA) alerted this nurse that there was a change in the resident's condition. The resident's skin was observed to be a waxy color and the resident took no breaths in 90 seconds. There was a faint heartbeat detected with a stethoscope. At 8:50 p.m. the resident no longer had a detectable pulse, heart sounds, breath sounds, or blood pressure. The resident's pupils were fixed and dilated. A narcotic count sheet started for Resident #1's liquid morphine sulfate solution documented that RN #1 initiated the first dose of morphine sulfate at 7:05 p.m. The form documented the morphine sulfate bottle had 30 ml of medication and the medication concentration was 20 mg/ 1 ml. RN #1 documented and signed that she drew up and gave Resident #1 3.75 ml of the morphine sulfate leaving 26.25 ml in the bottle. -However, the above amount given (3.75 ml) from the bottle of morphine sulfate was incorrect and excessive. The prescriber's order read Morphine sulfate 20 mg/5 ml give 3.75 ml. -Giving an amount of 3.75 ml at a concentration of 20 mg/1 ml meant Resident #1 received 75 mg of morphine instead of the prescribed dose of 15 mg of morphine, which was five times the prescribed dose. The May 2024 MAR revealed RN #1 gave the resident the incorrect dose of morphine sulfate at 7:07 p.m. VI. Staff interviews RN #1 was interviewed on 6/4/24 at 1:00 a.m. RN #1 said the pharmacy filled prescribed medications, however, the facility had an emergency backup medication stock for situations when a resident needed to start a medication right away and could not wait for the pharmacy to process and deliver the medication, as it could take hours or days. RN #1 said morphine sulfate solution 20 mg/1 ml was the only concentration of morphine sulfate solution available in the backup medication stock. RN #1 said when a nurse obtained morphine sulfate solution from the backup medication stock, the nurse was to verify the dosage concentration and compare it to the physician's order for accuracy. She said the verification process should occur each time the medication was administered to ensure accurate medication administration. RN #1 said she had recently received education on performing the seven rights of medication administration and was also educated on how to calculate the proper medication doses based on different concentrations of morphine sulfate solution to ensure the accuracy of the medication administered to a resident matched the prescriber's orders. The CP was interviewed on 6/4/24 at 12:36 p.m. The CP said orders were usually entered into the resident's EMR and transferred to the MAR so the nurse could administer the medication at the proper dosage, frequency, time and route. He said once a medication order was entered into the EMR, a second person, usually a nurse from the facility, was to check and verify the entered order for accuracy. The CP said after the second check was completed, the computerized system automatically sent the order electronically to the pharmacy where the pharmacist would perform a triple check to verify the order and screen for any drug interactions, warnings or inaccuracies. The CP said the third check occurred during normal business hours. The CP said if the third check revealed any concerns, the facility would be alerted of the concern. The CP said it was then up to the facility staff to contact the prescriber for further potential recommendations related to the alert and to act appropriately in coordination with the prescriber to avoid any drug interactions. The CP said the pharmacists were also available for further consultation if needed. The CP said when the physician's order for Resident #1's morphine sulfate solution at a concentration of 20 mg/5 ml was received by the pharmacy, he was concerned because he knew the nursing facility did not have the 20 mg/5 ml dosage concentration in the backup medication stock. He said the facility only had morphine sulfate solution 20 mg/1 ml in the backup medication stock and if the nurse gave the prescribed amount of 3.75 ml at the concentration of 20 mg/1 ml it would have been too much medication and would have caused an overdose of Resident #1. RN #1 was interviewed a second time on 6/4/24 at 3:02 p.m. RN #1 said she went to Resident #1's room around 6:45 p.m. to give the resident her medication. Resident #1 said she was ready to take her medications but was unable to swallow her pills so she called the resident's medical provider and requested an order for liquid morphine sulfate. RN #1 said NP #1 answered the phone call and said she would enter a new medication order for liquid morphine sulfate solution. RN #1 said the order showed up on the resident's MAR a few minutes later and she obtained the medication from the facility's backup medication stock. RN #1 said she went to the facility's backup medication stock and obtained a bottle of morphine sulfate solution in the dosage concentration of 20 mg/1 ml from the backup medication stock. RN #1 said the only morphine sulfate solution the facility had in its backup medication stock was in the dosage concentration of 20 mg/1 ml. RN #1 said at approximately 7:05 p.m., she drew up and gave Resident #1 what she thought was the prescribed dose of 3.75 ml of the morphine sulfate solution. RN #1 said when she obtained the medication from the facility's backup medication stock and went to administer the medication to Resident #1, she failed to check the order with the morphine sulfate solution on hand and did not notice that the physician's order was for a different dosage concentration than the available dosage concentration of morphine sulfate solution. She said she drew up 3.75 ml as the order indicated and administered it to the resident. RN #1 said the proper steps in medication administration were to read the physician's order to confirm that the medication on hand was the correct medication and the correct dose. She said she would also make sure to check the resident's name and make sure the resident did not have related medical allergies RN #1 said after giving Resident #1 the liquid morphine sulfate,she looked in on her a couple of times and noticed that her breathing was labored. She said a little after 8:00 p.m., the CNA informed her Resident #1 was not breathing. She said when she assessed Resident #1 she had a weak heartbeat and was not breathing. RN #1 said as the night went on she began to think more about the events of the evening and started to question the amount of morphine sulfate solution she had administered to the resident. RN #1 said following her shift, she had a discussion about the medication error with the DON. She said they discussed the incident in detail and she received education regarding medication administration. RN #1 said going forward she would perform the seven rights of medication administration and would verify all medication administrations for accuracy. RN #1 said she would also ask another nurse to double-check the physician's order with her to ensure she administered the medication correctly. NP #1 was interviewed on 6/4/24 at 3:50 p.m. NP #1 said, on 5/15/24 at approximately 7:00 p.m., she received a call from RN #1 who told her Resident #1 was unable to swallow her medication and she wanted to know if she could switch the MS Contin oral tablets over to a liquid form of morphine sulfate. NP #1 said she told RN #1 she would enter an order for liquid morphine sulfate. NP #1 said she did not discuss anything further with RN #1. The medical director (MD) was interviewed on 6/6/24 at 12:58 p.m. The MD was aware that Resident #1 was given an overdose of morphine sulfate by RN #1. The MD said, following the incident, she talked at length with the DON and the NHA about the potential causes and developed a plan of correction. The MD said the physician's order was written correctly by a provider but it was written at a strength that was not commonly used and at a dosage concentration that was not immediately available to the facility. She said the administration of the incorrect dose of morphine sulfate solution was RN #1's error as she did not check the medication strength with the physician's order before administering the medication to Resident #1. The DON was interviewed on 6/4/24 at 1:25 p.m. The DON said once she was notified by the pharmacist that there was a concern about Resident #1's morphine sulfate solution order and a potential for a medication error, she began an immediate investigation. She said the investigation revealed Resident #1 was given an incorrect dose of morphine sulfate solution. The DON said RN #1, who gave the incorrect dosage of morphine sulfate, was placed on immediate suspension. The DON said she provided immediate education to all licensed nurses on properly verifying all physician's orders for accuracy and how to calculate proper morphine doses if the provider ordered a morphine dosage concentration different from the morphine available in the facility's backup medication stock. The DON said the facility also talked to the medical providers to educate them about the facility's available dosage concentration of morphine sulfate solution. The NHA was interviewed on 6/6/24 at 3:01 p.m. The NHA said the details of the medication error incident would be presented at the next quality assurance quality improvement (QAPI) meeting. The NHA said the QAPI committee was expected to review the investigation findings and complete corrective actions to determine if further corrective actions were needed.

Based on record review and interviews, the facility failed to ensure timely physician visits for four (#9, #10, #12 and #13) of five residents reviewed for new admission physician visits out of 13 sample residents. Specifically, the facility failed to ensure the physician evaluated Resident #9, Resident #10, Resident #12 and Resident #13 within 30 days following admission to the facility. Findings include: I. Facility policy and procedure The Physician Visits and Delegation policy, revised 5/6/24, was provided by the nursing home administrator (NHA) on 6/5/24 at 1:48 p.m. It revealed in pertinent part, The physician should: -See the resident within 30 days of initial admission to the facility; -The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by the physician or physician delegate as appropriate by state law; and, -Review the resident's total program of care including medications and treatments at each visit. II. Resident #9 A. Resident status Resident #9, age greater than 65, was admitted on [DATE]. According to the June 2024 computerized physician's order (CPO), diagnoses included heart failure, atrial fibrillation (irregular heart rhythm), edema, bladder dysfunction, pelvic pain and hypertension. The 4/30/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident had an indwelling catheter and was prescribed antidepressants and diuretic medications. B. Record review -A review of Resident #9's electronic medical record (EMR) revealed the physician did not see the resident until 4/2/24, 57 days after the resident was admitted to the facility. III. Resident #12 A. Resident status Resident #12, age 79, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included hypertension, idiopathic progressive neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), sleep apnea and osteomyelitis. The 6/5/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident was prescribed opioid and antiplatelet medications. B. Record review -A review of Resident #12's EMR revealed the physician did not see the resident until 4/2/24, 47 days after the resident was admitted to the facility. IV. Resident #13 A. Resident status Resident #13, age 85, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included dementia with behavioral disturbances, adjustment disorder, bipolar disorder, diabetes, hypertension and osteoarthritis. The 6/6/24 MDS assessment revealed the resident had severely impaired cognition with a BIMS score of six out of 15. The resident was prescribed antipsychotic, antidepressant, diuretic, opioid and hypoglycemic medications. B. Record review -A review of Resident #13's EMR revealed the physician did not see the resident until 4/2/24, 47 days after the resident was admitted to the facility. V. Resident #10 Resident #10, age less than 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included heart failure, atrial fibrillation, dementia, benign prostatic hyperplasia, conjunctivitis and hypertension. The 6/5/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. The resident had an indwelling catheter and was prescribed antidepressants and anticoagulant medications. B. Record review -A review of Resident #10's EMR revealed the physician did not see the resident until 4/2/24, 42 days after the resident was admitted to the facility. VI. Staff interviews The director of nursing (DON) was interviewed on 6/6/24 at 9:02 p.m. The DON said residents should be seen timely by the physician following admission to the facility. The DON said the facility had talked to the residents' physician about the requirement to see the residents within 30 days of admission. The medical director (MD) was interviewed on 6/6/24 at 12:58 p.m. The MD said the facility had some issues in regards to the physician seeing residents within the first 30 days after admission and the frequency of physician's visits. The MD said she was working with the resident's physician to establish a more consistent schedule for physician visitation.

Based on observation, record review and interviews the facility failed to ensure three (#55, #35 and #32) out of 34 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Assess a Resident #55's change of condition and notify the resident's physician in a timely manner when the resident had ongoing vomiting and when the resident's abdomen was distended and tender to touch on 3/12/23; and, -Assess Resident #35 and Resident #32 vital signs were monitored prior to the administration of a blood pressure medication. Findings include: I. Resident #55 A. Professional references [NAME], D. A., [NAME], S. [NAME], S. M. (August 2022). Bowel obstruction. National Library of Medicine. Stat Pearls (Internet) https://www.ncbi.nlm.nih.gov/books/NBK441975/ retrieved on 5/22/23. Commonly in small bowel obstruction (SBO), abdominal pain is described as intermittent and colicky but improves with vomiting. The vomiting in SBO tends to be more frequent, in larger volumes, and bilious (yellowish green vomit). [NAME], P. (April 2023). Intestinal Obstruction. Merck Manual Professional Version. https://www.merckmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-and-surgical-gastroenterology/intestinal-obstruction retrieved on 5/22/23. Obstruction of the small bowel causes symptoms shortly after onset: abdominal cramps centered around the umbilicus or in the epigastrum, vomiting and, in patients with complete obstruction, obstipation (severe prolonged constipation). Patients with partial obstruction may develop diarrhea. Severe, steady pain suggests that strangulation has occurred. Sanivarapu, R. R., [NAME], G. (December 2022). Aspiration pneumonia. National Library of Medicine. Stat Pearls (Internet) https://www.ncbi.nlm.nih.gov/books/NBK470459/ retrieved on 5/22/23. The infectious pulmonary process that occurs after abnormal entry of fluids into the lower respiratory tract is termed aspiration pneumonia. The aspirated fluid can be oropharyngeal secretions or particulate matter or can also be gastric content. B. Facility policy and procedure The Change of Condition policy and procedure, reviewed on 2/1/23, was provided by the nursing home administrator (NHA) on 5/18/23 at 3:15 p.m. It revealed in pertinent part, The purpose of this policy is to ensure the (facility) promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life threatening conditions, or b. Clinical complications. C. Resident status Resident #55, age 80, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included dementia, dysphagia (swallowing difficulty), pain and gastroesophageal reflux disease (GERD). The 3/12/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory and daily decision making. He was dependent with the assistance of two people for transfers, toileting, personal hygiene, he required extensive assistance of two or more people with bed mobility and dressing and extensive assistance of one person for eating. D. Record review The pain care plan, initiated 2/23/23, indicated that resident was unable to verbalize pain description or pain level related to dementia progression. Interventions included monitor and document side effects of pain medication. Observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls and report to physician. Monitor and report any signs and symptoms of non-verbal pain changes in breathing, vocalizations, mood/behavior changes, eyes (wide open/narrow slits/shut, glazed, tearing, no focus), face (sad, crying, worried, scared, clenched teeth grimacing), body (tense, rigid, rocking, curled up, thrashing). Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care. The 2/26/23 physician progress notes revealed a diagnosis of GERD, dysphagia, diarrhea, constipation, colon polyps, bilious vomiting with a surgical history of appendectomy (removal of appendix), colon polyp removal and cholecystectomy (removal of gallbladder). The assessment revealed the abdomen was soft and non distended, non tender and bowel sounds active. Lung assessment revealed they were clear to auscultation (listened to lung sounds with a stethoscope) without crackles or wheezes. -A review of the physician documentation revealed no further physician assessment or follow up after 2/26/23. The 3/6/23 nursing progress notes revealed at 2:31 p.m. the resident refused to get out of bed, had refused meals and medications. He was tensed and made noises throughout the shift. The 3/6/23 nursing progress notes revealed at 5:08 p.m. the resident had a large emesis (vomiting). The 3/6/23 nursing progress notes revealed at 7:07 p.m. the resident had a large emesis and acetaminophen was held. -A review of documentation revealed no further nursing assessment, including an abdominal assessment, vital signs or communication with providers. The 3/7/23 nursing progress notes revealed at 12:20 a.m. Zofran 4 milligram (mg) was given for nausea after three emesis episodes. The 3/7/23 nursing progress notes revealed at 4:54 a.m. resident at midnight had a large emesis that was observed to be yellow with small streaks of red. The resident had a second emesis that was bile colored. The resident temperature was 100.3 degrees Fahrenheit. The resident had medium watery diarrhea. Message was sent to providers and infection control was notified. The 3/7/23 at 11:27 a.m. revealed the resident had a COVID test with negative results. -A review of documentation revealed no further nursing assessment, including an abdominal assessment or if the provider returned the message. The 3/7/23 nursing progress notes revealed at 10:27 p.m. the resident remained in bed and made continuous sounds. The resident's daughter gave resident a milkshake which he vomited. A review of documentation of 3/7/23 10:27 p.m. revealed no further nursing assessment, including an abdominal assessment, vital signs or providers being notified after resident vomited at 10:27 p.m. The 3/11/23 nursing progress notes revealed at 5:16 a.m. the resident had two episodes of emesis during the night shift and would not give a verbal response to the nurse. The 3/11/23 nursing progress notes revealed at 1:41 p.m. the resident refused oral care. -A review of documentation for 3/11/23 revealed no further nursing assessment, including an abdominal assessment, vital signs or communication with providers. The 3/12/23 nursing progress notes revealed at 12:14 a.m. the resident remained in bed with increased episodes of vomitus. Head of bed elevated and making quacking noise during care. The 3/12/23 nursing progress notes revealed at 1:53 a.m. the resident was given Zofran 4 mg for nausea. The 3/12/23 nursing notes revealed at 5:11 a.m. the resident was awake and making continuous quacking sounds. The 3/12/23 nursing progress notes revealed at 6:00 a.m. it was documented that at 5:00 a.m. the resident had a moderate amount of vomit. Resident #55's vital signs were blood pressure 150/74, heart rate 108, temperature 99.0 degrees Fahrenheit, oxygen saturation 91%. -A review of documentation revealed no further nursing assessment, including an abdominal assessment or communication with providers regarding increased heart rate, low grade temperature and vomiting. The 3/12/23 nursing progress notes revealed at 9:42 a.m. the resident vomited a large amount of food particles and Synthroid (thyroid medication) was held. The 3/12/23 nursing progress notes revealed at 9:43 a.m. the resident was left in bed at this time due to feeling sick. The 3/12/23 nursing progress notes revealed at 9:55 a.m. the resident vomited a large amount of food particles and light brownish fluid. He refused oral fluids and medications. The 3/12/23 nursing progress notes revealed the resident had vomited at 11:45 a.m. The nurse assessed the resident who appeared pale with sunken eyes and was slightly agitated. Pain medication was provided. The resident then slept and then vomited a second time. The abdomen was found to be distended and tender to the touch. The nurse was unable to assess the abdomen or lung sounds due to the resident making quacking sounds. The resident exhibited muscle rigidity and abdominal guarding. The 3/12/23 nursing progress notes revealed at 1:40 p.m. the resident's vital signs were blood pressure 100/64, temperature 99.1 degrees Fahrenheit, pulse 159, and oxygen saturation of 82%. Resident's head was raised and supplemental oxygen was administered at 2 liters via nasal cannula. Binax COVID test was done with negative results. The resident had a medium putty colored bowel movement. The 3/12/23 nursing progress notes revealed at 2:00 p.m. the on-call provider and on call nurse were notified at 2:00 p.m. A voicemail was left for the resident's power of attorney (POA). The 3/12/23 nursing progress notes revealed at 3:30 p.m. the POA requested the resident be sent to the emergency department for evaluation. The 3/12/23 nursing progress notes revealed the resident was transferred at 4:10 p.m. -A comprehensive review of the 3/12/23 documentation revealed the resident began vomiting at 5:00 a.m. with a change in vital signs, the resident did not have an abdominal assessment until 11:45 a.m. where the resident's abdomen was distended and tender to touch. The resident's vital signs were not documented at 1:40 p.m. The provider was not called until 2:00 p.m. which was over two hours later and the resident did not go to the hospital until over four hours later. The 3/12/23 nursing progress notes revealed at 10:00 p.m. report by the hospital staff to nursing home staff that the resident had a small bowel obstruction on computerized tomography (CT) with likely pneumonia on chest x-ray and potential sepsis. He was admitted to the medical surgical unit for end of life care and was treated with pain medication and intravenous fluids. The bowel elimination documentation revealed: -3/5/23 at 9:49 p.m. resident was incontinent; -3/7/23 at 5:59 a.m. resident was incontinent; -3/8/23 no bowel movement was recorded; -3/9/23 no bowel movement was recorded; -3/10/23 at 9:59 p.m. resident was incontinent; -3/11/23 at 1:50 p.m. resident was incontinent; -3/12/23 at 5:59 a.m. resident was incontinent; and, -3/12/23 at 1:59 p.m. resident was incontinent. -A review of documentation revealed no documentation of quality (formed versus diarrhea) or quantity of bowel movement. A review of the March 2023 CPO revealed: -Ondansteron (Zofran) 4 milligrams (mg) by mouth every four hours as needed for nausea, ordered 1/12/23. This medication was administered on 3/7/23 at 12:20 a.m. and on 3/12/23 at 11:53 a.m. A review of the March 2023 medication administration record (MAR) pain assessment in advanced dementia scale (PAINAD) revealed -3/6/23 day shift pain level 5, evening pain level 2, and night pain level 1. -3/7/23 day shift pain level 0, evening pain level 7 and night pain level 2. -3/8/23 day shift pain level 2, evening pain level 5 and night pain level 2. -3/9/23 day shift pain level 3, evening pain level 0 and night pain level 0. -3/10/23 day shift pain level 4, evening pain level 3 and night pain level 3. -3/11/23 day shift pain level 2, evening pain level 0 and night pain level 2. -3/12/23 day shift pain level 5. -A comprehensive review of pain assessment documented an elevated pain level on 3/6/23 day shift when resident was exhibiting tensed and vocalization behaviors, 3/7/23 evening shift when resident was experiencing emesis and making continuous sounds and 3/12/23 day shift when resident was exhibiting elevated temperature, emesis, elevated pulse and decreased oxygen saturation. C. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 5/18/23 at 10:15 a.m. She said Resident #55 had been throwing up prior to being hospitalized and he had not been feeling well and was making strange quacking noises. She said physicians and nurses had talked about the quacking noises and if they were the result of the resident experiencing pain or if it was related to something else. CNA #1 was interviewed on 5/18/23 at 10:20 a.m. She said the resident had not been feeling well and had been staying in bed. He had not been eating much and had been throwing up prior to being hospitalized . Registered nurse (RN) #1 was interviewed on 5/18/23 at 10:25 a.m. She said the resident had been having an overall decline. She said she took care of the resident the day before he was hospitalized . She said he was having bowel movements but he was having instances of vomiting. She said he may have been having a pain crisis because he was making frequent quacking noises. He had been having episodes of emesis and he had normal bowel sounds. She was not aware if the providers had been notified regarding his vomiting. She said when there was a suspected change of condition, providers were notified, vital signs were monitored and for gastrointestinal symptoms an abdominal assessment should be performed. She said providers were notified for residents ' changes of condition. The director of nursing (DON) was interviewed on 5/18/23 at 5:01 p.m. She said he had been having occasional emesis the entire stay. She said that the resident made quacking noises but they had been unable to determine if it was pain related. She said providers were notified on 3/7/23 regarding the vomiting and temperature but was unable to confirm if there was an abdominal assessment, return communication or follow up with the providers. She was unable to locate documentation if the provider was notified on 3/12/23 before 2:00 p.m. She said when a resident was having symptoms of vomiting with changes in vital signs, including an elevated temperature, an abdominal assessment should be completed and the provider notified. The medical director was interviewed on 5/18/23 at 6:00 p.m. The resident exhibited during his stay at the facility was quacking vocalizations. Staff were unable to attribute the quacking noises to pain or to a tardive dyskinesia (abnormal or impaired voluntary movement) type side effect of the medications. He said when there were episodes of vomiting with a fever there should be an assessment of vital signs, abdominal assessment, monitoring for constipation and a lung assessment (to assess for aspiration). He said the provider should be notified. II. Monitoring blood pressure medication A. Professional references Khashayar.F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 5/25/23. It read in pertinent part, Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta-blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers. Kizior, R. J., [NAME], K. J. (2023). Metoprolol. [NAME] Nursing Drug Handbook. Elsevier. p. 770. Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse is 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician. B. Observations On 5/16/23 at 3:00 p.m. registered nurse (RN) #5 was observed dispensing Metoprolol 25 milligrams (mg). RN #5 checked order for parameters and was observed checking Resident #32's pulse, which was 60 beats per minute (bpm) prior to administration of medication. RN #5 was not observed checking for the resident's blood pressure prior to administration. RN #5 was observed administering Metoprolol. The physician order documented Metoprolol 25 mg twice a day. Parameters ordered to hold medication if pulse was less than 55. On 5/17/23 at 7:30 a.m. RN #4 was observed dispensing Amlodipine 5 mg. RN #4 was not observed checking for a current blood pressure or pulse prior to administration. RN #4 then administered Amlodipine medication to Resident #35. The physician order documented Amlodipine 5 mg once a day. C. Staff interviews RN #1 was interviewed on 5/18/23 at 11:45 a.m. She said before giving a blood pressure medication the residents' blood pressure and pulse should be assessed. She said if blood pressure and pulse were below baseline a reassessment should be done and physician ordered parameters should be followed. She said if there were no physician ordered parameters an assessment of the resident including a blood pressure and pulse, along with signs and symptoms of low blood pressure were done. She said a physician should be notified if the resident experienced a blood pressure less than 100-120 systolic and pulse was less than 55 bpm. The DON was interviewed on 5/18/23 at 5:22 p.m. She said blood pressure and pulse were done prior to the administration of a blood pressure medication and physician ordered parameters should be followed. If there were no physician ordered parameters, an assessment of low blood pressure which included monitoring blood pressure, pulse and monitoring for signs and symptoms should be done.

Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in one of two dining rooms. Specifically, the facility failed to ensure residents had hand hygiene before meals. Findings include: I. Facility policy and procedure The Infection Prevention and Control policy, revised 1/31/23, was provided by the facility on 5/15/23. The policy read in pertinent part: The (facility's) Infection Prevention and Control (ICP) plan shall ensure the organization develops, implements and maintains an active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risk of epidemic and epidemic infections in residence, visitors and healthcare workers, and to optimize use of resources. According to the infection control policies the facility would implement appropriate infection prevention and control measures and communicate responsibilities about preventing and controlling infection. Responsibilities would include hand hygiene to all staff residents, families and visitors. The Hand Hygiene policy, reviewed 1/19/23, was provided by the facility on 5/18/23. The policy identified hand hygiene should be performed before and after eating. II. Observations Dinner observations were conducted 5/15/23 between 4:18 p.m. and 5:10 p.m. A free standing alcohol based hand rub (ABHR) dispenser with an orange sign requesting residents to use the ABHR was on the 2nd floor dining room near the entrance. Observations identified residents who brought themselves to the dining room did not stop to use the ABHR from the dispenser. The staff assisting residents into the dining room did stop with the residents at the dispenser and provide ABHR. Observations did not identify staff provided ABHR or hand hygiene wipes for most of the residents once they sat down and prepared for their meal, or once the residents were provided their meal. Only one resident in the dining room was provided hand hygiene before he was provided total meal assistance. In room meal delivery on 5/15/23 identified some residents were not offered hand hygiene during meal service. Between 5:14 p.m. and 5:30 p.m. the residents in room [ROOM NUMBER], #209 and #216 were not offered hand hygiene before they were served their meal tray. Observations were conducted on 5/17/23 during the lunch meal service. The meal included hand held items such as bread sticks and sandwiches. Residents were not observed to be encouraged or assisted with hand hygiene in their rooms prior to the meal. Residents assisting themselves into the dining room were not observed to use the ABHR dispenser. Staff assisting residents in their wheelchairs into the dining room, did not stop and assisted residents with ABHR. Staff did not encourage residents to use ABHR when entering the dining room. Residents were not provided or assisted with hand hygiene prior to meal service in the dining room or when offered their meal. One resident was observed touching the eating surface of his spoon with his fingers prior to eating. Another resident was observed to wipe his nose with his fingers before eating his sandwich. Observations were conducted in the dining room on 5/17/23 during dinner. Only one resident assisting herself into the dining room, used the ABHR dispenser. Residents were not provided or assisted with hand hygiene in the dining room before their meal. The 5/18/23 lunch observation did not identify residents were provided hand hygiene prior to their meal. Several residents were observed eating a hamburger with their hands. III. Resident interviews Resident #34 was interviewed on 5/17/23 at approximately 3:30 p.m. He said there was ABHR available in the dining room but he usually did not think about it or pay too much attention to it. He said staff does not remind him or encourage him to do hand hygiene in the dining room or in his room. He said he would usually wash his hands after using the restroom. Resident #7 was interviewed on 5/18/23 at 3:20 p.m. He said he was aware of an ABHR dispenser in the dining room. He said he did not usually see residents using it. Resident #7 said staff pushing residents would have to stop and assist the resident they were assisting to use the ABHR dispenser. He said he personally did not like to use the ABHR. He did not like the way it smelled or how it felt. He said he would prefer hand wipes offered in the dining room. He said his hands would feel cleaner with wipes. He said hand wipes were not offered in the dining room by staff. He said he figured if staff performed hand hygiene in the dining room, that would be enough for him. Resident #33 was interviewed on 5/18/23 at 3:26 p.m. He said he did not use the ABHR dispenser in the dining room because he used a walker. He said he would have to take his hands off the walker to use the dispenser and he was afraid if he let go of the walker he might lose his balance and fall. Resident #39 was interviewed on 5/18/23 at 3:34 p.m. He said he was not aware there was a place in the dining room that he could use ABHR before meals. IV. Staff interviews The director of nursing (DON) and the infection preventionist (IP) was interviewed on 5/18/23 at 12:30 p.m. According to the DON and the IP, the IP was new to the position and the DON was overseeing the program. The DON said the best way to prevent the spread of transmission based infections was to practice appropriate infection control such as personal protection equipment and hand hygiene. The DON said staff were trained on hand hygiene during staff in-services, online training, new hire orientation and the certified nurse aide (CNA) education class. The DON said infection control practices were included in a staff education fair last fall. She said part of the training included a return demonstration of hand hygiene. The IP said she conducted infection control rounds and audits throughout the week. She said the rounds included making sure staff performed hand hygiene. She said the audits did not include resident hand hygiene at meals. The DON said staff needed to ensure residents were offered and assisted with hand hygiene after use of the restroom, before and after eating, primarily, but not limited to anytime a resident needed and wanted hand hygiene. She said ABHR was available on the walls in the hallways but staff should be offering, reminding, encouraging, assisting the residents with hand hygiene. The DON said the residents live in a shared community environment and everyone touches everything. She said hand hygiene helped protect against the spread of transmission based infections by breaking the infection chain. The DON and the IP were informed of the above observations. The DON and the IP said they would re-educate staff on the importance of resident hand hygiene and remind residents where they could perform hand hygiene. The IP said she would do in service or activity residents with a glow light that would show them the germs on the hands and surfaces. The IP said she would include resident hand hygiene with her infection control rounds. The DON said she would look into ordering hand wipes for residents to use in the dining room and change the location and color of the sign on the ABHR dispenser stand in the dining room. V. Record review The DON provided an 11/7/22 staff inservice attendance sheet with an attached hand hygiene competency validation check list and an online course completion record on 5/19/23 via email. According to the attendance sheet, staff were in service on infection control practices, including hand hygiene. The hand hygiene competency check list requested staff to perform a return demonstration of appropriate hand hygiene practices. The course completion record identified staff completed an online training course of hand hygiene between 11/19/22 and 5/19/23. VI. Facility follow-up The DON was interviewed again on 5/18/23 at 5:17 p.m. She said the facility chose to offer hand hygiene in the dining room by way of the ABHR dispenser stand in the entry of the dining room for residents because the facility thought it would be more convenient for residents to use as opposed to the ABHR on the walls. She said they wanted a convenient system so residents could have cleaner hands just before they sat down at the dining table for meal service. She said the IP conducted staff education on 5/18/23 on the importance of resident hand hygiene. She said she changed the color of the sign to bright green which reminded residents to use. She said she would periodically change the colors of the sign to help catch staff and residents' attention. The DON said she had ordered wipe packets and hand hygiene wipes for use in the dining rooms. She said she would have a staff member assigned to each meal to assist residents with hand hygiene. The DON said the activities department scheduled an activity for residents on 6/5/23 to teach residents on the importance of infection control and hand hygiene. She said the facility may include infection control presentations as a monthly resident activity. The DON said she would continue to educate staff on infection control with a focus on resident hand hygiene before meals. She said during the 5/18/23 dinner after changing the color of the sign on the ABHR dispenser, the placement of the dispenser at the entrance of the dining room, and educating staff to remind and assist residents with hand hygiene before meals, she saw residents lining up to use the ABHR before sitting down at their meal table. The DON provided the records identifying facility follow up after the hand hygiene observations were shared with the facility on 5/19/23 via email. The records included: -An 5/18/23 dining room hand hygiene audit identified staff offered hand hygiene during the 5/18/23 dinner to all residents who ate in the dining room. The audit showed that residents in the dining room were provided hand hygiene in the dining room. According to the audit, only one resident refused hand hygiene. -An outline of hand hygiene improvements the facility would make to adhere to appropriate infection control practices, to include, one to one education with staff regarding the residents' need for hand hygiene before and after meals. According to the hand hygiene improvement outline, the staff needed increased education to remind residents to perform hand hygiene before meals. -A staff attendance sheet identified staff received resident hand hygiene before and after meals education on 5/18/23.

Based on interviews and record review, the facility failed to ensure one (#42) of four out of 34 sample residents were kept free from physical abuse. Specifically, the facility failed to ensure effective personalized care planned behavioral interventions were in place for Resident #43, who had a history of physically abusive behaviors towards Resident #42. Findings include: I. Facility policy and procedure The Abuse policy and procedure, last reviewed on 2/21/23, was provided by the nursing home administrator (NHA) on 5/18/23 at 8:30 a.m. It read in pertinent part, Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed, the extent or location of the injury is unusual, or because of the number of injuries whether at a single point in time or over time. II. Incident of abuse between Resident #42 and Resident #43 Resident #42 and Resident #43 were married with Resident #43 having a history of physically abusive behaviors towards Resident #42 (see care plan below). The 5/15/23 facility's abuse investigation documented staff members observed Resident #42 sitting and visiting with Resident #43 and Resident #42 was spitting on the floor. Resident #43 told Resident #42 that was not acceptable and was observed hitting Resident #42's hand in his lap. Staff immediately separated the residents and Resident #43 was returned to the second floor, where she resided. Resident #42 remained on the first floor where he resided. Resident #42 was interviewed after the incident and did not remember the incident and did not express any fear of Resident #43. No injury was observed. The facility investigation did not indicate if the abuse was substantiated or not. -However, the abuse should be substantiated based on Resident #43 willfully hitting Resident #42. III. Resident #43 A. Resident status Resident #43, aged 84, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO) diagnoses included dementia with other behavioral disturbance, adjustment disorder and depression. The 4/13/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 12 out of 15. She required set up assistance for eating and was independent with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated she was not exhibiting verbal and physical behaviors towards others. B. Record review The behavioral care plan, initiated on 5/30/22 revised on 5/9/23, documented Resident #43 had a history of physically abusive behaviors towards Resident #42 and interfered in his care. It indicated that she was quick to act and unable to remember coping skills. The interventions included assist resident to develop more appropriate methods of coping and interacting with Resident #42 that will not interfere with care, encourage resident to express feelings appropriately, provide opportunity for positive interaction, intervene as necessary to protect rights and safety of others, approach in a calm manner, divert attention, remove from the situation. Remind the resident, when she brings Resident #42 upstairs to eat or go to activities, not to leave unattended and monitor Resident #42's location. -A review of Resident #43's comprehensive care plan did not reveal effective personalized behavioral interventions for monitoring and preventing resident's behavior during interactions with Resident #42 during mealtimes or activities. The care plan was not updated after the altercation on 5/15/23. A 5/15/23 social services progress note revealed the social worker spoke with the resident regarding the incident that Resident #42 was spitting on the floor and Resident #43 told him to stop that and then slapped his hand and arm that was on his lap to get his attention to stop the behavior. Resident #43 became teary and left the interview and verbalized that Resident #42 was unable to understand and reason anymore. The social worker followed up with the resident in her room regarding how dementia affected people and to reach out to staff before she became frustrated. A 5/16/23 nursing progress note revealed the Resident #43 was on visual checks every 15 minutes, secondary to striking Resident #42 on 5/15/23. The facility had daily behavior monitoring of the Resident #43's behavior towards other residents in the facility. The 4/19/23 to 5/18/23 behavior tracking form indicated no physical or verbal behaviors directed at others. -However, the resident had an altercation on 5/15/23 (see above). -A comprehensive review of the progress notes did not reveal any further documentation of the incident. C. Resident interview Resident #43 was interviewed on 5/16/23 at 1:30 p.m She was not able to recall the incident on 5/15/23 and asked why she could not be in the same room as her husband. IV. Resident #42 A. Resident status Resident #42, age 90, was admitted on [DATE]. According to the May 2023 CPO, the diagnoses included Alzheimers's disease, type II diabetes mellitus and chronic kidney disease. The 3/30/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. He required the extensive assistance of two people with bed mobility, transfers, dressing, toileting, personal hygiene and the limited assistance of one person with eating. B. Record review The behavior care plan, initiated 5/30/22 revised 4/25/23, indicated that Resident #42 had a history of being resistive to care and would swing at staff and Resident #43 when he did not want care, was agitated or angry. The interventions included allow the resident to be involved with treatment and care regime, give resident clear explanation of all care activities prior to when they occur and do not rush resident. -A comprehensive review of Resident #42's care plan did not reveal any additional person centered interventions after the altercation on 5/15/23. C. Resident interview Resident #42 was interviewed on 5/17/23 at 3:00 p.m. He was not able to answer questions when asked. V. Staff interviews Certified nursing assistant (CNA) #6 was interviewed on 5/18/23 at 11:01 a.m. She said Resident #43 was a social person and she observed that Resident #43 and Resident #42 were together frequently during activities and meals. CNA #6 said she had not been closely monitoring the two residents and had not observed any physically aggressive behaviors by Resident #43 during activities or mealtimes. Registered nurse (RN) #4 was interviewed on 5/18/23 at 1:15 p.m. She said she had not observed any aggressive behavior by Resident #43 towards Resident #42. She said that historically Resident #43 had slapped Resident #42. She was unable to recall the last instance of physical aggression towards Resident #42 by Resident #43. She said the residents were frequently together at activities and at mealtimes. The director of nursing (DON) was interviewed on 5/18/23 at 5:00 p.m. She said Resident #43 and Resident #42 lived on separate floors due to Resident #43's history of physical aggression towards Resident #42 and interference in care. Resident #43 and Resident #42 had been having supervised meals in the past. There had been no observed physically aggressive behavior by Resident #43 for a significant amount of time until the incident on 5/15/23. Resident #43 and #42 had been assessed to need to be in line of sight during activities and mealtimes but since the incident occurred they would need to be supervised with staff present and monitoring activities and mealtimes.

Based on observations, record review and interviews, the facility failed to ensure effective interventions were in place to address weight loss for two (#3 and #37) of seven residents reviewed for nutrition out of 34 sample residents. Specifically, the facility failed to ensure Resident #3 and #37 were provided nutritional interventions identified for their weight losss. Findings include: I. Professional reference Roigk. P. (2018) Chapter 8: Nutrition and Hydration. In K. [NAME] and J. [NAME]-[NAME] Eds. Fragility Fracture Nursing: Holistic Care and Management of the Orthogeriatric Patient (Internet). [NAME] Publishing. https://www.ncbi.nlm.nih.gov/books/NBK543833/ retrieved on 5/24/23 at 9:24 a.m. According to the North American Nursing Diagnoses Association ([NAME]) malnutrition is: 'Intake of nutrients insufficient to meet metabolic needs'. The criteria for malnutrition are: Body mass index (BMI)< (less than) 18.5 kg/m2, unintended weight loss> (greater than) 10% in the last 3-6 months, BMI < 20 kg/m2 and unintended weight loss>5% in the last 3-6 months, fasting period>7 days. II. Facility policy and procedure The Weight Monitoring policy and procedure, last revised on 5/18/23, was provided by the nursing home administrator (NHA) on 5/18/23 at 4:20 p.m. It read in pertinent part, It is the policy of the facility to establish weight baseline, to monitor weight loss and/or gain, and to monitor residents for significant changes in weight that may require intervention. Weights are to be taken and recorded at the same time each month to assure consistent monitoring. The scale(s) for evaluating weight should be calibrated routinely to assure equipment is working properly and that information is accurate. III. Resident #3 A. Resident status Resident #3, age 92, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnosis included type II diabetes mellitus and vitamin B deficiency. The 2/2/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out 15. She required the extensive assistance of one person for dressing, toileting, personal hygiene, limited assistance of one person for bed mobility and transfers and was independent with eating. B. Observations On 5/17/23 at 9:19 a.m. snacks were not observed in the resident's room (as indicated in the care plan, see below). The resident was observed sitting in the lobby, the resident was observed not having or eating snacks. At 11:00 a.m. The resident was observed [NAME] self in the hallway past a snack cart. The resident did not attempt to take snacks from the snack cart. At 11:30 a.m. the resident was observed sitting in the dining area. The resident was served lunch at 12:03 p.m. - a small green salad, small bowl of soup and a breadstick. She ate 40% of green salad, three spoonfuls of soup and 0% of breadstick. She was given a small container of ice cream and ate 20%. She was not offered an alternative to the meal or additional food prior to the ice cream. At 1:45 p.m. the resident was observed [NAME] self around in the lobby area. The resident was observed not having or eating snacks. At 4:30 p.m. the resident was observed in the dining room. She ordered a half order of the special which consisted of mashed potatoes, roast beef and gravy and pudding. She ate approximately 30% of the scoop of mashed potatoes, 0% of roast beef and 80% of pudding. She was not offered an alternative meal or additional food. C. Record review The nutrition and weight management care plan, initiated on 10/8/2020 revised on 5/16/22, indicated resident was at a high nutritional risk with possibility of weight changes due to diabetes, cardiac fluid retention, desire to take in only minimal supplements and periods of poor appetite. It indicated the resident's ideal body weight (IBW) was 105 pounds (lbs) with a range of 95-115 lbs. Interventions included a regular diet with meats cut in half inch pieces, small portions and thin liquids.Ensure plus or supplement of choice every morning, shelf stable high calorie snacks for her room to consume, encourage resident to eat, monitor weight for significant weight changes, offer snack hydration cart twice a day between meals, record and monitor oral intake at meals and snacks between meals, review calories, protein and fluid needs as necessary. The resident's weights were documented as follows: -11/15/22 108 lbs (bath chair) -2/7/23 104.8 lbs (bath chair) -4/11/23 106.4 lbs (bath chair) -5/9/23 92.8 lbs (bath chair), and; -5/11/23 97.6 lbs (wheelchair) The 5/2/23 interdisciplinary weight team notes documented Resident #3 had a weight increase of 3% in one week, weight loss of 5% in one month, weight loss of 4.7% in three months and a loss of 6.8% in six months. It documented a recent weight loss but improved appetite with intake of 75-100% of meals. The resident declined any additional nutritional interventions but requested additional shelf stable snacks in her room. The 5/15/23 interdisciplinary weight team notes documented Resident #3 had weight loss of 2.9% in one week, weight loss of 8.4% in one month and 6.8% in three months. It documented variable oral intake with current intake of 95-100% of meals. It documented current interventions of Ensure plus once a day and snacks in her room. Recommendations were to try super cereal and bring in her favorite fast food. Current interventions included Ensure plus once a day and shelf stable snacks for room. -The resident's intake was indicated as 95-100% at meals, however based on observations (see above) she ordered a half order and she did not eat the full meal on both occasions. A comprehensive review of diet and supplementation orders revealed: -Ensure plus once a day, ordered 2/14/23. The medication administration record (MAR) revealed that she received the supplement once a day in the morning. -Regular diet ordered 1/3/19. D. Staff interviews Certified nurse assistant (CNA) #6 was interviewed on 5/18/23 at 11:14 a.m. She said Resident #3 was a picky eater and she did get offered Ensure and snacks. The registered dietitian (RD) was interviewed on 5/18/23 at 9:30 a.m. She said Resident #3 was hesitant to try snacks but liked M&M's with peanuts and cookies. She said she liked shelf stable snacks in her room that were kept at her bedside. The RD purchased snacks to keep at Resident #3's bedside. The RD was out of town for the last week and there was no plan for staff to supply the snacks at the resident's bedside while the RD was gone. It had only been recently discussed at the 5/15/23 IDT meeting to try super cereal and reassess food choices outside of what was being offered at the facility to bring resident food from outside of the facility. She said she did not have recent observations of Resident #3 at mealtimes. The director of nursing (DON) was interviewed on 5/18/23 at 5:30 p.m. She said monitoring and preventing significant weight loss was important for residents to prevent skin breakdown, keep them healthy and labs within normal limits. Weight loss triggered a review of the resident's weight by the RD and the interdisciplinary team and if they were trending downward they were monitored weekly. Weight loss monitoring was important to continue to discuss what did and did not work and the root causes. She said the goal was to see the weight trend back up. 40467 IV. Resident #37 A. Resident status Resident #37, age 74, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), peripheral vascular disease, abdominal aortic aneurysm (a swelling of the aorta) without rupture, alcohol dependence, and peripheral vascular angioplasty status with implants and grafts (a procedure to open narrow blocked arteries to improve blood flow. The 4/5/23 minimum data set (MDS) assessment revealed the resident's cognition was intact, with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #15 required extensive physical assistance from one staff member for locomotion off unit, dressing, toileting and personal hygiene. He required limited assistance from one staff member for bed mobility, transferring and walking in his room. He did not have a known weight loss of 5% or more in the last month prior to his admission or a 10% weight loss in the last six months. B. Resident interview Resident #37 was interviewed on 5/16/23 at 3:25 p.m. The resident said he thought he had recently lost weight but it did not bother him. He said he did not have much of an appetite. He said he usually ordered from the alternate menu because he did not like the main meal. The resident said he ordered watermelon for lunch. He said the portion sizes were large. He said there was a lot of waste because he could not eat it all at one time. Resident #37 was interviewed on 5/17/23 at 3:11 p.m. He said the facility did not have a lot of items he liked. He said they have fruit and vegetables available on the snack table. He said he likes salad but he did not like their salad because they did not have the spicy Italian dressing to put on it. He said the facility had offered him a dietary supplement but he did not want it because it was too thick and it clogged him up. Resident #37 said he preferred thinner drinks like juice, compared to supplements. He said he liked seafood but it was not offered. He said would always eat seafood. He said he understands that it could be costly but he hoped it could be offered at least once a month. Resident #37 said fish was on the menu but it was usually breaded, which he did not like. He said he would eat filets of fish that were not breaded. -Interviews with Resident #37 identified the resident was able to identify food/drink preferences that he would want to eat, potentially increasing his caloric intake. C. Record review The 3/29/23 CPO identified the resident was on a regular diet with thin liquids. The 3/29/23 CPO directed staff to weigh the resident weekly. The 3/29/23 vital record under weights identified the resident's admission weight using the standing scale was 137.2 pounds (lbs). A 3/29/23 diet communication slip was provided by the dietary manager on 5/18/23. The communication slip identified Resident #37 liked seafood, wanted small portions and did not have food dislikes. The undated diet card was provided by the dietary manager on 5/18/23. The diet card read the resident did not like chicken and liked fish, coffee, cereal, eggs and toast. The 3/30/23 nutritional assessment read the resident's ideal body weight (IBW) and adjusted IBW was 134 to 162 lbs. He currently had a body mass index (BMI) of 21.5. The assessment read weight loss had been gradual over several years. According to the assessment, the resident did not like chicken and preferred fish, coffee, eggs, bacon, cereal, and other meats. The assessment indicated the resident had unintended weight loss. The nutrition plan read to monitor weight intake status and provide preferences. The 4/3/23 dietary note read Resident #37 stated he had some weight loss prior to his admission but his appetite had been rebounding. He did not want supplements at this time (4/3/23). The 4/3/23 health status note identified Resident #37 was reviewed in the weight meeting. The note read the resident was taking meals in his room and an alternate menu was provided. He was on a regular diet. The registered dietitian recommended small portions and to cut up his meat. Additional interventions included shelf stable snacks and provide preferences. The 4/15/23 weight record identified Resident #37 weighed 131.2 lbs, indicating the resident lost six lbs and 4.37% of his body weight in just over two weeks since his 3/29/23 admission. The 4/17/23 health status note identified Resident #37 was reviewed in the weight meeting. The note read the resident weighed 131.2 lbs on 4/15/23. The resident had a 2% weight loss in a week and a 4.3% weight loss since admission (3/29/23). According to the note, the resident had clothes on during his 3/29/23 admission weight and lasix upon admission for diuresis could have contributed to weight loss. The resident had been skipping meals and ate very little. Interventions included to encourage food intake and to come out of his room. The assessment read staff should also encourage intake at activities and continue to provide snacks for his room. No additional interventions were identified other than encouraging the resident to eat more and provide snacks. The intervention to offer snacks was not a new intervention as identified as a 4/3/23 intervention. -However, according to the assessment, the resident's PO (by mouth) intake identified the resident ate 50-100% of his meals. The review of progress notes and nutrition concern list (weight meeting minutes) did not identify the resident was reviewed on 4/24/23 or 5/1/23 when the resident had a weight gain (see below) however, after the weight gain, the resident's weight continued to trend down. The 4/27/23 weight record identified Resident #37 gained 4.8 lbs with a weight of 136 lbs however the 5/8/23 weight record identified the resident dropped down to 129.6 lbs. The 5/8/23 weight identified the resident lost 6.4 lbs between 4/27/23 and 5/8/23. The weight identified the resident lost a total weight of 7.6 lbs at 5.54% since 3/29/23. The 5/8/23 nutrition concern list identified Resident #37 was discussed on 5/8/23 with the weight committee. According to the minutes, the resident's intake was variable and ordered very small portions. The minutes indicated the resident stated he weight fluctuates and stays low. The minutes read they were providing him his preferences and he refused nutritional interventions. The intervention read the RD was working on coming up with alternatives such as meal and snack ideas. The 5/10/23 weight record identified Resident #37 weighed 134 lbs on 4/8/23. The resident weighed 126.2 lbs on 5/10/23 indicating a 7.8 lbs weight loss. The RD 5/15/23 weight change note read the resident weighed 126.2 lbs on 5/10/23 with a 3.8% weight loss in a week and 5.9% in a month. The note confirmed the resident had significant continued weight loss. According to the note, he had variable PO intake with small portions of a minimal selection of food items and the dietary manager would continue to work with the resident to find preferences and ways to increase intake. The resident seemed to have very little interest in food and had a prior history of 12 or more beers a day and did not have a craving for sweets. The note read acute illness may have also contributed to weight loss. The resident did not have chewing or swallowing issues and had a history of declining nutritional interventions. -Review of records did not identify acute illness since admission. The 5/15/25 health status note read the resident was reviewed at the weight meeting. He had a weight of 126.2 on 5/10/23 with a 3.8% loss in one week and 5.9% in a month. According to the note, it had been very difficult to obtain preferences or to assist in coming up with nutritional strategies or even a to go to meal in which the resident could order when he did not want the special menu items. The note read the current interventions was: -Refused nutritional interventions; -Regular texture diet with thin liquids; -The dietary manager would follow up to see if they could figure out some food preferences and a way to increase intake; and, -Notify physician's assistant (PA) of significant weight loss. The nutritional management care plan, last revised on 5/15/23 read Resident #37 was at an elevated nutritional risk due to history of poor intake and weight loss prior to admission, and medical diagnosis which could contribute to increased nutritional needs. His diagnosis included COPD and alcohol dependence. According to the care plan goal, the resident would avoid significant weight loss over the next quarter. His goal weight was 155 lb. Interventions initiated on 4/3/23 included: -Weigh at the same time of day and record weekly. -Attempt to follow consistent times/type of scale/clothing/wheelchair weighed to ensure the most accurate weights. -Notify RD, and provider of weight loss greater than 5lb; -Invite the resident to activities to provide an additional avenue for intake. -Monitor meal/fluid and snack intake. -Monitor nutrition related labs prn (as needed). -Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of dehydration and dysphagia (swallowing difficulty). -Offer snack/hydration cart bid (two times a day) between meals. -Preferences: Likes coffee, does not chicken that much, likes fish and other meats, likes bananas, cookies, and will eat all breakfast foods. -Update preferences as needed. -Review calories, protein and fluid needs prn. -Stated he wished to eat half hour after taking his morning pills. -The resident did not want to be disturbed prior to 7:30 a.m. and would take his breakfast at 8:30 a.m. The review of the care plan only identified one intervention after 4/3/23 and after a 10 lb weight loss. On 5/10/23 the intervention read: (Resident #37) was not very forthcoming of his food preferences. -No other interventions were included after the resident continued to have a weight loss. In addition, the resident was able to indicate his food preferences (see resident interview above). The weekly weight record was collected on 5/18/23 after the interview with the RD (see below). The 5/18/23 weight identified the resident had a slight gain of 1.6 lbs with a weight of 127.8 lbs. D. Staff interview The RD was interviewed on 5/18/23 at 9:00 a.m. The RD confirmed Resident #37 had lost 10 lbs since his admission between 3/29/23 and 5/10/23. She said he had orders for weekly weights and had not been weighed since 5/10/23. She said she would request staff to obtain his weight today (5/18/23). The RD said she offered him high calorie dietary supplements on 4/3/23 but he refused. He said the supplements caused him too much phlegm/thick mucus. The RD said she could not get the resident to nail down a preference to help increase his calorie intake. The RD was informed the resident said he liked juice. She said there were thinner supplements that could be flavored with juice. She said she had not discussed the thin supplements with the resident and could order them and offered it to the resident. She said she asked the dietary manager this week if she could step in and help the resident identify other interests. The RD confirmed the resident had lost six lbs by 4/15/23. She said he was discussed at the weight meeting and the intervention was to offer snacks available in his room, inform him of meal options and try to find ways to increase his appetite. She said he did not like sweets. The RD said she did not look into other potential appetite stimulates. She said would speak to the PA to determine if there were additional appetite stimulating options. The RD confirmed the resident loss of almost five lbs between 5/4/23 and 5/10/23. The RD she would continue to focus on what they could offer the resident. She said she did not remember the resident liked seafood. She said she would talk to the resident about seafood options. The RD said the facility could order him shrimp. The RD said she would order the Boost Breeze clear supplement for the resident. The dietary manager (DM) was interviewed on 5/18/23 at 10:05 a.m. The DM said she attended the weekly weight meeting. She said staff had been monitoring Resident #37's weight and was trying to see what more they could do to encourage him to eat more. She said they offered an alternate menu that he would order from. The DM said the nursing home administrator (NHA) just told her to order shrimp for Resident #37. The DM said she was aware the resident liked seafood. She said she they already offered fish on the menu. The DM was informed the resident did not like most of the fish provided because it was breaded. The DM said she talked to the resident everyday and he, just like all the other residents, said he wanted a T-bone steak. She said maybe they could add more specialty items to the menu such as a special meal or ask activities if they could pick up more specialty foods for the resident. She said the resident told her that he did not like steamed vegetables. The DM said steamed vegetables were frequently on the menu. The DM said he liked salad but usually did not eat too much of it. The DM was informed the resident said he would eat more salads if he they would offer him spicy Italian dressing. She said they did not offer that dressing as an option but they could order the spicy Italian dressing for him. She said his preferences were on his diet communication card (see above). She said he did not like most of the meals provided. She said he would eat regular meals on occasion. She said he liked the chicken fried steak. She said she spoke to him a few days ago on what he might like to eat. He said he wanted more beer. The director of nursing (DON) was interviewed on 5/18/23 at 5:29 p.m. She said the facility just ordered different kinds of Boost as on 5/18/23. She said they ordered wild berry Boost for Resident #37. The DON said new residents recently admitted to the facility were followed in the weekly weight committee for the first two to three weeks and if there was a trending weight loss. The DON said the resident would be brought back to the weight meeting if the resident continued to lose weight. She said the weight committee discussed new interventions to promote weight gain and reviewed what was working and not working. She said the committee in the weight meeting would try to identify root causes of the weight loss such as pain or medications. She said the committee would continue to monitor changes if there was little to no improvement. The DON said the resident lost a lot of weight in a short period of time. She said from a nursing standpoint, increasing his calorie intake would be great for him and it would reduce his bony prominences and skin breakdown risk. She said nursing would like him to be able to eat anything he would like and eat. She said if he ate more, he could have improved strength and might feel better. The DON said the resident was not yet identified as malnourished but increased calories could reduce his risk for malnourishment. She said nursing staff would advocate for the resident's food preferences, visit with him on food options and monitor his weight.

Based on record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for one (#16) of four residents reviewed for abuse out of 21 sample residents. Specifically, the facility failed to ensure Resident #16 was free from verbal abuse from a staff member. Resident #16 was told by registered nurse (RN) #6 that Resident #16 risked having to leave the facility and find another place of residence because of discussions he had with his own power of attorney (POA). The interaction with the RN left the resident feeling threatened and intimidated by the RN. He was worried about losing his home. In addition, the facility failed to thoroughly assign and complete corrective action following a substantiated allegation of verbal abuse, resulting in the continuation of Resident #16 feeling bullied and intimidated. The RN continued to approach Resident #16 after it was determined RN #6 verbally abused Resident #16. Findings include: I. Facility policy and procedure The Abuse policy, last reviewed 12/7/21, was provided by the facility on 2/9/22 at 1:29 p.m. by the nursing home administrator (NHA). The policy read in part, It is the policy of (the facility) to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent mistreatment, abuse, neglect, and exploitation. (The facility) will take necessary precautions to prevent resident abuse by anyone including staff members, other residents, volunteers, contract staff, family members, resident representatives, visitors and any other individuals. Every resident has the right to be free from mistreat, abuse, neglect and exploitation. The policy defined verbal abuse as: Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: harassing a resident; mocking, insulting, ridiculing; yelling or hovering over a resident, with the intent to intimidate; threatening residents, included but not limited to, depriving a resident of care or withholding a resident from contact with family and friends; and isolating a resident from social interactions or activities. The Abuse policy under Identification of Abuse, Neglect and Exploitation read in part: Residents at risk for abusive situations are identified and appropriate care plans are developed. The Abuse policy under Reporting Abuse read in part: Assure that reporters are free from retaliation or reprisal. The Abuse policy under Protection of Abuse read in part: The facility will make efforts to ensure all residents are protected from physical and psychological harm during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation. Any employee of the facility suspected of abuse is placed on administrative leave. The employee is not permitted to enter the facility and/or around residents of the facility unless otherwise directed by the administrator, until the investigation has been completed and the final disposition has been given. Residents involved in allegations of abuse will be separated by staff .Provide Emotional support and counseling to the resident during and after the investigation, as needed. The Abuse policy under Prevention of Abuse-Training read Existing staff would receive annual education through planned in-services and as needed. Training topics would include: types of abuse prohibiting and preventing all forms of mistreatment, abuse, neglect and exploitation; identification of what constitutes mistreatment, abuse, neglect, exploitation, and misappropriation of resident property; recognizing the signs of use, neglect, exploitation and misappropriation of resident property .This facility will utilize the admission process and care conference meetings to provide residents and representatives information and how and to whom they may report concern, incidents and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. The Abuse policy under Follow up Reporting/Response read in part: Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: -Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of Resident property or exploitation occurred, and what changes are needed to prevent further occurrences; -Defining how care provision would be changed and/or improved to protect residents receiving services .Training of staff on changes made and demonstration of staff competency after training was implemented . II. Resident status Resident #16, age 74, was admitted on [DATE] and readmitted on [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/7/21 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. According to the MDS assessment, the resident was independent with eating, transfers and walking in his room. He required supervision with and without set up for bed mobility, dressing, toileting, personal hygiene and locomotion on and off the unit. The MDS identified the resident did not have behaviors or rejections of care. III. Resident interview Resident #16 was interviewed on 2/9/22 at 9:12 a.m. Resident #16 stated that he was intimidated by RN #6. The resident stated he contacted his power of attorney (POA) who was a family friend and family member of another resident, about some concerns he had regarding the facility. The resident said RN #6 was made aware of the conversation with his POA and informed him he was interfering with the other resident's cares, and the other resident and himself could be expelled from the facility. Resident #16 said he reported the incident to the director of nursing (DON). The resident said he was told the situation was under investigation. Resident #16 said a few weeks later after he reported RN #6, he entered his room and saw RN #6 looking around in the back of his room. The resident said RN #6 had a cup of medication in his hand but appeared to be looking for something, possibly to use to get back at him. The resident said he had seen a lot of bullies in his life and RN #6 was a bully. The resident said the RN still worked as his nurse or a certified nurse aide (CNA). He said sometimes nurses worked as CNAs if they needed more help on the hall. Resident #16 was interviewed again on 2/10/22 at 9:26 a.m. He said he had not had to work with RN #6 recently and thought the RN was moved to another hall, however, the RN recently approached him in the dining room. The resident said RN #6 tried to join the conversation the resident was having with his tablemates and tried to act all buddy, buddy with him. Resident #16 said it upset him. He said he did not want to see RN #6 or have to talk to him. He said he felt like the RN was a bully who was trying to control the situation. IV. Record review The care plan for Resident #16 did not reveal the resident was care planned as an at risk adult for potential or actual abuse. The nurse note on 12/20/21 at 6:20 p.m. created by RN #6 read: It was reported to this nurse that (Resident #16) made a phone call to another resident's POA to discuss current conditions at the facility. I had an extended conversation with the resident and explained it was not his responsibility nor appropriate for him to discuss another resident's care regardless of his familiarity or association with anyone's POA with (stet) expressed written consent from another resident's POA. I explained that this could be a violation of HIPPA (Health Insurance Portability and Accountability Act) regulations and that if he continued to discuss other resident's cares and conditions that it could be possible that he would be asked to leave the facility and find another place of residence. A 12/20/21 certified nurse aide (CNA) witness statement was provided on 2/14/22 at 9:41 a.m. by the NHA. The statement read Resident #16 contacted another resident's family member about his concern over the temperature in the facility. An abuse investigation report for Resident #16 was provided by the NHA on 2/9/22 at 2:37 p.m. According to the investigative report, the incident of alleged abuse occurred on 12/20/21. The facility was informed of the incident on 12/21/21 at 11:00 a.m. The investigation of alleged verbal abuse was initiated on 12/21/21. According to the initial report details, Resident #16 stated RN #6 was very unprofessional and inappropriate with his interaction concerning Resident #16 and his power of attorney (POA). The RN believed the resident was discussing the care of another resident who resided in the facility. The investigation read Resident #16 was threatened by RN #6 to be kicked out because of his behavior and the RN would not listen to his response. The resident felt the RN had no right to treat him in that manner. Statements were gathered from the alleged assailant and Resident #16. Resident #16 was interviewed on 12/21/21 at 11:00 a.m. The resident said RN #6 entered his room and sat on his bed. The resident said the nurse accused him of sharing information about another resident to his POA/family friend. According to the resident, the RN would not let him talk and said he would be kicked out if he did not stop. The resident said he refused to stop talking to his friends and the RN had no authority to tell him things like this. During the interview, the resident stated he was fearful of losing his home and being kicked out of the facility. He said he was angry and hurt that someone would speak to him in that way and not allow him to defend himself. Resident #16 said during the interview, he felt verbally threatened by RN #6. The alleged assailant interview summary, collected on 12/21/21 at 12:30 p.m., read: (RN #6) states that a CNA reported to him that (Resident #16) had been speaking with (his POA) about another resident who shares the same POA as (Resident #16). (RN # 6) reported that he informed (Resident #16) that he was not allowed to talk about things in the facility or other resident concerns with anyone as this was a HIPAA violation. He said that if (Resident #16) wanted to speak to POA about (other named resident), he would need it in writing that (Resident #16) was allowed to do that. (RN #6) stated that during the conversation, (Resident #16) tried to argue with him that (his POA) was a good friend and that he could talk to him. (RN #6) states that he 'shut him down.' In other words, (RN #6) would not allow (Resident #16) to provide an explanation as he interrupted him many times during the conversation and that 'he did not care' about what (Resident #16) was telling him. (RN #6) felt that it was not relevant to what they were discussing. When I asked (RN #6) if he thought his conversation was inappropriate or unprofessional he did not provide a clear statement. When asked if he felt that the statements could be taken as a threat, he stated he did not think so. According to the investigation, three other residents were interviewed who resided on the same hall as Resident #16 and three other staff members. The staff and residents were interviewed for any knowledge of the incident and/or having felt threatened. No additional feelings of threatening behavior or witnessing of such were reported during the interviews. The allegation was reported to police, the ombudsman, the physician, and the resident's POA. The facility implemented safety measures including the immediate request that the alleged assailant, RN #6, leave the premises. The RN was placed on administrative leave on 12/21/21, pending the conclusion of the internal investigation. The facility substantiated the allegation of verbal abuse. The investigation of abuse summary identified RN #6 did not follow HIPAA policy and his conversation with the resident was unprofessional and unwarranted. The summary read verbal abuse was substantiated, however, there was no intent. The summary identified the RN had a need for education. The summary included a second interview with Resident #16 on 12/23/21. Resident #16 stated he did not want RN #6 to enter his room and take care of him. The abuse investigation report under facility actions indicated no changes needed to the victim's treatment regime and/or care plan. The facility actions included: -The RN placed on administrative leave (see dates below). -The NHA and the DON would prepare for the external investigation meeting to gather additional information and the RN's education needs related to HIPAA and proper procedures surrounding the resident misconduct. According to the actions, the discussion would include who he was to communicate with, and what was appropriate for him to address himself versus what was not appropriate. Under facility actions, the abuse investigation report asked the facility to describe interventions that were put in place to help prevent a recurrence. The facility wrote: Education with staff regarding proper information on HIPAA. A written statement from the director of nursing (DON) was provided by the NHA on 2/14/22 (the statement was provided during the survey and not a part of the facility's investigation). The statement read: I (DON) spoke with (RN #6) on 12/21/21 in the first floor nurses station when I (DON) went to send (RN #6) home after allegations of verbal abuse were made. During this time I spoke to him on the allegations of verbal abuse and gave him a brief description of HIPAA. I then relayed to him that if he feels like a resident or staff member is violating a policy or is in the wrong, that he should take it to a manager, myself or the NHA. I informed him that he does not have the right to tell someone they may lose their home and asked if he understood how that could make someone feel. (RN #6) acknowledged my education, the allegations and voiced understanding of future ways to report to management. -According to the statement, no other education or expectations were provided to the RN at that time. An education/training attendance form was provided by the NHA on 2/10/22 at 4:31 p.m. According the form, RN #6 attended an education on investigations and abuse on 3/2/21. The online training transcript for RN #6 was provided by the NHA on 2/10/22 at 4:31 p.m. The transcript read the RN received the following education: -Understanding Abuse and Neglect training on 9/6/21. The review of the online transcript did not indicate RN #6 received additional abuse training after it was determined he verbally abused a resident; and, -Protecting Resident Rights in Nursing Facilities on 1/9/22. According to the NHA, the education was provided as part of RN #6's annual training. She said the training was not part of his corrective action interventions after the determination of verbal abuse. The course completion history for RN #6 was provided by the facility on 2/14/22. According to course history, education on effective communication was completed on 4/5/21. According to the course completion history, the RN was not assigned additional training on communication after the determination of verbal abuse. The archived training for RN #6 was provided by the facility on 2/14/22. According to the archived training, he received an overview of HIPAA privacy and security on 10/8/16. The archived training indicated the RN received HIPAA awareness in 2015. A date for the completion of the HIPAA awareness was not provided. The HIPAA policy and HIPPA notice of privacy practices was provided by the NHA via email on 2/14/22 at 11:33 a.m. According to the NHA, the HIPAA policies and practices were provided to RN #6 after the determination of verbal abuse. The policy and practices informed the RN, medical information was protected and staff must comply with those protections. The policy and practices did not state residents in a nursing facility must comply or were subject to actions such as discharge from the facility. According to the DON, RN #6 also received recent HIPAA training through their online training program. A timeline of RN #6's leave and presence in the facility was provided by the NHA on 2/14/22. The timeline read: Administrative leave start:12/21/21 Administrative leave end:12/25/21 Return to work:12/26/21 December 2021 scheduled days: 12/26/21, 12/27/21, 12/28/21 January 2022 schedule days: 1/8/22-1/11/22, 1/17/22-1/20/22, 1/22/22-1/25/22 February 2022 scheduled days: 2/1/22-2/3/22, 2/5/22-2/6/22 According the NHA, RN #6 was on vacation during the survey observation period. The staff schedule was provided by the NHA via email on 2/14/22 at 11:33 a.m. The review of the December 2021, January 2022, and February 2022 revealed RN #6 was scheduled as either a nurse or a certified nurse aide (CNA) on the same hall Resident #16 resided after verbal abuse was substantiated. The following dates indicated RN #6's strong potential of interactions with Resident #16: -On 1/17/22, the RN was scheduled as a CNA in the resident's hall. -On 1/20/22, the RN was scheduled as a day nurse in the resident's hall. -On 1/22/22, the RN was scheduled as a day CNA in the resident's hall. IV. Staff interviews The nursing home administrator (NHA) was interviewed on 2/10/22 at 2:54 p.m. with the deputy division director (DDD). The NHA said staff report all allegations of abuse, neglect, and mistreatment. She said anything deemed as reportable that meets the criteria would be reported and investigated. The NHA said RN #6 was placed on administrative leave during the investigation. After abuse was substantiated, the RN was allowed to return to the facility because the facility did not feel he was a threat to the residents because there was no willful intent. The NHA said RN #6 received immediate education on HIPAA policies and procedures. The NHA said RN #6 was informed that it was not appropriate in policy or approach when he addressed the resident on 12/20/21. She said the RN was not with (worked/around) the resident after he returned to work. She said the facility wanted to make sure the RN had understood the policies and received thorough education. The NHA said the education focused on HIPAA because RN #6 did not know residents were not bound to HIPAA regulations. The DDD said the internal investigation was complete but the corporate's external investigation was still in process. The NHA said final decision factors/actions would be determined after the employee had an opportunity to provide any new information he would like to share regarding the incident. The NHA said the employee received immediate education on HIPAA policies and procedures. She said RN #6 was already aware the other resident's family member was Resident #16's POA. The NHA said the DON spoke with Resident #16 and informed him of the investigation process. The NHA was interviewed a second time on 2/14/22 at 9:46 a.m. with the DON. The NHA said the facility substantiated the allegation of abuse because the incident was determined to be verbally abusive based on how RN #6's conversation made the resident feel. The DON said Resident #16 was interviewed regarding the 12/20/21 incident. The DON said when Resident #16 was interviewed on 12/21/21, he said was upset by the way RN #6 spoke to him. The resident said she felt intimidated by the RN. He said RN #6 threatened he would lose his home. The DON said he felt verbally abused and was worried about his potential loss in his securement in the facility. The DON said RN #6 was interviewed regarding the 12/20/21 incident. The DON said the RN was informed that the resident did not violate HIPPA and the incident was under investigation. The RN was made aware of the allegations. She said she told the RN it was not his place to tell the resident he may have to leave the facility after talking to his POA. RN #6 was sent home on leave pending the outcome of the investigation. The NHA said the facility provided a verbal education and had RN #6 review the HIPAA policies and procedures. She said the RN did not have a history of this behavior. He did not want to instill fear in the resident but said he wanted to give him a heads up of potential actions. The NHA said RN #6 felt bad that the resident was upset. His intention was not to cause verbal abuse. The RN was allowed to return to work after the completion of the internal investigation. The RN verbalized he understood how he made Resident #16 feel. The DON said she told RN #6 to stay away from Resident #16. She said she thought it was made clear to him. The DON said Resident #16 told her he found the RN in his room after the RN was asked to stay away from the resident. She said the RN should have had the other nurse pass his medications. Resident #16 told the DON that he did not want anything to do with RN #6 and he did not like him. The DON said she reminded the RN not to be the one to pass Resident #16's medications. The RN offered to apologize to the resident but Resident #16 has not been receptive to his apology yet. The DON said no additional corrective actions have been taken at this time. The NHA said RN #6 had not received additional education on abuse or effective communication since he was allowed to return to work. The DON confirmed the RN has been scheduled for the past two months since he returned from administration leave. The DON said they could have improved his education to ensure full understanding of expectations. The DON said she did not ask him why he went into Resident #16's room and after asking him to not work with him. She said she told him not to do it again. The DON said she was not aware the RN approached the resident in the dining room. She said RN #6 should not have approached Resident #16 in the dining room. The DON said the RN was primarily scheduled to work on a different floor or a different hall than where Resident #16 resided, but between staffing shortages and call ins there were times he was scheduled to work on the resident's hall. She said she would need to improve communication with the scheduler to help limit RN #6 on Resident #16's hall. The DON said no additional supervision over RN #6 was implemented after it was determined he verbally abused the resident, or after the RN was found in the resident's room or after the resident expressed the continued feelings of intimidation. The DON said she just did routine floor checks daily. The DON said she was waiting for the completion of the external investigation that was still in process before proceeding with additional corrective action such as training. She said she provided verbal education with the RN but should have provided him more intensive written education on abuse and communication. The DON said residents identified as at-risk adults should have a care plan directing staff what to look for, changes in behaviors, signs of potential abuse, and care plans should indicate to staff why the resident was at risk and how to address the risk. The DON confirmed the resident was identified at risk for abuse, as stated in the abuse investigation. The DON said Resident #16 should be care planned for risk and was not sure why a care plan was generated. The DON said moving forward, the facility would ensure more focused education and competency of the education would be implemented immediately after, or before the staff member was allowed to return to work. The DON said to help prevent potential future abuse on Resident #16 and other facility residents, the facility would improve their education, attempting to make it more user friendly and comprehensive. She said she would work with the staff scheduler to limit the times a resident had to be around a staff member who they felt uncomfortable with and review the daily schedule. The DON said she would continue to spend time with the residents and remind them they can report anything to her. The DON and the NHA said they would work on being even more involved in resident care. The social service director (SSD) was interviewed on 2/14/22 at 10:57 a.m. The SSD said when residents express concerns or feel abused by staff, she would make sure the DON and the NHA were made aware. The SSD said she would listen to the resident and validate his feelings. She said the facility needed to know when residents were upset and did not feel safe, so we could do something about it. The SSD said a plan would be put in place to include meeting with the resident regularly, reassuring them that they were safe, heard, and understood. She said her visits were not always documented, but she would continue to check in the resident. The SSD said Resident #16 was readmitted to the facility a few months ago because he felt lonely and people did not have time for him when he was at home. He was happy to return to the facility and was not someone who would normally complain about staff. The SSD said she approached Resident #16 and asked him what was bothering him. The resident said a nurse (RN #6) was invading his conversation with his POA. Resident #16 said the RN said the resident was wrong and could be kicked out of the facility. The resident said the RN would not allow him to speak and felt he was talked down to. He expressed he did not feel supported by the RN. She said no one should feel like that. The SSD reassured the resident his home was not in jeopardy and he would not have to have contact with the RN anymore. The SSD was informed Resident #16 has had to have additional contact with RN #6. The SSD said the resident should not have to have contact with the RN until he felt safe and the situation was resolved. The SSD said the RN should not have approached the resident regarding speaking to his POA. She said the resident had every right to talk to his POA. She said resident rights were reviewed with staff at least once or twice a year. She said all staff should have a good understanding of resident rights. The SSD said at risk care plans were to identify when someone has had an incident of abuse or potential abuse. She said interventions included having direct staff to listen to the residents and help with any situations that may arise. She said each at risk care plan would be individualized based on what each identified resident would need support with. The SSD reviewed Resident #16's care plan and confirmed he did not have an at risk care plan but should have. She said she would meet with her team and find out what the plan was for Resident #16, including checking the schedule of where RN #6 worked. The SSD said she would update his care plan and visit with Resident #16 to ensure he felt comfortable with the interventions and knew that he could speak to his POA at any time. The SSD she would check in with Resident #16 daily to ensure the resident felt safe, supported, and his concerns were validated. V. Facility follow-up An at risk care plan was initiated on 2/14/22. The care plan read Resident #16 was at risk for feelings of possible displacement in living arrangements as evidenced by feeling insecure and not feeling validated. Interventions included: -Staff would address any concerns/feelings of discomfort in his environment. -Staff would allow Resident #16 to express feelings, concerns and fears while offering support and validation. -Staff would monitor him for changes in mood, behavior, and/or isolation. -Staff would offer mental health as needed or allowed. -No documentation was provided before survey exit on 2/14/22 or 24 hours after regarding any further education or corrective action for RN #6 (he was on vacation during the survey).

Based on observations, interviews and record review, the facility failed to ensure each resident was treated with dignity and respect and cared for in a manner and in an environment that promoted maintenance or enhancement of quality of life for one (#10) of one resident reviewed for dignity out of 21 sample residents. Specifically, the facility failed to ensure Resident #10 was positioned correctly at the dining room table and while she received care from staff during meals. Findings include: I. Facility policy and procedure The Promoting/Maintaining Resident Dignity During Mealtimes policy, dated 2/10/22, was provided by the nursing home administrator (NHA) on 2/10/21 at 5:20 p.m. The date on the policy was the same date the policy was requested from the NHA. It documented the practice of this facility was to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintained or enhanced his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. It documented that all staff members involved in providing feeding assistance to residents should promote and maintain resident dignity during mealtimes. It documented staff should assist the resident with opening condiment packages, cutting necessary food items, such as ensuring each resident could see and reach their food and beverages. II. Resident #10 A. Resident status Resident #10, age 89, was admitted on [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/18/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. It documented the resident required supervision with set-up for her meals. B. Resident observations Resident #10 was initially observed on 2/8/22 at 12:14 p.m. She was petite, measuring 5 ' 3 who was seated in her wheelchair at a table in the first floor dining room. She was positioned at the table with her head below the level of the table's top. She was struggling to reach her food and drinks at this time. No staff was observed assisting the resident at this time. -At 12:20 p.m., the resident was seated at the dining room table with her head at table top level. She was having difficulty spooning her ice cream out of her dessert bowl. No staff were observed assisting the resident at this time. -At 12:33 p.m., the resident was observed rolling her wheelchair back and forth at the table in order to reach her food and drinks. She was observed hitting the top of her head on the side of the table. Certified nurse aide (CNA) #2 told the resident she was smacking her head on the table and telling the resident to be more careful. She did not ask the resident if her head was okay or assist the resident in any manner. She then walked away from the resident. Resident #10 was observed on 2/9/22 at 9:12 a.m. She was positioned at the dining room table with her forehead level with the table top. She was having difficulty reaching up to get her glass of juice. No staff was observed assisting the resident at this time. Resident #10 was observed on 2/10/22 at 8:20 a.m. She was seated at the dining room table, leaning slightly towards the left. Her forehead was at the level of the table top and the resident was having difficulty reaching her hot cocoa. She was observed from 12:20 p.m. through approximately 12:30 p.m., occasionally rolling her wheelchair back and forth at the dining room table. She was observed pulling herself forward in her wheelchair in order to reach her dinner roll. She dropped her spoon on the floor and called for CNA #3 to get her another spoon. The resident then propelled her wheelchair backwards out of the dining room. She returned to the dining room at approximately 12:23 p.m. At 12:25 p.m., CNA #3 was observed standing over the resident and was watching her eat a bite of blueberry cobbler off the table top after the resident had dropped it on the table. The CNA did not assist the resident with her dessert or try to prevent her from eating off the dirty top of the table where two other residents were also seated. Resident #10 was observed on 2/14/22 at 10:00 a.m. She was seated at her table in the dining room. Her eyes were level with the table top. She was observed struggling to reach her hot chocolate cup and to eat the oatmeal in her bowl. -At 11:10 a.m., staff was observed positioning the resident at an activity table in the common area. Her head was below the top of the table. -At 12:30 p.m., the resident was observed at the dining room table with her head below the level of the table top. C. Resident interview Resident #10 was interviewed on 2/10/22 at 8:20 a.m. She said she was seated so low at the dining room table that she sometimes hit her head on the tabletop reaching for her food. She said the facility had provided her a lower table in the past, but it had been sometime since they used it. She said she would like the lower table again for easier access to the food when eating. Resident #10 was again interviewed on 2/14/22 at 10:00 a.m. She said her positioning at the table was pretty uncomfortable. When asked if, besides the comfort level, she felt the positioning was undignified for an adult, she said, It's not really dignified, but I'm used to it. D. Record review Resident #10's care plan related to positioning, dated 2/9/22, documented the resident had limited physical mobility. The limitations were due to contractures and having sustained a previous stroke. The goal of this care plan was for the resident to remain free of complications related to immobility. The positioning schedule documented that the resident was to be up in her wheelchair for meals. III. Staff interviews The occupational therapist (OT) was interviewed on 2/10/22 at 10:35 a.m. He said the therapy department had previously attempted to use a lap tray for Resident #10 when she was dining, but the resident refused the tray. He said the table the resident always sat at had already been lowered as far as it could go. He said he did not want to give her a lower table because the more they compensate for her poor positioning, the less she would attempt to sit tall, which he felt she had the ability to do. He said the interdisciplinary team said Resident #10 had decompensated with her ability to position herself in the last week or so for some reason and he had a new screening request in to re-evaluate the resident for needing more assistance with her meals. -As of the survey's exit on 2/14/22 at 5:15 p.m., the OT had not completed his re-evaluation of the resident's assistance needs during meals. Registered nurse (RN) #6 was interviewed on 2/14/22 at 10:10 a.m. She said the dining room table was too high for Resident #10. She said the facility had another smaller-sized resident in the past and restorative therapy gave her a lap tray for her wheelchair that she could eat off of. She said Resident #10 refused to sit in a regular dining room chair and wanted to eat in her wheelchair. She said she did not know if restorative therapy had tried a lap tray for this resident, but felt she needed a smaller table because the resident had a lot of difficulty positioning herself at the table. She said she did not feel the resident was currently being positioned at the table in a dignified manner. She said the interaction with CNA #2 was poor because the staff should have stopped to ask the resident if she was okay when she hit her head on the table top and should have assessed for the resident's lethargy, having felt the resident must have fallen asleep at the table if she hit her head on the table top. The registered dietitian (RD) was interviewed on 2/14/22 at 12:30 p.m. She said she had brought Resident #10's poor positioning at the dining room table to the therapy department about a month ago. She said therapy tried a bedside table at the main table shortly before lunch was served this date and the resident did not want anything to do with that table. She said the resident's power of attorney (POA) was present and tried to encourage the resident to try the table, but the resident did not like something about the table. She said the dining table was at the lowest position already, but the resident looked like her positioning was even more slumped than she was a week and a half ago. She said she sent a message to the therapy department with her concerns, but felt the facility had to get creative with positioning for this resident. She said she and the restorative nurse brought up the possibility of using a computer table, which could be attached underneath the table and could adjust up or down for the resident. The RD said she did not feel this resident was appropriately positioned at the table because she could not even see her food and drinks at times and acknowledged this was a dignity issue for the resident. She said the resident's weight was stable despite the positioning issue. The NHA was interviewed on 2/14/22 at 3:21 p.m. She said she would have a conversation with the OT about Resident #10's physical ability to sit up straighter. She said she thought the facility needed to figure out something to make the resident more comfortable at meals. She said if the resident was uncomfortable and felt her positioning at the table was undignified, it was not okay. She said it was hard to find adaptive equipment that Resident #10 would accept because the resident did not want to be different. She said, we need to figure something out for her.

Based on observations, interviews and record review, the facility failed to provide the highest practicable quality of care for one (#40) out of two residents reviewed for skin conditions or injuries out of 21 sample residents. Specifically, the facility failed to for Resident #40 ensure the resident had proper protection of her right heel wound to promote healing. Findings include: I. Professional Reference The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (2/4/2018), retrieved on 2/18/22, rehttp://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. II. Facility standards The Wound Treatment Management policy, dated 1/5/22, was provided by the nursing home administrator (NHA) on 2/10/22 at 2:19 p.m. It read in pertinent part, To promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with the current standards of practices and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . III. Resident status Resident #40, age 75, was admitted [DATE]. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 1/27/22 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance of two or more persons for bed mobility, transfers, dressing, and toileting. Resident #40 required extensive assistance of one person for personal hygiene and locomotion. The MDS coded a pressure ulcer to her buttocks present on admission, her heel was not indicated. IV. Resident interview and representative interview Resident #40 was interviewed on 2/9/22 at 10:35 a.m. She said she spent a good portion of everyday in her wheelchair and out of bed. Resident #40 said she had a wound on her right foot. She said the last couple of days, her foot was feeling better since the staff provided her with a new boot to take the pressure off. The husband of Resident #40 was interviewed on 2/14/22 at 9:36 a.m. He said Resident #40 wore a foam boot at night to take off the pressure of foot when she was in bed. He said last week (2/8/22), she started wearing a different boot during the day to protect her heel. He said the new boot has seemed to help her with the pain from her heel. V. Observation and interview Resident #40's wound care was observed on 2/10/22 between 9:33 a.m. and 9:45 a.m. The wound care was conducted by the registered nurse (RN) #2. RN #2 applied Vashe cleanser on new gauze and removed the old dressing from the right heel of Resident #40. Dried yellow old skin was on the surface of the dressing. Observations of the heel identified two distinct wounds. The first wound/injury was on the posterior (back) part of her heel. The second wound/injury was located on her lower ankle. The lower ankle wound revealed black eschar in the bed. The lower heel wound was pink with granulation and did not have measurable depth. RN #2 said she did not know how the wounds developed but she confirmed they developed at the facility as originally a large wound. RN #2 said she could not identify the stages of the injury without looking at the stage chart. During the wound care with RN #2, potential contamination of the wounds were identified. RN #2 placed the new clean dressing and two tubes of [MEDICATION(S)] ointment directly on the seat of the resident's wheelchair before applying the treatments. The RN did not initiate hand hygiene after she removed the old dressing of the heel, doffed her old gloves and donned new gloves to cleanse and apply new dressing over the wounds (cross-reference F880 for infection control). VI. Record review The skin injury risk care plan, initiated 1/27/22 and revised on 2/10/22, read Resident #40 was at risk for potential/actual impairment to her skin integrity including MASD (moisture associated skin damage), skin tears and /or pressure injuries related to [CONDITION(S)], fragile skin, balance issues and incontinence. The care plan identified the resident had a large fluid filled intact blister on her right heel. The care plan also identified the blister ruptured without changes in wound care. Care planned interventions implemented on 1/27/22 read: -Heel elevating boot to be worn while in bed to promote skin integrity related to [CONDITION(S)] and right heal blister. -Monitor/reposition bilateral extremities (BLE) as needed and at least every two hours while in bed to ensure heels were elevated on a pillow or cushion. -Pressure relieving/reducing mattress to protect the skin while in bed. The care plan intervention on 2/1/22, directed staff to refer to orders for the current wound treatment plan. -The care plan did not include the use of a protection boot to her right foot when the resident was not in bed. The 1/20/22 admission assessment for Resident #40 did not identify concerns with her right heel. The 1/21/22 weekly skin assessment identified Resident #40's heels were red but blanchable indicating no development of injuries/wounds to her right heel. The 1/25/22 skin/wound note read Resident #40 had a blister to her right heel. According to the note the wound nurse notified. The note did not identify the changes to the resident's care. The 1/26/22 OT treatment note read the resident was provided an updated wheelchair to allow for better bilateral lower extremity contact with the ground for self-propelling with bilateral lower extremities. Education completed on using bilateral lower extremities and bilateral upper extremities to self-propel manual wheelchair. The resident was able to use the manual wheelchair for approximately 15 feet in the room. -The OT note did not include precautions related to the 1/25/22 identification of the resident's right heel blister. The 1/26/22 at 2:13 p.m. skin/wound note read the wound nurse assessed the resident's heel and what appeared to look consistent with a blister. According to the note, the wound nurse instructed the registered nurse on dressing the site on the right heel. The note identified an application of [MEDICATION(S)] was placed on the site. A foam heel covering was placed over and secured with [MEDICATION(S)]. The note indicated the heel was tender to touch. The 1/26/22 skin/wound note created by the wound nurse read she was assessed to Resident #40's right foot/heel. The wound described the area of concern as a large blister measuring 4x6 centimeters (cm). The blister was fluid filled and intact. According to the note, the resident reported pain in the area with pressure and palpation. The note indicated that wound care orders were written and the registered nurse and therapy was notified. Heel elevator boots were requested to alleviate pressure while in bed. According to the note, the resident prefered to spend most of her time lying down and/or sleeping. An air mattress was put in place while lying down for pressure prevention and offloading. The 1/27/22 skin/wound note read [MEDICATION(S)] and a heel protector in place. The note described the blister as intact. According to the note, the resident helped by elevating her legs. The resident was educated to keep her legs off the floor. The 1/27/22 OT treatment note read the resident participated in the function transfer training to wheelchair from recliner. The 1/30/22 and the 1/31/22 skin/wound note read Resident #40's right heel bandage was removed, the blister was swabbed with [MEDICATION(S)] and a new bandage was applied. According to the notes, the resident tolerated the wound care well with no pain or discomfort. The 1/31/22 OT treatment note read the resident continued to rest by lateral lower extremities off of the foot pedals and on the back of heels where she had a blister on her right lower extremity. According to the note, she had improved with self-propelling with a manual wheelchair with no foot pedals. She requires foot pedals for transport with caregivers. The note read education was provided to staff to cue the resident to rest her bilateral lower extremities on the foot pedals and not off of the pedals. The 2/1/22 skin/wound note created by the wound nurse, read the right posterior heel blister continued to be intact and fluid filled. According to the note, the blister measured 6x6 cm. Interventions continued to include a heel flotation cushion in place when the resident was lying in bed to avoid pressure to the area and continued use of an air mattress for pressure prevention and offloading. The note indicated the resident was educated by the wound nurse as well as therapy on the importance of not placing pressure on the blistered area. According to the note, the resident verbalized understanding. The note identified the resident did not receive compression to the right lateral extremity as an effort to keep the blister intact. The note indicated that therapy and the registered dietitian were aware of the wounds and were implementing necessary interventions. The wound physician was consulted for additional treatment options for the heel. The note read the physician did not recommend new interventions at that time. The review of the 2/1/22 wound measurement, according to the skin wound note, identified the blister increased in size between 1/26/22 and 2/1/22. The 2/2/22 OT treatment note read the resident was measured for the right lower extremity podus boot for heel protection during transfers for skin integrity. Education was completed with staff regarding recommendations for functional transfers. The positioning in the wheelchair interventions was completed to include foot rest adjustments. The OT note read Resident #40's blister on the right lower extremity, per wound care, was not improving. The care plan and the orders were updated to include no ambulation and weight bearing for transfers at the time of the OT note on 2/2/22. The 2/2/22 skin/wound nurse note read an Allevyn heel protector dressing was placed on the right heel and secured with tape. The note identified the heel as a blood blister. According to the note, the fluid filled area covered the entire heel. The 2/3/22 skin/wound note read the resident's right heel dressing was removed with no drainage noted on the dressing. The heel was covered with a large blister encompassing all of the heel. The heel was swabbed with [MEDICATION(S)] and allowed to air dry. An Allevyn heel protector was applied on her heel with a sock over her foot and the heel protector. According to the note, the resident denied pain at the site. The note identified the blister bed appeared to be dry and was still intact. The 2/5/22 skin/wound note read the wound was on the bottom and up the back side of the heel. It was covered in white thick peeling skin, with a slight odor and the surrounding skin was pink in color. According to the note, the resident complained of tenderness when removing and applying the new dressing. The 2/6/22 at 2:13p.m. skin/wound note read the resident had a dressing change and treatment per orders to the right heel. The skin is whitish in color and peeled back slightly. The 2/6/22 at 9:53 p.m. read Resident #40's right heel was missing the Allevyn heel dressing and tape. According to the note, the blister appeared to have ruptured and the resident had dried blood and peeling skin above the blister. The wound bed was described as dark red with dried skin peeling around it. The review of the note identified the blister ruptured during the same time period of the missing dressing. The 2/7/22 OT treatment note read adjustments were made to the resident's wheelchair pedals to decrease pressure on the right foot and heel. The 2/7/22 skin/wound note created by the wound nurse described the right heel blister as denuded and no longer fluid-filled. The wound bed was pink with two darker areas within. The proximal darkened area measured 1.5 x 2 cm with no measurable depth. The distal darkened area measured 2.5 x 2.5 cm with no measurable depth. According to the note, the total denuded area measures 6 x 5.5 cm with partial thickness and a scant amount of blood. The note indicated the resident reported tenderness to the entire area. The 2/8/22 OT treatment note read the resident was fitted with a shield protection boot on the right low extremity to protect the blister while sitting in the wheelchair and during functional transfers. The 2/8/22 skin and wound note read changes to the right heel blister treatment were made on 2/8/22 with new orders placed. The January 2022 CPO was reviewed for Resident #40. The order summary read as follows: The 1/27/22 order read the resident was to wear a heel elevating boot while in bed to promote skin integrity related [CONDITION(S)] and right heel blister. According to the order, staff were to monitor/reposition her bilateral extremities as needed and at least every two hours while lying in bed to ensure heels are elevated on a pillow or cushion on every shift for pressure prevention and wound healing. The 1/31/22 order read to change position every two hours during the day and elevate bilateral lower extremities when available and every two hours. The order on 2/2/22 read the resident was not to be weight-bearing on her right lower extremity except for transfers and a sit to stand mechanical light. The 2/8/22 order read to apply Iodosorb Gel 0.9 % (Cadexomer Iodine) to the right heel topically one time a day for the denuded blister. The 2/8/22 order instructed staff to monitor placement of Allevyn heel dressing q (every) shift and replace and/or secure as needed on every shift. The 2/9/22 new order for wound care for the right heel denuded blister read to apply Vashe wash and allow the site to dry. Cover with Allevyn gentle border heel dressing and daily and report changes or concerns to physician and wound nurse once a day. The 2/9/22 order read the resident was to wear a heel protection boot on the right lower extremity when out of bed. The order was placed after the blister had ruptured and after two wounds under the blister were identified. VII. Interviews RN #7 was interviewed on 2/9/22 at 12:20 p.m. Resident #40 often would drag her foot when she was in her wheelchair. She said the dragging created a blister. RN #7 said the blister had opened and now caused her pain. The RN said a new boot has been placed on the right foot for protection. She said 2/9/22 was the first day she was aware of the new boot. RN #5, who was the certified wound nurse, was interviewed on 2/10/22 at 1:12 p.m. The RN said therapy witnessed one of the areas on the heel was caused by her foot pressing against the foot pedal. She said the observation prompted therapy to fit Resident #40 with the podus boot. RN #5 was interviewed again on 2/14/22 at 1:45 p.m. RN #5 said she first observed the blister on 1/26/22. She said pressure relieving interventions were put in place. She said she felt the interventions and care provided to Resident #40 was appropriate. She said she did not consider the wound to the heel as two separated wounds even though she was recording measurements to the two separate areas because both areas were on the resident's heel and were both treated the same. She said she weekly assessed the wound. The RN said the heel would have only been staged if the wound/injury was from pressure. RN #5 said the wound was caused by friction and rubbing from her foot sliding in her sock and on the ground, creating a fluid filled blister. She determined the wound was caused by friction therefore the wound was not a pressure injury; however, as identified in the above progress notes, opportunities for pressure on the right heel were present. RN #5 said the only protection over the heel when the resident was up and out of her wheelchair was a protective cup/covering over her heel until she was fitted with a new podus boot from therapy. The wound nurse identified that no additional protective measures to the heel were put in place between the time the blister was identified on 1/25/22 and 2/8/22, when the podus boot was implemented other than a thin protective cup. The occupational therapist (OT) was interviewed on 2/14/22 at 2:22 p.m. The OT said a protective boot was implemented when Resident #40 so she could bear some weight and to reduce friction on her foot. He said the resident was frequently up and was observed to take her foot on and off her foot pedal. He said she tried to adjust the pedals to be more conducive to her not having her heel resting directly on the top of the pedal. He said he placed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The boot was fitted the following week on 2/8/22. He said the resident wears the boot (since 2/8/22), when she was out of bed, in her wheelchair and during therapy. The OT said prior to the podus boot, there was no weight bearing activities till the boot arrived to protect Resident #22's heel. The director of nursing (DON) was interviewed on 2/14/22 at 4:28 p.m. The DON said the physician assistant (PA) saw the heel on 2/10/22 via telehealth. The DON said the PA did not indicate the wound was a pressure injury at that time. The DON said a wound could start out from friction and exacerbate into a pressure injury. She said a darkened area on a wound could represent a pressure injury.

Based on observation, interviews and record review, the facility failed to promote healing and prevent the worsening of a pressure sore for one (#4) of one resident reviewed for pressure areas of 35 sample residents. Specifically, the facility failed to: -Ensure weekly wound assessments were accurately, completely and timely conducted and documented; -Ensure the care plan was updated to reflect the pressure ulcer on the resident's toe; -Evaluate the resident's nutrition needs timely related to wound healing; and -Provide wound care in a clean or sanitary manner to prevent infection. The failures contributed to the development and worsening of a pressure injury to the resident's right second toe, from intact skin to stage II to stage IV. The findings included: I. Professional References regarding Pressure Ulcers A. Pressure Injury Staging According to the National Pressure Ulcer Advisory Panel (NPUAP), NPUAP Pressure Injury Stages, 4/16, <http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/>,(10/16), the updated staging system included the following definitions: -A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. -Category/Stage I: Nonblanchable [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. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermisPartial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). -Stage 3 Pressure Injury: Full-thickness skin lossFull-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue lossFull-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -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. -Unstageable: Depth Unknown Full 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. B. Interventions for prevention and healing According to the National Pressure Ulcer Advisory Panel (NPUAP), NPUAP Pressure Injury Stages, 4/16, <http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf>, (10/16), interventions for prevention and treatment of [REDACTED]. -Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected despite appropriate local wound care and pressure redistribution. Expect some signs of pressure ulcer healing within two weeks. -If progress toward healing is not seen within two weeks, the individual, the pressure ulcer, and the plan of care should be re-evaluated. -Screen nutritional status for each individual at risk of or with a pressure ulcer .when progress toward pressure ulcer closure is not observed. -Wherever possible, do not position an individual on an existing pressure ulcer. -When pressure ulcers deteriorate or fail to heal, the clinician should consider replacing the existing support surface with one that will provide a properly matched support surface environment in terms of pressure, shear, and microclimate for the individual. Changing the support surface is only one of several strategies to consider. More frequent repositioning, preventive interventions and local wound care should also be intensified as needed. II. Resident #4 A. Resident Status Resident #4, age 93, was admitted on [DATE] and readmitted on [DATE]. According to the admission record, [DIAGNOSES REDACTED]. The 9/29/16 minimum data set (MDS) assessment documented the resident had severe cognitive impairment as evidenced by a brief interview for mental status (BIMS) score of four out of 15. The resident required extensive assistance with bed mobility, transfers and toileting; and limited assistance with personal hygiene. The resident was 64 inches tall and weighed 100 pounds. The resident had one stage two pressure ulcer. According to the MDS assessment she did not have stage three, stage four or unstageable pressure ulcers. The pressure ulcer/pressure area risk care plan, initiated on 4/30/15 and last updated on 9/26/16, identified pressure ulcer risk related to history of pressure ulcers and decreased mobility. Interventions included: -Provide assistance of one or two with transfers, bed mobility, dressing, toilet use and bathing. -Fragile skin, provide cues and redirection as needed to prevent injuries, bruising, and skin tears. -Special double bed from her home. -Roho cushion in her wheelchair. -Encourage her to wear TED ([MEDICAL CONDITION]) hose as ordered, as she will wear them. The care plan did not identify an actual pressure ulcer. The November 2016 treatment administration record (TAR) did not include orders related to use of TED hose. The care plan had not been updated related to the pressure ulcer of the second toe of the resident's right foot. The care plan was not updated to reflect that the TED hose had been discontinued. B. Observations The resident was observed asleep in bed on 10/31/16 at 12:40 p.m. She was lying in bed on her side with multiple pillows. The resident had a blanket covering her lower body and toes. On 10/31/16, she was awake at 1:46 p.m. and having a period of time where she agreed to answer interview questions. She repositioned herself to a sitting position in bed. She was able to carry a conversation and did answer the interview questions. She was observed on 11/2/16 at approximately 1:30 p.m. sitting in her wheelchair in the commons area. She was observed to have a slipper shoe on her left foot and a special Velcro sandal on her right foot. Her second toe of the right foot had a bandage around it. She was observed on 11/3/16 at approximately 9:30 a.m. sitting in her wheelchair in the commons area. She was observed to have a slipper shoe on her left foot and a special Velcro sandal on her right foot. Her second toe of the right foot had a bandage around it. C. Observation and Interviews The resident had a shower on the morning of 11/3/16. The dressing was removed for the shower. Registered nurse (RN) #11 moved the resident into the nurses' charting room after her shower was finished. The nurse placed a white plastic bag containing dressing supplies on the table top where some papers and miscellaneous charting notebooks were placed. She examined the foot and said it looked swollen and red colored on the outer right side. The nurse then called the medical director, who was in the facility. The nurse removed the dressing supplies and scissors from the white plastic bag and placed them on the table top. When asked what stage the pressure ulcer of the right second toe was, the nurse said stage two. She said the resident had been to the wound clinic recently, on 10/26/16. She said the pressure ulcer had been caused by her shoe. She said the shoes were not being used anymore. RN #11 said there had only been one visit so far to the wound clinic and the next appointment was for one week after her first appointment. She said at the time of her visit, the wound clinic doctor said it was a stage four. They could see the bone. She said the pressure ulcer had filled in now so she thought it was a stage two. When asked if she thought the filled-in portion of the ulcer was yellowish slough with a small piece of black, as observed, she agreed. The nurse said the physician had ordered antibiotics when the foot started to get redness the first time, and the antibiotics had just recently been completed. The nurse said now the foot was swollen and getting redness again, so she wanted the physician to look at it again. The physician entered the room and examined the resident's right foot. The physician said he also thought the foot was getting some redness and swelling and showing signs of inflammation. He said he would write orders for another round of antibiotics. When the physician was asked what stage the pressure ulcer was, he said the wound was unstageable due to the yellowish slough and the small black speck of eschar. The resident said her toe did have pain at times, but at present it only hurt if someone pressed on her toe or foot. The nurse then removed plastic gloves from her uniform pocket and put them on her hands. The nurse was observed to pick up the scissors from the table, cut a small piece of the dressing, and placed the remaining portion of the dressing back into the small paper wrapper that the dressing originally came from. The nurse then applied the endoform and [MEDICATION NAME] blue foam covering to the resident's right second toe and covered it with a cling bandage. The nurse was observed to place the dressing, scissors, and cling bandage wrap back into the white plastic bag she had removed them from. D. Record Review 1. Consultation Report Review of the 10/24/16 treatment administration record (TAR) revealed new orders for a consult with the wound clinic. The consultation report, dated 10/26/16, revealed the wound care orders from the wound clinic physician were endoform with [MEDICATION NAME] blue foam cover dressing to the right second toe, stage four pressure wound over the pip joint, apply weekly and as needed. 2. Weekly wound assessments Wound weekly assessment forms were requested and provided on 11/3/16 by the director of nurses (DON). Review of the weekly assessments beginning with onset 8/27/16 through 11/3/16 indicated a total of 10 assessments should have been completed. The facility furnished eight wound assessment forms. Review of the wound assessment forms revealed the following: -Wound assessment dated [DATE], stage two, length _ x width _ x depth, no slough, no drainage (void of measurements). The physician and family were notified. The physician ordered a band aid to toe to prevent trauma and not to wear shoes until healed. She was not on a turning and repositioning routine. -Wound assessment dated [DATE], stage two, length _ x width _ x depth, no slough, no drainage (void of measurements). The physician and family were notified. She was not on a turning and repositioning routine. -Wound assessment dated [DATE], stage two, length _ x width _ x depth, less than 25% slough, no drainage (void of measurements). The physician and family were notified. She was not on a turning and repositioning routine. -Wound assessment dated [DATE], stage two, length _ x width _ x depth, overall impression wound had worsened, yellow slough 76-100% (void of measurements). The physician and family were notified. She was not on a turning and repositioning routine. She was on a specialty mattress. -Wound assessment dated [DATE], stage two, length 1cm x width 1cm x depth_ (void of depth measurement), less than 25% slough, and a small amount of drainage. The physician and family were notified. She was on a turning and repositioning routine. She was on a specialty mattress. -Wound assessment dated [DATE], stage two, length 1cm x width 1cm x depth 1cm, less than 25% slough, small amount of purulent drainage, overall impression wound had worsened. The physician and family were notified. She was on a turning and repositioning routine. She was on a specialty mattress. One new order for foam boots while in bed. -Wound assessment dated [DATE], stage two, length 1cm x width 1cm x depth 1cm, less than 25% slough, no drainage, overall impression was the wound was not healing. The physician was notified and gave a new order for consult with the wound clinic. She was on a turning and repositioning routine. She was on a specialty mattress. -Wound assessment dated [DATE], stage two, length 1cm x width 1cm x depth 1cm, less than 25% slough, purulent drainage, overall impression was the wound had worsened. The physician was notified. She had a visit with the wound clinic and new orders for wound treatment. She was on a turning and repositioning routine. She was on a specialty mattress. 3. TARs Review of the October 2016 TAR revealed new orders for treatment to the right second toe, dated 10/17/16. The order was for calcium with silver in wound bed of the right second toe. Cover with island dressing and change on bath days Tuesday, Thursday, and Saturday, and as needed. Juven supplement one packet twice per day with once per day to be placed in her juice. There was no specific order how the resident was to receive the second dose of Juven per day. Review of the October 2016 TAR revealed treatment orders initiated 8/27/16, for a band aid to the right second toe, change every three days and as needed until the stage two pressure ulcer resolved. 4. Nutritional Notes Review of the Dietary Nutritional Reassessment Quarterly forms dated 4/5/16, 6/30/16, and 10/4/16 revealed the diet orders were for a regular diet, mechanical soft. Supplements for the 10/4/16 assessment included calcium with vitamin D, and multiple vitamins, and she refused other supplements. The 4/5/16 and 6/30/16 dietary assessments revealed the refusal of supplements but that she would often consume ice cream snacks. Her weight was at 101 pounds on each of the three dietary assessments. There was no Dietary Nutritional Reassessment form related to her newly developed pressure ulcer of the right second toe, first found on 8/27/16. E. Staff Interviews The nursing home administrator (NHA) and DON were interviewed on 11/3/16 at 2:44 p.m. about pressure ulcers. They acknowledged the improper wound dressing technique and incorrect staging of the pressure ulcer. They further acknowledged the wound assessment forms that were staged incorrectly, with documentation by multiple nurses that had staged the pressure ulcer at stage two, but also documented yellow slough had been observed. The NHA said the wound clinic doctors had agreed to come into the facility and provide additional education and training for the nursing staff. She said that would happen but had not yet been scheduled. She said there was one nurse that worked at the facility who had been wound certified and when asked said she would help with wound care and management.

Based on observations, record review and interviews, the facility failed to provide supervision and assistance to prevent falls and ensure safe transfers for one (#6) of three residents reviewed for accidents of 35 sample residents. Specifically, the facility failed to: -Thoroughly investigate, assess and implement timely interventions in response to multiple falls for resident #6; and -Provide supervision to prevent further falls and accidents for resident #6. These failures contributed to resident #6 experiencing five falls over a three-month period, resulting in a laceration to her right temple, skin tears and bruising. The findings included: I. Facility Policy The policy entitled Protocol for Fall, revised 11/05, included: PURPOSE: To identify whether the fall was avoidable or unavoidable. To assess potential causes of falls. To identify steps needed for the prevention of falls. -WARNING SIGNS TO IDENTIFY RESIDENTS AT RISK: Identified on risk assessment for fall potential. Unsteady gait. Need for assistive devices. Receiving medications which may cause postural hypotension, dizziness or syncope . Cognitive loss/dementia . -ACTION STEPS: Investigate any fall to determine possible cause(s). Establishment of preventive measures . QA/QI study to monitor falls in the facility to determine number or pattern . Review the care plan with each fall for any needed changes. A handwritten note on this policy from the nursing home administrator (NHA) read, Per Action Plan - Policy will be reviewed and re-written through QAPI (quality assurance and performance improvement). II. Resident #6 A. Resident Status Resident #6, age 91, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 9/1/16 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. The resident was independent to needing supervision for ambulating in her wheelchair; and required extensive assistance for bed mobility, transfers, dressing, toileting, personal hygiene and bathing. B. Resident Observations Resident #6 was observed on 11/2/16 at 9:40 a.m. She was in her room, asleep in her recliner in the reclined position. The resident was covered with a blanket and she had one shoe on and one shoe off. Her wheelchair was on the other side of the room and out of reach. Her walker was folded up and placed against the wall and was also out of her reach. There was no fall mat in place and the bed appeared to be in the low position. There was a handwritten sign posted on the wall on the side of her bed which read, (Resident's name): Call for help to stand. NO FALLS. There was a transfer pole on the right side of the resident's bed. On 11/2/16 at 10:45 a.m., this resident was observed outside getting some sunshine with the activity department. On 11/2/16 at 11:45 a.m., the resident was observed in the dining room, seated at the table in her wheelchair. There were anti-tip roller bars on this resident's wheelchair. On 11/2/16 at 3:38 p.m., a motion detector was observed on the resident's floor, approximately four feet in front of her recliner. There were no skid strips observed in this resident's room, either in the bedroom or bathroom. The resident was not present in the room at this time. On 11/2/16 at 5:30 p.m., the resident was observed in her bed, resting. There were now skid strips in place by the side of the resident's bed, in front of her recliner and in front of the toilet. On 11/2/16 at 5:45 p.m., the resident was observed being toileted. There was a leaf on the side of the door to the resident's room. On 11/3/16 at 9:00 a.m., the resident was observed in her recliner in the reclined position. She was covered with a blanket. She had one shoe on and one shoe off. The motion detector was in place on the floor by the resident's bed. Her call light was within reach, but her wheelchair was out of reach. During the week's observations, there was only one observation of this resident sitting close to the nurse's station for safety. This was observed on 11/2/16 at approximately 4:00 p.m. The resident was unable to respond to questions during interview attempts. C. Record Review 1. Fall Investigations The fall investigation records were reviewed for resident #6 from August 2016 through October 2016. The resident had fallen on five separate occasions: 10/29/16, 9/6/16, 9/5/16, 8/27/16 and 8/11/16. 10/29/16 Fall The fall investigation dated 10/29/16 at 8:51 p.m. revealed the resident had an unwitnessed fall in her room. This resident was found on the floor in front of her wheelchair and had sustained a skin tear to her right posterior forearm measuring 3x6 cm. This resident said that she fell waiting for the toilet. The skin tear was cleaned, steri-stripped and covered with a dressing. This report read that the resident was wheelchair dependent, and there were no predisposing environmental factors contributing to her fall. The predisposing physiological factors were confusion, incontinence, gait imbalance and impaired memory. The predisposing situational factors contributing to this fall were ambulating without assist and improper footwear. The nurse's statement on this form read, At approximately 8:00 p.m Passing (resident's name's) room, her call light went off, I stepped into (resident's room) to tell her I would be right back. (Resident's name) told me she needed to use restroom and get ready for bed. At the time, she still had her day clothes on including shoes. I told her someone was on the toilet and I would come get her when the other resident was done, I would help her . I stopped by (resident's name's) room to tell her another resident was in the bathroom and left. (Resident's name) was still dressed, she told me OK, she would wait. I went to help someone else shortly after the nurse rang emergency call light and stated (resident's name) had fallen upon entering the room. (Resident's name) was partially undressed and her shoes were off. There was a final statement on this report, which read 10/31/6: Fall committee review - continue with current fall interventions. 9/6/16 Fall The fall investigation dated 9/6/16 at 8:15 p.m. revealed the resident had an unwitnessed fall in her room. This report read, At approximately 8:15 p.m., heard a loud call for HELP. This nurse and a CNA (certified nurse aide) responded to call. Found resident by her TV on her right side, blood on the floor. Chair facing her bed, floor alarm on her left side and missing a battery, not alarming. Asked resident what happened and she stated, 'I was trying to go to bed and I did not want to bother anybody.' Call light not on. Head to toe assessment done and found a laceration to right temple, approximately 1 1/2 inches long by ¼- inch wide, bleeding frank red blood. Pressure was applied to forehead to stop bleeding and area cleansed and bandaged. The medical director notified and order received to transfer to ER for stitching. Checked wheelchair to make sure her anti-skid mat was under her wheelchair cushion and it was in place. The predisposing environmental factors contributing to this fall were: fall alarm misuse/malfunction and other (describe), which there was no additional description for. The predisposing physiological factors were weakness/fainted and gait imbalance. The predisposing situational factors were alarm malfunction/misuse and ambulating without assist. Additional information read that this resident does not use call light for assistance; dismantles floor alarm (takes batteries out, moves floor alarm out of her way). Transfers self without calling for assistance. There was a final statement on this report, which read 9/7/16: Fall committee review: Will check on (mental health) appointment. Have (resident's name) as close to the nursing station as much as possible for safety. 9/5/16 Fall The fall investigation dated 9/5/16 at 6:31 p.m. revealed the resident had an unwitnessed fall in her room. This report read, Resident was in bed with socks on. She had her TED hose removed and requested non-slip socks for comfort when in bed. As resident attempted to stand, her feet slipped on floor alarm and she slid off bed onto floor. The resident was standing upon staff arrival and staff assisted resident into wheelchair and did some safety awareness education. The resident was unable to repeat or teach back educational tutorial. The nurse completed a head to toe assessment. The predisposing environmental factors were fall alarm misuse/malfunction and furniture. The predisposing physiological factors were confusion, incontinence, recent change in cognition, weakness/fainted, gait imbalance and impaired memory. The predisposing situational factors included: alarm malfunction/misuse, during transfer, resident did not press call light, alarm sounded, ambulating without assist, improper footwear and resident did not use ambulatory equipment. This report read, Resident is non-compliant with education and instructions to use call light before all transfers and when needing assistance. Resident disassembled floor alarm by removing batteries before CNA discovered resident on floor. The CNA involved in this incident documented, I was in another resident's room when I heard a woman yelling help me! I went towards the cries for help and discovered resident lying beside the bed on the floor. The floor alarm was not going off. It appeared as though she had slipped on the floor alarm. I immediately pushed the emergency alarm. I knelt down to assist resident and she grabbed my arm and would not let go. As soon as my co-workers came in, another CNA and I picked resident up and then assisted her into wheelchair. The nurse had us leave the room as he assessed her condition. There was a final statement on this report, which read 9/6/16: Fall committee review: DC floor alarm. Place remote motion alarm. Waiting for skid strips to be delivered. 8/27/16 Fall The fall investigation dated 8/27/16 at 1:45 p.m. documented the resident had an unwitnessed fall in her room. This report read, Heard resident yell and this nurse went into resident's room and found her lying face down on her floor between recliner and bed. Call light was not on. Assisted resident to lie on bed and called nurse supervisor for assistance. Nurse supervisor assessed situation and went to call MD for order to send resident to ER. This nurse assessed resident's injuries and did neuros. Resident stated, I was reaching for my water and fell out of my wheelchair on the floor and I called for help. The resident's injuries were assessed and cleansed. Neuros and vitals were taken before the ambulance arrived and were within normal limits for this resident. This report read that the resident sustained [REDACTED]. The predisposing physiological factors included confusion, impaired memory and pain. The predisposing situational factor was resident not pressing call light. Other information included the resident refusing to allow a tab alarm on her chair. This report noted the resident had a large laceration to her frontal lobe, a large skin tear to her right elbow and back of left hand, a small skin tear to her left knee and a cut to the bridge of her nose. There was a final statement on this report, which read 8/29/16: Fall committee review: Continue with current interventions and MD will do med review. 8/11/16 Fall The fall investigation dated 8/11/16 at 5:04 p.m. documented the resident had an unwitnessed fall in her room. This report read, Resident found on floor in front of bed, denies new injury. Refuses to go to the hospital. The resident said she slid off the bed. The predisposing situational factors were: resident did not press call light and ambulating without assist. The CNA who was involved in this accident said in the report, I was walking down the hall and heard this resident yell for help. Went into resident's room and found her on the floor. When asked, the resident stated that she was reaching for her wheelchair and slid off the bed. Call light was not on. There was a final statement on this report, which read 8/12/16: Reviewed by fall committee: recommends: gripper tape in front of bed and chair on floor. 2. Fall Risk Assessment Restorative nursing completed a quarterly fall risk assessment on 8/30/16. It read, in pertinent part, that this resident had intermittent confusion, had sustained three or more falls in the past three months, that she was chair dependent or required assistance with elimination, that she had balance problems when standing and walking, that she jerked or was unstable when turning, had an unsteady or shuffling gait, that she required an assistive device, that she received two or more medications which could affect her ambulation, and that she had the following pre-disposing conditions that could affect ambulation: stroke, arthritis, osteoporosis and fractures. This risk assessment was scored at a 10 or more which meant this resident was a high risk for falling. 3. Progress Notes The restorative program note dated 10/27/16 read that this resident participates with PROM (passive range of motion) to bilateral hands and AROM (active range of motion) to bilateral left extremity. The restorative program note dated 10/19/16 read, Monthly Note: (Resident's name) participates in her restorative program. She has declined only once this month. At times, she is not able to ambulate with restorative CNA using her front wheeled walker. The restorative program note dated 8/30/16 read, Quarterly Note: (Resident's name) is independent with locomotion in her wheelchair. She requires extensive assistance with bed mobility, dressing, toileting, personal hygiene and transfers . She has had seven falls this quarter of which three resulted in injuries. She currently has two skin tears and abrasion, which are healing from a recent fall. She does participate in a restorative program. 4. Care Plans The care plan dated 8/26/16 read in pertinent part, (Resident's name) has had an actual fall with injury 9/6/16. The goal was for the resident's laceration to head to be resolved without complication. Interventions included: Check range of motion daily. (Resident's name) often refuses to do exercises. Continue interventions on the at-risk plan. For no apparent acute injury, determine and address causative factors of the fall. Have (resident's name) near nurse's station as much as possible for safety . PT consult for strength and mobility. The care plan dated 8/7/16 read in pertinent part, (Resident's name) is high risk for falls related to perceived independence not reflecting true ability, lower extremity weakness, poor balance, dementia and poor safety awareness. Interventions included: Continue to remind (resident's name) to call when needing assistance. Keep call light and most frequently used personal items within reach . Assess medications for contributing factors. Ensure she is wearing proper footwear: Shoes well-fitting with non-slip soles or gripper socks. Guardian program. Informed consent signed for no anti-roll back brakes on her wheelchair. Make sure that all staff members are aware that (resident's name) is at high risk for falls. Falling leaves program. Guardian program. (Resident's name) will take the batteries out of her fall mat alarm or any other alarm. Staff to check alarms every two hours for operation. The care plan related to fall prevention was not updated after the resident's most recent fall on 10/29/16. 5. Guardian Program Documentation The Guardian Program documentation for this resident was reviewed on 11/2/16 at 5:50 p.m. At that time, there was no evidence that any staff had conducted the 15-minutes checks for this resident since 4:00 p.m. The instructions in this book read, Sign off on each resident's schedule when checks are done. When documentation was reviewed for this resident, there were 28 documentation omissions as of 10/27/16. On 10/28/16, the facility did not document on this resident at all until 6:00 p.m. There were 15 omissions on 10/29/16, none on 10/30/16, seven on 10/31/16 and 24 on 11/1/16. D. Staff Interviews The director of nursing (DON) was interviewed on 11/1/16 at 1:05 p.m. The DON stated that this resident was her frequent faller. The DON said that resident #6 had bad dementia and kept trying to be independent. She said that the facility had tried alarms and that the resident took the batteries out and threw them across the room. The DON said the facility tried a fall mat, which the resident picked up and moved. In the course of moving the fall mat, she fell when trying to move the mat and ended up with stiches in her head. She said this resident had been showing increased behaviors and was on many meds, including luvox and wellbutrin. The nursing home administrator (NHA) was interviewed on 11/2/16 at 1:35 p.m. The NHA said that the interdisciplinary team met each morning to review falls. She said that their falls form was new and that it was still being used inconsistently. She said that historically this facility had never considered a fall as requiring an investigation. She said that they did them for abuse investigations and things of that nature, but had not been doing them for falls. She stated that she told the facility they must treat falls like an accident scene and do a thorough investigation. The NHA said that she had developed an action plan related to falls, which would include a thorough investigation for each fall in the facility and that all staff would become aware of the care plans and interventions and adhere to the same. The NHA and MDS Coordinator were interviewed together on 11/2/16 at approximately 11:00 a.m. Both stated that the therapist at the local mental health center felt that this resident's falls were purposeful. The facility staff stated that they were taking this theory with a grain of salt and did not truly believe that was the case. RN #6 was interviewed on 11/2/16 at 3:39 p.m. This RN was asked about the motion detection observed on the resident's bedroom floor. She stated that this resident did not use her call light and took the batteries out of the floor alarm. She said that this motion detector would sound at the nurse's station if the resident attempted to transfer herself without assistance. Directly following this interview, it was observed that no staff members were currently staffing the nurse's station for that hall. However, a test of this motion detector showed it sounded loudly enough so that staff not sitting at the desk could still hear it. RN # 14 was interviewed on 11/2/16 at 3:53 p.m. This RN said that there were skid strips in this resident's room, by the resident's chair and in the bathroom. This RN went into the resident's room and discovered that housekeeping had removed the strips by the recliner and in the bathroom. She said that they would be replaced immediately. The NHA arrived with the third revision of the action plan related to falls on 11/2/16 at 4:07 p.m. This action plan contained, in pertinent part, that the falls committee would continue to meet daily, Monday through Friday, to review each fall with the chart; a 24-hour report would be reviewed; an investigation report form would be completed with each fall; and trending patterns for falls would be reviewed. The NHA acknowledged that a large percentage of this resident's falls revolved around toileting, and the trend could have easily been discovered and addressed if the facility had been doing complete fall investigations. She stated that the third revision included all staff becoming aware of the care plans and fall interventions, and adhering to them. The DON and NHA were interviewed about the facility's Guardian program on 11/2/16 at 5:30 p.m. This Guardian program was alluded to in resident #6's care plan. They said that if a resident was on the Falling Leaves program (a program to designate which residents were at risk for frequent falls), there would be a picture of a leaf on the side of the door. If they were on the Guardian program, there was a log book located at the nurse's station requiring staff to check on those residents every 15 minutes and document those checks in the log. They stated that the restorative department oversaw that program.

Based on observations, record review and staff interviews, the facility failed to ensure a resident's environment remained as free of accident hazards as was possible and adequate supervision was provided to prevent accidents for one of 33 sample residents (#5). Specifically: The facility failed to ensure all injuries were thoroughly investigated to identify causes of injury in order to reassess the resident's safety needs. As a result of these failures, the resident sustained [REDACTED]. The findings include: I. Facility Policies: Policy on Transfers, revised June 2003: "Moving a resident with a mechanical lift - always have 2 nurse aides present when using a lift." A. Resident #5 Resident #5, age 82, was admitted to the facility on [DATE] according to the facility face sheet. His pertinent admission [DIAGNOSES REDACTED]. 1. Resident Status According to the quarterly minimum data set (MDS), dated [DATE], resident #5 had a brief interview for mental status (BIMS) and could not be scored, which indicated he was not cognitively intact. Resident #5 could not speak, make his needs known to others, or understand others. Under behavior, he was coded for an altered level of consciousness and his vision was highly impaired. Resident #5 was totally dependent, requiring two staff members for bed mobility, transfers, dressing, toileting, hygiene and bathing. He required extensive assistance of one staff member for locomotion on and off the unit and for eating. He had range of motion impairment to both the upper and lower extremities. The most current nursing Resident Monthly Summary, dated 11/17/13, documented a weight of 194 pounds. The resident's care plan, initiated 6/08/13 and updated 10/10/13, documented the goal was to ensure resident #5 "will have no injuries over the next ninety days." Interventions on the care plan included, "Total assist of one to two with bed mobility, transfers w/c (wheelchair) locomotion, dressing, eating, toilet use, personal hygiene, and bathing. Hoyer lift for all transfers. Use full body sling only." There were no revisions to the care plan. Review of certified nursing assistants (CNA) documentation for assistance with daily living activity (ADL) flow sheets, from May 2013 through November 2013, included both paper and electronic documentation. Staff documented one to two staff provided assistance with all ADLs including transfer with a mechanical lift. Specifically, staff documented only one staff provided transfer assistance with the mechanical lift, on the night shift of 7/17/13, and the evening shifts of 5/31, 9/07, 9/08, 11/20, 11/21, 11/22, 11/23, and 11/29/13. A. Observation On 12/04/13 at 11:45 a.m., a CNA and licensed practical nurse (LPN) were observed providing Activity of Daily Living (ADL) care and transfer of resident #5 with a Hoyer (mechanical) lift. Shortly after beginning care, a second CNA added her assistance. One CNA and the LPN were observed to roll resident #5 onto his right side, so an incontinence brief could be removed and pericare provided by the second CNA. Resident #5 was observed to have his left arm secured underneath his shirt. All three staff assisted in applying a clean incontinence brief, sweat pants, and placing the Hoyer lift sling under resident #5 by repeatedly rolling the resident from side to side on the bed, until the briefs could be applied/secured, the sweat pants pulled up and the Hoyer sling placed under the resident. Both CNAs then positioned the Hoyer lift over the resident and secured the sling straps to the device so the resident could be raised above the bed. One CNA guided the lift to resident #5's wheelchair, while the second CNA guided the sling and pulled on the sling, so resident #5 would be positioned correctly over the wheelchair. After resident #5 was lowered into the wheelchair, both CNAs were required to take a hold of each side of the sling and reposition resident #5 into proper alignment in the wheelchair. All three staff members stated that it was facility policy to have two staff provide transfer assistance when using a mechanical lift. 2. Incident/Accidents Review of the nurses' notes revealed six incidents that resulted in multiple injuries, including arm fracture, multiple bruises, and a dislocated shoulder. a. Incident #1 - Nurses Notes -5/15/13 - 5:30 a.m. "(Resident #5) has bruise 2 cm (centimeters) x (by) 1 cm deep purple on L (left) arm area surrounding yellowish in color, also has bruising noted on hand. This was noted by the CNAs at the beginning of shift - (L) arm swollen unable to determine level of pain..." -5/18/13 - "Noc (night shift) Noted several yellow/green/purple bruises on (L) arm from elbow to palm. (Increased) pain when moving arm with slight moaning and pulling arm away. Slight swelling....." -5/18/13 - 8:30 a.m. Resident #5 had "facial grimacing & moaning (with) palpation of (left) arm. Contusion on palmar side of (left) hand, which is from medial aspect, involving 2nd & 1st phalange (fingers) w/is (which is) blue/purple. Contusion then extends medial aspect of inner arm w/is healing color yellow." Physician was notified and x-ray was ordered. -X-ray report, dated 5/18/13, "Probably avulsion fracture of the posterior (outside) aspect of the elbow..." b. Incident #2 - Nurses Notes -8/01/13 - 6:45 p.m. "2 CNAs on duty assisted this res (ident) to bed. While using Hoyer lift, they heard a popping noise from either (R) or (L) arm....No notable injuries seen. Reported to NP (nurse practitioner)." An x-ray was negative for a fracture. c. Incident #3 - Nurses Notes - 8/04/13 - 10:44 a.m. "Resident found to have half dollar size bruise to left forearm by wrist, and has some swelling in inner and outer elbow area." The nurse notified the physician and an x-ray was ordered, negative for fracture. -8/04/13 - 5:09 a.m. "Bruises noted on resident left forearm back side with increased swelling and warm to touch.....Throughout the night the bruising became more purple." -8/05/13 - NP examined resident #5 and noted bruising, with "fair range of motion" to the arm. d. Incident #4 - Nurses Notes -9/14/13 - 9:00 a.m. "Reported by bath aide that there was a contusion/abrasion on Rt (right) temple approx (imately) 2 cm. There is also a small (less than) 1/2 cm red spot above (rt) eyebrow, midline. Etiology is not directly known, however, it was discussed in report, that (resident) possibly rubbed his head against sling." e. Incident #5 - Nurses Notes -10/18/13 - 11:30 a.m. "CNAs were moving resident from bed to chair (with) Hoyer lift, had legs spread under chair, getting ready to lower into seat and the Hoyer tipped- causing the upper bar, where you attach the sling, to break and hit resident's (L) eyebrow area - causing raised approx 2 x 2 cm red area." NP notified. f. Incident #6 - Nurses Notes -11/30/13 - 6:00 a.m. Resident #5 "appears to have (L) shoulder deformity (with) lump by axilla (armpit)." X-ray ordered. X-ray report, dated 11/30/13, "Left shoulder dislocation." A second x-ray, dated 12/01/13, read "Hill-Sachs deformity of the proximal left humerus." Progress note from NP, dated 11/30/13, documented the NP, with staff assistance, used an "external rotation method supplemented with some traction with counter traction," to realign resident #5's shoulder. The NP's assessment documented his opinion was the dislocation was "just situational, in the fact that (resident #5) is a very large gentleman with barely any muscle tone at this point in his life. He is transferred from his specialty recliner to his bed back and forth with lift such as a Hoyer. My guess is that the patient's arm was dislocated at some point during transfer." 3. Facility Investigations On 12/04/13 at 1:30 p.m., the director of nurses (DON) was asked for any evidence the facility had investigated the aforementioned incidents. On 12/04 and 12/05/13, she provided the following information: -The DON provided a copy of the x-ray report, dated 5/18/13, with two handwritten staff notes. A registered nurse (RN) documented on 5/19/13, that he had worked the evening of 5/15/13 and did not observe any "new changes" or "new pain indicators" with resident #5. A second RN documented on 5/20/13, "I worked on the evening of shift of 5/14/13. During this period of time the CNAs that worked with me did not report any s/s (signs or symptoms) of injury on this patient." She documented that during direct care of resident #5, she had not noticed any pain, swelling, or bruising. She listed three CNAs and one orientee that worked that evening; however, there was no documentation any other staff were interviewed. -"Post/Fall Incident Reports," dated 8/01/13, completed by two CNAs read in part: CNA #1 wrote, "While helping put Res to bed, was lifting arm (R) side to take off shirt, Res arm popped. (CNA #2) was lifting (L) side, thought it was her side. So finished putting him to bed & told nurse what happened just in case." CNA #2 wrote, "Was aiding resident to bed, I lifted (L) side arm to get shirt off and (CNA #1) lifted (R) side to get his shirt off and we both heard a pop. Not sure what side the pop came from......Reported to nurse about the pop because of last time of broken arm." -The facility had no evidence of an investigation for the bruising noted on 8/04/13, or the contusion/abrasion noted on 9/14/13, and she had no explanation for this failure. -A Post/Fall Incident Report, dated "Spet 18 2013 (sic)", was attached to the Nurses Note of 10/18/13. "Was putting (resident #5) in his chair (Hoyer), had his chair brake on. Leg set on Hoyer - lowering him and Hoyer all at once when (sic) over, hit (resident #5) on the head. Called the nurses." There was no report provided for a second CNA assisting with the transfer. -The investigation for incident #6 included the nurses' note and handwritten statements from six CNAs and one RN. The RN and five CNAs noted nothing unusual. A sixth CNA documented on 12/01/13, that he had provided a bath to resident #5 on 11/30/13, and noted the left shoulder was "different" than the right shoulder and notified the nurse. 4. Failures -The facility failed to have evidence it conducted a thorough investigation of the fracture and multiple bruises that occurred in May of 2013. -There was no evidence the facility had responded to the inappropriate manner in which two CNA's simultaneously removed resident #5's shirt, on 8/01/13, causing resident #5's shoulders to "pop." -There was no evidence the bruises noted to the forearm, wrist, and elbow swelling, noted on 8/04/13, were investigated. -There was no evidence the contusion/abrasion of 9/14/13, was investigated. -There was no evidence the facility had developed interventions to ensure resident #5's shoulder dislocation was not repeated. -See above; review of the care plans revealed no revisions to care approaches from 6/13 through 11/30/13 with the last injury of a shoulder dislocation. -Although the MDS assessment reflected two people assist with bed mobility and transfers, the care plan indicated one to two staff members were required. The facility's mechanical lift policy noted two staff members were required for all transfers. -There was no evidence of staff retraining to ensure staff was appropriately handling the resident during positioning, mobility and dressing. -There was no evidence the facility had re-evaluated the resident's ADL needs, to ensure that provision of care by two staff was considered for bed repositioning, dressing, and other ADL cares, to prevent resident #5 from being re-injured. 5. Interviews On 12/04/13 at 4:15 p.m., the DON stated that the RN who had conducted the investigation for the dislocated shoulder would be in the following day and could provide information on her investigation. She stated that the NP had written a report, that resident #5's arm had been dislocated from the shoulder because the resident was so flaccid (relaxed, flabby, or without muscle tone). On 12/05/13 at 10:30 a.m., a CNA who worked with resident #5 stated that she had been trained to remove a resident's shirt by removing the item of clothing, one sleeve at a time. On 12/05/13 at 11:05 a.m., a CNA who worked with resident #5 stated that one or two staff would dress the resident. She stated that in either case, the resident should be undressed by removing one shirt sleeve, from the arm, at a time. On 12/05/13 at 11:43 a.m., the maintenance director stated that a second maintenance person had found a loose bolt in the Hoyer lift, which they believed was the cause of the lift tipping in October 2013. On 12/5/13 at 12:10 p.m., the CNA transfer charting was reviewed with the DON, where staff had documented only one person had been present for the Hoyer transfer (see above). She stated staff should have been documenting a two person transfer, per facility policy. She stated she would "have to ask my CNAs about their understanding of coding (for transfers)." When asked about her expectation for staff to have removed resident #5's shirt with both sleeves at the same time, she stated, "they should take off one shoulder at a time." Further, she stated that she thought someone had "verbally" spoken with the two CNAs about the manner in which they had removed resident #5's shirt. On 12/5/13 at 1:30 p.m., the RN who was on call the morning of 11/30/13, provided the following information regarding her investigation of the dislocated shoulder. "I got a call about 6 (a.m.) from the night nurse, explaining that I needed to evaluate his shoulder because there looked like something was wrong with it. I told her to do an assessment and call the physician. I came in and the left shoulder looked odd and she had gotten an order for [REDACTED]. No one noticed anything out of the ordinary. The (NP) thought that it could have occurred because (resident #5) was so flaccid and it could be because of the sling. (The Hoyer) is putting pressure on the shoulder." On 12/5/13 at 2:30 p.m., the Restorative Nurse reviewed resident #5's most current quarterly range of motion evaluation, dated 4/09/13. She explained that the resident had minimal to moderate range of motion and was able to provide resistance if his arm was moved in any direction, outside of his comfort zone. Further, she stated that after the resident's shoulder injury, the sling used for transfers was evaluated for size and was found to be appropriate for him. At the exit conference, on 12/05/13, the DON was advised to fax any additional information the facility had related to the incidents to the department for further review. As of 12/09/13, no further information was provided by the facility.

Based on observation, interview and record review, the facility failed to ensure that one of 25 sample residents (#51) received the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, the facility failed to ensure that resident #51's pain was minimized. The facility contributed to resident's pain by causing the resident to participate in painful transfers related to improper placement of the standing lift sling and use of the Sara lift. The findings include: Resident #51, a [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly minimum data set ((MDS) dated [DATE], revealed that resident #51 had no communication deficits, was independent in cognitive skills for daily decision-making (BIMS score 15/15), exhibited no behaviors, required 2-person physical assist for bed mobility, transfers, toileting, personal hygiene and bathing, 1-person physical assist for eating and self-propelled his wheelchair for mobility. -The MDS reported that resident #51's balance was unsteady and was only able to stabilize with human assistance. He was 5' 10" tall and weighed 193 pounds. -The resident was on a scheduled pain medication regimen and had not received PRN (as needed) medication for pain. Resident #51's MDS pain assessment interview revealed that he had occasional pain with the highest rating of pain being 10/10 but pain had not made it hard for him to sleep at night and had not limited his day-to-day activities. Resident Interview: At 10:59 a.m. on 2/29/12, the resident was interviewed regarding his pain. Resident #51 stated, ". . . It (pain) is mostly when I stand up; always then . . . it is at least 7/10. Two people have to help me transfer." When asked if the aides placed a sling around him, he replied, "That painful thing? Yes they do. It hurts. My arms go to sleep. It (the sling) cuts off my circulation. It's not padded. That thing (sling) always rides up under my armpits . . . My legs get wobbly especially when I have to try to stand up too long, like when they are changing me." Observations: At 10:56 a.m. on 2/29/12, resident #51 was sitting in his room in a recliner watching television. The resident exhibited no visual signs, symptoms or indications that he was having pain. He did exhibit both upper arm and neck erratic involuntary movement due to [DIAGNOSES REDACTED]. The resident also said that he had no pain at that time. At 11:42 a.m. on 2/29/12, a transfer of the resident from his reclining chair into his wheelchair was observed. Two certified nurse aides (CNAs) brought a Sara lift (standing type of lift) into his room. They placed the Sara lift sling around the resident and tightened the sling with the Velcro. The resident made the comment, "Oh, the thing from hell" (referring to the sling) while the CNAs were placing the lift sling around him. -The bottom of the lift sling was placed around his trunk above his waist line, not low on his back. One CNA attached the closest of the loops on both sides to the first knobs (closest to the end and furthest up when standing) on the lift and then activated the mechanism that raised the lift. -The sling rode up under the resident's armpits and doubled over (from approximately 15 inches to about 8 inches wide) so much that even the back of the sling fabric was bunched up and rested across the resident's shoulder blades. When the lift extended to its full height, his arms were extended upward and the weight of his (193 pound) body was being largely supported by the sling across the brachial [MEDICATION NAME] area (see below for definition) of his anterior shoulders and under his arm pits. His back was bowed out with little support from his legs, as if he was dangling or suspended from the sling under his arms. -The resident was observed to have difficulty maintaining a tight grip on the handles of the lift due to his upper limbs' involuntary movement. As they were lifting him and transferring him to his wheelchair, he grimaced and his breathing became labored and uneven. When asked about his pain level when they transferred him, he said emphatically "10 out of 10." When asked how they knew which loops to use and which knobs to attach the loops to, one CNA said that "this is just how we do it" and the other nodded. According to medilexicon.com (Stedman's online medical dictionary) the brachial [MEDICATION NAME] is "a network of spinal nerves that originate in the back of the neck and extend downward under the clavicle and through the axilla (armpit). Injuries to the brachial [MEDICATION NAME] affect the nerves supplying the shoulder and upper extremity causing pain, numbness and even paralysis of the upper limb." At 1:31 p.m. on 3/1/12, a CNA, who routinely transferred resident #51 using the Sara lift, demonstrated the placement of the sling and how to attach the sling to the Sara lift. The CNA failed to ensure that bottom edge of the sling was placed low enough on the back. This CNA also attached the closest of the loops on both sides of the sling to the first knobs (closest to the end and furthest up when standing) like the two CNAs observed earlier. When asked how she knew which loops and knobs to attach the loops to, the CNA said, "He's tall, so we always put the loops on the knobs closest to the ends for tall people." However, see above; when the lift was raised, the sling rode up the torso and bunched under the arms/back to the shoulder blades and exerted pressure on the brachial [MEDICATION NAME] causing the resident pain ("10 out of 10"). Record Review: The resident's Care Plan for falls, last updated 2/7/12, was related to history of falls, impaired mobility, impaired balance and unsteady gait and included the following pertinent approaches: "(Resident) is extensive assist with transfers, toileting and bathing. He to be transferred with two people at all times . . . (12/4/11) Sara lift as needed for transfers." The Care Plan for pain, last updated 11/14/11 was reviewed and it did not mention that resident #51 had pain when he was transferred with the Sara lift. It identified "pain management program r/t (related to) chronic pain and listed pain medications that had been prescribed by his physician." The most recent care conference summary dated 2/27/12, revealed "He has complained of pain and is on a pain management program." Review of the physician's Progress Notes from 8//22/11 to 2/29/12 recorded no issues concerning pain. The Nurses Notes were reviewed from 9/28/11 to 2/29/12. There was no documentation that resident #51 suffered from pain during transfers with the Sara lift. The Monthly Summaries for December 2011 and January and February 2012 were reviewed and there was no documentation that resident #51 suffered from pain during transfers with the Sara lift. The most current Initial Pain Review assessment dated [DATE] - 1/9/12 reported no concerns that resident #51 suffered from pain during transfers with the Sara lift. The Daily Pain Assessment Flow Sheets for January and February 2012 recorded resident #51 exhibited no non-verbal signs of pain and expressed no verbal complaints of pain. Review of the January and February 2012 Medication Administration Records (MARs) reported that the only PRN (as needed) pain medication was administered on 2/16/12; a [MEDICATION NAME] was administered at 11:00 p.m. for suprapubic catheter site pain. CNA Interviews: A CNA, who routinely provided care for resident #51 and who also worked the night shift, was interviewed at 11:59 a.m. on 3/1/12. She stated, "He complains more in mornings and not as much at night." - When asked if the resident ever complained of pain when he was being transferred in the Sara lift, the CNA replied, "He does and sometimes he doesn't . . . The Hoyer is not for him because of his MS. The Sara is our best option . . . We put him to bed at 10 after we come on - he's usually resting in his recliner when we come on. Some nights (he) needs toileting for bowels and some mornings we (night shift) get him up . . . - When we use the Sara lift we always have two CNAs. He is definitely hard to transfer - you always want to have two for safety." When asked about sling placement, the CNA said, "We have him lean forward and place it behind him . . . Because of how tall he is - the lower loop is for shorter people. We have tried different loops on him in the beginning. It always rides up - that one (loop) helps him stand best with the least amount of pain . . . - Yes, we have told the nurses and let restorative know that it is hurting him under the arms. He usually is not having pain when just sitting in his chair." During an interview with another CNA at 1:31 p.m. on 3/1/12 who worked days and who routinely provided care for resident #51, she stated, "He says that the lift hurts his arms really bad. Some days worse than others - about half the time he complains of the pain. Most of the time it's worse when we are putting him down because it takes us some time to clean him up and change his briefs and he's standing the whole time before we can get him back in his chair." A CNA who worked both day and night shifts was interviewed at 4:31 a.m. on 3/1/12. The CNA stated, "I have transferred him (resident #51) on day shift. We use a gait belt and help him up while he is grabbing onto the pole next to his bed and lately we have been having to use the Sara (lift) on him too. If he's incontinent of bowel it is best to lay him in his bed so then he can roll and it is more comfortable for him. He can't stand comfortably for very long. " Licensed Nurse Interviews: The Restorative Nurse was interviewed at 1:36 p.m. on 2/29/12 and related, "(Resident #51) self directs his own cares. He has attempted to stay as independent as possible as long as possible. He doesn't necessarily make the most safety conscious decisions for himself. At times he has impulsive behaviors. When he first came in (his) tremors were not so bad but now his balance is worse. We have attempted to do many safety things for him. We had PT (physical therapy) do evaluation and specific hands on training related to transfer from chair to recliner, recliner to bed and wheelchair to toilet. He had refused multiple interventions." -When asked how CNAs are currently transferring him, the Restorative Nurse replied, "Right now they are using a Sara lift and that has to be two-person because it is a mechanical lift. If he's shaking bad or if CNAs feel that he's unsafe, then they can get third person. I am not sure how much they are using the lift . . . No, I have not seen him this week, and I'm unsure of the last time I observed the CNAs transfer him. If there was an issue, what has happened in the past was that PT trained the nursing staff on how to transfer him. We did not do Sara-lift training explicitly for transferring him." The nurse said the therapist was off this week. -When asked how CNAs knew which loops and which knobs to attach on the Sara lift, the Restorative Nurse responded, "I don't know - can I get back to you on that? (The RN did not follow up on this as of survey exit 3/2/12.) The Restorative Nurse said, "I did not attend the last transfer training. . ." I know it's (which loops and knobs on the Sara lift should be used) not written on the care plan and it's not in the Nursing Staff Education book." -The Restorative Nurse further stated, "I am not aware that he has pain being transferred (with the Sara lift). I know that he was having some pain issues but not specifically with transfers. I know the pain committee is following him." One of the Pain Committee co-chairs, a registered nurse (RN) who was also the staff development coordinator (SDC), was interviewed at 2:21 p.m. on 2/29/12. She was asked to describe the pain committee process and said, "The committee meets every week. We take one hall per week; whoever is on pain meds or had pain issues in the past . . . Anybody can bring issues to the pain committee. We review monthly pain assessments, the MDS, the daily pain flow sheet in MAR and PRN (as needed) use of pain meds. - When asked specifically about resident #51 and pain during transfers, the RN related, "I know that he said that sometimes the lift is painful because of his tremors because he will hit the lift or the wall with his upper body tremors . . . I have assisted with some of his transfers on the Sara lift and have seen the increase in [DIAGNOSES REDACTED] . . ." - She said, "Staff are trained in how to use the Sara lift in CNA classes and yearly when we have our 'skills fair' and of course as needed with either a staff member or a particular resident. When asked if physical therapy (PT) or any staff had given an inservice on the use of the Sara lift to transfer resident #51, the RN replied, "No, but there have been a lot in general for safety awareness. There was a copy of how to transfer him for his safety when he changed from two-person to Sara lift." A copy of this document was requested but was not submitted by the facility as of survey exit 3/2/12. She further stated, "No one has advised me that he has pain when he is being transferred with the Sara lift." During an interview with the other co-chair RN on the pain management committee at 3:44 p.m. on 2/29/12, she stated, "I know we have had to discuss him (resident #51) pretty often . . . I don't ever recall that he complained of that particular problem (pain with transfers using Sara lift)." - When asked if CNAs found out he was having pain during a transfer what would be her expectation, the RN replied, "Stop what they are doing, report it to the nurse to see if there was some other way to transfer him without it hurting him. . . On the pain committee, we would probably have someone from restorative nursing come up and observe the transfer and do an evaluation . . . Hopefully we would find a solution for his problem." - The RN stated, "We would have to write out the specific instructions to be posted at the nurses' station so that we could let everyone know during a period of time - so that they would catch everyone. The care plan would have to be updated to indicate what the new plan for transferring him." - When asked how you know on a Sara lift specifically which loops to use and which knobs to use, the RN responded, "Oh goodness, I haven't used one for a long time. . . The Restorative Nurse would do that (determine specifically which loops and knobs to use for the resident) and I believe they are taught that in their CNA class (and) if not, they need to be taught by the rehab department." An attempt was made to interview the facility's physical therapist about her most recent assessments of resident #51's transfer abilities, any training she had provided to staff about the Sara lift's use for resident #51, and if she had been broached by nursing staff about the need to reassess him. The physical therapist was out of town; unavailable for interview. Policies and Procedures: (1) The facility's policy "Using a Portable Lifting Machine," revised 7/05 was submitted for review by the Director of Nursing (DON) on 3/1/12. It included in pertinent part: "Purpose: The primary purpose of using a portable lifting machine is to transfer residents who cannot bear full weight. Two nursing assistants are required to perform this procedure. The portable lift is also used to promote comfort and to maintain good body alignment while the resident is being moved." (2) The facility's policy "Transfers" directed to "Nurse Aide," revised 6/03, included in pertinent part: "Policy: Transfers: Transfer means moving a resident from one surface to another, such as from a bed to a chair, chair to toilet, bed to commode and so on." Review of the Procedures portion included transferring with gait belts, with canes or walkers and with Hoyer-type mechanical lifts. The Procedures did not include transferring a resident using a standing (Sara-type) mechanical lift. (3) On 3/1/12, the DON provided a CNA competency checklist for Mechanical Lifts that included in pertinent part: - "Utilize lifts when ordered or as needed to ensure safety. - Use Sara lift for resident who can stand and bear weight. - Use proper fitting sling, measure residents to ensure fit. - Demonstrate knowledge of manufacturer guidelines for sling placement and proper use of Sara or Hoyer lifts. (4) Also submitted was a document, of unknown source, that included in Chapter 6, page 18 and 19: "Using Standing, Stand Assist, Transfer and Transfer One-Piece Style Slings." It included in pertinent part: "WARNING! Individuals that use the standing sling MUST be able to support the majority of their own weight, otherwise injury may occur . . . Before lifting the patient, make sure the bottom edge of the standing sling is positioned in the lower back of the patient and the patients arms are outside the sling." On page 20 of this same document was a section titled "Attaching the Sling to the Stand Up Lift" . . . "Determine the best attachment point for the sling on each lift arm. Use the following chart as a guideline to determine attachment point." A drawing depicts the three knobs (attachment points) on the lift with the following: "Attachment points - Short - for under 5ft. 6in.; Medium (center) 5ft. 6in. to ft; and the one closest to the end Tall - for over 5ft. 10in. WARNING! Always use the color coded strap on the standing sling closest to the patient while still maintaining patient stability and comfort." See MDS above; resident's #51's height was 5 ft 10 in. See above observations; the CNAs used the Tall instead of Medium knob (attachment point) which when the lift was raised, placed the ends of the attachments higher than his shoulders, causing the sling to ride up under the resident's arm pits. Also on page 23 of this document it stated " . . . #5. Once a stable and comfortable position is found for the patient, mark the attachment points and color coded strap used in the patient file for future use." This, by observation and interview above, was not done by the physical therapist and passed on to all of the nursing staff who transferred him to ensure the resident's comfort and safety. Facility Failures: Interview revealed that the CNAs were aware of the severe pain resident #51 suffered during transfers and said that they had reported this to the nursing staff. However, the facility: - failed to investigate the contributing factors as to why he was having the pain during transfers on the Sara lift, - failed to adequately assess his declining condition with less ability to bear weight, - failed to adequately train the CNAs in the application of the sling and use of the lift with personalized guidelines specifically for him, - failed to refer him to physical therapy for determination of how resident #51 could be safely transferred without having to endure pain each time.

Based on observation, staff interview and record review, the facility failed to ensure a resident who entered the facility without pressure sores did not develop pressure sores unless the individual's condition demonstrated that they were unavoidable. Specifically, the facility failed to prevent the development and promote healing of pressure sores for one of 40 sample residents (#63). The findings included: Resident #63, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses, per the facility face sheet, included aftercare for upper arm fracture and upper leg fracture, [MEDICAL CONDITION], spinal stenosis, malaise and fatigue, diabetes mellitus type II, dementia, B-complex deficiency, [MEDICAL CONDITIONS], and urinary incontinence. I. Observation A registered nurse surveyor observed a pressure ulcer on resident #63's coccyx on 11/16/10. She reported the wound was in the same area described in a nursing note dated 10/5/10 (see below). The wound nurse documented that the wound was unstageable due to yellow slough and was measured at 0.5 cm x 0.3 cm. The observing surveyor stated she would have identified the pressure ulcer as Stage III with yellow slough. She stated she also observed a small (pencil-lead sized) Stage II sore above the yellow slough. II. Record Review A. Assessment 1. Admission Nursing Assessment A nursing assessment completed on 10/1/10 did not identify any wounds to resident #63's coccyx or buttocks. The resident's general skin condition was noted to be pale, moist and warm with [MEDICAL CONDITION] to the left hip. The resident was admitted with staples at the site of her left hip surgery and a [MEDICAL CONDITION] arm. The assessment was void of any other reference to her skin condition. 2. Braden Scale Braden Scales completed on 10/1 and 10/18/10 resulted in scores of 14 and 12 respectively, with a score of 16 or less indicative of a risk for pressure ulcer development. 3. Bladder Continence Assessments Bladder assessments completed on 10/1/10 and 11/4/10 resulted in scores of 12, with a score of 10-14 indicative of a low restorative potential. 4. Elimination Assessment Summary An elimination assessment summary dated 10/14/10 stated the resident "is incontinent of bladder and currently being treated for [REDACTED]. Provide pericare with each episode." An assessment completed on 11/4/10 stated, "Change of condition (due to) weight loss and Stage II to coccyx ... Long-standing hx (history( of urinary incontinence, requires extensive assist bed mobility, total assist with toilet use and personal hygiene. Has cleared from UTI she had upon admission ... Prompt and assist (resident) with toileting as per facility routine." 5. Failure to assess and implement dietary interventions to facilitate healing, per review of Weight/Pressure Ulcers/Hydration Assessments Assessments completed by nursing staff were completed weekly. On 10/06/10 and 10/12/10, documentation was void of identification of pressure ulcers. Documentation entered on 10/18/10 stated the resident had a Stage II pressure ulcer over her coccyx that measured 1.3 cm x 0.6 cm. She also had a Stage II pressure ulcer on her left lateral coccyx that measured 1.7 cm x 0.5 cm. Documentation entered on 10/26/10 stated the Stage II over the coccyx was 1.0 cm x 0.5 cm and the Stage II left lateral coccyx was healed. The assessment completed on 10/6/10 stated the resident was not receiving any dietary supplements and fluid intake was poor. Her weight was noted to be 125 pounds. The assessment completed on 10/12/10 was void of a current weight. Documentation stated, "Res(ident) meal intakes overall are poor. She will frequently accept yogurt or soup, rarely requests entire meal. She does not currently have supplements ordered, will request review/recommendations from RD (registered dietician). Rec'd (received) order to initiate sugar free Med Pass 120 cc TID (three times a day) between meals. " The assessment completed on 10/18/10 noted the resident's weight to be 118.2 pounds, a 5.6% loss in 12 days. Documentation stated the resident was refusing meals and offers of snacks. Fluid intakes were noted to be poor. The only supplement listed was Med Pass 120 cc TID (three times daily), with acceptance noted to be 100%. The assessment completed on 10/26/10 listed no current weight. The section for supplements stated, "N/A." Documentation stated, "Continues to have a 1.0 cm x 0.5 cm Stage II over coccyx. Meal intakes remain poor and res. Frequently refuses meals, multiple reasons include not wanting to be in dining room, however poor intakes noted with room trans. Multiple interventions and recommendations made to resident, however she is often resistant to suggestions. Request review by RD (registered dietitian) or possible supplement to aid with wound healing." The assessment completed on 11/1/10 noted the resident's weight to be 117.7 pounds on 10/26/10. No current weight was noted. The coccyx pressure ulcer was noted to measure 1.0 cm x 0.5 cm. Supplements included one container of Ensure pudding per day and one package [MEDICATION NAME] twice a day, with acceptance noted to be 100%. Documentation stated, "Resident with loss of 7.3 lbs since admit...poor fluid intakes r/t resident refusal to accept fluids because they cause her to urinate more frequently. RD did interview resident on 10/27/10 and changes were made to supplements. Will continue to encourage resident to drink fluids even though she has several refusals." The assessment completed on 11/15/10 noted the resident's weight to be 115.8 lbs. The wound to the coccyx was measured at 0.8 cm x 0.6 cm. 6. Resident Monthly Summary A monthly nursing summary completed for 10/01-11/09/10 stated, "Res(ident) does have stage II pressure ulcer to coccyx, she had been dragging buttocks on w/c seat during therapy to get to edge of seat for standing, caused increased shearing and pressure to area. Res also incontinent of urine causing increased risk to skin integrity. She will alert staff when she is incontinent. " B. Care Plan review revealed inadequate comprehensive assessment and planning regarding incontinence care, repositioning, and pressure/shearing relief 1. A care plan developed on 10/14/10 identified the resident was at risk for development of pressure ulcers based on impaired mobility, leg immobilizer and incontinence. An addition to the care plan on 10/18/10 stated, "(Resident) currently has a stage II pressure ulcer to her coccyx." Approaches included: -Two-person total assist for toilet use, personal hygiene and bathing, and extensive two-person assist for bed mobility and transfers. -Provide wound care per MD orders -Prompt and assist resident to use toilet -Provide peri-care with toileting and changing briefs -Weekly skin check and document on MAR -Check areas under leg immobilizer daily -Pressure-reducing mattress -Pressure-reducing cushion in w/c (wheelchair) -Encourage and assist (resident) to change her position in w/c and bed frequently -Encourage resident to change positions during activities. There were no specific schedules for toileting, turning, checking, or repositioning. There was no mention of assessing the appropriateness of the resident's mattress or wheelchair cushion. 2. A problem area was identified for bladder incontinence and occasional bowel incontinence with an increased risk of urinary tract infections. Approaches included providing total assist with toilet care, prompting resident to use toilet, providing peri-care, encouraging increased fluid intake at and in between meals, and taking the resident to the bathroom during activities if requested. Approaches were void of reference to a specific check and change or toileting schedule. 3. A care plan was developed for the identified problem area, "At risk for dehydration r/t diuretic use." Approaches did not identify the need to toilet or check and change the resident in relation to urinary frequency. C. Nursing Note A nursing noted dated 10/5/10 Stated, "Res(ident) with tan/brown discolored intact area, irregular-shaped on each side of tip of anal crease...new order written for [MEDICATION NAME] ointment q (every) shift to buttocks until dryness resolved." (according to the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The order was discontinued on 10/19/10. Application of a [MEDICATION NAME], to be changed twice a week, was ordered on [DATE].) D. Additional documentation Documentation by a CNA on 10/15/10 stated resident's personal w/c cushion was replaced by a low profile ROHO cushion due to skin issues. No other information was provided in this documentation. III. Staff Interviews revealed failure to identify, communicate and implement preventive measures A. The facility's wound care nurse was interviewed on 11/15/10 at 10:30 a.m. She stated the development of the Stage II pressure ulcers was the result of the resident's refusal to get up, and the resident's habit of lying on her back despite efforts to reposition her. The wound care nurse said the resident was admitted with "superficial, brown, thin abrasions on her buttocks." She stated the family requested the resident be allowed to stay in bed until 7:30 a.m. She said the resident often did not get up due to arm pain related to a fracture, and she had recent hip surgery. The wound nurse stated the resident's skin was very fragile and she had "skin on bone at coccyx." She stated the resident refused to use the call light to request assistance with toileting or to request being changed when wet (contrary to the care plan - see above). She said the resident "doesn't want to bother anyone." She stated the resident did not have a foley catheter when admitted , and insertion of a foley to assist with wound healing was not considered as the resident had a recent urinary tract infection. When asked if the resident was on a specific check and change program, the wound care nurse stated there was "nothing special" to her knowledge. When asked if the resident let staff know when she needed to be toileted for bowel movements, the wound care nurse stated she did not know. The wound care nurse reported the resident "won't stay positioned on her side in bed. She has been educated about this multiple times." She stated the resident currently had a pressure-reducing mattress with an alternating air mattress overlay and a Rojo cushion in her wheelchair. When asked about the efficacy of a pressure-reducing mattress versus a low air-loss mattress, she stated she was planning to switch the resident to the latter type of mattress. She said the facility had only two low air-loss mattresses, so she would have to trade out mattresses with another resident who was using one of the low air-loss mattresses. The wound care nurse stated that on one occasion the resident reported to her that she had pain at the site of the pressure ulcers. The resident told her the pain was worst when she was working with therapists. The wound care nurse stated she learned from therapy that they were teaching the resident to stand from her wheelchair by scooting to the edge of the wheelchair to stand. The wound care nurse stated therapy had removed the resident's Rojo cushion during these exercises. She said she educated therapy about the resident's fragile skin. In a follow-up interview with the wound care nurse on 11/15/10 at 1:05 p.m., she stated she was making arrangements for resident #63 to receive a low air-loss mattress later that day. When asked what the facility would do if there was a need for more than the two low air-loss mattresses currently on-site, the wound care nurse stated she had been told the facility could rent another one. When asked if it would have benefited the resident to have a low air-loss mattress when the pressure ulcers were first identified, she stated she did not think that would necessarily be the case and that she had other interventions she tried first. B. A registered nurse who provided care for resident #63 was interviewed on 11/15/10 at 11:00 a.m. She stated the resident "doesn't want to tell anyone anything. She doesn't want to be a bother." She stated the resident was "checked by CNAs" (certified nursing aides) every 1 ? to 2 hours, and she was not always incontinent. C. A CNA who provided cares for resident #63 was interviewed on 11/15/10 at 11:30 a.m. She stated that CNAs tried to check resident #63 "at least once an hour" to identify if she needed incontinence care. She said the resident needed to be changed due to incontinence episodes "about every hour." D. The interim director of nursing (DON) was interviewed on 11/16/10 at 8:50 a.m. She stated she would expect resident #63 to "be on some type of protein supplement for wound healing." She said the resident did not like to get up early and often stayed in bed for prolonged periods. When asked about initiation of the Rojo cushion two weeks after the resident's admission, she stated that she would have expected the need for the Rojo cushion to have been identified earlier in the resident's stay. She said usually the Rojo would have been initiated sooner. She stated she would investigate when the Rojo was initiated and for what reason. As of this writing, no further information was received. E. A restorative nurse was interviewed on 11/16/10. She stated she had no knowledge of a therapist allowing resident #63 to slide her bottom across her wheelchair to position herself to stand. F. On 11/16/10 at 3:00 p.m., the facility's physical therapist was interviewed. She stated she recalled resident #63 complaining on day one of buttock pain. She could not recall the date or find any documentation of the incident. She stated she thought a nurse told her the resident either had a pressure ulcer, or was at risk for a pressure ulcer, and she stopped having the resident scoot on her wheelchair to stand.