Every finding on record at Colorow Care Center

Based on observations, record review and interviews, the facility failed to ensure food was stored, prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure staff followed appropriate hand hygiene practices during the meal service. Findings include:I. Professional referenceAccording to the Colorado Retail Food Regulations (3/16/24), chapter 2-301.12, retrieved on 5/5/26, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.14)II. Facility policy and procedureThe Handwashing/ Hand Hygiene policy, revised December 2025, was provided by the nursing home administrator in training on 4/30/26. Hand hygiene is the primary means for preventing healthcare-associated infections (HAIs) and the transmission of multidrug-resistant organisms (MDROs). This facility requires strict adherence to evidence-based hand hygiene practices for all personnel, including licensed, unlicensed, contracted, therapy, dining, housekeeping, volunteers, and students. Perform hand hygiene before applying non-sterile gloves. The use of gloves does not substitute for hand hygiene. Always perform hand hygiene after gloves are removed.According to the policy, hand hygiene should be completed after touching contaminated surfaces. The Food Preparation and Service policy, revised January 2024, was provided by the nursing home administrator (NHA) on 4/30/26 at 11:38 p.m. The policy read in pertinent part, Food is handled properly with frequent hand washing and proper sanitation guidelines per local, state and federal guidelines and codes. Hand washing is done regularly after using the restroom, after breaks and after handling raw foods, bare hands do not touch ready to eat foods. Handwashing signs are posted above hand washing sinks and employees have hand washing techniques reviewed regularly and at orientation. III. Observations During a continuous observation of the lunch meal service in the kitchen on 4/29/26,, beginning at 11:00 a.m. and ending at 12:33 p.m., the following was observed:At 11:36 a.m the dietary manager (DM) was going in and out of the walk-in refrigerator, retrieving items for a chef salad. She donned gloves on her hands and proceeded to assemble the salads. -The DM did not perform hand hygiene prior to donning her gloves.At 11:39 a.m. the DM completed the salads, removed her gloves from her hands and dropped a glove on the floor. She picked up the glove, threw it away and washed her hands.At 11:41 the DM dropped a second glove on the floor, picked it up right hand, tossed the glove in the trash, sealed an onion in a plastic baggie and placed the bag in the walk-in refrigerator. She wiped down her work station counter and washed her hands.-The DM did not perform hand hygiene prior to sealing the onion in the bagging and touching the refrigerator door handle with her right hand. At 11:57 a.m. dietary aide (DA) #1 placed a glove on her right hand without performing hand hygiene. She pulled up the back of her pants with the gloved hand and placed her hands in and out of the front pockets of her apron.At 12:00 p.m. DA #1 placed a glove on her left hand without performing hand hygiene and used the thermometer to check the temperature of the egg rolls. At 12:06 p.m. cook (CK) #1 placed her left thumb on the eating surfaces of the plates as she dished the ready-to-eat food. At 12:09 p.m. a resident's diet card fell to the floor. CK #1 picked up the diet card with her left hand and placed it on a meal tray next to the plated food. The DM handed the tray with the meal and the diet card to a staff member for delivery. CK #1 continued to plate resident's food for the remainder of the meal service, frequently placing her thumb on the eating surface and without performing hand hygiene.-The laminated diet card was not wiped down after it fell to the floor. -CK #1 did not wash her hands after she picked up the diet card off the floor.At 12:13 p.m. DA #1 placed her hands in her apron pocket, pushed up glasses with fingers and took the temperature of a corn dog without performing hand hygiene.At 12:15 p.m. DA #1 pushed up glasses with fingers, held a plate with her thumb on the eating surface of the plate and then placed the corn dog on the plate without performing hand hygiene.At 12:17 p.m. without performing hand hygiene, DA #1 took the temperature of the hamburger patties and placed the patties on a plate, touching the edge of one of the slices of lettuce with her thumb.At 12:18 p.m. DA #1 touched her nose with her left hand, without performing hand hygiene she took the temperature of chicken nuggets and placed her right thumb on the plate with the chicken nuggets. She touched her glasses with the back of her right hand and donned gloves on both of her hands. At 12:20 p.m. DA #2 sniffed with her nose and placed the back of her left hand to her nose. Without performing hand hygiene, she then retrieved several adaptive equipment plates and placed them next to the steam table. She moved a clean large cook sheet and retrieved a small bag of potato chips from the storage room and handed the chips to the DM. The DM placed the bag of chips on a meal tray next to a resident's plated food and the tray was sent out for delivery. At 12:24 p.m. DA #1 was preparing a grilled cheese sandwich. She touched the sandwich with her left hand as she flipped the sandwich with a spatula.At 12:25 p.m. without performing hand hygiene or removing her gloves, DA #1 removed the grilled cheese from the pan, placed it on a plate and cut the grilled cheese in half, holding the grilled cheese steady with her gloved fingers and she cut it. DA #1 removed her gloves and washed her hands.At 12:29 p.m. DA #1 pulled the back of her pants up with hands, scratched her face near her mouth with her index finger, wiped down a thermometer, touched the microwave handle and buttons and used the thermometer multiple times to warm up and temperature the collard greens while pushing her glasses with the back of her hand and touching her nose twice with her left index knuckle. -DA #1 did not perform hand hygiene after touching her pants, her glasses and her face before touching the thermometer and the microwave to prepare the vegetables.IV. Record reviewA 2/4/26 dietary staff in-service participation log was provided by the administrator in training on 4/30/26 at 12:48 p.m. The participation log documented eight dietary staff received hand hygiene education, conducted by the DM on 2/4/26. The participation log documented CK #1 and DA #2 attended the hand hygiene training. The log did not indicate DA #1 attended the in-service on hand hygiene. V. Staff interviewsDA #2 was interviewed on 4/30/26 at 10:16 p.m. DA #2 said she should wash when she was working in the kitchen and after touching her face, trash or after touching anything that was potentially contaminated. CK #1 was interviewed on 4/30/26 at 10:18 p.m. CK #1 said she should wash hands any time she changed tasks or any time there was a risk of cross-contamination. She said if something dropped on the floor, she should pick it up, toss it away and wash her hands. She said not washing hands could contaminate the food.The DM was interviewed on 4/30/26 at 11:12 p.m. The DM said hand hygiene should be conducted after every task change and before putting gloves on. She said if something drops to the floor. Staff should wash their hands after picking the item off the floor. The DM said she saw CK #1 pick the diet card off the floor and place it on the tray. The DM said the floor was a contaminated surface. She said she would re-educate CK #1 to wash her hands after picking anything off the floor and not to place something on a resident's meal tray that was cross-contaminated.

Based on record review and interviews, the facility failed to ensure residents grievances were resolved in an acceptable and timely manner for four (#67, #26, #39 and #62) of five residents reviewed for grievances of 35 sample residents.Specifically, the facility failed to:-Resolve grievances concerning long call wait times for Resident #67 and Resident #26; and, -Resolve grievances concerning missing personal belongings for Resident #39 and Resident #62.Findings include I. Facility policy and procedure The Grievance policy, dated 5/8/23, was received from the nursing home administrator in training on 4/30/26 at 6:34 p.m. It read in pertinent part, To provide residents and responsible parties with information on the facility grievance procedure. To ensure that residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded to promptly and in written form. Upon receipt of a Grievance and Complaint Report or Complaint Concern form, the social services director or designee will explore the allegations/concerns. The appropriate department director will be notified of the nature of the complaint and that follow-up is necessary. The Grievance and Complaint Investigation Report (resolution) must be filed with the administrator within five (5) working days of receipt of the grievance or complaint form. II. Call light grievances A. Resident #67 1. Resident status Resident #67, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, diabetes with diabetic neuropathy, congestive heart failure and chronic respiratory failure. The 2/4/26 minimum data set (MDS) assessment revealed the resident was moderately impaired with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required substantial or maximal assistance from staff for transfers. The resident did not walk and used a wheelchair to get around. 2. Resident interview Resident #67 was interviewed on 4/27/26 at 2:52 p.m. Resident #67 said the facility's administration told the resident council that staffing and the long call wait times would change but it had not. He said the resident council brought up the concern about long call light wait times four months ago and nothing had changed. Resident #67 was interviewed again on 4/29/26 at 2:00 p.m. Resident #67 said that the east hallway had three good, certified nurse aides (CNA), but the East hall was staffed with one CNA per shift and they needed more than one staff member to help residents. He said there were several residents needing two staff members to assist them with transfers. He said there was a CNA who floated from unit to unit, but that CNA rarely responded to provide assistance on the East hall and the nurse was busy performing nursing duties, which made the wait time long when care assistance was needed. He said the other problem with getting the nurse to help the CNAs was that the nurses on the east hallway were older and not physically able to help with a resident's transfer/lift. Resident #67 said all of this contributed to the long waiting times for call lights. Resident #67 said when he brought the call light wait time concern to the facility's leadership, he was told they could not schedule more staff because the current resident census numbers did not support scheduling additional staffing. Resident #67 said that the facility had a staff member float to help on hallways, but it was not enough. 3. Record review A grievance form, dated 1/13/26, revealed Resident #67 reported call lights were not getting answered in a timely manner. He said long call lights were occurring after 6:00 p.m. and during shift change at 2:00 p.m. Resident #67 said no one showed up for work. The activities director (AD) documented a response and action taken on 1/14/26. The AD documented said she spoke with Resident #67 about the call light time complaint and he reported that he continued to make the complaint because he wanted two CNAs on the East hall. The director of nursing (DON) spoke with the resident and explained that two CNAs on the East hall was not possible with the facility's staffing allowances. The follow-up action to the grievance, documented by the facility, revealed call light times were pulled from 1/1/26 to 1/16/26. The follow-up documented there was only one call light time longer than 30 minutes during that timeframe and the average call light wait time was 6.2 minutes. The call light times were pulled to identify trends in high call light times. The follow-up documented the nurse management team used a pager to assist with answering call lights and call light trends were addressed with each shift. There was no signature from Resident #67 on the form, but the form documented the resolution was discussed with Resident #67 who verbally agreed the grievance was resolved. The resolution date was documented as 1/19/26. The nursing home administrator (NHA) signed the grievance form on 1/19/26. -However, per the interview with Resident #67 during the survey, the resident said call light times were long and nothing had changed (see Resident #67's interview above). B. Resident #26 1. Resident status Resident #26, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included diabetes with other circulatory complications, morbid obesity, congestive heart failure and depression. The 4/6/26 MDSassessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required substantial assistance from staff for transfers, as the resident used a wheelchair for mobility and could not walk on her own. 2. Resident interview Resident #26 was interviewed on 4/29/26 at 2:00 p.m. Resident #26 said that the facility had older nurses that worked the floor and they were unable to lift residents, or use the Hoyer lift (mechanical lift), and this created longer call light wait times, especially on the evening and night shifts. 3. Record review A grievance form, dated 4/13/26, was written by the social services director (SSD) on behalf of Resident #26. The grievance form revealed Resident #26 said she was throwing up last night (4/12/26)and there was only one registered nurse (RN) in the hall. The resident said she was changed at 11:00 p.m. and did not get changed again until 6:00 a.m. (seven hours later). The resident said she was soaked by 3:00 a.m. and did not get assistance to get changed, even though she had activated her call light for help. The grievance response documented that the NHA checked the call light system records to determine how long it took staff to respond to Resident #26's call light. Additionally, the nursing schedule was checked and two nurses and three CNAs were on shift the night of 4/12/26. The call light times for 4/12/26 were reviewed and revealed the resident's call light was on for longer than 48 minutes during the night. The follow-up action for the grievance revealed that staff were educated on the expectations to check in on Resident #26 when her call light was on, even when her eyes were closed. -The grievance investigation completion date was documented as 4/17/26 and signed by Resident #26; however, the grievance was not signed by the NHA or the designee completing the investigation. -Additionally, there was no response or resolution to the resident's allegation that she was left soaking wet from urine for three hours, despite activating her call light for assistance to get cleaned up. C. Resident council grievance A grievance form, dated 3/10/26, revealed the resident council group complained that call light wait times at night, between 10:00 p.m. and 6:00 a.m., were too long. The facility's response to the grievance was that nursing staff were educated to carry radios and pagers at all times and to respond to call lights promptly. Call light report times were now being pulled for residents' rooms throughout the building. The grievance form was signed by the DON on 3/13/26. -However, no was circled, indicating that the concern was not resolved for the resident council. D. Staff interviews CNA #3 was interviewed on 4/30/26 at 2:50 p.m. CNA #3 said when answering call lights, it was based on which resident called first and, depending on what the resident may need, depending on the resident's needs of that day. She said typically she would work her way down the residents' call lights and call for help if she needed assistance. CNA #3 said she had heard of long call light wait times and that it was unfortunate, but when providing the same level of care to all residents, call light wait times might be a little longer. She said her response time typically took less than five minutes. She said that she had not been made aware of any call lights being longer than five minutes. CNA #3 said call light times had been a topic of discussion at staff meetings since December 2025, as that was when she started working at the facility. CNA #4 was interviewed on 4/30/26 at 2:59 p.m. CNA #4 said he could manage answering call lights effectively with the pager that he had. He said if things got busy, he would call for help as well. He said when it was busy, he took care of the residents, in the order they called for assistance. He said when it came to mechanical lifts, he would coordinate with other staff members to make sure the lift transfer with the resident was completed quickly and safely. CNA #4 said that he had not noticed long call light wait times, and the facility had implemented systems in place to track and manage the call light wait times, such as the pagers, and a monitor near the administration offices to track call light times. CNA #4 said when he answered a call light, he would stay there until the task was completed and the resident did not need anything else. He said that he would not answer the call light and leave. CNA #5 was interviewed on 4/30/26 at 3:05 p.m. CNA #5 said that he responded to call lights as they came in. He said that he prioritized call lights as needed. He said if he knew a resident was a fall risk, he may go there first if they had their call light on, but it was based on urgency and safety. CNA #5 said he had not witnessed the long call wait times, but he had heard residents complaining about the wait times. He said that typically long call light wait times did not happen, but if there was an emergency, it could happen. He said he did not rush the residents or the care that he provided. He said when providing care to the residents, it could take a while and residents understood this. CNA #5 said he felt like staffing was good but he thought the overnight staff might need more CNAs. He said that as needed nurses (PRN) and CNAs were not available all the time and this put a strain on the staff. The SSD was interviewed on 04/30/26 at 5:06 p.m. The SSD said that grievances started with social services and once she took the grievances, she would give the grievances to the proper department, such as nursing, maintenance or environmental cleaning for follow-up to the concern. She said generally, the turnaround time for responses was about a day for the department to respond to the grievance, unless it was urgent and it would occur the same day. She said that the grievance, once it was resolved, would go to the NHA. The SSD said the NHA would look over each grievance and the response and sign the form. The SSD said that when it came to call lights, the facility had been putting out education for CNAs and other staff members as needed. She said everyone had been trying to resolve the call light concerns. She said any call light time over 15 minutes, in her opinion, was too long. She said management had stepped up to help and that they had been answering call lights. The SSD said there were a few residents that were constantly using the call light, and did not give staff enough time to respond. The SSD said when doing transfers with Hoyer lifts, it would take staff a while to complete the transfer and there was no way around this. She said that was why management had been answering call lights and had encouraged staff to ask for help from other hallways. The DON was interviewed on 4/30/26 at 5:17 p.m. The DON said she was made aware of long call light times and a grievance had been created for the concern at the resident council meeting. She said she would randomly pull call light times. She said she would pull them mostly at night as there had been more complaints regarding night shift call light times. The DON said she liked to answer call lights when she was in the building and it was not just her department that did so. She said the NHA was also very hands-on and was willing to help when needed. The DON said she has been putting out reminders for staff to always wear their pagers and walkie-talkies at all times, to ensure that call lights were answered in a timely manner. She said that she had a pager as well that was on a delay and was giving staff the ability to answer call lights in their hallways before she intervened. She said with the implementation of her pager, she had seen an improvement with call light times. The DON said during the night shift, it could get complicated and the call light times really depended on what was going on at night. She said the night shift did have less staff. The DON said Hoyer lifts could make longer call light wait times, but if this was happening, staff had been encouraged to ask for help and she felt like staff was comfortable and would ask for help. The DON said the facility would continue to educate CNAs and make sure that they had pagers. She said the facility would continue to work on improving call light wait times. III. Missing personal belongings grievances A. Resident #39 1. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included cerebral infarction (stroke), Parkinson's disease and hypertension. The 3/15/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. He required maximum assistance with activities of daily living (ADL). 2. Resident representative's interview Resident #39's representative was interviewed on 4/26/26 at 12:45 p.m. The resident's representative said he had concerns about missing money for Resident #39 that he reported a week ago to the DON. He said he did not want to fill out a grievance form because he wanted to handle the matter with the DON. He said he was told by the DON that he would have answers within the week but he had not heard anything yet. B. Resident #62 1. Resident status Resident #62, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included adult failure to thrive, chronic respiratory failure and cerebral infarction. The 2/13/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. The resident required substantial maximal assistance from staff for all ADLs. 2. Resident interview Resident #62 was interviewed on 4/27/26 at 10:05 a.m. Resident #62 said she had moved rooms three or four times and she was upset about this because she had missing items after the room changes. She said she was missing clothes, a blanket, a microphone and checks. 3. Record review The facility's grievance reports from January 2026, February 2026 and March 2026 were provided by the NHA on 4/29/26 at 6:09 p.m. The grievance forms revealed the following: -On 1/9/26 Resident #62 reported a missing blanket and microphone; -On 2/18/26 Resident #62 reported missing clothes and room move concerns; and, -On 2/27/26 Resident #62 reported missing checks. C. Staff interviews CNA #2 was interviewed on 4/30/26 at 9:20 a.m. CNA #2 said when an item was reported missing, she would notify the nurse. She said she assisted the resident to find the missing item, such as clothes, and looked in the laundry department. She said there was a form the resident could fill out for missing items and then the form would be given to the nurse or the social services department. CNA #1 was interviewed on 4/30/26 at 9:40 a.m. CNA #1 said he helped residents look for missing items when needed. He said Resident #62 reported things missing often. He said he reported the missing items to the nurse and social services when the resident reported them to him. The SSD was interviewed on 4/30/26 at 10:45 a.m. The SSD said residents filled out grievance forms when they wanted to report missing items and the form was given to the appropriate staff members to investigate. The SSD said concerns for missing clothes went to the laundry department and everything else went to social services. She said, If needed, the facility would replace the missing items after the investigation. She said she was not familiar with the missing checks for Resident #62 or the missing money for Resident #39. She said she was not aware of the follow-up for those concerns. She said the residents were notified of the outcome of the grievance, usually within five days. The social services assistant was interviewed on 4/30/26 at 10:48 a.m. The social services assistant said she was aware of the missing checks for Resident #62 and she was the one who did the investigation for the concern. She said Resident #62's representative took the check book home because Resident #62 ran out of checks in the book. She said a grievance form had been filled out, but the outcome of the investigation into the concern was not completed. She said she had not spoken to Resident #62 about the grievance, just the resident's representative. The DON was interviewed on 4/30/26 at 1:30 p.m. The DON said she spoke with Resident #39's representative (the week prior to the survey) regarding his concern for the missing money. She said she decided to offer a lock box to keep the resident's valuables in the resident's room. She said the lock box was purchased today (4/30/26). -However, per Resident #39's representative's interview, the DON had not followed up with him after their initial conversation (see interview above). -Additionally, the lockbox for the resident's belongings was not purchased until 4/30/26 (during the survey).

Based on observations and interviews, the facility failed to follow infection control measures with hand hygiene when performing housekeeping duties and medication administration. Specifically, the facility failed to:-Ensure housekeeping staff cleaned residents' rooms from a cleaner area to a dirtier area;-Ensure housekeeping staff performed appropriate hand hygiene when cleaning residents' rooms;-Ensure registered nurse (RN) #1 performed appropriate hand hygiene after picking up a medication off the floor;-Maintain a water program to prevent pathogens from building up in the sink drains in the satellite kitchen, the hand washing sink in the common area and the residents' room sinks; and, -Clean the facility sinks to prevent build-up and keep the drains of the sinks in the common areas of the kitchen, hallways and public restrooms free of food waste and other buildup which promotes the development of pathogens and biofilm.Findings include: I. Housekeeping failures A. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, dated February 2026, was provided by the nursing home administrator in training on 4/30/26 at 1:02 p.m. The policy read in pertinent part, The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. Supplies and equipment appropriate for the task (for example), disinfectant solution, cleaning cloths, mop, bucket and personal protective equipment ( gowns, gloves and mask). Steps in the procedure for resident room cleaning: If the resident is in their room, request permission to enter and clean the room. Gather supplies and equipment. Apply gloves and other personal protective equipment (PPE) when applicable. Clean all high-touch items with disinfectant solution: bedside tables, overbed tables, chairs, beds, lights, call bells, bedrails, mop the floors, discard mop solution, remove gloves and perform hand hygiene. The Handwashing and Hand Hygiene policy, dated December 2025, was provided by the nursing home administrator in training on 4/30/26 at 1:03 p.m. The policy read in pertinent part, Hand hygiene is the primary means for preventing healthcare-associated infections (HAIs) and the transmission of multidrug-resistant organisms (MDROs). This facility requires strict adherence to evidence-based hand hygiene practices (as described in this policy) for all personnel, including licensed, unlicensed, contracted, therapy, dining, housekeeping, volunteers, and students. All personnel are provided with hand hygiene training upon hire and annually thereafter. Hand hygiene competency of staff is measured, including through return demonstrations to verify technique. All personnel are required to adhere to hand hygiene policies and practices. Staff adherence to hand hygiene is incorporated into infection prevention and control process surveillance and monitored by the infection preventionist as part of the facility infection prevention and control program. Hand hygiene is indicated: Before touching a resident, before preparing or handling food, medications, or parenteral solutions, after exposure to blood, body fluids, excretions, or contaminated surfaces, after touching the resident's environment or belongings, after glove removal and whenever hands are visibly soiled. Use an alcohol-based hand rub (ABHR) containing at least 60% alcohol for most clinical situations. Unless hands are visibly soiled, ABHR is the preferred method of hand hygiene in clinical situations because it is more effective at killing germs, faster to use, and less irritating to the skin than soap and water. The use of gloves does not substitute for hand hygiene. Always perform hand hygiene after gloves are removed. B. Housekeeping observations On 4/29/26 at 10:20 a.m. housekeeper (HK) #1 was mopping the floor in resident room [ROOM NUMBER]. HK #1 left room [ROOM NUMBER], dropped the mop into the bucket outside the room and went directly into resident room [ROOM NUMBER] to remove the trash inside the bathroom. -HK #1 failed to perform hand hygiene after exiting room [ROOM NUMBER] and prior to entering room [ROOM NUMBER]. HK #1 proceeded to put the trash from room [ROOM NUMBER]'s bathroom in the bin outside the room and then donned (put on ) gloves. -HK #1 did not perform hand hygiene after handling the trash from the resident's bathroom prior to putting on gloves. After putting on the gloves, HK #1 returned to resident room [ROOM NUMBER]. HK #1 sprayed the toilet in room [ROOM NUMBER] and immediately wiped down the toilet with a wet sponge from top to bottom, then the toilet seat and inside the rim of the toilet bowl. After wiping everything down with the wet sponge, he repeated the process with a rag. He flipped the rag inside out to wipe around the outside of the toilet. -HK #1 did not allow the disinfectant to remain on the surface of the toilet for any period of time, prior to wiping it off with the wet sponge. -HK #1 failed to clean the toilet in room [ROOM NUMBER] from a cleaner area to a dirtier area. HK #1 proceeded to put the rag and the sponge in a bag that hung on the housekeeping cart outside the room, but he did not perform hand hygiene. He doffed (took off) his gloves and proceeded to sweep the floor of the resident's room and the bathroom and then switched out the broom for the mop to complete cleaning the floors. He put the mop back in the bucket outside the room, and again did not perform hand hygiene. -HK #1 failed to perform hand hygiene after cleaning the resident's toilet and prior sweeping and mopping the floors in room [ROOM NUMBER]. Without performing hand hygiene, HK #1 proceeded to don gloves and returned to resident room [ROOM NUMBER]. He blew his nose with his gloved hands, touched the door handle in room [ROOM NUMBER] to throw the tissue away and walked out of room [ROOM NUMBER] -HK #1 failed to perform hand hygiene prior to putting on gloves and returning to room [ROOM NUMBER] after cleaning the toilet in room [ROOM NUMBER]. -HK #1 failed to perform hand hygiene after blowing his nose and prior to touching the door handle in room [ROOM NUMBER]. After throwing his tissue away in room [ROOM NUMBER] and exiting the room, HK #1 took off his gloves and without performing hand hygiene, put on a new pair of gloves. He proceeded to go into resident room [ROOM NUMBER]'s bathroom with disinfectant spray, a sponge and a rag to clean the toilet. HK #1 proceeded to clean the toilet in room [ROOM NUMBER] in the same manner he had just cleaned the toilet in room [ROOM NUMBER] (see above). -HK #1 failed to perform hand hygiene after cleaning the toilet in room [ROOM NUMBER]. -HK #1 failed to clean the toilet in room [ROOM NUMBER] from a cleaner area to a dirtier area. -HK #1 did not allow the disinfectant to remain on the surface of the toilet for any period of time, prior to wiping it off with the wet sponge. C. Staff interviews HK #1 was interviewed on 4/29/26 at 10:38 a.m. HK #1 said the process for cleaning residents' rooms was to clean the residents' room and then sweep and mop. He said he cleaned the rooms with a sponge soaked in a floor cleaner solution and the mop water came from a dispensing machine in the housekeeping closet. He said he sprayed the toilets, sinks, handles and faucets and wiped them down with the sponge first and then a rag to dry the areas. He said he knew how to clean toilets from his previous job and he received in-person training when he started working at the facility a few months ago. HK #1 said he changed his gloves in between residents' rooms and used hand sanitizer when he finished cleaning residents' rooms. HK #2 was interviewed on 4/30/26 at 11:35 a.m. HK #2 said residents' rooms were cleaned with a bleach solution. She said housekeeping staff were supposed to spray the residents' mirrors, sinks and high touch areas, such as the call lights and door handles of the resident's rooms and let the solution sit on the surfaces before wiping the surfaces down with a sponge and a dry rag. She said the toilets in the resident's rooms should be cleaned last. She said hand hygiene was performed before entering the resident's room, before donning gloves and after doffing gloves. She said each housekeeping cart had hand sanitizer to use. The maintenance director (MTD) was interviewed on 4/30/26 at 11:40 a.m. The MTD said housekeepers were educated on how to clean residents' rooms and to perform hand hygiene in between glove use and entering or exiting the residents' rooms. He said housekeeping education was completed upon hire and annually. He said he would expect the housekeepers to follow the appropriate cleaning procedures for the safety of residents and staff. II. Failed to ensure RN #1 performed appropriate hand hygiene after picking up a medication off the floor A. Observation On 4/29/26 at 4:41 p.m. RN #1 was observed during medication administration. RN #1 dropped one medication tablet onto the floor. She picked up the tablet with her bare hands and put the medication tablet in the medication destruction solution. Without performing hand hygiene, RN #1 proceeded to remove another medication tablet from the medication package -RN #1 failed to perform hand hygiene after picking up the medication from the floor and prior to dispensing another medication tablet from the medication package. B. Staff interview The director of nursing (DON) was interviewed on 4/30/26 at 12:15 p.m. The DON said hand hygiene was completed before and after each resident medication administration. She said RN #1 should have performed hand hygiene after picking up the medication tablet from the floor, prior to dispensing another medication. She said staff were educated to perform hand hygiene during medication administration and she would be completing spot checks for competencies. III. Sink drain failures A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Project Firstline: Drains and Biofilms: Hiding Places for Germs, undated, retrieved on 5/5/26 form https://www.cdc.gov/project-firstline/media/pdfs/microlearn-drains-508.pdf, Germs can live and grow in drain biofilms and can spread to patients and cause infections, but they don't have to. You can stop the spread by being aware of the risks of water in healthcare settings and taking action to prevent infections. Germs in the sewer, including drug-resistant germs, can be found in the plumbing all the way up to the drain. These germs can buildup in the plumbing to form slimy layers called biofilms. Germs in biofilms can spread to patients and cause infections that are difficult and sometimes impossible to treat. When water splashes out of a drain, it can spread germs from the biofilm to your skin and nearby surfaces and equipment. According to the CDC's Considerations for Reducing Risk: Water in Healthcare Facilities (2/6/26), retrieved on 5/5/26 from https://www.cdc.gov/healthcare-associated-infections/php/toolkit/water-management.html, Opportunistic pathogens of premise plumbing (OPPP) microorganisms in building water systems that are more likely to cause disease in at-risk or immunocompromised individuals. Tap water meets stringent safety standards in the United States, but it is not sterile. Germs may be present when water leaves the tap. For typical household uses, these germs rarely pose a serious health risk. However, in healthcare settings, water uses are more varied, and patients are more vulnerable to infection. Certain plumbing conditions can even encourage microbial growth, leading to dangerously high levels of potential pathogens. Healthcare facilities must evaluate their water use for its risk to harbor and transmit healthcare-associated pathogens. Biofilm- collections of microorganisms that stick to each other and adhere to surfaces in moist environments, like the insides of pipes. It can last in drains for long periods of time and are often difficult or even impossible to remove. Water can carry germs that threaten patient safety and spread antimicrobial-resistant pathogens or cause healthcare-associated infections (HAIs). Healthcare facilities can reduce water-based risks through infection prevention practices and management of the building premise plumbing system. A healthcare water management program identifies both hazardous conditions and corrective actions that can minimize the growth and spread of waterborne pathogens in healthcare facilities. According to the Infection Prevention and Control Resource Hub Water Management: Sinks and Drains 2026, retrieved on 5/5/26 from https://infectioncontrolma.org/water-management.php, Recent scientific evidence has shown that sinks and other drains, such as those in toilets or hoppers, can become contaminated with multidrug-resistant organisms (MDROs) in healthcare facilities. This is because different types of bacteria may contaminate the same drain, so antibiotic resistant genes can be transferred between bacterial species. These pathogens can stick to the pipes and form biofilms, which allow them to stay in drains for long periods of time. Biofilms are often difficult or impossible to fully remove. The following measures can reduce the risk of MDRO transmission events from occurring in healthcare facilities: Clean and disinfect all surfaces near the drain at least once per day, this includes the sink basin, faucet, faucet handles, and surrounding countertops. B. Facility policy and procedure The Water Management Plan to Reduce the Risk of Growth and spread of Legionella and Other Opportunistic Pathogens in the Building Water System, dated 2021, was provided by the nursing home administrator (NHA) on 4/27/26. It read in pertinent part, This Water Management Plan establishes direction for the compliance determination and annual evaluation of legionella. This document is to serve as that plan. Preventative maintenance: Another measure to consider will be the preventative maintenance approach to water systems. Water system description: Water enters the facility's front entry patio/NHA's office via a four-inch (4) main line that then goes through the backflow preventers from the central supply room. Potable cold water is distributed to the facility that provides skilled nursing and mechanical spaces. From there it supplies the boiler's water for the heat exchange system. The remainder of the facility, which includes dietary and resident rooms. The end-use systems include ice machines, hand sinks (wrist blade), mop basins, prep sinks, showers, bath tubs, laundry, and eye wash stations. -Although the title documented the plan was to reduce legionella and other opportunistic pathogens, the plan did not document the steps the facility planned to take to prevent the development of the other opportunistic pathogens within the water system. C. Observations Observations of the common area sinks and residents' room sinks were conducted on 4/28/26 at approximately 1:15 p.m. and again on 4/30/26 at approximately 3:30 p.m. The condition of the sink drains as described below did not change throughout the survey (4/27/26 to 4/30/26). The north hall common area double basin sink in the dining room area was heavily soiled. The drain on the garbage disposal side had a heavy buildup of chunky solid debris stuck on to the rubber insert splash guard. The rubber guard had degraded in areas and exposed the inner disposal blades clearly. The inside blades had built up brown debris. The drain on the other side of the skin basin had a heavy buildup of brown debris on and around the rim of the drain flange and there was a buildup of sludge inside the drain on the piping. The sink in the staff bathroom on the north hall had a heavy buildup of black sludge inside the drain and down into the piping. When the pipe was wiped with a clean white paper towel the paper towel had a heavy layer of black sludge from the drain; however, the drain remained soiled with the black sludge. The west hall common area double basin and handwash sink in the food preparation area was heavily soiled with a heavy buildup of black sludge in the drain. The double basin sink had a heavy film of brown buildup around the outer rim of the drain flange and a buildup of blackened sludge in the sink drain. The handwashing sink had a heavy tarry buildup of black matter inside the white drain pipe. The hand washing sink outside of the south staff bathroom had a moderate amount of brown buildup in the drain around the sink drain flange. The sink in the rehabilitation therapy room had a thickened layer of black buildup in the drain and a heavy buildup of green chalky buildup on the skin faucet where the water comes out. The hand washing sink in the east hall nurses cart area had a buildup of brown staining and sludge on the sink drain stopper and blackened buildup inside of the drain. In addition the drain was extremely slow to drain. Sink drains in the residents' rooms had a mild buildup of brown sludge in the drains under the drain flange. D. Resident group interview A group of four alert and oriented residents (#22, #26, #67 and #68), deemed interviewable by assessment and the facility, were interviewed on 4/29/26 at 3:10 p.m. The residents said the facility had problems with sewage back up about six to seven months ago, in the winter months, and had to make repairs to improve drain flow. E. Staff interviews HK #1 was interviewed on 4/29/26 at 10:38 a.m. HK #1 said each resident's room was cleaned daily, including the resident's sink. He said the sinks were to be sprayed with a cleaning solution and then wiped with a sponge and dried with a clean rag. The MTD was interviewed on 4/29/26 at 1:45 p.m. The MTD said the certified nurse aides (CNA) cleaned up the satellite kitchen and dining room areas in the common space areas after each meal and the housekeeping staff cleaned the high touch surfaces in the common space areas of each resident unit. He said he did not have a clear explanation of how and who cleaned the sinks in the common space areas, including the hand washing sinks and sinks in resident units and the food prep areas. The MTD said the housekeeping staff were responsible for cleaning sinks in the facility's bathrooms and residents' rooms on a daily basis. HK #2 was interviewed on 4/30/26 at 11:35 a.m. HK #2 said residents' rooms were cleaned with a bleach solution that was sprayed on all high touch areas, including the sink. She said the cleaning solution was to sit on the surfaces before wiping the surfaces down with a sponge and then a dry rag. The MTD and the housekeeping supervisor (HKS) were interviewed together on 4/30/26 at 3:46 p.m. The MTD said he never noticed the condition of the common handwashing and satellite kitchen sinks which had visible food in the drain. The MTD said to prevent legionella in the water system, he and/or facility staff ran hot water down drains for several minutes and the sinks should be cleaned daily. The MDT said a plan of action would be developed with the interdisciplinary team (IDT) to maintain drains in clean condition.

Based on observations, record review and interviews, the facility failed to ensure nursing staff followed physician's orders in accordance with professional standards of practice for one (#61) of two residents out of 35 sample residents.Specifically, the facility failed to ensure physician's orders for the settings on Resident #61's alternating air mattress was monitored and set properly for effective pressure relief.Findings include:I. Facility policy and procedureThe Medication and Treatment Orders policy, undated, was provided by the nursing home administrator in training on 4/30/26 at 6:34 p.m. The policy read in pertinent part, Orders for medications and treatments will be consistent with principles of safe and effective order writing.II. Resident #61A. Resident statusResident #61, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included paraplegia, west nile infection, muscle weakness, acute respiratory failure and chronic pain syndrome. The 2/5/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated the resident was dependent on staff assistance for completing all care. B. Resident observations and interviewsOn 4/27/26 at 10:18 a.m. was lying in bed. Resident #61's air mattress was observed to be set to 350 pounds of pressure. -However, per the physician's orders, the resident's air mattress was to be set to 150 pounds of pressure (see physician's orders below).Resident #61 said she was comfortable lying in her bed, but her mattress pinched her when the head of the bed was in an upright position and made her uncomfortable. She said it was important to have a nurse reposition her approximately every hour before pain set in or the pain could become excruciating and intolerable. Resident #61 said the facility gave her the mattress to prevent pressure sores; however the mattress recently failed and deflated and she was left lying on the metal frame, which was very uncomfortable. She said it took a long time for the maintenance director (MTD) to fix and reinflate the mattress. On 4/28/26 at 9:01 a.m. Resident #61's air mattress was observed to be set at 350 pounds of pressure.On 4/29/26 at 4:17 p.m. Resident #61's air mattress was again observed to be set at 350 pounds of pressure.On 4/30/26 at 10:05 a.m. Resident #61's air mattress was observed to be set at 150 pounds of pressure. The resident said her bed was more comfortable now that the mattress and air pump had been replaced (see staff interviews below).On 4/30/26 at approximately 3:53 p.m. Resident #61's air mattress pump was observed to be labeled with the physician-ordered settings and directions to not change the settings from 150 pounds of pressure.C. Record reviewReview of Resident #61's April 2026 CPO revealed the following physician's order: Alternating pressure mattress to bed. Set at 150 pounds of pressure. Check the mattress every shift for proper setting and function. Air mattress to improve circulation and help with skin itchiness, ordered 1/20/26.Review of Resident #61's April 2026 treatment administration record (TAR), from 4/1/26 to 4/29/26 revealed that nurses were signing off each shift that the resident's air mattress was on the proper settings and functioning properly. -However, observations during the survey revealed the air mattress settings were incorrect and the nurses were not able to accurately explain the settings and process for monitoring of the mattress (see observations above and interviews below). III. Staff interviewsRegistered nurse (RN) #3 was interviewed on 4/29/26 at 4:33 p.m. RN #3 said she was not sure of the correct mattress settings for Resident #61's air mattress. She said the maintenance director (MTD) set the controls on the residents' air mattresses and she would find out the answer.The MTD and the director of nursing (DON) were interviewed together n 4/29/26 at 4:41 p.m. The MTD said that an outside durable medical equipment (DME) vendor installed and set up the residents' air mattresses and ensured the beds were set at the proper settings. The MTD said he was not sure how the facility could tell what the air flow on the mattresses was supposed to be set to and he did not know if there were physician's orders for guidance. He said the air mattress settings should be set based on the resident's weight and after the resident was on the air mattress, the staff could increase the pressure setting to make sure the mattress stayed inflated.The DON said that she would have to look into Resident #61's physician's orders to see if they included setting orders for the air mattress. The MTD said he was having problems keeping some of the air mattresses inflated. He said he just took one out of a room today (4/29/26) that was not working properly. He said that he was not aware of any issues with Residents #61's air mattress until he was alerted of the problem today (4/29/26).The MTD said he understood a properly inflated air mattress was necessary to prevent bed sores. RN #4 was interviewed on 4/30/26 at 10:27 a.m. RN #4 said Resident #61's air mattress was to be set based on her weight. She said that currently, the mattress was set to 150 pounds of pressure, which was equal to the resident's current weight. She said that if the resident weighed more, she would just change the air flow based on her weight. RN #4 said she was unsure if Resident #61 had physician's orders for the mattress settings. She said she knew there was something in the TAR about the resident's air mattress, but she did not know exactly what the orders were. She said that having the mattress at the proper setting for the resident's weight was important to prevent skin break down. She said she would have to refer back to the TAR for more information.The MTD was interviewed again on 4/30/26 at 10:33 a.m. The MTD said on 4/29/26, he discovered that the electric pump for Resident #61's mattress was not working properly. He said he replaced the pump and the resident's air mattress seemed to be working better. He said he was not sure how long the mattress had not been working properly and could not guess. The nursing home administrator (NHA) was interviewed on 4/30/26 at 10:35 a.m. The NHA said she was educating nursing staff to monitor the settings of each resident's air mattress and to report functional failures and changes in the mattresses. She said that the facility was looking at other mattress options as they continued to fix existing problems with the air mattress in the facility. The DON was interviewed again on 4/30/26 at 5:17 p.m. The DON said Resident #61's air mattress had continued to malfunction, so a new air mattress was ordered and was being installed today (4/30/26).

Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for one (#62) of two residents reviewed for notifications out of 35 sample residents.Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #62 and/or the resident's representatives.Findings include:I. Facility policy and procedureThe Room Change and Roommate Assignment policy, dated November 2025, was provided by the nursing home administrator (NHA) on 4/30/26 at approximately 12:32 p.m. The policy read in pertinent part, Resident room or roommate assignments may change if the facility deems it necessary. Resident preferences are considered when roommate changes are necessary. Prior to changing a room or roommate assignment, all parties involved in the change/assignment (residents and their representatives) are given at least a 24-hour advance written notice of the change. Documentation of a room change is recorded in the resident's medical record.II. Resident #62A. Resident statusResident #62, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included adult failure to thrive, chronic respiratory failure and cerebral infarction (stroke). The 2/13/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident required substantial maximal assistance from staff for all activities of daily living (ADL).B. Resident interviewResident #62 was interviewed on 4/27/26 at 10:05 a.m. Resident #62 said she had moved rooms three or four times and she was upset about this because she had missing items after the room changes. She said she was not provided anything in writing or provided with any verbal notice prior to her room changes.Cross-reference F585 for failure to resolve grievances. C. Record review-Review of Residents #62's electronic medical record (EMR) revealed documentation to indicate the resident or the resident's representative was verbally informed the resident was changing rooms.The alert note, dated 3/28/26 at 12:16 a.m., documented Resident #62 was on alert charting for a room change and had adjusted well. She was pleasant with her roommate at that time and no verbal outbursts were noted. All of the resident's needs were met.The alert note, dated 3/28/26 at 1:52 p.m., documented Resident #62 was on alert charting for a room change and had adjusted well. She was pleasant with her roommate at that time.The alert note, dated 3/28/26 at 9:36 p.m., documented Resident #62 was possibly not doing well with the room change. The resident's roommate had complaints of Resident #62 yelling at her and being belligerent. Staff would continue to monitor.The Room and/or Roommate Change Authorization Notification form, dated 5/14/25, revealed a verbal okay was obtained from the resident's representatives to move Resident #62 from her room on the 100 hall to a room on the 400 hall for maintenance concerns. The form documented consent was given verbally and was signed by the social services director (SSD).-However, there was no documentation in Resident #62's EMR to indicate the facility provided the resident or the resident's representative with a copy of the room change form.The Room and/or Roommate Change Authorization Notification form, dated 2/17/26, revealed a verbal okay was obtained from the resident's representatives to move Resident #62 from the room on the 400 hall back to her room on the 100 hall or maintenance concerns. The form documented consent was given verbally and was signed by the social services director (SSD).-However, there was no documentation in Resident #62's EMR to indicate the facility provided the resident or the resident's representative with a copy of the room change form. The Room and/or Roommate Change Authorization Notification form, dated 3/27/26, revealed a verbal okay was obtained from the resident's representative to move Resident #62 from her room on the 100 hall to a different room on the 100 hall for maintenance concerns. The form documented consent was given verbally and was signed by the social services director (SSD).-However, there was no documentation in Resident #62's EMR to indicate the facility provided the resident or the resident's representative with a copy of the room change form.III. Staff interviewsThe SSD was interviewed on 4/30/24 at 10:45 a.m. The SSD said a room change authorization form should be filled out for each resident room change or when a resident got a new roommate. She said the form included a verbal consent from the family to move the residents. She said residents were informed of the move. She said she was responsible for completing room change forms. The SSD said that there were written room changes or new roommate authorization forms completed for Resident #62. She said she had no other documentation to show Resident #62 was informed of the moves.-However, the room change forms indicated by the SSD did not reveal documentation that Resident #62 or her representative had received a copy of the room change forms. The NHA was interviewed on 4/30/26 at 6:10 p.m. The NHA said residents and their representatives were provided a copy of the room change form and agreed upon the move. The NHA said residents' representatives received a copy of the room change form when the residents were not cognitive enough to make decisions. The NHA said the facility received verbal consents from representatives when the decision was made by the representative. The NHA said Resident #62's representatives were notified of the resident's room changes. She said she had no documentation to show the resident was informed of the room changes.-However, the room change forms indicated by the SSD did not reveal documentation that Resident #62 or her representative had received a copy of the room change forms.

Based on record review and interviews, the facility failed to ensure one (#38) of five residents out of 35 sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #38 from physical abuse by Resident #3.Findings include: Record review, observations and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/27/26 to 4/30/26, resulting in the deficiency being cited as past non-compliance with a correction date of 2/5/26.I. Incident between Resident #38 and Resident #3 on 1/31/26On 1/31/26 at approximately 1:30 p.m. registered nurse (RN) #2 heard a commotion in the hallway, outside the room of Resident #3. RN #2 witnessed Resident #3 hit Resident #38, causing Resident #38's lip to bleed. The two residents were immediately separated from each other and placed on frequent checks. Resident #38 had a small laceration to the middle of her upper lip and a small bruise below her lower lip. II. Facility plan of correctionThe plan of correction the facility put in place in response to the physical abuse incident between Resident #38 and Resident #3 was provided by the NHA on 4/29/26 at approximately 3:00 p.m.The plan read: A. Immediate action to correct the deficient practice The plan of correction, dated 1/31/26, identified the facility's noncompliance concern was related to staffing levels. The plan documented corrective actions taken to correct the noncompliance included education to nurse management on appropriate staffing levels on the memory care unit and medication changes for pain reviewed care planned and updated for Resident #3 and Resident #38. B. Systematic changesEducation was provided to all nurse management and the staffing coordinator on 2/5/26 to ensure appropriate staffing levels included two licensed certified nurse aides (CNA) on the memory care unit on the day shift and the evening shifts and the availability of the on-call nurse until appropriate coverage was met.C. MonitoringThe staffing team, which included the nursing home administrator (NHA), the director of nursing (DON), the assistant director of nursing (ADON), the staff development coordinator , the memory care director, the human resource director and the staffing coordinator, met and reviewed the staffing needs for each day, week and weekend. A daily audit (Monday through Friday) addressing any staffing needs was implemented. A monthly review of staffing levels and needs would be reviewed in the facility's quality assurance and performance improvement (QAPI) meeting every one to three months.III. Facility policy and procedureThe Abuse policy, dated 5/3/23, was provided by the nursing home administrator in training on 4/28/26 at 11:24 a.m. The policy read in pertinent part, (The facility) does not condone resident abuse and will take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident symptoms. Providing a safe environment for the resident is one of the most basic and essential duties of our facility.IV. Incident of physical abuse of Resident #38 by Resident #3 on 1/31/26A. Facility investigationThe facility investigation provided by the nursing home administrator (NHA) on 4/29/26 at approximately 3:00 p.m. The investigation documented RN #2 heard a commotion in the hallway, outside the room of Resident #3 on 1/31/26 at approximately 1:30 p.m. The nurse witnessed Resident #3 hit Resident #38, causing Resident #38's lip to bleed. The residents were immediately separated from each other and placed on frequent checks. According to the investigation, Resident #38 had a small laceration to the middle of her upper lip and a small bruise below her lower lip. The investigation documented 15-minute checks for Resident #3 and Resident #38 were initiated on 1/31/26 after the incident. The 15-minute checks continued through 2/2/26. The investigation included statements from staff members working on the memory care unit on 1/31/26. RN #2's statement identified that she was near her medication cart when she saw Resident #38 standing outside Residents #3's room. She went to the residents in an attempt to separate them but could not get there in enough time before Resident #3 hit Resident #38. According to the statement, RN #2 saw both residents near her cart a few minutes prior to the incident and there was no concern at that time. Activity assistant (AA) #1's statement identified that AA #1 was at lunch at the time of the incident and did not witness the altercation. According to the statement, she felt resident pain could have caused increased agitation, contributing to the altercation. CNA #3's statement identified that CNA #3 was charting in the dining area and did not witness the incident. The statement indicated that CNA #3 felt there were no concerns with either Resident #38 or Resident #3 prior to the incident as CNA #3 had seen both residents five minutes earlier. The statement documented CNA #3 stated it was hard when there were not two CNAs on the memory care unit.The investigation summary identified both Resident #38 and Resident #3 could have been experiencing an increase in pain leading up to the altercation. The residents were frequently monitored and residents were redirected from Resident #3's room. According to the summary, Resident #3 was very protective of her room. Resident #3 was care planned to have a velcro stop sign across her doorway or her door closed to help deter other residents from going into her room. However, Resident #3 would often not allow the sign up or the door closed. The investigation summary addressed the need for the medication cart and the charting area to be closer to Resident #3's room for increased monitoring of the resident. The medications were reviewed and adjusted for both residents related to pain/discomfort as potential contributing factors to the incident. The investigation documented that the memory care unit staff were educated on 2/3/26 regarding person-centered care, after the altercation. Pertinent members of the interdisciplinary team (IDT) were provided education on 2/5/26 related to ensuring two CNAs were present/scheduled on the memory care unit during the day and evening shifts. According to the education, the on-call nurse would be utilized as necessary until coverage was found. Review of the investigation identified the facility substantiated the abuse. B. Resident #38 (victim)1. Resident statusResident #38, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included vascular dementia, severe, with agitation, Alzheimer's disease unspecified, neurological disorder with Lewy bodies disease, bipolar disorder and chronic pain. The 4/16/26 minimum data set (MDS) assessment identified Resident #38 exhibited short and long term memory problems, inattention and disorganized thinking. She had hallucinations, delusions and physical and verbal behaviors directed towards others.The staff assessment for mental status indicated the resident's cognition was moderately impaired with impaired decision making. The resident required supervision and cues. The MDS assessment indicated Resident #38 was independent with her mobility.2. Record reviewThe wandering and elopement care plan, revised 3/31/26, identified Resident #38 was at risk for wandering related to Alzheimer's disease, but was pleasantly confused and could be easily redirected. Interventions, initiated 1/9/24, directed staff to identify patterns and purpose of wandering, offer pleasant diversions, structured activities, food, and reorientation strategies. The dementia care plan, revised 3/31/26, documented Resident #38 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease. Interventions included directing staff to offer toileting or assessing the resident for pain if she appeared agitated and providing pain medication as ordered (initiated 2/3/26). The interventions indicated staff should offer toileting and fluids frequently due to her history of constipation that contributed to her urinary retention (revised 2/5/26). According to the interventions, Resident #38 became agitated when she was retaining urine or constipated, causing pain/discomfort with cystocele/prolapse (dropping of the bladder) requiring staff to monitor for the signs and symptoms (initiated 3/5/26). The dementia care plan further identified that Resident #38 would become agitated; she could become loud, disrupting the environment. Interventions included offering to take her to her room to sit in her recliner to calm and reset her mood, if she continued to escalate, staff should offer to calmly sit with her (initiated 3/13/26). The 1/31/26 nurse progress note documented Resident #38 was involved in a resident-to-resident altercation with another resident (Resident #3). The residents were separated and Resident #38 was placed on frequent checks. The physician and the resident's representative were notified and an investigation was initiated.The 2/1/26 nurse progress note documented Resident #38 was on alert charting to monitor related to a resident-to-resident altercation on 1/31/26. The note documented the resident had a small bruise to her mid-lower lip and her skin was intact. According to the note, 15-minute checks were in place and non-interviewable charting was completed. The note indicated staff monitored her whereabouts and assisted in keeping her away from the other resident's (Resident #3) bedroom to avoid confrontations. C. Resident #3 (assailant) 1. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included vascular dementia, severe with agitation, memory deficit following other non-traumatic intracranial hemorrhage, and depressive disorder recurrent, moderate. The 4/30/26 MDS assessment documented Resident #3 exhibited short and long term memory problems, and fluctuating disorganized thinking. The staff assessment for mental status indicated the resident was moderately impaired in cognition, poor decision making and required supervision and cues. According to the MDS assessment, the resident had verbal behaviors directed toward others, could significantly intrude on the privacy or activity of others and disrupt care or living environment.2. ObservationsObservations during the survey period identified Resident #3's velcro stop sign was frequently across her doorway, staff were redirecting residents away from Resident #3's room. Additionally, staff were requesting, and receiving, other staff members on the memory care unit to assist in the supervision of residents whereabouts when both memory care unit CNAs were providing care in residents' rooms. 3. Record reviewThe behavior/dementia care plan, revised 3/11/25, documented Resident #3 had impaired cognitive function/impaired thought processes related to dementia. She had verbal aggression of yelling/screaming and physical aggression, including hitting. Additional behaviors included refusal of care, being withdrawn, tearfulness/crying and negative statements. Interventions included assessing for pain (initiated 2/5/26) and keeping the resident's door closed when she refused to have her stop sign up in her doorway (revised 2/5/26). However, according to the care plan, Resident #3 would often decline for her door to be closed so staff should help redirect other residents away from her room (revised 2/5/26). The care plan identified Resident #3 was protective of her room and would become upset if others entered or tried to enter the room.The 1/31/26 alert note documented Resident #3 was on alert charting due to a resident-to-resident altercation. According to the note, the resident was pleasantly confused with no noted injury.The 2/2/26 nursing note documented Resident #3 continued on alert charting related to the altercation on 1/31/26. According to the note, Resident #3 had decreased agitation on 2/2/26. The staff monitored her for signs of pain and offered activities and personal care when she was distressed. The note identified Resident #3 was refusing to allow staff to replace the stop sign to the doorway of her room and would not allow the nurse to apply analgesic gel to her contracted hand. However, 15-minute checks were continued and the other resident involved in the altercation (Resident #38) was removed from areas near Resident #3.V. Staff interviewsThe NHA was interviewed on 4/30/26 at 12:57 p.m. The NHA said Resident #3 hit Resident #38 (on 1/31/26) and the investigation determined physical abuse was substantiated. She said RN #2 witnessed the incident, but was not able to separate the residents before Resident #38 was hit. The NHA said Resident #3 did not like people in her room but she would often take down the stop sign that helped deter other residents from entering her room. The NHA said pain was a factor for both residents. The NHA said Resident #38 had difficulty communicating her needs and time and the staff determining her needs related pain, constipation, and urinary retention. The NHA said staff should assess the resident for pain related to constipation and urinary retention. She said the pain medication ordered for Resident #38 increased her constipation. The NHA said Resident #3 had pain related to her hand contracture but would often refuse interventions. She said pain could have contributed to Resident #3's agitation on 1/31/26. She said the nurse practitioner reviewed the residents' medication management with new treatment orders implemented following the incident. The NHA said staff were educated on person-centered care after the incident between Resident #3 and Resident #38, to include behaviors and contributing factors.The NHA said the facility investigation identified there was one CNA and one nurse on the memory care unit at the time of the altercation. She said there were usually two CNAs scheduled on the memory care unit and she felt that the staffing levels in the unit on 1/31/26 was an isolated incident. She said there was a CNA who called in that day and the CNA had not been replaced in coverage. She said there should have been two CNAs scheduled on 1/31/26 so the facility implemented past non-compliance correction actions to include education with staff management to ensure appropriate staffing coverage daily for the memory care unit.

Based on record review and interviews, the facility failed to ensure one (#2) of five residents out of five sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #2 from physical abuse by Resident #1.Findings include: I. Incident of physical abuse of Resident #2 by Resident #1 on 9/22/25A. Facility investigationThe facility investigation was provided by the nursing home administrator (NHA) on 10/27/25 at approximately 2:00 p.m. The facility investigation documented that on 9/22/25 at 3:30 p.m. the maintenance assistant witnessed Resident #2 mumbling, prompting Resident #1 to use an expletive word towards Resident #2 and directing her not to speak. Resident #1 reached out with her left hand and lightly hit Resident #2 on the right cheek without injury. According to the investigation, Resident #2 responded to the hit by saying There is no reason for that. The maintenance assistant separated the residents and notified the nursing staff. The investigation identified that no other memory care staff working on the unit witnessed the incident.The investigation documented both of the residents were interviewed after the incident. Resident #2 said she did not hit people and it was not nice to hit people. Resident #1 was unable to answer the questions when interviewed. Resident #1 and Resident #2 were placed on 15-minute checks for 72 hours following the altercation. Review of the investigation identified the facility substantiated abuse. The investigation revealed a root cause analysis was completed to determine the possible causes on the 9/22/25 altercation. According to the analysis, Resident #1 had agitation beginning in the morning on 9/22/25. The agitation continued, prompting Resident #1 to hit Resident #2 (on 9/22/25 at 3:30 p.m.) The analysis identified the underlying issue of the agitation was related to an ingrown toenail causing Resident #1 discomfort and new medication changes. According to the investigation analysis, the ingrown toenail was not addressed prior to the incident because Resident #1 could not always verbalize pain/discomfort. The corrective action identified in the root cause analysis was to schedule a podiatry visit for Resident #1, apply Vicks Vaporub to the toe, offer the resident Tylenol and monitor her for pain. The investigation documented staff were educated after the altercation related to Resident #1's ingrown toenail. The staff were informed the resident's toenail was causing her pain and agitation. The education directed staff to encourage Resident #1 to wear non-skid socks without shoes until she was seen by a podiatrist. B. Resident #2 (victim)1. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included dementia, severe, with mood disturbance and Alzheimer's disease. The 9/23/25 minimum data set (MDS) assessment identified Resident #2 exhibited short and long term memory problems, inattention, disorganized thinking and had physical behaviors directed to others. The staff assessment for mental status indicated the resident's cognition was moderately impaired. The MDS assessment indicated Resident #2 was independent with her mobility.According to the MDS assessment, Resident #2 would significantly intrude on other resident's privacy or activity and disrupt care or living environment.2. Record reviewResident #2's wandering care plan, revised 11/22/23, identified Resident #2 was at high risk for wandering and elopement. According to the care plan, Resident #2 could easily be redirected. The care plan directed staff to monitor the resident's location frequently (initiated 6/1/23).The dementia care plan, revised 3/13/25, indicated Resident #2 had behaviors such as wandering, poor safety awareness and repetitive verbalizations. Interventions included directing staff to encourage Resident #2 to participate in simple, structured activities of interest and incorporate cues, reorientation, and supervision as needed (initiated 4/5/24). According to the interventions, staff should assist Resident #2 to a quieter environment if she became agitated in a louder environment (initiated 4/5/25). The interventions indicated Resident #2's wandering and exit-seeking behaviors may be triggered when the resident was bored and hungry. The resident should be redirected and guided from other residents' rooms/doorways when wandering, because she tended to enter the rooms and rummage through other residents' belongings (initiated 8/26/25). Additional wandering interventions directed staff to de-escalate the wandering behavior by involving the resident in activities of choice, engagement, one-to-one supervision and providing snacks/meals (initiated 3/13/25). Resident #2's communication care plan, revised 11/22/25, indicated Resident #2 had a communication problem related to senile degeneration of the brain, dementia in other diseases elsewhere, with agitation and psychotic disturbance. Interventions, revised 6/2/25, directed staff to anticipate and meet needs and encourage Resident #2 to focus on a word or phrase at a time. The 9/22/25 nursing progress note documented a maintenance assistant notified the nurse that he witnessed another resident (Resident #1) lightly hit Resident #2 in the face. According to the note, the maintenance assistant separated the two residents and walked Resident #2 to the nursing staff. The note indicated Resident #2 was assessed and there were no injuries identified or a notable change in her baseline for mood and cognition as a result of the altercation. The note documented that Resident #1 and Resident #2 were placed on frequent checks after the incident.C. Resident #1 (assailant) 1. Resident statusResident #1, age greater than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included Alzheimer's disease, dementia and other diseases elsewhere classified, moderate with agitation, major depressive disorder, recurrent, mild and generalized anxiety disorder.The 8/18/25 MDS assessment documented Resident #1 exhibited short and long term memory problems, inattention and disorganized thinking. The staff assessment for mental status indicated the resident was moderately impaired in cognition. According to the MDS assessment, the resident had verbal behaviors directed toward others and other behavioral symptoms not directed toward others.2. Record reviewResident #1's cognition care plan, revised 5/29/25, indicated Resident #1 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease and dementia. According to the care plan, the resident had verbal and physical aggressive behaviors that included yelling/screaming, kicking, hitting, scratching and throwing objects. The care plan revealed Resident #1 was sensitive to noise and did not like loud environments or other people telling her what to do. Pertinent interventions included staff were to identify environmental triggers, such as noise and remove the resident to a quieter area, if she became agitated, staff were to offer her other distractions (revised 9/5/25) and monitoring the resident for ingrown toenails which caused her increased agitation and pain (initiated 9/26/25). The pain care plan, revised 2/20/25, identified Resident #1 had a potential for pain. The resident had a history of ingrown toenails which caused pain and agitation. Interventions included monitoring Resident #1 for the probable cause of each pain episode, documenting and removing/limiting the causes where possible (initiated 2/20/25). The 9/19/25 nursing progress note identified Resident #1 became very irritated with Resident #2 in the morning on 9/19/25. According to the note, the nurse broke up the disturbance when Resident #2 balled up her hand in a fist, pulled back her arm and threatened to hit. The resident did not hit anyone and there were no injuries. The note identified the residents were safely separated and redirected. The 9/22/25 nursing note documented the altercation between Resident #1 and Resident #2 reported by the maintenance assistant (see investigation above). Resident #1 was not injured as a result of the altercation. The progress note revealed Resident #1 had increased agitation on the day of the altercation (9/22/25). The note identified Resident #1 had a recent medication change. The 9/23/25 nursing note documented Resident #1 was on alert charting for a resident-to-resident altercation initiated by Resident #1. The note indicated Resident #1 had behaviors on 9/23/25 following the 9/22/25 altercation with Resident #2. According to the note, she was agitated in the early morning hours, kept her distance from others, did not want others to approach her, paced the halls and was exit seeking. The note documented the resident was administered PRN (as needed) acetaminophen with improvement to her behavior. Following the medication administrations, Resident #1 participated in group activities and sat with other residents for lunch. The note identified staff monitored Resident #1's whereabouts every 15-minutes and assured she maintained distance from the other resident (Resident #2) involved in the (9/22/25) altercation. The note indicated the staff would continue to monitor for Resident #1 for signs and symptoms of pain and offer pain management to assist in her decline of behaviors.The 9/25/25 nurse practitioner (NP) note identified Resident #1 was seen by the NP to follow up with Resident #1 pain to her bilateral great toes and an ingrown toenail to her right great toe. The note identified the resident's toes were very sensitive during the NP visit and she remained at elevated risk of interfering with other residents' cares. The note documented the NP was informed Resident #1 swatted another resident (Resident #2) on the face when another resident interfered with Resident #1's personal space. The NP note identified Resident #1 had a recent (9/18/25) increase to her quetiapine (antipsychotic medication). II. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 10/27/25 at 2:22 p.m. CNA #2 said Resident #1 would become agitated when Resident #2 would come up to her and speak to her in incomprehensible verbiage. CNA #2 said Resident #2 was most active in the morning and usually took a nap in the living room in the afternoon where staff could watch her related to her history of seizures. She said Resident #2 was not on any extra supervision or monitoring. She said the staff just tried to know where she was and what she was doing. CNA #1 was interviewed on 10/27/25 at 2:29 p.m. CNA #1 said Resident #2 was intrusive of other residents' space. She said Resident #1 would become irritated with Resident #2's intrusive behavior so staff usually would redirect Resident #2 with a drink and warm blanket so she could rest in the living room. CNA #1 said they tried to keep Resident #2 in the main living area of the memory care unit so staff could keep her within sight. She said Resident #2 did not usually go down the hallway. The maintenance assistant was interviewed on 10/27/25 at 2:34 p.m. The maintenance assistant said he walked onto the memory care unit and was waiting for the door to lock closed after he entered the memory care unit. He said he heard Resident #1 and Resident #2 arguing by the piano. He said Resident #1 cursed at Resident #2 while she told Resident #2 not to speak. He said he then saw Resident #1 lightly slap Resident #2 in the face. The maintenance assistant said he walked over to the residents and separated them. He said he guided Resident #2 away from the piano and brought her to a CNA who was around the corner in the hallway and reported the incident to the nurse on the memory care unit.Licensed practical nurse (LPN) #1 was interviewed on 10/27/25 at 2:37 p.m. LPN #1 said staff tried to have residents not too close to Resident #1 or in her personal space. She said staff tried to keep Resident #1 involved in activities to help prevent altercations with other residents. She said staff tried to keep Resident #2 in the main living area so they could watch her. She said the goal was to keep both residents busy and keep an eye on them so Resident #2 was not in Resident #1's personal space. LPN #1 said Resident #1 had an ingrown toenail at the time of the incident on 9/22/25 but there were no injuries as a result of the incident. LPN #1 was interviewed a second time on 10/27/25 at 4:20 p.m. LPN #1 said the 9/22/25 resident-to-resident altercation happened shortly after the start of her shift. She said Resident #1 was playing the piano and Resident #2 was in the main living room. She said she did not see Resident #2 leave the living room and go down the hall because she was talking to a resident's family member. She said she did not know if there were activities going on at the time or where the two CNAs were. Activity assistant (AA) #1, who worked in the memory care unit was interviewed on 10/27/25 at 4:17 p.m. AA #1 said she was in the dining hall/main living area during activities and she did not always have a clear sight of the hall or small living room on the other side of the unit by the unit entry doors when was engaged with the residents in her activity or in the dining hall. She said she did not remember hearing an event happen down the hall on the day in question (9/22/25). She said other staff, including CNAs and nurses, frequently rounded the halls to keep track of residents, but she said she tended to stay in the same area for her activities. AA #1 said she would have been conducting an activity around 3:30 p.m. on 9/22/25. She said she could not recall if Resident #1 or Resident #2 participated in activities that day. She said Resident #1 could have waves of irritability but did not remember a particular change in behavior or irritability during activities that week. She said Resident #2 could be intrusive even if she was meaning well and/or not showing signs of agitation. AA #1 said Resident #2 did not mean to upset people but her intrusiveness could conflict with other residents' personalities. The unit manager (UM) was interviewed on 10/27/25 at 4:25 p.m. The UM said to prevent resident-to-resident altercations, staff looked at the residents' environment, noise level, temperature, bathroom needs and any other unmet need. She said the staff received continued education and tried to learn residents' personalities and personal history. The UM said Resident #1 thought the memory care unit was her personal space and she was in charge of everything. She said Resident #1 had some pain related to her ingrown toenails. The UM said staff tried to keep her from other residents that seemed to irritate her and offer redirection. She said staff usually had Resident #1 and Resident #2 in different locations to keep attention away from each other. The UM said on 9/22/25, Resident #2 was speaking in incomprehensible verbiage and was too close to Resident #1 so Resident #1 hit Resident #2 with her hand.The UM said Resident #1 had had ingrown toenails for the past couple of months prior to the incident. She said she and the NP would clip Resident #1's toenails but the nails would continue to cause the resident discomfort. She said Resident #1was in the process of seeing a podiatrist. She said she felt the root cause of the altercation was pain related to Resident #1's ingrown toenails. The UM said Resident #1's toes were red and inflamed. The UM said there were no new interventions or revisions to the care plan after the 9/22/25 incident. She said Resident #1 care plan was updated after the altercation to include discomfort to the resident's toes and provide redirection.The UM and the NHA were interviewed together on 10/27/25 at 4:52 p.m. The UM said she felt there was enough staff on the memory care unit at the time of the 9/22/25 altercation between Resident #1 and Resident #2. The NHA said none of the memory care staff witnessed the altercation. She said during the investigation, she did not ask the staff when Resident #2 was last seen. She said one of the staff members told her Resident #2 was in a quiet area next to the unit doors prior to the event. She said she did not ask the memory care staff where they were or what they were doing when the altercation occurred. The NHA said she would want to know the last known whereabouts of residents prior to the altercation and would add those questions to her abuse packet. The NHA said Resident #1's care plan did not identify she would become agitated when other residents were in her personal space. She said Resident #2's care plan documented Resident #2 rummaged and went into other residents' rooms but the care plan did not identify that she would intrude on other residents' personal space. The NHA said Resident #1 had moments when she thought she was in charge and if she thought other people should be doing something that they were not doing. The NHA said Resident #1 would get upset with other people in her space. The UM said sometimes Resident #1 would not always have an issue with residents who spoke to her with incomprehensive speech but sometimes she would. The UM said it all really depended on Resident #1's mood at the time. The UM said Resident #1 had toe pain at the time of the altercation with Resident #2 on 9/22/25. The NHA said Resident #1 had a recent medication change. She said her quetiapine was increased on 9/18/25, prior to the incident. The NHA said it was a combination of increased behaviors regarding the medication change and pain related to the ingrown toenail. The UM said following the incident, Resident #1 was seen by an outpatient podiatrist appointment and would be seen by the outpatient provider. The NHA said she would update Resident #1's care plan to include to monitor Resident #1 when she was in boss mode. The NHA said the facility would update Resident #2's care plan regarding her intrusiveness.

Based on record review and interviews, the facility failed to ensure four (#1, #2, #3 and #4) of eight residents out of nine sample residents were free from abuse.Specifically, the facility failed to:-Protect Resident #2 and Resident #1 from physical abuse by each other;-Protect Resident #3 from physical abuse by Resident #1;-Protect Resident #4 from physical abuse by Resident #1; and,-Protect Resident #2 from physical abuse by Resident #1.Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 8/13/25 at 8:30 a.m. via email. The policy read in pertinent part, “The facility does not condone resident abuse and will take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. “Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident symptoms. “Providing a safe environment for the resident is one of the most basic and essential duties of our facility.” II. Incident of physical abuse between Resident #1 and Resident #2 on 6/18/25 A. Facility investigation The facility investigation was provided by the NHA on 8/11/25 at 4:30 p.m. The investigation, documented on 6/18/25, revealed Resident #1 dumped a glass of water on Resident #2 and Resident #2 retaliated by kicking Resident #1 in the right thigh. The investigation documented Resident #1 was having frequent aggressive behavior with labile mood. The intervention put in place as a response to the event was to change the antipsychotic medication for Resident #1. The facility investigation documented the allegation of abuse on 6/18/25 was substantiated. B. Resident #1 (victim and assailant) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged on 7/3/25. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease with early onset, frontal lobe dementia, unspecified mood disorder dementia and other diseases elsewhere classified with unspecified severity with other behavioral disturbance, severe with agitation, anxiety disorder and major depressive disorder. The 5/23/25 minimum data set (MDS) assessment identified Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. According to the MDS assessment, Resident #1 had inattention, disorganized thinking and delusions. The assessment indicated Resident #1 had physical and verbal behavioral symptoms directed towards others. The assessment identified she had other behavioral symptoms to include rejections of care and wandering. The assessment indicated she did not have upper or lower extremity impairment and did not require a mobility device. 2. Record review Resident #1’s trauma informed care plan, initiated 4/21/25, indicated Resident #1 had behavior related to a history of trauma related to abandonment. Interventions included involving family support in the care of Resident #1, providing peer support services, providing unsolicited validation for prosocial behavior, providing consistent caregivers whenever possible, speaking with Resident #1 in a calm soothing voice, approaching Resident #1 directly and avoiding approaching from the side or behind Resident #1. Resident #1’s anti-anxiety care plan, initiated 6/3/25, indicated Resident #1 had anxiety related behaviors including pacing, slapping/hitting themself and pulling their own hair. Interventions included administering anti-anxiety medication as ordered, behavior monitoring, side effect monitoring and quarterly medication review. The care plan documented non-pharmacological interventions for anxiety included cold, range of motion activities, massage, relaxation and breathing techniques, imagery and distraction techniques, aromatherapy and therapeutic touch. Resident #1’s behavior care plan, initiated 4/21/25, indicated Resident #1 had aggressive behaviors including yelling, screaming, hitting, biting and scratching. Interventions included administering antipsychotic medication as ordered, behavior monitoring, side effect monitoring and quarterly medication review. The care plan documented non-pharmicological interventions for aggressive behavior included redirecting Resident #1 outside, reducing stimuli, staff were not to respond to argumentative or sarcastic statements and remove of other residents from the area when Resident #1 was agitated. The progress note, dated 6/18/25 at 1:42 p.m. and entered into Resident #1’s electronic medical record (EMR) on 6/19/24, revealed Resident #1 was standing at the nurses’ cart, while Resident #2 was in her wheelchair. The two residents were talking with licensed practical nurse (LPN) #3. Both residents were at arms length apart. The note documented Resident #1 became agitated and threw a glass of water at Resident #2. Resident #2 was startled and kicked Resident #1 in the right thigh from her wheelchair. LPN #3 separated the two residents and Resident #1 denied any pain. No injuries were found on assessment. Both residents were placed on 15-minute observations for the rest of the shift. C. Resident #2 (victim and assailant) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia, unspecified, with behavioral disturbances, neurocognitive disorder with Lewy bodies, degenerative disease of the nervous system and anxiety. The 6/20/25 MDS assessment identified Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. According to the MDS assessment, Resident #2 had inattention, disorganized thinking and delusions. The assessment indicated Resident #2 had physical and verbal behavioral symptoms directed towards others. The assessment indicated she did impairment to her lower extremities and required a walker or wheelchair. Resident #2 was dependent on staff for toileting and footwear, and required assistance with bathing, dressing and hygiene. 2. Record review Resident #2’s behavior care plan, initiated on 2/26/25 and revised 7/7/25, indicated Resident #2 had behaviors including verbal aggression, cursing, yelling, crying, hitting, pushing and kicking. Interventions included using yes/no questions to determine needs, providing low stimuli environments when Resident #2 was overwhelmed, providing activities including crafts, gardening, puzzles, music, looking at photos, therapeutic massage and going outdoors. The progress note, dated 6/19/25 at 1:44 p.m., documented Resident #2 was sitting at the nurses’ cart with Resident #1 at arm’s length also talking with LPN #3. The note documented Resident #1 became agitated and threw a glass of water at Resident #2. Resident #2 was startled and kicked Resident #1 in the leg from her wheelchair. LPN #3 separated the two residents and no injuries were found on assessment. Both residents were placed on 15-minute observations for the rest of the shift. The nurse practitioner (NP) visit note, dated 6/24/25 at 5:30 p.m. The note documented Resident #1 had modestly improved behavior since the medication change from Seroquel to Zyprexa and addition of non-pharmacological interventions. The note documented a plan to continue to monitor Resident #1 for medication effectiveness with the plan to taper and discontinue Resident #1’s as needed (PRN) anti-anxiety medication as Resident #1 adjusted to the scheduled Zyprexa and the environment. III. Incident of abuse of Resident #3 by Resident #1 on 6/21/25 A. Facility investigation The facility investigation was provided by the NHA on 8/11/25 at 4:48 p.m. The investigation documented that on 6/21/25 a physical altercation occurred between Resident #3 and Resident #1 that involved yelling and pushing. The altercation resulted in Resident #3 sustaining a skin tear on her right great toe. No other injuries were identified as a result of the incident. The residents were separated and monitored. The investigation identified Resident #1, who had a history of resident-to-resident altercations, was the aggressor in the altercation. The facility investigation included an analysis of the potential root cause of the altercation. According to the analysis, there was a baby with her mother in the secured unit prior to the altercation. Resident #1 attempted to pick up the baby and staff intervened, upsetting and possibly embarrassing Resident #1. The analysis identified Resident #1 had difficulty calming down after she became upset. The facility investigation included an interview with certified nurse aide (CNA) #4. CNA #4 said the incident occurred after dinner. CNA #4 described the environment after dinner as busy and a little chaotic, which was normal. Resident #1 had been upset since before dinner and declined encouragement to eat outside. CNA #4 said when dinner concluded, Resident #1 pushed Resident #3 into a chair causing Resident #3 to stub her toe. The facility investigation revealed education was conducted with the memory care staff on 6/25/25. The minutes from the education indicated Resident #1 liked Resident #4’s walker and would regularly try to take it (see 7/2/25 incident of physical abuse below). According to the minutes, Resident #1’s behaviors would be triggered when her representatives would leave her after they visited with her. Resident #1 was very difficult to redirect when she was upset, to include after dinner when everyone was getting up from their meal and the environment was busy. The minutes identified staff recommended calming music be played at that time to help with sundowning behaviors. The minutes documented staff felt that residents would become scared when Resident #1 was upset. The facility investigation documented the allegation of abuse on 6/21/25 was substantiated. B. Resident #3 (victim) 1. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included Alzheimer's disease, unspecified dementia and other diseases classified elsewhere, unspecified severity, with psychotic disturbances, unspecified dementia other disease classified elsewhere, severe with mood disturbance. The 7/1/25 MDS assessment identified Resident #3 had moderate cognitive impairments, per a staff assessment for mental status. According to the MDS assessment, Resident #3 had a short term and long term memory problem with fluctuating inattention and disorganized thinking but could recall staff names and faces. The assessment indicated Resident #3 did not have physical or verbal behavioral symptoms directed towards others. She was independent with mobility without the use of a mobility device. 2. Record review The secured memory care placement care plan, revised 11/22/23, identified Resident #3 required placement in a secure neighborhood due to senile degeneration of the brain and dementia with agitation and psychotic disturbance. The care plan goal was to keep Resident #3 safe. The delirium care plan, revised 11/22/23, identified Resident #3 had delirium or an acute confusion episode related to dementia but was able to communicate her wants and needs verbally and nonverbally with simple communication. According to the care plan, she was easily redirected. Pertinent interventions, initiated 10/4/23, included the staff should promote the appropriate sensory stimulation and monitor/address environmental factors such as noise and commotion. The 6/21/25 nursing progress note documented Resident #3 was standing with the nurse (LPN #1) when another resident (Resident #1) proceeded to yell at Resident #3 and was in close proximity to Resident #3’s face. According to the note, the nurse attempted to stand between both residents as Resident #1 was pushing the nurse. Resident #3 turned around with her back facing Resident #1 and Resident #1 pushed Resident #3. The note identified the push caused Resident #3 to stumble forward and stub her toe on the table in front of her. C. Resident #1 (assailant) 1. Record review The 6/21/25 nursing progress note documented the resident-to-resident altercation. The progress note identified Resident #1 was taken outside away from Resident #3 and was placed on 15-minute checks and her physician and responsible party was notified. The 6/22/25 nursing progress note documented Resident #1 was placed on alert charting following the incident and was administered a PRN dose of Ativan (an antianxiety medication. According to the note, Resident #1 was in good spirits until later in the day when she began to display increased agitation but allowed staff to provide activities of daily living (ADL) care. The progress note indicated the resident’s agitation did not rise to the level of physical aggression. IV. Incident of abuse of Resident #4 by Resident #1 on 7/2/25 A. Facility investigation The facility investigation was provided by the NHA on 8/11/25 at 4:48 p.m. The investigation documented that a physical altercation on 7/2/25 occurred between Resident #4 and Resident #1 without injury or redness. The residents were separated and monitored. The investigation identified Resident #1 was the aggressor in the altercation. The investigation identified Resident #1 attempted to take Resident #4’s walker. Resident #1 became upset when she could not have Resident #4’s walker and open hand slapped Resident #4 in the face. The residents were separated and Resident #1 spent most of the day off the secured unit with nurse management staff providing one-to-one visitation and supervision. According to the investigation, Resident #1’s representative was contacted. The facility recommended and sent out referrals to other facilities that had a less stimulating environment. The investigation documented the facility would conduct a medication review and offer Resident #1 supervised time off the unit when her behaviors escalated. The facility investigation included an interview with CNA #1. CNA #1 said Resident #1 was agitated prior to the resident-to-resident altercation on 7/2/25. Staff offered interventions of one-to-one visits, taking her outside and toileting her. The interview indicated Resident #1 had refused to let staff change her brief. The facility investigation included an analysis of the potential root cause of the altercation. According to the analysis, Resident #1 was overestimulated by the general activity of the secured memory care unit. The analysis also indicated Resident #1 would take anything that rolled in front of her, such as rolling carts, rolling chairs and, in the case of the 7/2/25 altercation, Resident #4 used a walker (with wheels). The facility investigation documented the allegation of abuse on 7/2/25 was substantiated. B. Resident #4 (victim) 1. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included Alzheimer's disease with late onset, dementia and other diseases elsewhere classified, severe with agitation, lack of coordination and anxiety disorder. The 6/25/25 MDS assessment identified Resident #4 had moderate cognitive impairments, per a staff assessment for mental status. According to the MDS assessment, Resident #4 short term and long term memory problems with fluctuating inattention and disorganized thinking but could recall staff names, faces and location of her room. The assessment indicated Resident #4 did not have physical or verbal behavioral symptoms directed towards others. The assessment indicated she was independent with mobility with use of a walker. 2. Record review The 7/3/25 nursing progress note identified (on 7/2/25) that Resident #1 and Resident #4 were observed by the shower room together as Resident #1 tried to take Resident #4’s walker, became upset and slapped Resident #4 across the left side of her face. According to the progress note, the CNA immediately intervened and redirected Resident #1. Resident #4 was able to tell the staff she was slapped by Resident #1. The 7/3/25 interdisciplinary team (IDT) note documented the IDT reviewed the 7/2/25. According to the note, Resident #4 had no changes from mood or cognition baseline and was not able to recall the event. C. Resident #1 (assailant) 1. Record review The 7/3/25 nursing progress note described the incident between Resident #1 and Resident #4. According to the note, all appropriate parties were notified including the physician and the representative. V. Incident of physical abuse between Resident #1 and Resident #2 on 7/3/25 A. Facility investigation The facility investigation was provided by the NHA on 8/11/25 at 4:30 p.m. The investigation documented that on 7/3/25 at 3:20 p.m. Resident #1 was agitated, intermittently hitting herself and pulling her hair out and pacing between the common area and the dining area. The investigation documented Resident #1 was walking with the activities assistant. Resident #2 was being assisted out of the dining area by CNA #3. Resident #1 grabbed Resident #2 by the wrist with both hands, twisting and pulling on Resident #2’s arm. CNA #3 and the activities assistant separated the two residents but their attempts to redirect Resident #1 were unsuccessful as Resident #1 pushed and knocked over furniture in the common area. The unit manager notified the director of nursing (DON), who called 911. A police officer arrived to the scene but was unable to redirect Resident #1. Emergency medical services (EMS) were called after police were unable to de-escalate Resident #1. Resident #1 attempted to kick and bite EMS staff and police. The investigation documented EMS staff administered Haloperidol (an antipsychotic medication) 5 milligrams (mg) intramuscular (injection) into Resident #1. Resident #1 remained combative with EMS staff and required soft restraints to be placed by EMS in order to transport Resident #1 to the local area hospital. Resident #2 was assessed for injuries. Bruises were found on her arm, but Resident #2 had full range of motion and denied pain. The investigation documented the DON contacted Resident #1’s daughter (one of her representatives) to inform of the event and to inform her that Resident #1 was not safe to return to the facility at this time because Resident #1 was a danger to herself and others. The intervention listed in the facility investigation was that Resident #1 would not be allowed to return to the facility unless the resident received additional support and medication management in an inpatient setting and Resident #1’s behavior symptoms were stable. The facility investigation documented the allegation of abuse on 7/3/25 was substantiated. VI. Staff interviews LPN #2 was interviewed on 8/12/25 at 11:25 a.m. LPN #2 said Resident #1 had very unpredictable behavior. LPN #1 said she remembered the facility working with the resident’s representative, who was providing care to find approaches and interventions that Resident #1 responded well to. LPN #2 said one of the interventions was for staff to report they needed to use the restroom and to ask Resident #1 if she wanted to go with them instead of informing Resident #1 they were incontinent or they needed to be changed. LPN #2 said this was helpful as Resident #1 was very agitated when incontinent, but not always aware that the source of her discomfort was incontinence. CNA #1 was interviewed on 8/12/25 at 12:19 p.m. CNA #1 said Resident #1 had increasingly unpredictable behaviors in the last week or two prior to her discharge. CNA #1 said she remembered attending unit education about different interventions specific to Resident #1 in June 2025. CNA #1 said one of the interventions was for staff to mention they needed to use the restroom and then ask Resident #1 if she wanted to go with them, instead of informing Resident #1 she was incontinent and needed to be changed. CNA #1 said some of the interventions to redirect Resident #1 would work the first few times but then would stop being effective. The DON and the NHA were interviewed together on 8/12/25 at 1:18 p.m. The DON said the facility started weekly care conferences with Resident #1’s representatives in June 2025 due to Resident #1’s frequent agitated and combative behavior. The NHA said one of the issues identified in the facility’s investigation was that the resident’s representative and caregiver for Resident #1 prior to admission continued to provide most of the bathing and incontinence cares to Resident #1. The NHA said the staff needed the opportunity to build rapport with Resident #1 and asked the representative to avoid coming to the facility for a week. The NHA and the DON said Resident #1’s behavior improved temporarily and Resident #1 was more cooperative with care and assessments during the time Resident #1’s representatives were not visiting. The NHA said the representative and caregiver returned to visit the next week and Resident #1’s behavior escalated again. The NHA said it appeared to be related to Resident #1’s trauma history related to abandonment. The DON said she remembered the events on 7/3/25 when Resident #1 was hospitalized and discharged from the facility. The DON said she received a call from the unit manager asking for help with Resident #1. The DON said the situation sounded emergent so she called 911. The DON said when she arrived to the unit, the unit manager had already cleared all other residents out of the area near Resident #1. The DON said Resident #1 was pushing staff into walls, hitting herself and pulling her hair out. The DON said the police arrived but were unable to direct Resident #1 to her room and the police officer contacted EMS. The DON said EMS was also unable to de-escalate Resident #1 and Resident #1 attempted to hit and bite EMS staff. The DON said the police and EMS spoke with her and told her that Resident #1 was a danger to herself and others and everyone was in agreement that Resident #1 needed to be hospitalized . The DON said EMS had to give intramuscular haloperidol and use soft restraints to get Resident #1 onto the stretcher. The DON said she contacted Resident #1’s representative and told her about the situation. The DON said the resident’s representative said she was not surprised by Resident #1’s aggressive behavior and agreed at the time that Resident #1 needed hospitalization. The NHA was interviewed again on 8/12/25 at 4:41 p.m. The NHA said physical abuse could occur any time willful contact was made between two people, even if those people did not intend to harm each other. The NHA said abuse could also be verbal or sexual and that all reports in which abuse could have occurred were investigated by the facility. The NHA said when the facility was conducting investigations, they would interview the managers, any staff that witnessed the incident, any staff that were working on that unit and any pertinent residents. The NHA said Resident #1 was a complex case due to her diagnosis of frontal-lobe dementia. The NHA said the nurse practitioner for Resident #1 provided education to unit staff about the disease process, including extremely impulsive behavior and rapid mood swings. The NHA said the facility tried to implement multiple interventions to keep Resident #1, other residents and unit staff safe. The NHA said an intervention would be successful for Resident #1 for a short period of time and then stop working for no clear reason. The NHA said the facility planned to be more diligent in their referral process. The NHA said the current population of the memory care unit could be overstimulating to younger residents with frontal lobe dementia compared to their current population, which was a majority of older residents.

Based on record review and interviews, the facility failed to ensure one (#1) of seven residents out of nine sample residents were kept free from physical restraints. Specifically, the facility failed to prevent manual holds being used on Resident #1 during incontinence care. Findings include:I. Facility policy and procedureThe Abuse policy, revised February 2024, was provided by the nursing home administrator (NHA) on 8/13/25 at 8:30 a.m. It read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms.II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and discharged on 7/3/25. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease with early onset, frontal lobe dementia, unspecified mood disorder dementia and other diseases elsewhere classified with unspecified severity with other behavioral disturbance, severe with agitation, anxiety disorder and major depressive disorder.The 5/23/25 minimum data set (MDS) assessment identified Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. According to the MDS assessment, Resident #1 had inattention, disorganized thinking and delusions. The assessment indicated Resident #1 had physical and verbal behavioral symptoms directed towards others. The assessment identified she had other behavioral symptoms to include rejections of care and wandering. The assessment indicated she did not have upper or lower extremity impairment and did not require a mobility device.B. Facility investigation of bruises of unknown origin on 6/6/25The facility investigation was provided by the nursing home administrator (NHA) on 8/11/25 at 4:30 p.m. The investigation documented that on 6/6/25 the resident's representative brought bruises of unknown origin found on the resident's back and left shoulder to the attention of the facility. The investigation documented the resident's representative did not know when the bruising occurred and initially did not report the bruises because he was not concerned and was aware how combative Resident #1 could be with care. The investigation documented Resident #1's representative told the facility he saw the bruises approximately three weeks prior to the report made to the facility on 6/6/25. The investigation documented interviews with all staff assigned to Resident #1 in the three weeks prior to the report.The investigation documented licensed practical nurse (LPN) #2 was interviewed on 6/8/25 at 11:15 a.m. LPN #2 said approximately three weeks ago, Resident #1 was incontinent of bowel in the common area. Resident #1 had severely agitated behavior, pacing in the common area and would not follow staff cues to the bathroom for incontinence cares. LPN #2 and the director of nursing (DON) had their arms underneath Resident #1 holding her hands to guide Resident #1 to her bathroom. The investigation documented when the staff and Resident #1 arrived to her room, Resident #1 went limp with her legs, putting her weight on LPN #2 and the DON, causing Resident #1 to slide to the floor. LPN #2 and the DON lifted Resident #1 from the floor to the bed. The investigation documented LPN #2 thought this event could have caused the unknown bruising on Resident #1. LPN #2 said she provided incontinence care to Resident #1 while certified nurse assistant (CNA) #1 and the DON held Resident #1's hands and CNA #2 held Resident #1's feet to prevent Resident #1 from hitting or kicking staff during care. The investigation documented the DON was interviewed on 6/8/25. The DON said she assisted with incontinence care for Resident #1 approximately three weeks prior. The DON said Resident #1 was very combative at this time and the DON had to hold her arm to prevent Resident #1 from hitting staff. The DON said Resident #1 threw herself onto the bed and slid to the floor and she assisted her back into bed. The DON said it was possible the bruises came from the bed frame. The investigation documented CNA #2 was interviewed on 6/9/25 at 11:48 a.m. CNA #2 said she remembered assisting with care for Resident #1 approximately three weeks prior. CNA #2 said Resident #1 was covered in bowel movement and would not follow the cues from CNA #2 or other staff. CNA #2 said the DON and another staff member held Resident #1's hands, looping their arms under Resident #1 to guide her to her room. When CNA #2 entered the room to assist with care, Resident #1 was combative with staff. CNA #2 said she saw the legs of Resident #1 drop out from under her and Resident #1 landed on the bed. CNA #2 said she held Resident #1's legs during the incontinence care because Resident #1 was trying to kick the nurse cleaning her up. CNA #2 said she remembered another time when Resident #1 grabbed and pulled CNA #2's hair. CNA #2 said she hugged Resident #1 so she could not hit her, then Resident #1 threw herself backwards and both Resident #1 and CNA #2 landed on the bed. The investigation documented CNA #3 was interviewed on 6/10/25. CNA #3 said she saw the bruises on Resident #1's back one time while helping the resident's representative bathe Resident #1. CNA #3 said she did not report the bruises at the time because she thought the nurse was already aware of them. CNA #3 said Resident #1 was difficult to care for and was often combative during care. CNA #3 said she remembered crossing the arms of Resident #1 across her chest during incontinence care to prevent her from hitting staff. C. Resident #1's representatives interviewsA representative for Resident #1 was interviewed on 8/11/25 at 4:08 p.m. The resident's representative said they found large bruises on Resident #1's back and took pictures of the bruises on 5/30/25. She said to her knowledge, there was no documentation of the cause of the bruising until Resident #1's representatives brought it to the facility's attention. She said to her knowledge, the facility was not able to find a cause for the bruising. Another representative for Resident #1 was interviewed on 8/12/25 at 2:05 p.m. The resident's representative said he found bruises on Resident #1 while bathing her during the week of 5/18/25 to 5/24/25, but he could not remember the exact day. He said he did not report it to the facility right away because he did not know it needed to be reported at the time. He said he reported the bruising. He said the facility investigated once he mentioned it and he was not sure if they ever found out what caused them. He said he remembered hearing about a day of the week he found the bruises in which Resident #1 was very agitated and resisting care. He said he thought this incident might have caused it. He said Resident #1 went to the emergency room on 5/21/25 due to a high heart rate and high blood pressure, but he did not think this visit was the cause of the bruising. He said the resident was agitated when she was informed the hospital staff needed to place a catheter to obtain a urine sample, but the hospital staff gave sedating medication into her intravenous (IV) catheter . The resident's representative said he did not remember emergency room staff having to physically hold or restrain Resident #1 in the emergency room. He said he did remember Resident #1 had bruises to her arms after the emergency room visit, but he thought they were from the IVs inserted in each arm. He said he did not remember telling facility staff Resident #1 was combative with emergency room staff. D. Record reviewThe progress noted, dated 5/16/25 at 1:22 p.m., documented Resident #1 had a skin check completed by the unit manager with no bruising documented at the time of the assessment. The progress note, dated 5/20/25 at 5:47 p.m., documented Resident #1 had agitated and labile behavior. Resident #1 paced in the common area, had episodes of crying and apologizing to staff followed by yelling and verbally abusive statements toward others. Resident #1 received one-to-one interventions and supervision for the safety of Resident #1 and other residents on the unit. Interventions included redirecting Resident #1 outside and providing as needed medication.The progress note, dated 5/20/25 at 8:14 p.m., documented Resident #1 was pacing in the halls, crying and yelling at others. The progress note, dated 5/23/25 at 9:04 a.m. documented Resident #1 had bruising and discoloration to both arms. The progress note documented the resident's representative told the facility the emergency room staff had to physically restrain Resident #1 to place the IVs in each arm, requiring multiple attempts. The progress note documented the resident's representative confirmed the location of the bruises were where the IV attempts occurred. -Review of Resident #1's electronic medical record (EMR) did not include documentation that they found the bruising could have been related to the DON, LPN #2 and CNA #2 physically holding the resident in bed when providing care (see facility investigation above).III. Staff interviewsCNA #2 was interviewed on 8/12/25 at 11:10 a.m. CNA #2 said Resident #1 became agitated and combative frequently when she was incontinent. CNA #2 said she remembered some of the events around the incontinence care provided on 5/20/25 (the estimated date of the care that potentially caused the bruising). CNA #2 said Resident #1 was agitated and refused care. CNA #2 said she would become more agitated when the staff tried to get her to the bathroom and after several unsuccessful attempts to redirect Resident #1, the floor staff called management. She said she did not remember who, but some staff members helped the resident to her room while CNA #2 got supplies from storage. She said she remembered assisting with care but could not remember if Resident #1 was combative during care or if any staff members had to hold her to provide the care. CNA #2 said Resident #1 was calm after the incontinence care was completed. LPN #2 was interviewed on 8/12/25 at 11:25 a.m. LPN #2 said she remembered Resident #1 was pacing in the common area and was incontinent. LPN #2 said the unit CNAs made several attempts to direct her to a bathroom but were unsuccessful. LPN #2 said using words, such as toilet or bathroom, with Resident #1 escalated her agitation. LPN #2 said she and the DON held Resident #1's hands with their arms underneath the resident to guide her to her room. LPN #2 said she and the DON attempted again to prompt Resident #1 into her bathroom, but Resident #1 became agitated again. She said additional staff members came into the room to help. LPN #2 said she provided the incontinence care while a staff member held each hand and another staff member loosely held her legs when Resident #1 attempted to kick LPN #2. LPN #2 said they completed the care and assessed Resident #1's skin as quickly as possible. She said after care was completed, Resident #1's behavior was deescalated and she was able to be redirected to ambulate outside in the courtyard with another staff member. LPN #2 said this was not a normal situation and it was not normal to have to hold a resident's limbs to provide care. LPN #2 said Resident #1 had extremely unpredictable behavior and became combative quickly. LPN #2 said staff spoke with the resident's representative, who was the caregiver prior to admission, in order to learn new ways to successfully cue Resident #1 to the bathroom without agitation. LPN #2 said the facility also provided additional education about how to approach agitated residents to prevent future incidents. LPN #2 said if she were in a similar situation, she would direct CNA staff to remove all other residents out of the area, alert other staff and try to redirect the agitated resident to go on a walk. LPN #2 said if the resident became combative, she would stop care and try again later. CNA #1 was interviewed on 8/12/25 at 12:19 p.m. CNA #1 said she did not remember the day but remembered the incident. CNA #1 said Resident #1 was in the common area and was incontinent with stool on her hands that she was smearing on tables and chairs. CNA #1 said she remembered she and CNA #2 attempted to direct Resident #1 to the bathroom multiple times, but every time Resident #1 saw the toilet in the bathroom, she would get upset and walk away. CNA #1 said additional staff members were called and two staff members walked with Resident #1 to her room. CNA #1 said Resident #1 became resistant and combative when they tried to perform care in the room. CNA #1 said she could not remember if she saw Resident #1's legs give out, but CNA #1 remembered Resident #1 was hitting and kicking staff in the bed. CNA #1 said she held the resident's hand on one side while another staff member held her other hand and a third staff member held her legs briefly while LPN #2 provided incontinence care. CNA #1 said that the incident was not a normal situation. CNA #1 said Resident #1 resisted care on other occasions but usually would cooperate if CNA #1 or another staff member tried again a few minutes later. CNA #1 said she never had to hold another resident to complete incontinence care. The DON and the NHA were interviewed together on 8/12/25 at 1:18 p.m. The DON said during the investigation process of Resident #1's bruises, conducted on 6/6/25, she and other staff members recalled a day approximately three weeks prior, in which Resident #1 was extremely difficult to toilet. The DON said on that day Resident #1 was incontinent of stool and smearing it with her hands all over the common area. The DON said she remembered she and the NHA tried to verbally direct Resident #1 to the bathroom but were not successful. The DON said it was becoming an infection control risk to the unit, so she and another staff member held Resident #1's hands and walked with her to her room. The DON said Resident #1 was cooperative at first, as staff could typically convince Resident #1 to walk to another location with them. The DON said however, when she attempted to prompt Resident #1 to walk to her bathroom, she pulled her legs up putting all of her weight on the DON and the other staff member. The DON said when this happened they assisted her to her bed and then she slid to the floor. The DON said she and another staff member assisted Resident #1 back on to the bed and when they attempted to provide incontinence care, Resident #1 began to yell, hit and kick the staff. The DON said she and CNA #1 held the hands of Resident #1, but she was able to move her arms. The DON said another staff member initially had her arms above Resident #1's legs to block them from kicking LPN #2 who was cleaning, but for brief periods her legs were held. The DON said all of this happened very quickly and all staff members let go as soon as care was complete. The DON said Resident #1 stood up and pulled up her own pants after care was complete. The DON said she did not consider this as a hold because the time period was so brief and the resident could still move her extremities, just not in a way that could injure staff. The NHA said during the investigation, it was found that the resident's representative was doing most of the care for Resident #1. The DON said the facility began to have weekly care conferences with Resident #1's family to find more successful interventions and staff on the unit were educated on different approaches to use with Resident #1 to prevent combative behavior.The NHA was interviewed again on 8/12/25 at 4:41 p.m. The NHA said physical abuse could occur anytime there was willful physical contact between two people, even if those people did not intend to harm one another. The NHA said a physical restraint could include tie down restraints or isolation. The NHA said she did not consider the incident with Resident #1 a restraint because she was told Resident #1 could still move her extremities, just not in a way that could harm herself or others. The NHA said after reviewing the regulation, the events described in the investigation, as well as the other reports of staff members holding Resident #1 to provide care met the definition of a manual hold. The NHA said she believed some of the verbiage used by staff to describe the events found in the investigation did not accurately reflect the events. The NHA said after the review of the definitions in the regulation, the NHA said she planned to provide education to the staff on what a manual hold was and to never physically restrict the movement of a resident in order to provide care.

Based on observations, record review and interviews, the facility failed to ensure four (#1, #2, #3 and #4) of six residents out of six sample residents were free from abuse. Specifically, the facility failed to: -Protect Resident #1 from physical abuse by Resident #3; -Protect Resident #3 from physical abuse by Resident #1; -Protect Resident #1 from physical abuse by Resident #4; -Protect Resident #3 and Resident #1 from physical abuse from each other; and, -Protect Resident #2 from physical abuse by Resident #1. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 5/7/25 at 3:45 p.m. The policy read in pertinent part, The facility does not condone resident abuse and will take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident symptoms. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. II. Incident of abuse of Resident #1 by Resident #3 on 2/15/25 A. Facility investigation The facility investigation was provided by the NHA on 5/6/25 at approximately 11:30 a.m. The investigation documented that on 2/15/25 at 2:13 p.m. Resident #1 attempted to enter her room but Resident #3 was in front of the door. According to the investigation, Resident #3 became upset and pushed her walker into Resident #1 and then smacked Resident #1 across the face with an open hand. Both residents were separated, assessed for injuries and placed on 15-minute checks for 72 hours. The investigation documented both residents were severely cognitively impaired and could not recall the incident. The investigation indicated there were no injuries to either resident. A witness statement from certified nurse aide (CNA) #1 documented CNA #1 witnessed Resident #3 push Resident #1 with her walker and then proceed to smack her across the face. A staff interview from CNA #4 documented after lunch was served, she heard a smack and a CNA say oh she just got slapped. According to staff interview, CNA #4 ran to the hall and separated the residents. The facility investigation identified staff observed eight non-interviewable residents, including the two residents involved in the incident. According to the investigation, there was no change in the residents' baseline behaviors after the incident. The investigation documented Resident #1 and Resident #3's care plans were updated. The facility investigation documented Resident #1's hospice physician was notified on 2/18/25 regarding the altercations between Resident #1 and Resident #3 on 2/15/25 and 2/17/25 (see 2/17/25 incident below). According to the physician notification, the facility was reviewing the resident's medications to determine if the incidents were related to possible pain or constipation. The facility investigation documented a staff inservice was conducted on 2/18/25 with 13 staff members. The inservice agenda documented that all residents who resided on the memory care unit had their care plans reviewed and individualized memory care sheets were created for each resident. The facility investigation documented both Resident #1 and Resident #3 were newer to the memory care unit, neither resident had prior aggression and staff were still learning their behaviors and patterns. According to the investigation, Resident #1 had limited communication and needed a way to communicate with others. A request was made with speech therapy for a communication device. B. Resident #1 (victim) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included degenerative disease of the nervous system, generalized anxiety disorder dementia, unspecified severity with other behavioral disturbance, senile degeneration of the brain, cognitive communication deficit and depression. The 1/25/25 minimum data set (MDS) assessment identified Resident #1 had moderate cognitive impairments, per a staff assessment for mental status. According to the MDS assessment, Resident #1 did not have inattention or disorganized thinking. She remembered the location of her room and staff names and faces. The assessment indicated Resident #1 did not have physical or verbal behavioral symptoms directed towards others. She did not use a wheelchair but she needed supervision or touching assistance for mobility. 2. Record review The secured memory care placement care plan, revised 1/28/25, identified Resident #1 required placement in a secure neighborhood due to dementia with agitation. The communication care plan, revised 1/28/25, identified Resident #1 had a communication problem related to dysphasia (difficulty with speech) and dementia. The care plan identified she was able to use a whiteboard for communication. The dementia with behaviors care plan, revised 3/6/25, identified Resident #1's targeted behaviors included wandering and exit seeking, mood issues of tearfulness and increased anxiety, poor safety awareness delusions/hallucinations and pushing and shoving. According to the care plan, the resident did not like to have people getting in her face, her space, loud environments or being told what to do. The interventions, initiated on 1/24/25, directed staff to present just one thought, idea, question or command at a time and use task segmentation to support short term memory deficits, breaking tasks into one step at a time. The interventions, revised 1/28/25, directed staff to provide cues and reapproach if agitated. Provide her with a consistent routine and care givers to decrease her confusion. According to the care plan, Resident #1 understood consistent, simple and direct sentences. The interventions, initiated 2/20/25, directed staff to assess Resident #1 for pain and provide her with rest periods, Resident #1 liked to lay down in bed and rest, assist her with toileting and offer fluids soft food/fluids if she was pacing, give her a clear explanation when doing something and remove Resident #1 from loud environments if she became agitated, placing her in a quieter space and redirect/distract her. According to the care plan, Resident #1 preferred to eat alone in the dining room. The interventions, initiated 2/20/25, identified Resident #1 was routine driven and directed staff to keep Resident #1's routine free of disruption, providing her with a designated place to eat during meal time and a designated place to sit when in the common area. The care plan identified activities the resident enjoyed engaging in. -Review of the care plan did not indicate Resident #1 was at risk for abuse or had been a victim of physical abuse. The interventions, initiated 3/23/25, identified a stop sign was placed on her doorway to help redirect others from entering her space. -The care plan did not identify new interventions were put in place for Resident #1 to decrease future occurrences of resident-to-resident altercations after the 2/15/25 resident altercation with Resident #3. The care plan was not updated until 3/23/25 and after Resident #1 had had three more altercations with residents (see 2/17/25, 2/18/25 and 3/22/25 resident-to-resident altercations below). The intervention, revised 3/25/25, directed staff to communicate with Resident #1 with a whiteboard or pictures, using yes/no questions and work with speech therapy on communication techniques. The intervention, initiated 4/1/25, identified Resident #1 could target other residents/staff and push/shove them, sometimes causing them to fall. The intervention directed staff to make sure her stop sign was on the doorway and the door was shut when she was in her room. According to the care plan, staff needed to keep Resident #1 in their line of sight when she was out of her room. The 2/15/25 nursing progress note documented the nurse was cleaning her medication cart when she heard a slap. CNA #1 reported Resident #3 struck Resident #1 with an open hand. The note revealed Resident #1 was tearful and had some redness to the left cheek. According to the nursing note, staff was able to console Resident #1. The 2/16/25 nursing progress note documented Resident #1 was on 72-hour charting with 15-minute checks related to an altercation with another resident. Resident #1 was in view of staff throughout the shift and no agitation was noted. According to the note, Resident #1 was pacing the halls between her room and the dining area and had not come into contact with Resident #3. The note indicated staff would continue to monitor Resident #1. C. Resident #3 (assailant) 1. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included Alzheimer's disease with late onset, dementia and other diseases elsewhere classified, severe with agitation, lack of coordination and anxiety disorder. The 4/1/25 MDS assessment identified Resident #3 had moderate cognitive impairments, per a staff assessment for mental status. According to the MDS assessment, Resident #3 did not have inattention or disorganized thinking. The assessment indicated Resident #3 did not have physical or verbal behavioral symptoms directed towards others. The assessment indicated she needed supervision or touching assistance for mobility. 2. Record review The dementia care plan, revised 3/6/25, identified Resident #3 had impaired cognitive function or impaired thought processes related to dementia. According to the care plan, Resident #3 did not like people getting in her face or space, loud environments and being told what to do. The care plan directed staff to offer interventions that the resident believed were her idea. The intervention, initiated 12/24/24, directed staff to use task segmentation to support short term memory deficits and break tasks into one step at a time with just one thought, idea, question or command at a time. The interventions, revised 12/26/24, directed staff to face Resident #3 when speaking, identifying self, reduce directions and provide her necessary cues and reapproach if she was agitated. According to the care plan, the resident understood consistent, simple and direct sentences. Staff should keep Resident #3's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. The interventions, initiated 2/19/25, directed staff to ask Resident #3 yes/no questions in order to determine needs, assess her for pain, provide rest periods and use non-pharmacological pain relief prior to utilizing PRN (as needed) medications, monitor her behaviors, communicate with Resident #3/family/and caregivers of Resident #3's capabilities and needs, engage Resident #3 in simple, structured activities that avoid overly demanding tasks, give Resident #3 a clear explanation when doing something with her, provide her with a homelike environment, she enjoyed being helpful and liked visiting with others, if agitated in a loud environment, remove the resident into a quieter area, then try to redirect and distract her with something else, coordinate with her physician and review medications for pain relief and effectiveness and record possible causes of cognitive deficit such as new medications or dosage increases, anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. The behavior care plan, initiated 3/6/25, identified Resident #3 was triggered for verbal/physical behaviors such as verbal outbursts, hitting/kicking and scratching. According to the care plan, Resident #3 was de-escalated by one person to assist with care, using a slow approach. More than one person caused her to become anxious and lash out at staff. The care plan directed staff to praise Resident #3's progress/improvement in her behavior, offer and document non-pharmacological interventions prior to administering medications, administer medications as ordered, monitor her for side effects and effectiveness, anticipate her needs and assist as indicated, provide Resident #3 an opportunity for positive interaction and attention by talking to her when staff was near her, explain all procedures to the resident before starting care and allow her to adjust to the changes, intervene as necessary to protect the rights and safety of others, approach Resident #3 in a calm manner, divert attention and remove her from the situation and take to an alternate location as needed, monitor behavior episodes and attempt to determine the underlying cause, consider location, time of day, persons involved, and situations and document/report behavior and potential causes if indicated. The intervention, initiated on 3/25/25, indicated Resident #3 did not like to be told what to do and could become agitated. The care plan directed staff to place a stop sign across her doorway to help others go into Resident #3's space and monitor her for non-wanted intrusions of others' space when she was wandering and looking into other residents' doorways. The 2/15/25 nursing progress note identified Resident #3 had increased agitation related to chronic pain and staff was monitoring. According to the note, she was more assertive to others. A second 2/15/25 nursing progress note documented Resident #3 slapped another resident with an open hand. The note indicated a different pain management was recommended and the nurse practitioner was made aware. According to the note, there were no new orders as of 2/15/25. The 2/16/25 nursing progress note documented Resident #3 continued on 72-hour charting with 15-minute checks related to the altercation with another resident. Resident #3 was showing signs of agitation/aggression with staff after dinner and one-to-one interventions were implemented and effective. According to the note, Resident #3 was not showing signs of pain. III. Incident of abuse of Resident #3 by Resident #1 on 2/17/25 A. Facility investigation The facility investigation was provided by the NHA on 5/6/25 at approximately 11:30 a.m. The investigation identified Resident #1 and Resident #3 were involved in another resident-to-resident altercation. The altercation occurred on 2/17/25 at 11:00 a.m. The incident was witnessed by a CNA. According to the investigation, the residents were not able to recall the incident. There were no injuries and the residents had no changes in the baseline behaviors. -However, Resident #3 was identified to have injuries to her arm and Resident #1 had increased anxiety and PRN anti-anxiety medication was requested (see record review below). The facility investigation documented Resident #1 had a change in her bowel medication and staff was educated to utilize Resident #1's PRN pain medications. According to the investigation, Resident #1 was routine driven and Resident #3 was in her routine path so she moved Resident #3 out her way. Resident #1 did not communicate verbally. Staff was educated on Resident #1's routine. The facility continued both residents on 15-minute checks. -The investigation identified both residents were on 15-minute checks when the 2/17/25 resident-t0- resident altercation occurred. However, the 15-minute checks did not prevent the resident-to-resident altercation from occurring. According to the follow-up action on the incident report, the action taken to protect the victim (Resident #3) or reduce vulnerabilities of further abuse was 15-minute checks, medication reviews and staff education. B. Resident #3 (victim) 1. Record review The 2/17/25 nursing progress note documented a CNA reported a resident-to-resident incident between Resident #3 and another resident (Resident #1). The note indicated Resident #3 was ambulating with her walker in the hallway towards the dining room when Resident #1 exited her room. Resident #1 then stood behind Resident #3 and grabbed Resident #3's arms. Resident #1 pushed Resident #3 towards the right side, causing Resident #3 to hit the door with her arm and shoulder. According to the note, a CNA ran to the area, checked on Resident #3 and then left Resident #3 to go find Resident #1. The CNA returned to Resident #3, assisted her to a chair and notified the nurse. The nurse assessed Resident #3. Resident #3 was not able to remember the incident. The note indicated there were no injuries identified on Resident #3. The intervention documented in the 2/17/25 nursing note was for staff to make sure Resident #3 was seated or in a place where she was clear from other residents, to better monitor her safety, continue to do the 15-minute checks and to monitor her for any injuries. The 2/18/25 nursing progress note documented Resident #3 was on alert charting for a resident-to-resident incident on 2/17/25. The note identified Resident #3 had injuries. -The nursing note did not identify what the injuries were to Resident #3's arms. The 2/18/25 nursing note further documented Resident #3 also had old bruising to her arms. The review of the electronic medical record (EMR) did not identify what the old bruising was from. -Cross reference F610: failure to investigate abuse. According to the 2/18/25 note, Resident #3 remained in the common area so staff could monitor her safety. The note indicated Resident #3 continued to be on 15-minute checks to observe and monitor Resident #3's whereabouts and safety. C. Resident #1 (assailant) 1. Record review The 2/17/25 nursing progress note, documented Resident #1 walked to the dining room after the resident-to-resident altercation. According to the note, Resident #1 was very anxious and restless during the shift. The note indicated Resident #1 would be monitored of her whereabouts and continue on 15-minute checks. The 2/21/25 interdisciplinary team (IDT) risk management review note documented Resident #1's physical aggression on 2/17/25 was related to her constipation, anxiety and possible pain. According to the note her medications were reviewed. Her bowel medication was discontinued and she was placed on a new bowel medication. Staff were educated to utilize Resident #1's PRN morphine. Resident #1 was newer to the facility and staff were still learning her behavior triggers. Resident #1 had excessive anxiety which hospice was trying to manage, she had a difficult time communicating and at times would use a white board to communicate. IV. Incident of physical abuse of Resident #1 by Resident #4 on 2/28/25 A. Facility investigation The facility investigation was provided by the NHA on 5/6/25 at approximately 11:30 a.m. The investigation documented there was a physical abuse altercation that was witnessed between Resident #1 and Resident #4 on 2/28/25. The investigation report included three interviews from staff witnesses and notification of the incident to the appropriate parties. The investigation report documented that neither resident involved in the altercation and no resident witnesses were able to be interviewed due to significant memory impairments. Resident #1, Resident #4, and three other resident witnesses were placed on observation for physical or behavioral changes for 72 hours after the altercation occurred. The investigated report documented Resident #4 pushed Resident #1 causing Resident #1 to fall backward when Resident #4 attempted to take Resident #1's shoe on 2/28/25 at 6:00 p.m. The two residents were separated and LPN #1 contacted the DON who was on site. The residents were separated and no injuries were observed. The residents were placed on 15-minute checks 72 hours after the altercation. The investigation documented Resident #4 did not like clutter and liked to clean, which led to the altercation. The investigation documented the underlying cause for the altercation was that Resident #1 was unable to communicate verbally and recently had her routine changed when her roommate had to move to a different room. Staff were educated following the interdisciplinary team (IDT) meeting 3/3/25. The investigation report documented LPN #1 who witnessed the event was interviewed. LPN # 1 said she observed Resident #4 attempt to take Resident #1's shoe. Resident #1 pulled the shoe back, then Resident #4 pushed Resident #1 causing Resident #1 to fall backward. LPN #1 contacted the DON who was on site. LPN #1 said that she felt she had adequate training related to preventing resident-to-resident abuse but she just could not get to the residents in time to stop the altercation. B. Resident #4 (assailant) 1. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included anxiety and dementia with restlessness and agitation. The 4/1/25 MDS assessment revealed the resident had short-term and long-term memory deficits, per staff assessment. She required substantial assistance with personal hygiene, bathing and dressing. She required cues and supervision with toileting. The assessment indicated the resident exhibited verbal behaviors (yelling, cursing, or threats) towards others. The assessment indicated the resident exhibited physical behaviors (hitting, kicking, pushing, or grabbing) towards others. The assessment indicated the resident wandered daily and the wandering, as well as behaviors, significantly intruded on the privacy or activity of others. 2. Record review The dementia care plan, initiated 4/10/24 and revised 3/11/25, indicated Resident #4 had behaviors of being disruptive or intrusive towards other residents, wandering and exit seeking, mood issues or tearfulness, sleep disturbances, poor safety awareness and delusions or hallucinations. Pertinent interventions included offering non-pharmacological interventions prior to administering PRN medication. The care plan indicated the non-pharmacological interventions included removing clutter from areas to reduce her anxiety, redirecting her to activities she was interested in, including gardening and cleaning, range of motion therapy, massage, relaxation and breathing techniques, imagery and distraction techniques, aromatherapy, or offering snacks or drinks, separating her from other residents when agitated and providing one-to-one support if needed until she was calm. The anti-psychotic medication care plan, initiated 4/10/24 and revised 3/5/25, indicated Resident #4 had behaviors of physical aggression, including hitting, kicking, or biting and verbal aggression, including yelling, screaming, or cursing at others. Pertinent interventions included offering non-pharmacological interventions prior to administering a PRN medications. The care plan indicated the non-pharmacological interventions included cold therapy, range of motion therapy, massage, relaxation and breathing techniques, and use of imagery and distraction techniques to redirect the resident. The nursing progress note, dated 2/28/25 at 9:14 p.m., documented Resident #4 attempted to take a shoe from Resident #1. Resident #1 pulled her shoe back and Resident #4 pushed Resident #1 down causing Resident #1 to fall down. Interventions included separating the residents and initiating 15-minute checks. Both residents were assessed for injuries and no physical injuries were noted. C. Resident #1 (victim) 1. Record review The nursing progress note, dated 2/28/25 at 8:48 p.m., documented Resident #4 attempted to take a shoe from Resident #1. Resident #1 pulled her shoe back and Resident #4 pushed Resident #1 down causing Resident #1 to fall down on her bottom with her back against the tray table. Interventions included separating the residents and initiating 15-minute checks. Both residents were assessed for injuries and no physical injuries were noted. V. Incident of abuse between Resident #3 and Resident #1 on 3/22/25 A. Facility investigation The facility investigation was provided by the NHA on 5/6/25 at approximately 11:30 a.m. The investigation documented on 3/22/25 at 3:35 p.m. Resident #3 was making her rounds and stopped at Resident #1's doorway. Resident #3 was looking in Resident #1's room. According to a CNA witness statement, the CNA saw Resident #3 attempt to force her way into Resident #1's room. The investigation documented Resident #3's walker touched Resident #1 and Resident #1 pushed against the walker. According to the nursing note, Resident #3 made contact with Resident #1's left side of her face. -The note did not identify in what way Resident #3 made contact with Resident #1's face. Resident #1 then pushed Resident #3, causing Resident #3 to hit her right side hip on the floor and the right back side of her head on the door frame as the CNA entered the room. According to a nurse witness statement the registered nurse (RN) heard a resident's loud voice in the hallway. The RN observed Resident #3 laying on the floor on the right side of her body and the CNA was holding her head. Another resident (Resident #1) was standing in front of Resident #3 and was touching the left side of her face. There was slight redness to her face. According to the witness statement, there was no obvious injuries to Resident #3 but she complained of pain in her right elbow. The statement documented the CNA told the nurse she was redirecting another resident when she saw Resident #3 make contact with Resident #1's left side of her face. The CNA said Resident #1 placed her hands on Resident #3's bilateral arms, resulting in Resident #3 losing balance and falling to the floor. The CNA who witnessed the incident was able to hold Resident #3's head as she fell to soften the hit to the head and the resident's head made contact with the door frame. According to the staff interview, the RN felt one-on-one conversations, companionship and speaking in a calm and positive tone were interventions that worked well with Resident #3. The investigation identified staff placed stop signs at both resident's doors. Resident #1 received more speech therapy treatments with collaboration with hospice to include devices such as picture boards. B. Resident #3 (victim and assailant) 1. Record review The 3/22/25 nursing progress note documented Resident #3 was on 15-minute checks due to a resident-to-resident altercation this shift (3/22/25). According to the note, Resident #3 had a witnessed fall with head involvement from the altercation. The 3/23/25 at 4:39 a.m. nursing progress note identified Resident #3 was on alert charting for a resident-to-resident altercation and a witnessed fall. According to the note, Resident #3 started hitting and yelling at staff to get out (of her room) when they attempted to get her vital signs. The staff attempted to try to reassure the resident but she continued to yell and hit the staff. C. Resident #1 (victim and assailant) 1. Record review The 3/22/25 nursing progress note documented the nurse heard a resident's loud voice in the hallway. The nurse then observed Resident #1 standing in front of her door and another resident (Resident #3) was on the floor with the CNA holding Resident #3's head. Resident #1's left hand was touching the left side of her face which was slightly red. There were no open wounds identified on either resident. Resident #1 was redirected and was kept separated from Resident #3 throughout the shift. According to the note, the residents were placed on 15-minute checks and a stop sign was placed over Resident #1's door to ensure other residents would not enter her room. The note identified the redness on Resident #1's face dissipated by the end of the shift. The note documented a CNA witnessed the event and reported the CNA was standing outside of the room, redirecting another resident. The CNA witnessed Resident #1 make contact with Resident #3's walker. Resident #3 made contact with the left side of Resident #1's face. Resident #1 then placed her hands on Resident #3's bilateral arms, which made Resident #3 lose her balance and fall to the floor. VI. Staff education The 3/24/25 staff education was provided by the NHA on 5/6/25 at approximately 11:30 a.m. The education agenda identified 10 staff members, which included two licensed practical nurses (LPN) and eight CNAs who worked on the memory care unit, attended the education. The education outlined the interventions of a stop sign on the doorway of Resident #1's and Resident #3's rooms to help keep others out of their space, utilizing pictures/whiteboard for communication speech working with Resident #1 to help her with better communication, speaking to Resident #3 in a calm manner, not telling her what to do and monitoring Resident #3 so that she does not intrude on other spaces and cause behaviors. VII. Staff interviews The unit manager (UM) and the NHA were interviewed together on 5/7/25 at 12:15 p.m. The UM said the staff on the memory care unit should know the residents and their preferences to develop interventions and individualized care plans. She said to help prevent resident-to-resident altercations, the staff should have eyes on the residents and de-escalate/redirect residents if they became agitated. The UM said individualized resident information sheets were created. The UM said the sheets identified residents' preferences, behavior triggers, what to watch for and a quick reference to residents' interventions. The UM said sometimes behaviors were an unmet need. The UM said Resident #3 had behaviors with staff during care and had difficulty trusting people. She said she needed familiar and consistent staff. The UM said Resident #3 would round the hallways, checking on residents because she used to work at an assisted living facility. The UM said staff watched her as she rounded the halls to make sure she was not intrusive or disruptive to other residents. She said Resident #1 did mind if Resident #3 peeked in her room, she just did not want Resident #3 to enter her room. The UM said to prevent more resident-to-resident altercations from occurring between Resident #1 and Resident #3, the staff placed a stop sign across the Resident #1's room so Resident #3 did not enter her room. The UM said they also encouraged the staff to speak to the residents in a calm manner because they did not like being told what to do, offering the residents walks, intervening when needed and watching for chronic pain. The UM said staff needed to keep Resident #1 in direct line of sight when she was out of her room. She said Resident #3 did not require a direct line of sight. She said staff should just generally watch her. The UM said the resident-to-resident altercations between Resident #1 and Resident #3 occurred mainly because Resident #3 entered Resident #1's room. The UM said Resident #1 would put up her own sign and shut her door. The NHA said Resident #1 was not having physically aggressive behaviors prior to the 2/15/25 altercation. She said neither resident was involved in resident-to-resident altercations prior to 2/15/25. The UM said Resident #1 had no known altercations prior to the 2/15/25 until she was hit by Resident #3. The UM said after the 2/15/25 resident to resident altercation, Resident #1 initiated the other resident-to-resident altercations. The NHA said Resident #1 did not like other people in her space. The NHA said the first three resident-to-resident altercations (2/15/25, 2/17/25 and 2/28/25) involved Resident #1 and Resident #3. The UM said she thought Resident #1 recognized Resident #3 from prior[TRUNCATED]

Based on record review and interviews, the facility failed to investigate an allegation of abuse and neglect for one (#3) of four residents out of six sample residents. Specifically, the facility failed to complete thorough and timely investigations when Resident #3 sustained injuries of unknown origin. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 5/7/25 at 3:45 p.m. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident symptoms. If resident abuse, neglect, exploration, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. According to the abuse policy, the facility would conduct an investigation to include interviews with staff members, residents, or family members who may have knowledge of the incident. II. Resident #1 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, dementia and other diseases elsewhere classified, severe with agitation, lack of coordination and anxiety disorder. The 4/1/25 minimum data set (MDS) assessment identified Resident #3 had moderate cognitive impairments, per a staff assessment for mental status. According to the MDS assessment, Resident #3 needed staff assistance with most of her activities of daily living (ADL). B. Record review The dementia care plan, revised 3/6/25, identified Resident #3 had impaired cognitive function/dementia or impaired thought processes related to dementia. The ADL care plan, initiated 12/18/24, identified Resident #3 required skin inspections and directed staff to observe for redness, open areas, scratches, cuts and bruises and report changes to the nurse. The skin care plan, initiated 4/4/25, documented if the resident had a bruise or skin tear, staff should treat the injury per facility protocol and notify the physician and family. The care plan directed staff to identify potential causative factors and eliminate/resolve the causation factors when possible. The 2/4/25 weekly nursing documentation form documented Resident #3 had an existing skin condition identified as bruising and noted the resident had some discoloration on her forearms. Review of Resident #3's electronic medical record (EMR) did not identify the bruising or discoloration on her forearms prior to the 2/4/25 weekly nursing documentation form. The 2/18/25 nursing progress note documented Resident #3 was on alert charting for a resident-to-resident incident on 2/17/25. The note documented Resident #3 was observed to have injuries to her arms. The nursing progress note identified Resident #3 also had old bruising to her arms. Cross reference: F600: failure to protect residents from abuse. -The 2/18/25 nursing note did not document what kind of injuries were on her arms and where the injuries were on her arms. -The note did not identify how Resident #3 sustained the old bruising to her arms or when the bruising occurred. -The review of the resident's EMR did not identify what the old bruising was from or when it occurred. C. Staff interviews The NHA and the director of nursing (DON) were interviewed together on 5/7/25 at 4:03 p.m. The NHA said Resident #3's injuries to her arms on 2/18/25 were identified after she was involved in a resident-to-resident altercation on 2/17/25. The NHA and the DON said they did not know what the old bruising was from, when it occurred or if there was old bruising actually present, even though it was documented on a 2/18/25 nursing note. The NHA and the DON said they were not aware of the bruising/discoloration documented in the 2/4/25 weekly nursing documentation. The DON said the last known bruising on the resident's arms prior to 2/4/25 was in December 2024 when Resident #3 was combative with care. The NHA said she reviewed Resident #3's EMR. The NHA said the 2/4/25 bruising/discoloration to the resident's forearms and the old bruising to the resident's arms, identified on 2/18/25, were not documented anywhere else. The NHA said the staff should go back into Resident #3's EMR to create a risk management report or document when the bruising was first observed. The NHA said bruises and injuries of unknown origin needed to be investigated according to the facility's policy. She said the bruising on Resident #3's arms should have been investigated to rule out abuse. The NHA said the documented 2/4/25 bruises and the old bruises identified on 2/18/25 were not investigated. She said she should have been notified of the bruising so she could have started an investigation if Resident #3's bruising was of unknown origin. The NHA said she would interview staff today (5/7/25) regarding the 2/4/25 and 2/18/25 bruising. The NHA said she would look at the resident's skin to determine if the resident still showed bruising or discoloration. III. Facility follow-up The NHA provided documentation of a staff interview that was conducted on 5/8/25, physician notes and skin observation sheet (2/1/25 to 2/16/25) on 5/8/25 via email. The 5/8/25 staff interview was conducted by the unit manager (UM). It documented she interviewed licensed practical nurse (LPN) #3 regarding her 2/18/25 documentation (on Resident #3). The UM documented LPN #3 did not recall any skin issues. The staff interview sheet documented the nurse who wrote the 2/4/25 note (weekly nursing documentation) no longer worked at the facility. The 2/5/25 physician encounter note did not identify if there was bruising or discoloration on Resident #3's arms at the time of the exam. The note documented the resident's skin was examined and there were no physical findings pertinent to the encounter. The note identified the physician saw Resident #3 on 2/5/25 due to her lethargy and lack of intake. The 2/17/25 physician encounter note documented Resident #3 was involved in a resident-to-resident incident. The encounter note did not identify if there was old bruising, new or any bruising or discoloration on Resident #3's arms. The note documented the resident's skin was examined and there were no physical findings pertinent to the encounter. The note identified the physician saw Resident #3 on 2/17/25 due to the resident's family's request to review her pain control. The February 2025 (2/1/25 to 2/16/25) skin sheet identified the nursing staff marked no to the question is there a new skin issue on the skin observation sheet. -A record of the skin observation sheet after 2/16/25 was not provided.

Based on record review and interviews, the facility failed to ensure one (#1) of three free of significant medication errors out of four sample residents. Resident #1 was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure and cognitive communication deficit. On 2/19/25 a nurse administered Resident #1 200 milligrams (mg) of pregabalin (nerve pain medicine) and 25 mg of metoprolol (blood pressure medication) in error. The resident began to experience nausea and was sent to the emergency room for monitoring. The resident experienced cardiac dysrhythmia (irregular heartbeat), hypotension (low blood pressure) and bradycardia (low heart rate). Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia, chronic diastolic (congestive) heart failure and cognitive communication deficit. The 2/14/25 minimum data set (MDS) assessment revealed Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #1 required partial assistance with self-care, functional cognition, upper body dressing and was independent with mobility. B. Resident #1's representative interview Resident #1's representative was interviewed on 3/26/25 at 9:20 a.m. The representative said she received a call from a nurse apologizing for giving Resident #1 the wrong medication. She was informed the resident was being sent to the emergency room to be monitored for adverse reactions. The representative said she was frustrated the medication error occurred. C. Record review On 2/19/25, a progress note documented that a nurse gave Resident #1 200 mg of pregabalin and 25 mg of metoprolol in error. The resident experienced nausea and was sent to the hospital to be monitored. On 2/20/25, emergency room notes documented Resident #1 experienced cardiac dysrhythmia hypotension and bradycardia. III. Staff interviews The nursing home administrator (NHA) was interviewed on 3/26/25 at 10:45 p.m. The NHA said the nurse that administered the wrong medication to Resident #1 on 2/19/25 resigned after the incident. Registered nurse (RN) #1 was interviewed on 3/26/25 at 11:30 a.m. RN #1 said she was new to the facility but in order to prevent a medication error she asked residents for their date of birth to confirm it was the right person. RN #1 said if the resident was unable to provide their date of birth she asked other staff to confirm she had the right medications for the right person. The NHA was interviewed again on 3/26/25 at 12:00 p.m. The NHA said she did not get to complete an interview with the nurse who accidentally gave Resident #1 the wrong medications. The NHA said the nurse managers completed medication pass observations with all the nurses to ensure education was up to date and no further medication errors would occur after the medication error occurred on 2/19/25.

Based on observations, record review and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two of two kitchenettes. Specifically, the facility failed to ensure: -Dented canned foods were not stored to be served to residents and food items were labeled with use-by dates; -Kitchen staff appropriately cleaned thermometers before temperatures were obtained from ready-to-eat foods; -Spare thermometers were kept in each refrigerator and freezer in case the digital thermometer went out and thermometers in the refrigerators and freezers were not broken; -Kitchen refrigerators were held at the appropriate temperature; and, -Cold foods were held at 41 degrees Fahrenheit (F) or below before serving residents. Findings include: I. Pantry items and food storage A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved 4/2/24 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Products that are held by the permit holder for credit, redemption or return to the distributor, such as damaged, spoiled or recalled products shall be segregated and held in designated areas that are separated from food, equipment, utensils, linens, single-service and single-use articles. The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 4/2/24 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, A date marking system that meets the criteria stated in (2) of this section may include: Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. B. Facility policy The Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions policy, revised January 2024, was provided by the nursing home administrator (NHA) on 3/27/24 at 4:00 p.m. read in pertinent: Foods not in original containers are labeled and dated with an opening date and suggested to have a use-by date. C. Observations On 3/24/24 at 9:28 a.m. during the initial kitchen tour, a large can of potatoes was observed with a large dent in the can on the shelf in the pantry to be used in a meal. Large plastic containers were observed with dates that were not specified as being an opening date or a use-by date. The large plastic containers were not labeled as to what the item was inside. There was a prepared container of food in the walk-in cooler that appeared to be tomato based that was not labeled or dated. D. Staff interviews The dietary manager (DM) was interviewed on 3/27/24 at 10:49 a.m. She said she was unaware there was a defective can in the pantry. She said the kitchen staff did not use defective cans and would remove the canned potatoes. The DM said the dates were the dates when the items were opened. She said she saw the issue with just writing a month and day because some of the days were interpreted to be years. She said she was going to address the labels and ensure they said when they were opened and would display the entire date. II. Improper cleaning of food thermometer A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved 4/2/24 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. Equipment food-contact surfaces and utensils shall be cleaned before using or storing a food temperature measuring devices. B. Lunch observations on 3/26/24 at 11:45 a.m. At 12:10 p.m. a resident requested soup for lunch. The dietary aide (DA) was observed removing the soup from the microwave. She took an alcohol wipe out to clean the thermometer before she obtained the temperature. She poked the thermometer through the middle of the alcohol wipe, without fully opening the wipe. She then ran the alcohol wipe and its packaging up and down the thermometer probe. She obtained the temperature of the soup and cleaned the thermometer probe by poking a hole through another alcohol wipe and moving it up and down the thermometer probe. At 12:25 p.m. a resident requested a side of soup with his lunch. The DA was observed removing the soup from the microwave. She took an alcohol wipe out to clean the thermometer before she obtained the temperature. She poked the thermometer through the middle of the alcohol wipe, without fully opening the wipe. She then ran the alcohol wipe and its packaging up and down the thermometer probe. She obtained the temperature of the soup and cleaned the thermometer probe by poking a hole through another alcohol wipe and moving it up and down the thermometer probe. At 12:30 p.m. another resident requested soup for lunch. The DA was observed removing the soup from the microwave. She took an alcohol wipe out to clean the thermometer before she obtained the temperature. She poked the thermometer through the middle of the alcohol wipe, without fully opening the wipe. She then ran the alcohol wipe and its packaging up and down the thermometer probe. She obtained the temperature of the soup and cleaned the thermometer probe by poking a hole through another alcohol wipe and moving it up and down the thermometer probe. At 12:31 p.m. the DA removed a personal-sized mini pizza from the oven to check the temperature before serving it to a resident. The DA was observed removing the pizza from the microwave. She took an alcohol wipe out to clean the thermometer before she obtained the temperature. She poked the thermometer through the middle of the alcohol wipe, without fully opening the wipe. She then ran the alcohol wipe and its packaging up and down the thermometer probe. She obtained the temperature of the pizza and cleaned the thermometer probe by poking a hole through another alcohol wipe and moving it up and down the thermometer probe. The pizza was returned to the oven because it was not the correct temperature. At 12:44 p.m. the DA removed the pizza from the oven and was observed taking an alcohol wipe out to clean the thermometer before she obtained the temperature. She poked the thermometer through the middle of the alcohol wipe, without fully opening the wipe. She then ran the alcohol wipe and its packaging up and down the thermometer probe. She obtained the temperature of the pizza and cleaned the thermometer probe by poking a hole through another alcohol wipe and moving it up and down the thermometer probe. The pizza was returned to the oven for still being at the incorrect temperature. At 12:47 p.m. the DA removed the pizza from the oven and was observed taking an alcohol wipe out to clean the thermometer before she obtained the temperature. She poked the thermometer through the middle of the alcohol wipe, without fully opening the wipe. She then ran the alcohol wipe and its packaging up and down the thermometer probe. She obtained the temperature of the pizza and cleaned the thermometer probe by poking a hole through another alcohol wipe and moving it up and down the thermometer probe. The pizza was served to the resident. C. Staff interviews The DM was interviewed on 3/27/24 at 10:49 a.m. She demonstrated how the kitchen staff were to clean the food thermometers. She took an alcohol wipe and removed the paper packaging. She then took just the wipe, folded it around the thermometer probe and moved the wipe along the probe. She said she was unaware the DA poked through the packaging of the wipe to sanitize the thermometer probe. The DM said the way the DA cleaned the thermometer was not sufficient because the alcohol wipe needed to be removed from its packaging to clean the probe. She said she was going to provide education to all of the kitchen staff and ensure they cleaned the thermometer correctly. III. Refrigerator and freezer thermometers and temperatures A. Observations on 3/24/24 At 9:28 a.m. the silver side-by-side freezer had a digital thermometer but there was not an internal thermometer as a backup in the freezer. The walk-in cooler had a digital thermometer that did not show the temperature, the screen was black. A spare thermometer could not be located inside the refrigerator or freezer located within the walk-in cooler. At 9:40 a.m. the refrigerator and freezer in the south hall's kitchenette were observed. The thermometer in the refrigerator read 50 degrees Fahrenheit (F). The thermometer in the freezer displayed a red line that was not solid which indicated that the thermometer was broken. There was not a digital thermometer for this refrigerator and freezer. At 9:50 a.m. the refrigerator and freezer in north hall's kitchenette were observed. The spare thermometers in the refrigerator and freezer displayed a red line that was not solid which indicated the thermometers were broken. B. Staff interviews The DM was interviewed on 3/27/24 at 10:49 a.m. She said the kitchen staff were responsible for the refrigerators and freezers but that nursing staff assisted with checking on foods stored in the unit refrigerators. She said she was unaware some of the thermometers were missing and some were broken. She said she was not sure why the walk-in cooler digital thermometer did not display the temperature. She said she had spare thermometers and would replace them and worked with the kitchen staff to ensure temperatures were obtained and monitored for each refrigerator and freezer at the facility. IV. Cold foods A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19 and retrieved 4/2/24 from https://cdphe.colorado.gov/environment/food-regulations read in pertinent part, Except during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. Equipment for cooling and heating food, and holding cold and hot food, shall be sufficient in number and capacity to provide food temperatures as specified. The FDA (Food and Drug Administration) food code reviewed on 3/27/23 and retrieved 4/2/24 from https://www.fda.gov/food/fda-food-code/food-code-2022 read in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long. B. Facility policy The Food Wholesomeness: Procurement, Storage, Preparation and Service Sanitary Conditions policy, revised January 2024, was provided by the nursing home administrator (NHA) on 3/27/24 at 4:00 p.m. read in pertinent: Cold foods are kept between 34 to 41 degrees Fahrenheit (F) before serving; and Foods not in original containers are labeled and dated with an opening date and suggested to have a use-by date. C. Observations on 3/26/24 At 11:45 a.m. the DM and DA were preparing to start serving lunch. There were individual bowls of fresh mixed fruit sitting on the counter but were not on ice. At 12:10 p.m. the meal cart for [NAME] Hall was completed. The DM started plating for the next meal cart. The mixed fruit was not on ice. At 12:23 p.m. the meal cart for South Hall was completed. The DM started plating for the next meal cart. The mixed fruit was not on ice. At 12:38 p.m. the final meal cart for North Hall was completed. The mixed fruit was not on ice. At 12:48 p.m. after all the residents were served, the fresh fruit was 63.6 degrees F. D. Staff interviews The DM was interviewed on 3/27/24 at 10:49 a.m. She said she had been at the facility for about a year and the temperature of the meals had been a continuous issue since she started. She said the lettuce and tomato that was used as a topping was on ice and she did not think about the fruit. The DM did not obtain the temperature of the fruit at the beginning of lunch and did not check the temperature after lunch was served. She said she was going to make sure it did not happen again.

Based on observations, interviews and record review, the facility failed to address and/or act promptly upon the grievances and recommendations during resident council on issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to ensure resident council concerns were addressed timely with interventions to resolve the resident's call light concerns. Findings include: I. Facility policy The Grievance policy, dated 5/8/23, was provided by the nursing home administrator (NHA) on 3/27/24 at 4:00 p.m. The policy read in pertinent part: To ensure that residents are forwarded their right to file grievances without discrimination or appraisal and such grievances shall be responded promptly and in written form. The administrator may assign the responsibility of investigating grievances and complaints to the appropriate department. Upon the receipt of a grievance and complaint report or complaint concern form, the social service director or designee will begin an exploration into the allegation/concerns. The appropriate department director will be notified of the nature of the complaint and that follow-up is necessary. Grievance and complaint investigation report must be filed with the administrator within five working days of the receipt of the grievance or complaint form. The resident or the person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 10 working days of filing the grievance or complaint. II. Group interview Five residents, (#6, #18, #25, #33 and #40) were interviewed during a group interview on 3/26/24 at 1:15 p.m. The residents were deemed alert and oriented by the facility. Two of the five residents expressed concerns with receiving care timely. -Resident #6 said she had to wait up to 45 minutes to use the restroom. She said she has had an accident because she had to wait too long for staff assistance. -Resident #25 said he had waited 30 minutes to use the restroom. III. Resident council minutes The review of the resident council minutes from December 2023 through March 2024 identified the residents in resident council had concerns regarding long call light times since December 2023. The concerns remained unresolved. The minutes did not identify how the facility was addressing the unresolved concern. The November 2023 resident council minutes read the social service director (SSD) told the council that if residents had any complaints or concerns she would provide them with a form. The December 2023 resident council minutes read the residents said they were having to wait for longer periods of time to receive care. According to the minutes, the residents felt long call light waits were usually between 5:00 p.m. and 7:00 p.m. The minutes read a grievance was filed for call wait times. The minutes did not identify how the facility planned to address the residents' call wait times. -The grievance form related to the residents' call light concerns was requested, however, the facility was unable to provide documentation to indicate a grievance form had been completed for the resident council concern. The January 2024 resident council minutes read residents felt they still had a slight wait time with their call lights. According to the January 2024 minutes, the group grievance regarding call wait times was not resolved. -The minutes did not identify how the facility addressed and was addressing the unresolved concern on call light wait times. The February 2024 council minutes read resident council stated call light wait times were beginning to improve and answered more promptly. The minutes read grievance regarding call light times was not resolved during the February 2024 council. -The minutes did not identify how the facility was addressing the ongoing unresolved concern. The March 2024 council minutes under new business read call lights were answered promptly; however, the review on the last two councils, the residents did not resolve the grievance on call lights. The March 2023 minutes under new business read resident council felt call lights were improving but did not feel their grievance regarding call light wait times should be resolved. -The minutes did not identify why the resident felt the call light grievance was not resolved. -The minutes did not identify how the facility was addressing the ongoing resident concern. IV. Staff education A 2/29/24 staff inservice form was provided by the facility on 3/27/24. The inservice topic was call light times. The form was signed by nine CNAs. The inservice was the provided intervention after the residents expressed and carried over call light concerns in the December 2023, January 2023 and February 2023 resident council. In March 2024, and after the nine staff were in-serviced on 2/29/24, the residents still did not feel the call light concern could be resolved. V. Staff interviews The nursing staff scheduler (NSS) was interviewed on 3/27/24 at approximately 10:00 a.m. The NSS said residents had come to her expressing they needed more help with care. She said the residents said they needed more assistance so they could timely use the restroom. She said most of the concerns were in the evening. She said the concerns were sporadic. She said the residents might have felt they needed more assistance in the evenings because during the day the management staff answered call lights. The social services director (SSD) was interviewed on 3/27/24 at 12:05 p.m. She said when she received a grievance she brought up the concern in the morning meetings with leadership. She said the week of 3/18/24 she identified an issue with the facility's grievance follow-up. She said the responsible department was not following up with the residents or correcting the issue. She said to fix the problem each department manager was going to touch base with the resident and see if the grievance was resolved. A three-check system was created to ensure the grievances were followed up on by the department head first, then the SSD and the NHA provided the final check. The nursing home administrator (NHA) was interviewed on 3/27/24 at 1:33 p.m. She said she and the SSD started looking at grievances last week (on 3/20/24) and identified the grievance system needed to be revamped. The NHA said she identified concerns were not being responded to in a timely manner, the responses were incomplete and/or the response did not resolve the concern. The NHA said when she was made aware of call light concerns, she could pull the call light report. She said the report was usually not pulled for the quality assurance and performance review meetings unless there was an identified problem. The NHA said she attended the resident council meetings when she was asked to attend the meetings. The NHA said the activity director shared the minutes with her each month but she had not looked at the minutes to know call light timing was an ongoing concern. The NHA said with concerns addressed in resident council, a grievance form was started with activity director or designee, the grievance was shared with the SSD and then it would be reviewed in the interdisciplinary committee (IDT). The IDT determined who was best to address the concern. The grievance would be given to the appropriate department with an expectation of a 72 hour follow up. The NHA said she felt there was a lot of opportunity to improve the grievance process. She said there was a lack of accountability. The NHA said she had a lot of new members of management and she was not sure the team members understood the importance of addressing the concerns timely and accurately and returning the grievance forms. The NHA said the SSD said she had been struggling with the department's to return the grievance forms. The NHA said she would continue to work on oversight of the process.

Based on observations and interviews, the facility failed to maintain the emergency response equipment in safe operating condition for one of two emergency response carts. Specifically, the facility failed to: -Ensure the oxygen cylinder on the south emergency response cart was secured on the emergency cart; -Ensure nursing staff were trained to use portable oxygen; and, -Ensure expired medical supplies on the south unit emergency cart were removed from the care area. Findings include: I. Oxygen cylinder failures A. Facility policy The Oxygen policy, dated 2/29/24, was received 3/26/24 at 12:26 p.m. by the director of nursing (DON). The policy read in pertinent part, Secure each tank individually, by a chain, on a cart or on a stand. B. Observations and interviews On 3/25/24 at 11:57 a.m., the emergency response cart was observed and inspected with registered nurse (RN) #1. The emergency response cart was designed to secure a type E (25.5 inches in length) oxygen cylinder. -The emergency cart was observed with a smaller size M (16.5 inches in length) oxygen cylinder that hung loosely by the oxygen regulator and swung back and forth freely when touched. -The oxygen cylinder was not secured to the emergency equipment cart. RN #1 said the cylinder should be secured but did not know if a size E oxygen cylinder was available. RN #1 said she was unable to verify the oxygen level in the cylinder because she was not familiar with the cylinder, had not been trained on the cylinder and was unsure how to turn on the oxygen in the cylinder. She observed the oxygen flow regulator and said the indicator read empty. RN #1 said the oxygen cylinder was not correctly secured to the emergency cart and she did not know if a replacement oxygen cylinder that could be secured on the equipment cart was available. RN #1 reviewed the daily checklist record for the emergency cart and said the cart had been checked daily in March 2024. RN #1 said the daily checklist did not include the requirement to inspect and check the oxygen on the cart. She said if she needed emergency oxygen, she would use an oxygen supply from a resident room. She said if an emergency occurred away from a resident room and she needed the oxygen cylinder, she would ask a staff member to assist her with the oxygen. RN #1 said the city emergency response teams usually arrived in about ten minutes and they would assist with oxygen administration. RN #1 said it was the responsibility of the night shift nurse to inspect and verify the emergency equipment care was inspected and ready for use. On 3/26/24 at 9:05 a.m. and 11:45 a.m., the oxygen cylinder was observed again. The smaller oxygen cylinder continued to be unsecured to the emergency response cart and hung on the cart from the oxygen regulator. II. Emergency equipment failure A. Professional reference According to [NAME], [NAME], (2022). Crash cart preparedness and failure to rescue a case study review,retrieved on 3/29/24 from https://www.researchgate.net/publication/360555126_Crash_cart_preparedness_and_Failure_to_rescue_A_case_study_review,, A crash cart is a mobile cabinet on wheels that contains equipment required for emergency cardio-pulmonary resuscitation. The carts are individualized and conveniently located throughout healthcare facilities for rapid access in the event of an emergency. A crash cart is typically located in the setting of an unexpected medical emergency. This could include severe allergic reaction, cardiac or respiratory arrest, and conditions with an unexpected sudden deterioration of vital signs. This would require equipment located on the card cart which would be used by a credentialed life support provider. While crash carts vary depending on location, the fundamentals for the crash cart will contain similar equipment. Although the organization of requirements for a crash cart is not generic, there is a fundamental standard which provides effortless access to emergency medical equipment. Note that all these organizational points are checked, dated, and signed by the staff member who performed the daily routine inventory and inspection. Side or rear -The oxygen cylinder should be secure on the side of the cart, with a full oxygen pressure level. Recommended equipment and medications -Organization and location specific. Recommended maintenance -Check expiration dates on equipment and medications per organization policy and replace as required. Schedule inventory check -The purpose of a crash cart inventory is to organize a schedule of when to check for expiration dates of equipment and supplies. -Check that equipment is operating as required in the event of an emergency. In addition to recording who performed the inventory checks, with dates, times, and signatures. An alarming situation for the healthcare personnel requiring a crash cart is to find unusable equipment or expired medications in an emergency. Ensuring that an up-to-date, accurate, and truthful inventory record can avoid potential patient safety situations such as absence of equipment, equipment failure, expired or missing medication, and empty oxygen cylinders. The patient safety risk incident failure to rescue is perpetrated by healthcare professionals when they do not check cart accurately. Failure to follow standard or policy for checking equipment compromises patient safety and creates potential to harm patients. B. Facility Policy The emergency equipment policy was requested on 3/25/24, however, a policy was not provided by the end of the survey. C. Observations and interviews On 3/25/24 at 11:57 a.m., a plastic pencil box labeled cor (emergency) cart was observed with RN #1 in the top drawer of the emergency response cart. The pencil box contained a glucometer designated for emergency use. The pencil box included a glucometer, lancets, loose cotton balls, alcohol wipes and glucometer test strips. RN #1 observed the glucometer test strip container, labeled assurance platinum test strips 50 count, expired 9/17/21 and included four test strips. RN #1 said if an expired test strip was used, an incorrect blood sugar level could be the result. RN #1 immediately removed the expired test strips from the emergency equipment cart. RN #1 said the night shift nurse was responsible for checking the supplies and should have removed the expired glucometer test strips. IV. DON observation and interviews On 3/25/24 at 12:25 p.m., the DON observed the emergency response cart. She said the oxygen cylinder was not secured safely to the emergency response cart and the cylinder should not hang or swing by the regulator valve. She said the facility would replace the small cylinder with a larger cylinder for secure storage. -Despite the DON indicating the facility would replace the oxygen cylinder with a larger cylinder on 3/25/24, the smaller oxygen cylinder continued to be unsecured to the emergency response cart and hung on the cart from the oxygen regulator (see observations above). The DON said the glucometer should not have been stored in the emergency response cart. She observed several medical supplies such as various sizes of oral airways that were not included on the inventory list but were stored in the equipment drawers. The DON said she would provide mandatory education on the emergency response cart storage and oxygen use with nursing staff. The DON was interviewed again on 3/26/24 at 12:35 p.m. The DON said the facility did not have a policy for the emergency response cart. She provided a copy of a blank, undated, emergency response cart checklist. The DON said the checklist did not include a check for a glucometer or the oxygen cylinder. She said the glucometer should not have been stored on the emergency response cart.

Based on interviews and record review, the facility failed to ensure three (#23, #36 and #42) of four residents reviewed were free from abuse out of 26 sample residents. Specifically, the facility failed to ensure: -Resident #23 was free from physical resident to resident altercations/physical abuse by Resident #42; and, -Resident #36 was free from physical resident to resident altercations/physical abuse from Resident #42. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/27/23 at 6:10 p.m. The policy identified in pertinent part: (The facility) does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. According to the policy, abuse was defined as The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a care, of goods or service that are residents from abuse, necessary to attain or maintain physical, mental, or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. II. Incident of physical abuse of Resident #23 by Resident #42 A. Incident on 1/27/24 The 1/27/24 nursing progress note for Resident #42 read Resident #42 was involved in an altercation with another resident. There were no injuries. The 1/27/24 incident report was provided by the NHA on 3/26/24 9:25 a.m. The report identified the nurse was informed Resident #23 was slapped by another resident (Resident #42). The residents were separated and 15 minute checks on the residents were implemented. The residents were assessed and there were no injuries on either resident. The altercation was witnessed by certified nurse aide (CNA) #1. According to the incident report, the predisposing factor was wandering. The abuse investigation read on 1/27/24 at approximately 10:45 p.m., CNA #1 witnessed Resident #42 walk up to Resident #23 who was on the couch (in the common area). Resident #42 attempted to take Resident #23's hat from her. The CNA got up to intervene and at that time Resident #42 hit Resident #23 in the face. The CNA was able to separate the residents and call the nurse to assist. No injuries were noted and residents did not recall the incident and were both at baseline. The registered nurse (RN) was interviewed and identified Resident #42 refused her medications all day. The resident accepted her medication later that evening and was agitated. The report read Resident #23 was sleeping when Resident #42 approached her. The residents were speaking normally to each other when out of nowhere Resident #42 became upset and took Resident #23's hat. Resident #42 then extended her hand and slapped Resident #23. The incident was substantiated without injury. B. Resident #42 1. Resident status Resident #42, over the age of 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnosis included unspecified dementia, unspecified severity, with other behavioral disturbance and Alzheimer's disease. The 2/1/24 minimum data set (MDS) assessment identified the resident had moderate cognitive impairment with a staff assessment for mental status. The resident had short and long term memory problems. Resident #42 had hallucinations and delusions. She had physical and verbal behaviors directed to others. The resident was identified to have other behavioral symptoms not directed toward others. The resident had rejections of care and exhibited daily wandering behaviors. The resident's functional ability on admission identified the resident did not have limitations of her upper or lower extremities. The resident did not require a mobility device. 2. Record review The verbal and physical aggression care plan, initiated on 10/4/22 and revised on 3/18/24, identified Resident #42 was at risk for resident-to-resident altercations related to verbal/physical aggression and dementia with behavioral disturbances. According to the care plan, the resident had a a history of being involved in resident-to-resident altercations. The resident's aggression was often unprovoked and unpredictable. The care plan directed staff to anticipate her needs. The care plan identified the following interventions: -Stop sign to be placed at resident's level on door to help prevent others from wandering into her room and staff to monitor. The care plan intervention was initiated on 7/28/23. -Resident #42 enjoyed attending equine therapy and spending time with the facility pets. The care plan intervention was initiated on 10/4/22 and revised on 5/16/23. -Resident #42 was placed on frequent checks and closely watched by staff. The care plan intervention was initiated on 9/8/23 and revised on 9/13/23. -Provide one-on-one visits as needed if the resident was not able to be soothed. The staff may assist the resident of the unit or to a quiet/ less stimulated place until her mood was alleviated. The care plan intervention was initiated on 10/4/22 and revised on 3/14/24. -The resident would be evaluated for pain and constipation when the resident had an increase in agitation and excess pacing. The care plan intervention was initiated on 3/14/24. -Monitor Resident #42 for constipation daily. The care plan intervention was initiated on 3/14/24. -Monitor the resident for pain frequently throughout the day. The care plan intervention was initiated on 3/14/24. -A psychoactive medication pharmacy review would be conducted as needed. The care plan intervention was initiated on 3/14/24. -Staff was to be educated on anticipating needs and watching Resident #42 closely for agitation. The care plan intervention was initiated on 3/14/24. The behavior care plan, initiated on 11/19/21 and revised on 11/22/23, identified Resident #42 had behavior challenges related to her severe cognitive impairment. According to the care plan, The resident had exit seeking behaviors that caused the resident to become frustrated with her surroundings and others. The care plan read the resident was able to be redirected to safe tasks. Interventions included: anticipating her needs; behavior monitoring; provide opportunities for positive interaction; provide activities of interest and ability and praise positive interaction; and monitor the resident behavioral episodes and attempt to determine the cause. According to the care plan intervention, initiated 2/1/24, the resident had chronic pain which could increase her behaviors. The intervention directed staff to monitor her pain and ensure the resident took all her medications. C. Resident #23 1. Resident status Resident #23, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included dementia, senile deterioration of the brain, glaucoma and presence of a cardiac pacemaker. The 1/11/24 MDS assessment identified Resident #23 had severe cognitive impairment with a BIMS score of three out of 15. The MDS assessment identified the resident did not have functional range of motion impairment with her upper or lower extremities. She was to ambulate independently and wandered daily. The resident had hallucinations, delusions and behaviors of verbal aggression. 2. Record review The secured unit care plan, initiated 6/1/23 and revised on 11/22/23, read Resident #23 required a secure neighborhood due to senile degeneration of the brain, dementia with agitation and psychotic disturbances. The cognition care plan, initiated 6/2/23 and revised on 11/22/23, read Resident #23 had impaired cognitive function/dementia or impaired thought processes related to impaired decision making. The resident was able to communicate her needs and wants verbally and nonverbally with simple communication. The behavior and wandering care plan, initiated 6/2/23 and revised on 11/22/23, read Resident #23 had a behavior problem of wandering and exit seeking. According to the care plan, staff were to monitor behavioral episodes and attempt to determine the underlying cause considering location, time of day, persons involved and situations. 3. Staff education The 1/30/24 in-service instructed the memory care unit nurses to attempt to administer medications (when Resident #42 was resting) before charting the resident was sleeping or refused. The in-service read staff should crush medications and give in a medium of choice to ensure the medications were and apply pain gel as ordered. Three nurses signed the in-service. III. Incident of physical abuse of Resident #36 by Resident #42 A. Incident on 3/10/24 The 3/10/24 nursing progress note read Resident #42 was pacing back and forth in the hall and was agitated on 3/10/24 from approximately 3:00 p.m. to 3:30 p.m. The activity assistant (AA) and the nurse witnessed Resident #42 walk past Resident #36 and smack the back of her head. Resident #36 was not injured. Resident #42 remained agitated another 40 minutes then settled down to rest in a chair. According to the note, attempts to redirect Resident #42 were ineffective. The resident was administered her medication which was effective. The 3/10/24 alert note for Resident #42 read Resident #42 smacked Resident #36 with the palm of her hand. Resident #36 said oh and Resident #42 continued to walk. There were no injuries involved in the incident. The abuse investigation read on 3/10/24 at approximately 3:22 p.m., residents were sitting in a group engaged in a bowling activity. Resident #36 was participating in the activity when Resident #42 walked up behind her and hit her on the back of the head with an open palm and walked away. No injuries were noted and neither resident recalled the incident during the investigation. According to the abuse investigation report, the incident was substantiated. D. Resident #36 1. Resident status Resident #36, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included Alzheimer's disease, dementia, unspecified severity, with other behavioral disturbance and glaucoma. The 1/3/24 MDS assessment identified Resident #36 had severe cognitive impairment with a BIMS score of seven out of 15. The MDS assessment identified the resident did not have functional range of motion impairment with her upper or lower extremities. The resident used a walker for ambulation. The resident had behaviors of verbal and physical aggression. 2. Record review The secured unit care plan, initiated 1/23/23, read Resident #36 required a secure neighborhood due to her wandering without the ability to find her way back. The cognition care plan, initiated 10/4/23 and revised on 11/22/23, read Resident #36 had delirium or an acute confusional episode related to dementia. The resident allowed staff assistance and was easily redirected. The communication care plan, initiated 1/20/23 and revised on 1/31/23, read Resident #36 had communication problems related to dementia. The resident was very soft spoken and non-verbal the majority of the time and occasionally would speak in her native Japanese language. The resident was able to follow simple commands. 3. Staff education A 3/14/24 staff in-service was provided by the director of nursing (DON) on 3/26/24 at 12:26 p.m. The in-service read when Resident #42 was agitated, re-direct the resident from other residents to a less stimulating environment. Provide Resident #42 one-on-one support and anticipate her needs. Evaluate Resident #42 for pain and constipation. To reduce the risk of recurrence of resident to resident altercations, place Resident #42 on frequent checks and monitor her for an increase in agitation. The in-service was provided to the nurses, CNAs and an activity assistant (AA) who worked on the memory care unit. IV. Staff interviews The NHA, the DON and the memory care unit manager (UM) were interviewed on 3/26/24 at 9:25 a.m. The abuse investigations involving Resident #42 were reviewed. The NHA said Resident #23 was on the couch on 1/27/24 at 10:45 p.m. when Resident #42 walked up to her and took her hat. The residents exchanged words. The CNA on the unit saw Resident #42 take the hat and then slap Resident #23 in the face before the CNA could intervene. At the time of the incident, Resident #23 and Resident #42 were the only residents up and in the common area. The UM said Resident #23 usually preferred sleeping on the couch. There was no injuries or redness to Resident #23's face and the nurse said neither resident was upset. Both residents were placed on frequent checks for 72 hours with frequent observations. There were no significant changes with either resident after the incident The NHA said Resident #42 had declined her medications during the day on 1/27/24 but received her medications in the evening before the incident. The UM said Resident #42 would not always take her medications but she was more receptive since the incident. The NHA said the resident was on a new antipsychotic medication at the time of the incident and was adjusting to it. Resident #42's family member said the resident was suspicious of her medications. The UM said after the 1/27/24 physical altercation between Resident #42 and #23, she completed an education with the nurses on effective ways to give medications. She said medications could be crushed if deemed appropriate and placed in a medium of choice (apple sauce, pudding) The UM said a pain medication was added because a contributing factor could also have been pain related. The UM said she educated the staff to attempt to administer routine medications by gently waking Resident #42 if she was sleeping because the resident would wake up agitated. The NHA said the resident did take the medications in the evening so the medications were in her system at the time of the 10:45 p.m. incident. The UM said the resident had an order to crush the medications if needed since September 2023 but she would take the medications whole for some of the nurses. The nurses were reminded to crush appropriate medications to help in the administration of the medications on 1/30/24 which had helped improve the receipt of Resident #42's medications. The NHA said the other interventions were to focus on pain management. The resident had a chronic back injury. The UM said the resident had oral pain medications in place and topic gel. There had been no other incidents or concerns between Resident #42 and Resident #23 after 1/27/24. The resident to resident altercation between Resident #42 and Resident #36 on 3/10/24 was reviewed with the NHA, the DON and the UM. The NHA said Resident #42 walked behind Resident #36 when she was in a bowling activity and hit her. Resident #42 was not participating in the activity at the time but she was walking by. The nurse did not believe pain was a factor in the altercation and Resident #42 was receiving all her medications. The nurse witness statement read Resident #42 was agitated all day and was combative and verbally aggressive with staff. The NHA said during the investigation, the nurse and the AA felt the large bowling activity group was too stimulating in the common area for Resident #42 and caused her to act out. The NHA said another factor was the resident had not had a bowel movement in three days. The UM said the physician was contacted with a request for the resident to be placed on a bowel management regimen to help keep the resident more regular with bowel movements. She said the resident's pain medications could cause constipation. The NHA said staff were educated that if Resident #42 was pacing, she may have increased agitation, increasing her behavior risk. The staff were directed to assist Resident #42 to a less stimulating environment away from other residents and/or take her for a walk. If the resident was agitated, the staff should place her on frequent checks and assess for pain and if she had a bowel movement. The NHA said the goal was to identify any potential triggers before it became a concern. The UM said the care plan was updated to include the risk for unprovoked aggression, the identification of potential triggers, monitor daily for constipation and notify the physician. The activity director (AD) was interviewed on 3/27/24 at 4:59 p.m. She was aware of Resident #42's resident to resident altercations. The AD said when the resident was agitated, her staff would focus on distraction. She said the activity staff was providing one-on-one resident interaction for Resident #42. She said the staff talked to her about things she liked to do. The AD said the resident used to be a receptionist. Staff took her for walks outside and had her hold the facility bunny and cat. She said the staff watched her for signs of agitation such as her tone of voice or changes in her facial expressions and/or would say that she was closed. The AD said social activity groups triggered her sometimes but not always. She said she had not noticed a specific time in day the resident was more triggered the other times in the day.

Based on observations, interviews and record review, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance to prevent accidents for two (#52 and #50) of 11 residents reviewed for accident hazards out of 26 sample residents. Specifically, the facility failed to: -Ensure a baseline fall care plan with fall interventions was implemented in a timely manner for Resident #52 who was assessed to be a high risk for falls upon admission; -Implement an appropriate fall intervention for Resident #52 following his fall out of his recliner on 2/20/24; -Implement timely and effective fall interventions for Resident #50; and, -Ensure fall interventions were updated on Resident #50's care plan and staff were consistently implementing the interventions. Findings include I. Facility policy The Fall Management policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 3/27/24 at 4:00 p.m. It read in pertinent part, The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. To be effective, a fall reduction program is characterized by four components: -Fall risk evaluation; -Care planning and implementation of interventions; -Ongoing evaluation process quality assurance performance improvement (QAPI); and, -A commitment by caregivers to make it work. A fall risk evaluation will be completed within the first 24 hours following admission using the fall risk evaluation. A baseline plan of care will be initiated for residents determined to be at risk. Each resident will be re-evaluated quarterly, annually and when a significant change occurs. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Resident and resident representatives (if applicable) will be invited to all care plan meetings. Please note interventions are to be re-evaluated when a resident falls for efficacy. The following interventions may be considered after identification of root cause: -A physical therapy (PT) evaluation or screen should be considered; -Medications will also be reviewed; -Evaluate physical health status; -Assess the environment and make appropriate changes (like bed in lowest position, night light and placement of furniture); -Offer frequent toileting or follow individualized toileting schedule; -Assess need for a potential room change (as in a room closer to the nursing station); -Positioning devices; -Protective devices; -Restorative nursing; and, -Complete a thorough analysis of the fall including the time of day, location of call, causative factors. Identify whether the interventions were in place at the time of the fall. II. Resident #52 A. Resident status Resident #52, age 81, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbances, severe chronic stage four kidney disease, blindness in both eyes, muscle weakness, unsteadiness on feet and unspecified parkinsonism. According to the 2/16/24 minimum data set (MDS) assessment, Resident #52 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. Resident #52 was dependent upon staff for self-care, functional cognition (planning regular tasks), toileting hygiene, low body dressing, putting on or taking off footwear, transitioning from a sitting position to standing and transfers. Resident #52 required substantial or maximal assistance for rolling over, moving from a sitting to a lying position and transferring from a lying position to sitting on the edge of his bed. B. Record review The 2/13/24 nursing admission assessment identified Resident #52 had diagnoses of Parkinson's disease and dementia, required extensive assistance from staff for activities of daily living (ADL) and was at risk for falls. -Despite the assessment identifying the resident was at risk for falls, the facility failed to implement a baseline fall care plan upon admission. A fall investigation was completed on 2/20/24 for an unwitnessed fall. Resident #52 was observed lying on the floor by his recline in a supine position (on his back). The resident was unable to recall what he needed before he fell or how he got out of his recliner. Resident #52 had cognitive deficits and was bleeding from his right toenail. His nail was still in place and the area was cleaned and bandaged. The registered nurse (RN) completed an assessment and noted no other injuries and his range of motion was within normal limits to all joints. The RN started neurological checks and his bed was placed in the lowest position with his call light within reach. The immediate actions taken by the nurse were notifying the resident's representative, the physician and the nurse manager. A post-fall assessment was completed on 2/20/24 and documented Resident #52 had an unwitnessed fall. He had his call light within reach and the call light was on. He was identified as a high risk for falls. Resident #52 was sleeping in his recliner and was observed 15 minutes before he fell . The resident could not recall what he was trying to do before he fell . The certified nurse aide (CNA) was in the area but did not witness the fall. The root cause was believed to be cognitive deficits and the intervention implemented was to keep his bed in the lowest position. -However, the facility failed to implement a fall intervention in regards to the resident falling out of his recliner. Resident #52's fall care plan; initiated on 2/21/24 (the day after he fell ), documented Resident #52 was at high risk for falls related to confusion, vision or hearing problems, Parkinson's disease, dementia and a history of falling. Interventions were documented as: -Anticipate and meet Resident #52's needs; -Assess the resident's needs for adaptive devices as indicated; -Be sure Resident #52's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; -Encourage rest periods when signs of fatigue are noted; -Encourage Resident #52 to participate in activities that promote exercise and physical activity for strengthening and improve mobility; -Ensure adequate lighting and visual aids are in place on admission assess for communication needs as indicated; -Ensure appropriate position in the wheelchair. Provide assistance with repositioning as indicated; -Ensure that Resident #52 is wearing the appropriate footwear when ambulating or mobilizing in the wheelchair; -Physical therapy to evaluate and treat as ordered and as needed; and -Resident #52 needs prompt response to all requests for assistance. The resident has fluctuating ability to utilize the call light. Provide consistent rounding and offer redirection as indicated. -However, the facility failed to implement any interventions related to preventing another fall for Resident #52 from his recliner. C. Staff interviews The director of nursing (DON), assistant director of nursing (ADON) and clinical consultant (CC) were interviewed on 3/27/24 at 2:08 p.m. The ADON said Resident #52 was admitted as a high risk for falls and the assessment was completed when he was admitted . She said Resident #52 had a fall care plan in place before he fell . She said the baseline care plans were completed at admission during the admission assessment. However, the ADON was unable to provide a baseline care plan for Resident #52. The DON said Resident #52 was attempting to self-transfer and fell out of his recliner on 2/20/24. She said the only injury he sustained was a scrape on his toe. The DON said the interventions put on the resident's care plan did not include an intervention to prevent falls from the recliner. The CC said the RN did not complete the baseline care plan at admission. She said the nurse had to check one of the boxes for the fall care plan to generate and the nurse failed to do that. The CC said it was an educational thing and the facility would ensure the nurses completed the assessments accurately. Licensed practical nurse (LPN) #1 was interviewed on 3/24/24 at 4:45 p.m. LPN #1 said Resident #52 was a fall risk before he fell . She said his fall interventions were frequent checks from staff and to ensure he was positioned in the middle of his bed because sometimes he had rolled toward the edge of the bed. She said Resident #52 had never tried to transfer himself before his fall on 2/20/24. She said the resident was good at using his call light and waiting for assistance. LPN #1 did not mention any interventions for Resident #52 to prevent falls while he was in his recliner. 40467 III. Resident #50 A. Resident status Resident #50, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included dementia, history of falls, repeated falls, fracture of the right femur, unsteadiness on feet, muscle weakness, difficulty walking and cognitive communication deficit. According to the 12/30/23 MDS assessment, Resident #50 had severe cognitive impairment with a BIMS score of four out of 15. The resident did not have rejection of care behaviors. The resident's functional ability at admission was identified as limited range of motion on one side of her lower extremity, dependent on staff for toileting, dressing including putting on and taking off footwear. The resident required substantial assistance during bed to chair transfers. B. Observations Continuous observations were conducted on 3/24/24 from 9:32 a.m to 9:59 a.m., 11:39 a.m. to 12:40 p.m. and 2:50 p.m. to 4:10 p.m. Resident #50 was observed in her wheelchair in the common area of the memory care unit during all of the observations. -The resident's wheelchair did not have anti-tip brakes attached on the back of her wheelchair to prevent the wheelchair from rolling backwards (see 3/11/24 interdisciplinary team (IDT) risk management note and interviews below). -At 2:55 p.m. the activity assistant (AA) attempted a reading activity with Resident #50 and two other residents. As the AA moved one of the residents closer to her, Resident #50 placed her hands on her armrests and pushed herself up to a partial standing position and then sat back down in her wheelchair. Continuous observations were conducted on 3/25/24 from 11:50 a.m. to 12:42 p.m. and 2:00 p.m. to 3:44 p.m. -The resident did not have anti-tip brakes attached to the back of her wheelchair. -At 2:07 p.m., Resident #50 sat still in her wheelchair as she listened to a harpist playing in the common area. -At 2:12 p.m., the harpist finished playing and Resident #50 was leaning to her right side. Her body jerked up slightly and then she leaned to the right again. The resident was not offered to lay down when the music was over despite the resident displaying signs of being tired. -At 2:19 p.m., Resident #50 started leaning and reaching forward and as she proceeded to lift herself up from the seat of her wheelchair. The right wheel of the resident's wheelchair rolled backwards as she sat back down. A CNA, who was the only staff member in the vicinity, was in the kitchenette and did not notice the resident's wheelchair roll backwards. A resident next to Resident #50 asked her if she needed help and Resident #50 responded yes. The other resident started to lift himself out of his wheelchair to help her. The CNA saw the male resident and asked him what he needed. The resident motioned to Resident #50. The CNA asked Resident #50 what she needed and Resident #50 reached her arms forward. The CNA unlocked the resident's left wheelchair brake and told her she could go forward with her feet. The resident proceeded to use her feet to mobilize herself in her wheelchair in the common area. -At 2:28 p.m. Resident #50 was offered a snack pack of mini muffins. The resident ate the muffins in the hall and common area, dropping one and attempted to pick it up by reaching down to the floor and placing another muffin on the floor in front of her as she sat in her wheelchair. A continuous observation was conducted on 3/26/24 from 9:04 a.m. to 9:20 a.m. The resident received a massage and was assisted to exercise. -Resident #50 did not have anti-tip brakes on her wheelchair. A continuous observation was conducted on 3/26/24 from 12:20 p.m. to 12:47 p.m. -The resident did not have anti-tip brakes on her wheelchair. On 3/27/24 at 3:38 p.m., Resident #50 was observed in her wheelchair with the DON, the CC, the unit manager (UM) and the ADON. -Resident #50 did not have anti-tip brakes on her wheelchair. The UM said Resident #50 was in the wrong wheelchair. The CC said all the wheelchairs, including Resident #50's, would be labeled with the residents' name to ensure the residents were placed in their correct wheelchairs. The CC said the lack of the anti-tip brakes probably contributed to the resident's two falls on 3/24/24 because the resident did not have the right equipment that she was identified to need. C. Record review The 10/17/23 fall risk evaluation identified Resident #50 was a high risk for falls. The fall risk evaluation read the resident was at high risk for falls related to a history of falls, poor vision and had medications and diagnoses that could contribute to falls. The 10/17/23 progress notes read Resident #50 was admitted to the facility on [DATE] for physical therapy (PT) and occupational therapy (OT) following surgery for a right hip internal fixation. The notes identified the resident suffered a fracture to right hip from a fall prior to her admission, she had impaired vision related to macular degeneration and was at risk for falls. The 10/18/23 skilled nursing note read Resident #50 had weakness and an unsteady gait requiring supervision. The fall care plan, initiated on 10/18/23, read Resident #50 was a high risk for falls due to history of falls resulting in a femur fracture. The 10/18/23 interventions included PT to evaluate and treat as ordered or as needed. The review of Resident #50's electronic medical record (EMR) identified Resident #50 had eight falls between 11/15/23 and 3/24/24. 1. Fall #1 The 11/8/23 nursing progress note read the resident had increased confusion and tried to get out of her chair (wheelchair). The 11/15/23 at 8:17 a.m. nursing progress note read Resident #50 was observed by a CNA on the floor next to her bed in a sitting position with legs out in front of her. The resident was upset and scared. An abrasion on her back was identified when she was getting dressed. The 11/17/23 interdisciplinary team (IDT) note read Resident #50 had an unwitnessed fall with no signs of obvious injuries. Resident #50 had poor safety awareness and attempted self transfer. The staff was verbally educated to frequently check on Resident #50 to alleviate risk of falls. -The IDT note did not identify the abrasion on the resident's back after the resident's fall, The fall care plan, initiated on 10/18/2023 and revised on 11/21/2023 (six days after the fall on 11/15/23), directed staff to anticipate and meet the resident's needs, complete frequent checks to prevent falls, assess the resident's need for adaptive devices as indicated and ensure the resident wearing appropriate footwear when mobilizing in her wheelchair. 2. Fall #2 A 12/3/23 nursing note read Resident #50 was observed at the table in the dining room repeatedly standing up from her wheelchair by herself. The resident lacked safety awareness, her wheelchair wheels were not locked, and her foot pedals were down in the front and her feet were crossed while standing. Education was provided and the resident was reminded to ask for staff assistance but she often seemed to forget. A 12/4/23 late entry incident note read the nurse entered Resident #50's room after she heard a loud noise and Resident #50 yelling. The resident was found sitting on the floor by her bed and her recliner. The blankets were slightly pulled off her bed on the same side of the bed where she was found. The resident was not in acute distress but reported pain on the left side of her ribs under her arm. There was no bruising or skin injury observed at the time of the fall. The resident said she was trying to move from the bed to the chair and slipped. The intervention was identified as a low bed would be placed in her room and the resident was encouraged to wear non-skid socks at night to reduce future fall risk. The 12/4/23 incident report read the 12/4/23 fall at 7:00 a.m. was unwitnessed. Predisposing factors included poor gait and balance, a high risk for falls and poor safety awareness, ambulating without assistance and had a recent room change. -According to the incident report, the resident's bed was not in its lowest position at the time of her fall. The 12/6/23 IDT risk management note read Resident #50 had an unwitnessed fall on 12/4/23. The resident had poor safety awareness and was attempting to self transfer from bed to chair. The resident reported pain to her left ribs. There was no bruising or injury noted. The intervention was identified as a PT referral, frequent checks and rounding by staff and anticipate Resident #50's needs. -The review of Resident #50's fall care plan did not identify new fall interventions that were put into place after the resident tried to ambulate from the bed to her chair and fell on [DATE]. 3. Fall #3 The 12/9/23 nursing progress note read Resident #50 was trying to get up out of her wheelchair without assistance. She would get mad when staff told her it was unsafe and she had to wait for someone to help. She continued to try to get up from her wheelchair throughout the evening until she settled in bed. Her call light was placed within reach. The 12/15/23 nursing progress note read Resident #50 was sitting in the dining room recliner and tried to get up from it. She was told she had to wait for staff to help her get into her wheelchair. According to the note, the resident became upset and started to kick and swing at the staff. The resident was told it was unsafe for her to get up by herself and she proceeded to continue to try to swing at staff and said she did not need assistance. The resident calmed after staff sat with her for an hour. The 12/25/23 at 4:00 a.m incident note read Resident #50 was found scooting on the floor in a sitting position by her door entry in her room. The resident said her brief was soiled. There were no injuries noted. The intervention was staff to attempt to check and change her first for a wet brief during staff rounds. The 12/25/23 incident report read the resident was identified as high risk for falls, incontinent, poor safety awareness and gait imbalance. The 12/26/23 IDT risk management note read Resident #50 had an unwitnessed fall on 12/25/23. The root cause of the fall was poor safety awareness. The resident said she was scooting around on the floor and had a soiled brief. The intervention noted on the IDT note was to start PT again and staff to check on her first when doing rounds. -The review of the care plan did not identify new fall interventions were put into place after the resident was incontinent and found scooting on the floor in her room on 12/25/23. The 1/22/24 care plan for wandering read Resident #50 wandered related to her dementia and impaired safety awareness. According to the care plan, the resident was easily redirected. The care plan directed staff to assess the resident for a fall risk. 4. Fall #4 The 1/7/24 skilled nursing note read Resident #50 was observed wandering around the unit for most of the shift. She frequently entered others' rooms. She attempted to open back doors several times and got her wheelchair stuck on furniture and on other resident's wheelchairs. She was tearful at times and did not respond well to redirection. The 1/17/23 fall risk evaluation identified Resident #50 was a high risk for falls. The fall risk evaluation read the resident remained at a high risk for falls to include contributing factors of blood pressure changes between lying and standing. The 1/31/24 nursing progress note read the activity assistant yelled out to the nurse. The nurse observed Resident #50 in a standing position with her wheelchair directly behind her. The resident's balance was poor as she attempted to take a step and slid herself to the floor and fell backwards. She landed on her buttocks and then rested her upper torso down onto the floor. The resident did not hit her head. The resident was assessed as staff removed objects out of the way. The resident was not able to describe why she got up from her wheelchair. The 1/31/24 fall incident report read Resident #50 fell on [DATE] at 3:05 p.m. The incident report read factors to the fall included an impaired memory, a high fall risk and poor impulse control. The 1/31/24 post fall assessment report and fall huddle read the root cause analysis identified the resident was very emotional and tearful throughout the day prior to the 1/31/24 fall. The resident was seated in a wheelchair and self-propelling in the dining room. The resident wanted to get up and walk for unknown reasons. The intervention was for staff to monitor placement and whereabouts of Resident #50 and keep her at a close distance at all times. The 2/7/24 IDT risk management note read Resident #50 had a witnessed fall on 1/31/24. The root cause of the incident was poor safety awareness and was attempting to self transfer. She was witnessed standing up from her wheelchair and then sliding to the floor as she attempted to walk. There were no injuries noted. According to the note, the interventions put in place were a fall mat at bedside, and a soft touch call light pad to replace the call light button. -The intervention to add a soft touch call light and a fall mat were interventions to address previous falls, however, the interventions did not address the contributing factors to the 1/31/24 fall when she was witnessed standing up from her wheelchair. The fall care plan, revised on 2/7/24 (eight days after the resident's 1/31/24 fall) directed staff to ensure the resident's fall mat was in place besides her bed. 5. Fall #5 The 2/12/24 nursing progress note read Resident #50 had a new pharmacy recommendation to discontinue Celecoxib (a medication used for pain) 100 milligrams (mg) BID (two times per day) and to have APAP (acetaminophen) as needed. The order was updated. The 2/19/24 nursing progress note read the nurse was called into the room of Resident #50. The resident was sitting with her back against her bed. Her wheelchair was across the room by the bathroom. The resident stated she was trying to get into the bed. According to note, the staff had toileted the resident a couple of minutes prior to the fall. The staff identified the resident's wheelchair brakes were not locked and her wheelchair slid out from under her. There were no injuries. The intervention to the fall was to offer to lay her down after toileting and not leave her alone in her room (in her wheelchair). The 2/19/24 post fall and fall huddle root cause analysis read there was nothing unusual or different on 2/19/24. Staff were in the dining room and heard the fall. The resident tried to self transfer. According to the post fall and fall huddle, the resident's brakes were not on. The intervention was for staff to offer the resident to lay down after toileting and not to leave her alone in the room as an intervention. The 2/19/24 incident report read Resident #50 had an unwitnessed fall on 2/19/24 at 1:15 p.m. The resident was ambulating without assistance during a transfer. Her brakes on the wheelchair were not locked. The wheelchair slid out from under her. Predisposing factors included fall in the past 30 days, identified as a high fall risk, impaired memory, restlessness gait and poor balance. The 2/19/24 fall risk assessment identified the resident remained at a high risk for falls. The fall care plan, revised on 2/20/24, directed staff to ensure her bed was in a low position when the resident was in bed. -However, the resident's fall occurred when the resident was trying to transfer herself to bed, not when she was already in bed. The 2/20/24 nursing progress note read the resident's medication of Celebrex (Celecoxib) was recently discontinued. Resident #50 had been more tearful and had increased pain. Her increase in pain may have contributed to her fall. A request had been sent (to the provider/physician) for pain management or restarting Celebrex. -However, review of the resident's EMR revealed the medication was not restarted until 3/20/24. The 2/20/24 staff inservice for nine CNAs was provided by the ADON on 3/27/24 at 3:29 p.m. The inservice read to lay Resident #50 down after meals if falling asleep or tired when up and monitor frequently. The 2/21/24 nursing progress note read the resident was on (alert) charting for an unwitnessed fall. She had some discomfort in her hips the morning of 2/21/24. The 2/21/24 nursing progress note read the resident attempted to stand from her wheelchair unattended. She was reminded to wait for assistance for safety reasons. -The review of progress notes after the 2/19/24 fall did not identify the resident was reviewed in the IDT risk management meeting following the fall. 6. Fall #6 The 3/6/24 weekly nursing note read Resident #50 had an increase in crying and limited assistance when standing related to pain to legs and right hip. A call was placed to ask for Celebrex medication to be reordered as she has shown signs of an increase in pain since the medication was discontinued. -However, review of the resident's EMR revealed the medication was not restarted until 3/20/24. A 3/10/23 nursing progress note read Resident #50 was found sitting on the floor in another resident's room. According to the note, Resident #50 had been attempting to get out of bed before she fell so the staff placed her in her wheelchair. The resident proceeded to get her wheelchair stuck against the furniture. The resident then tried to stand and her wheelchair went out from underneath her. The resident had slight redness to her middle and upper spine. The intervention was to educate the CNAs on ensuring the resident had non-skid socks on at all times when out of bed. The 3/10/24 incident report read the resident had an unwitnessed fall on 3/10/24 at 7:55 p.m. The factors to the fall included the resident was ambulating without assistance, was wandering and was wearing improper footwear. The 3/11/2024 IDT risk management note read Resident #50 had an unwitnessed fall on 3/10/24. The root cause was poor safety awareness and she tended to try and stand from her wheelchair when she became stuck somewhere. There were no injuries. The IDT note read Resident #50 was very restless. The CNAs had placed Resident #50 in her bed but in fear of the resident falling out of bed, the CNAs transferred her back to her wheelchair. The resident had been wandering into another resident's room. She got stuck between the bed and the recliner. When the resident stood up, the wheelchair rolled out from behind her. -According to the note, anti-tip/roll back locks/brakes would be placed on her wheelchair, however, observations revealed the resident did not have anti-tip/roll back devices on her wheelchair (see observations above). -The fall care plan did not identify new interventions were placed on the care plan such as placing anti-tip/roll back locks/brakes to her wheelchair and monitor. 7. Fall #7 The 3/18/24 fall risk assessment identified the resident was at a high risk for falls related to history of falls, periods of confusion, was wheelchair bound and required assistance with toileting. The 3/24/24 nursing progress note read the nurse was informed of the resident's fall at 2:47 a.m. Resident #50 was observed sitting on the floor beside her bed. There were no injuries and the resident was assisted back to bed. The 3/24/24 post fall assessment report documented the resident was not wearing footwear at the time of the fall. The 3/24/24 at 4:48 p.m. IDT risk management note read Resident #50 had an unwitnessed fall on 3/24/24. The resident was found sitting on the floor in her bedroom with the bed not in the lowest position. The root cause of the fall was poor safety awareness and the resident was impulsive. According to the note, the resident would often try to stand up or transfer without assistance. The resident was not injured. The intervention was to conduct a facility wide staff education on ensuring beds are in lowest position and call lights are within reach every time staff left a room. -According to the report, the resident's bed was not in its lowest position at the time of her fall. 8. Fall #8 The 3/20/24 nursing progress note read Resident #50 received a new order for the medication Celecoxib 100 mg BID. According to the note, the resident had the medication previously and it was discontinued. The note read after the discontinued medication, the resident became tearful and complained of pain to her left inner groin and had trouble standing related to pain. The first dose of the medication was given without adverse reactions. The 3/23/2024 nursing progress note read the resident had no adverse reactions to the new medication Celecoxib. The resident had been more active while in her wheelchair and was less sleepy and tearful. According to the note, the resident stood better during transfers and did not complain of discomfort or pointing to her left hip and inner groin. The 3/24/24 nursing note read Resident #50 had no adverse reactions noted to the new medication Celecoxib. The resident had an unwitnessed fall and would continue to be monitored. A 3/24/2024 nursing progress note identified Resident #50 had a second fall on 3/24/24 at 7:20 p.m. The note read the nurse was called to the unit to assess the resident after a fall. The resident did not have discomfort on injuries. The 3/24/24 incident report identified the resident had another unwitnessed fall in another resident's room. The resident was found on the floor in another resident's room on 3/24/23 at 7:20 p.m. The resident was found between her wheelchair and a recliner. According to the report, the resident was possibly self transferring from her wheelchair to the recliner when she fell . The resident did not have injuries as a result of her fall. Predisposing factors included poor lighting, impaired memory and history of falls in the past 30 days. The 3/25/24 IDT risk management note read Resident #50 had an unwitnessed fall. She had poor safety awareness and was impulsive. She recently had pain medication discontinued and was noted to be restless, tearful, and pacing. The resident had had repeat falls since the discontinuation of her pain medication. She was found on the floor in another resident's room up against a recliner. She attempted to self transfer from her wheelchair to the recliner and fell . -The IDT note did not identify if the intervention of anti-tip brakes on her wheelchair were in place. The intervention after the 3/24/24 fall was to place the resident back on Celecoxib as 3/25/24 for pain management. The March 2024 CPO read to give Resident #50 Celecoxib (Celebrex) oral capsule 100 (mg by mouth two times a day for pain. The order read it was active as of 3/25/24. -However, according to nursing [TRUNCATED]

Based on observations, record review and interviews, the facility failed to ensure one (#1) out of five sample residents remained free from accident hazards. The facility failed to ensure a safe environment to prevent injury and death when transporting Resident #1. Resident #1 was involved in a motor vehicle accident on his way to an appointment on 6/29/23. The resident was taken to the hospital from the scene of the accident. He passed away on 6/29/23, shortly after the accident. The facility driving coordinator was the driver at the time of the accident. The facility driver rear ended another vehicle stopped in front of her at a traffic light when she took her eyes off the road. Findings include: I. Facility expectations The Fleet Safety procedures, undated, were provided by the nursing home administrator (NHA) on 7/24/23. The safety procedures were read in part: (The facility) considers the prevention of automobile accidents essential to the well-being of our employees, our residents, the public, and company equipment. A safe driver is not merely someone who has been lucky enough to avoid accidents, but is one who drives defensively and looks out for others. Drivers who are safety conscious have developed good habits and practices daily. A defensive driver keeps a sharp eye for the miscues of others and anticipates situations that may give rise to an accident. Stay a safe distance back from the vehicle in front of you. The 'three second rule' is one of the most important concepts of defensive driving. Always stay three seconds behind the vehicle in front of you. Accidents at intersections occur all too frequently but there are some basic tips that you can take to avoid them. Always look well ahead. If the traffic light ahead of you has been green for a while, anticipate that it will be changing to yellow or red and take the appropriate action. Take your foot off the accelerator. Always approach an intersection with caution and your wheels straight. Defensive driving is driving to prevent accidents in spite of the incorrect actions of others or adverse weather conditions. Anticipate driving hazards and know how to protect yourself from them. Be alert while driving by keeping your mind free of distractions and your attention focused on driving; alertness involves watching and recognizing accident-causing factors instantly. The defensive driver has foresight, the ability to size up traffic situations as far ahead as possible. The driver must anticipate traffic problems that are likely to develop and decide whether these developments could be dangerous. According to the safety procedures, drivers would be required to complete all online defensive driver programs, an annual fleet safety and service and pass the accompanying test before operating any facility vehicle. New drivers would be given a driver's road test to assess driving skills. A new driver check list would be completed to ensure that all aspects of the training had been covered. II. Resident status Resident #1, age 86, was admitted on [DATE]. According to the June 2023 admission record, diagnoses included infectious gastroenteritis and colitis (inflammation in stomach, intestines and colon), chronic obstructive pulmonary disease with acute lower respiratory infection (a lung disease causing restricted airflow and breathing problems) and multiple myeloma (a cancer forming in white blood cells). The admission record identified Resident #1 was discharged to the hospital on 6/29/23 at 1:45 p.m. The 6/25/23 minimum data set (MDS) assessment identified Resident #1 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out 15. The MDS assessment indicated Resident #1 required extensive assistance from more than two staff members for bed mobility and transfers. He required physical assistance of one staff member for locomotion. III. Record review A 6/29/23 nursing progress note read a nurse contacted the family of Resident #1 to inform them that Resident #1 was involved in a vehicle accident on his way to an appointment with his physician. A second 6/29/23 nursing progress note read the nurse contacted the hospital at approximately 4:00 p.m for a report on the condition of Resident #1 after the motor vehicle accident. The nurse was informed the resident had passed away. The 7/7/23 facility investigation after the 6/29/23 accident indicated FD #1 was driving Resident #1 to an appointment when she rear ended another vehicle. According to the investigation, FD #1 took her eyes off the road when a vehicle in front of her stopped. The facility investigation read the FD was issued a citation for careless driving causing death. FD #1's employment at the facility was terminated on 7/10/23. A citation, issued by the police department for the facility driver (FD) #1, dated 7/7/23, was provided by the NHA on 7/24/23 at 10:30 a.m. The citation summons FD #1 to appear in court for a violation on 6/29/23 at 1:20 p.m. for careless driving resulting in death. In the folder for the 7/7/23 facility investigation, provided by the NHA on 7/24/23 at 10:30 a.m. was a 7/7/23 training for safe following distance provided by the NHA at 10:30 a.m. The safe following distance training identified the facility's second driver, FD #2, was educated on 7/7/23 on safe distances with driving, following the 6/29/23 accident. The inservice reviewed: -The three second rule (distance/space between vehicles). -When to increase the following distance. -Stay alert when driving. IV. Observations The facility vehicle dash camera video was reviewed on 7/24/23 at 10:55 a.m. The video identified Resident #1 sat in the front passenger position next to the FD #1, in his wheelchair. The video showed the facility vehicle approaching an intersection at 24 miles per hour (MPH) to 30 MPH. Multiple vehicles were stopped in front of the facility vehicle at a traffic light. The dash camera video identified FD #1 briefly looked down just before she rear ended the vehicle in front of her. V. Staff interviews The NHA was interviewed on 7/24/23 at 10:31 a.m. The NHA said FD #1 was driving Resident #1 to an appointment when she rear ended another vehicle at a stop light. Resident #1 was taken to the hospital from the scene of the accident and then passed away. The NHA said the driver was terminated after she received a citation for careless driving resulting in death. The NHA said she interviewed FD #1. The FD said another vehicle ran a red light, causing the other vehicles in front to stop suddenly. The NHA said she was the supervisor of FD #1 but she was not at the facility at the time of the accident, so the maintenance service director (MSD) went to the scene of the accident. The MSD was interviewed on 7/24/23 at 12:25 p.m. He said the facility had one vehicle staff could use for business needs and two wheelchair accessible vehicles the drivers would use routinely to transport residents. The MSD said none of the facility vehicles required a commercial driving license (CDL). He said on 7/21/23, he and a few other staff members were trained how to safely operate the vehicles so they could drive if needed. He said prior to 7/21/23, he primarily just ensured the vehicles were serviced timely. The MSD said on 6/29/23, the director of nursing (DON) was contacted after the accident and he was asked to go to the scene of the accident. The MSD said he when he arrived, Resident #1 had already been taken to the hospital and the facility vehicle was loaded on top of the tow truck bed. He said the front end of the facility vehicle was crushed inward towards the engine, just above the front bumper. The MSD showed a photo he took of the facility vehicle, which confirmed his description. He said no one else appeared to be hurt from the accident. He said FD #1 told him the light was green and the vehicles were moving. She looked down to change the air conditioning and then looked up and the vehicle in front of her was right there. FD #2 was interviewed on 7/24/23 at approximately 1:45 p.m. She said FD #1 was her supervisor. She said she started in January 2023. She said she had a road test in January 2023. She confirmed on 7/7/23 she had a safe distance reminder training and attended a portion of the training on 7/21/23. FD #2 said after the 7/21/23 training, she had a better understanding on how to properly secure the resident's wheelchair. FD #2 said FD #1 had originally reviewed with her on how to secure the wheelchairs to the facility vehicle. The CTC was interviewed on 7/24/23 at 2:54 p.m. The CTC said he was responsible for helping train the facility's drivers. The CTC said he did not retain who he had trained or the driving training records of staff. He said the records would be the responsibility of the facility. The CTC said when he trained facility drivers, he provided driver training education on proper use of facility vehicles. The CTC said his education included: the review of the complete fleet manual safety handbook; instruction on how to drive in bad weather; demonstration of the proper use facility vehicle lifts and wheelchair securements; and, he conducted drive tests with lane changes, passing maneuvers and safe distances. The NHA was interviewed on 7/24/23 at 3:26 p.m. The NHA said corporate (CTC) was responsible for the class room training for the drivers. The NHA was interviewed on 7/24/23 at 4:04 p.m. The NHA said she and the facility's human resources director attended the driver training provided by the CTC to have a better understanding of all requirements. The NHA was interviewed on 7/24/23 at 5:50 p.m. She said FD #1 returned to work on 7/5/23. She did not drive but scheduled the upcoming appointments and conducted other job duties. The NHA said FD #1 was placed on suspension on 7/7/23 after the facility learned she was ticketed. The NHA said FD #1 was terminated on 7/10/23 because she ticketed for careless driving resulting in death. The police officer who was at the scene of the accident and issued the citation was interviewed on 7/25/23 at 3:59 p.m. The police officer said his investigation identified the light was green when FD #1 approached the intersection but the vehicles in front of FD #1 was at a stopped position because another vehicle was still in the intersection. The police officer said the dash camera video was reviewed. The video showed the light was green when the driver looked down for half a second, expecting the vehicle in front of her to be moving and then rear ended the vehicle in front of her. The police officer said FD #1 took no evasive actions such as applying the brakes prior to the accident. The police officer said FD #1 was issued a citation because she was at fault. The officer said FD #1 was ticketed on 6/29/23 after the accident for careless driving causing injury. She was reissued the citation on 7/7/23 for careless driving causing death after the determination of the resident's passing after the accident.

Based on record review and interviews, the facility failed to provide relief from acute pain during a condition change for one (#2) of three residents reviewed out of six sample residents. Resident #2 was experiencing a change of condition on [DATE] as evidenced by calling out, thrashing in bed, and guarding her left leg during assessment attempts. However, physician-ordered [MEDICATION(S)] medication to treat the resident's pain did not arrive and was not authorized for removal from the facility's emergency kit. Facility nursing staff did not follow up when the medication was not authorized in a timely manner, and the resident continued to experience pain assessed as high as severe 10 out of 10 pain. The resident's pain was not relieved until she received emergency department (ED) treatment several hours later. She was diagnosed in the ED with a fractured femur (thigh bone), fractured humerus (upper arm), and stroke. Findings include: I. Facility policy The Pain Management policy, developed [DATE] and revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 4:50 p.m. The policy documented in part: Pain is subjective and is what the resident says it is, existing when and where the resident says it does. -Pain evaluations will be conducted upon admission, readmission, quarterly, and with any significant change in condition. -The pain evaluation includes the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness. -All subsequent pain evaluations will be documented on the Pain Evaluation in PCC (electronic medical record) and/or the MAR (medication administration record) as applicable, to include location, intensity rating, and response to pain management interventions. When a resident complains of pain, ask the resident to rate the level of pain using the numerical scale using a pain level of zero (none) to ten (severe). -Non-verbal indicators of pain include: increased agitation, crying, grimacing, holding the area where the pain is located, calling out, decreased appetite, and any other behaviors which are unusual for the resident. -Document your findings on the pain evaluation in PCC and/or MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Rescue doses (bolus) may be prescribed for periodic breakthrough or incident pain related to activity, treatment and/or diagnostic procedures. -Around the clock (ATC) dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management. Intermittent pain can be managed with intermittent (PRN) [MEDICATION(S)] administration. (Every shift pain checks on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .) -Success rate is increased utilizing a multi-disciplinary, multi-treatment modality approach and using a combination of [MEDICATION(S)] and adjuvant drugs and therapies. II. Resident status Resident #2, age 87, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the [DATE] minimum data set (MDS) admission assessment, Resident #2 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. No [CONDITION(S)] or behavioral symptoms were documented. The resident mood interview revealed she had symptoms including little interest or pleasure in doing things; feeling down, depressed or hopeless; sleep difficulties; feeling bad about herself; and trouble concentrating with a total severity score of eight out of 27. It was somewhat important to her to have family or a close friend involved in discussions about her care. She needed extensive assistance with bed mobility, transfers, ambulation, toilet use and personal hygiene. She used a walker for ambulation. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She had pain almost constantly, which made it hard for her to sleep at night. She rated her worst pain over the last five days at ,d+[DATE] (nine out of 10). The resident's verbal descriptor pain scale was left blank. III. Record review The [DATE] admission nursing assessment documented the resident's pain frequency was constant, to her neck, and most recent pain level was ,d+[DATE]. The [DATE] pain evaluation revealed the resident had chronic neck and shoulder pain due to cervical spinal stenosis, which the resident described as aching, exhausting, and sharp. The resident's preferred pain scale was numeric, her current pain level was ,d+[DATE], and her acceptable level of pain was ,d+[DATE] out of 10. Pain affected her ability to focus, decreased her physical and social activity, and caused changes in her mood/emotions. Nonverbal pain indicators were facial grimacing and grunting. Pain was relieved by medication and relaxation. She was not on a scheduled pain management program, and utilized PRN pain medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, initiated [DATE] and revised [DATE], identified chronic pain related to [CONDITION(S)], spinal stenosis and cervicalgia (neck pain). The resident had PRN medications available for pain. The goal was inadequate pain relief will be minimized through the review date of [DATE]. Interventions included: -Pain is alleviated/relieved by PRN pain medications -Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident's satisfaction with results, impact on functional ability and impact on cognition. -Monitor/record/report to nurse any signs/symptoms of nonverbal pain: changes in breathing, vocalizations (grunting, moans, yelling out, silence); mood/behavior changes (more irritable, restless, aggressive, squirmy, constant motion); 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). -Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. -Offer non-pharmacological interventions for pain prior to administering medication and PRN: offer a snack, drink, redirect to an activity, offer independent activity supplies, offer to call a loved one, assist outside, sit with resident as needed, offer shower or bath, active listening and validation, relaxation & breathing techniques, imagery & distraction techniques, repositioning, aromatherapy. Review of October and [DATE] medication administration records (MARs) revealed the resident had the following pertinent physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Monitor pain every shift, ordered [DATE]. -Acetaminophen tablet, 650 mg by mouth every 6 hours as needed (PRN) for pain ,d+[DATE]/fever, ordered [DATE]. -[MEDICATION(S)] HCI, 25 mg every 6 hours for pain above 6, ordered [DATE]. -[MEDICATION(S)] HCI, 50 mg, give ,d+[DATE] tabs as needed for pain, ordered [DATE], discontinued [DATE]. -[MEDICATION(S)] HCI, give 100 mg by mouth every 6 hours as needed for pain ,d+[DATE], ordered [DATE]. -Oxycodone HCI tablet, 5 mg one time only for excessive pain greater than 6 for 1 day, ordered [DATE]. The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was ineffective four times. [MEDICATION(S)] was given for pain above ,d+[DATE] on 18 occasions and was ineffective twice. The [DATE] MAR, reviewed through [DATE], documented the resident was given [MEDICATION(S)] or Acetaminophen for pain above ,d+[DATE] on 21 occasions. The Acetaminophen was documented as ineffective twice, and unknown once. The Oxycodone, ordered for one time administration, was never given. The pain monitoring section documented a day shift pain level on [DATE] of ,d+[DATE]. The resident was sent to the hospital on [DATE] at approximately 11:30 a.m. According to the hospital transfer form, the resident's most recent pain level was ,d+[DATE] at 10:18 a.m. The pain location was left lower extremity, left arm, neck and shoulders. The most recent pain medication given was [MEDICATION(S)] HCI tablet 50 mg; the date/time given was [DATE] at 1:32 a.m., 10 hours before. Review of nursing notes just prior to the resident's hospital admission revealed in pertinent part: On [DATE] at 1:32 a.m., the resident was given 100 mg of [MEDICATION(S)], ice pack, repositioning, toileting. Administration was effective and follow-up pain scale was ,d+[DATE]. On [DATE] at 1:51 a.m., the resident appeared to be talking in sleep, began screaming and throwing arms around. Elder (the resident) grabbed CNA's (certified nurse aide's) breast, private area and CNA's shoulder. This nurse attempted to talk with elder to calm her. Elder's eyes were closed during the entire interaction. Elder then laid back on her pillow and began to snore. Elder is resting at this time. Will continue to monitor. On [DATE] at 4:29 a.m., the resident was lying in bed yelling, reported she was having pain to her right leg, said she could not move it and that it hurt. Second nurse assisted with assessment. Will call doctor and family. -The note documented pain to her right leg, although it was her left side in subsequent notes (see below). On [DATE] at 4:38 a.m. the DON (director of nursing) was notified and will come in to evaluate the resident lying in bed with right leg crossed over the left leg. Began yelling when this nurse placed hand on leg, denies injury or fall, no apparent cause of pain, ambulated to and from bathroom earlier this shift with no signs/symptoms of pain and has been in bed the rest of shift. Will continue to monitor and await DON. On [DATE] at 4:46 a.m., 650 mg Acetaminophen was given for pain to right hip. -The note documented pain to her right hip, although it was her left side in subsequent notes (see below). On [DATE] at 5:05 a.m., the DON was with the resident. At 5:18 a.m., the Acetaminophen was documented as ineffective, follow-up pain scale ,d+[DATE]. On [DATE] at 5:21 a.m., the DON documented a change in condition related to uncontrolled pain. Vital signs were blood pressure ,d+[DATE], pulse 104, respiration 24, temperature 97.5, pulse oximetry 94% on room air. Medication changes within the past week: [MEDICATION(S)] increased to 100 mg every 6 hours PRN. The resident had decreased mobility, physical aggression, resting pulse greater than 100, pain, and abnormal speech. Uncontrolled pain, has been combative during the night, biting, grabbing at self and staff, then would fall asleep. Was up and ambulated to the bathroom earlier in shift, her left leg is rigid, will now allow assessment or bend knee, complains of left shoulder pain, able to move arm at the elbow but will not move at the shoulder, she does place her right leg over her left leg, no hypersensitivity, no redness, excessive warmth, unable to assess for homan's ([CONDITION(S)] test) but no symptoms noted. Primary care provider responded with the following feedback: (physician/medical director) will call in a 1 time order for Oxycodone 5 mg PO (by mouth) to pharmacy, call office to set up a Telemedicine visit this morning. On [DATE] at 12:59 p.m., the nurse documented the resident was transferred to the ED for eval (evaluation) and treat (treatment) with change in mental status. The final note nursing note dated [DATE] at 1:04 p.m. documented: RN (registered nurse) arrived on shift at 0600 am (6:00 a.m.), and received report that this Pt. (patient) had been complaining of Lt (left) leg pain for several hrs (hours) during the night and early morning. It was reported that she was not moving her Lt leg at times, and refused to let the night nurse assess the leg. Report also stated that she was combative, confused, at times unable to move and at other times trying to hit the staff. DON was present this am and had completed assessment. At 0620 (6:20 a.m.) resident was sleeping, in supine position in bed, she was snoring. A script, and E kit (emergency kit) pull authorization for Oxycodone was pending per an order the DON had received from on call physician. By 0740 (7:40 a.m.) the Pt woke up and was calling out for help. When asked what she needed she stated 'my leg hurts, and I think I should have some help getting up.'RN explained that staying in bed would be a better plan as the Pt is not feeling well. The Pt was also informed that a Telehealth visit was scheduled this am to address her leg pain and general discomfort. She verbalized understanding and agreed to stay in bed. A pillow was placed under her left calf to increase comfort in positioning and she stated that felt better. Her calf muscles appeared tense, the leg did not have any outward rotation or shortening. She did not allow any active or passive ROM and appeared to have a muscle spasm. She drifted off to sleep. RN woke her at 0925 (9:25 a.m.) to inform her of the upcoming appt with (physician). RN had also received a notice from (the pharmacy) at 08:44 (8:44 a.m.) that script for Oxycodone had not been received, and the med (medication) could not be dispensed. RN was going to address this with (physician) during the appt. The appt took place at 0930 (9:30 am.), and during the appt the Pt started slurring her words while talking to PCP. This was a new development and (physician) at that point suggested that it would be better to send her to ER for eval and treat, but wanted to confirm with her daughter/POA (power of attorney) first, as the Pt. was listed as comfort focused care only on the MOST (medical orders for scope of treatment) form. He stated that he would call the daughter, and then call the facility right back 'in 2 minutes.' About one hr (hour) went by without a call from (physician) so RN reached out to POA on POA's cell and left message with request for urgent call back. Pt. was awake at that time and reporting pain in the leg and all over, her speech continued to be slurred, and she was confused, not able to hold eye contact very well. RN called place of work of the POA, and requested to speak to POA urgently. POA called back within 5 to 10 min, RN reported current findings and asked for consent to send Pt to ER. Consent was given. RN started process of sending Pt to ER, and heard the Pt. calling from her room 'my arm hurts, my arm hurts' RN went into room to assess the situation, Pt was alone in the room and reported Lt arm pain, she was moving her arm at that time. This was a new symptom. RN rechecked VS (vital signs) at that time as Pt appeared anxious but also somewhat lethargic. RN was concerned about the arm pain being a potential symptom of cardiac problems. VS were as follows: BP (blood pressure) was ,d+[DATE] Rt arm lying down, HR (heart rate) 107 regular, resp. (respirations) rate 24/min, Temp (temperature) 97.0 on forehead, 02 94% at RA. RN informed the Pt that EMS (emergency medical services) are on the way. Shortly thereafter the EMS team arrived, assessed the Pt., asked about the pain and asked if she had fallen. The Pt. stated 'No I did not.' EMS transported Pt. to (local hospital), stating that they suspected a [CONDITION(S)] (stroke) by the Pt's appearance. Report was called to ER by RN. Appropriate paperwork such as med list, COR status, face sheet, change in condition forms were sent with the team. Review of the emergency department record revealed the resident was admitted on [DATE] with severe pain which was not alleviated until a nerve block was administered. The resident was diagnosed with fractures to her left femur and left humerus. She had suffered a stroke. Resident #2 died in the hospital on [DATE]. IV. Staff interviews The director of nursing (DON) was interviewed by phone on [DATE] at 11:36 a.m. She said that on [DATE] she received a call from licensed practical nurse (LPN) #1 at about 4:30 a.m. that Resident #2 had a bad night, was in and out of pain, sleeping and then waking up and saying she was in pain. The nurse was wanting to send Resident #2 to the ER because she did not know what to think, was not finding any explanation for Resident #2 calling out or for her pain. The DON said when she arrived, Resident #2 was lying in her bed, eyes closed, and woke up when the DON called her name. Resident #2 said she had pain in her shoulder, and was cooperative with an assessment. However, she would not move her left leg and her toes were splayed almost like she was having a spasm and she would not allow the DON to touch or move her leg. She had some discomfort when the DON assessed her arm. When asked to describe her pain, Resident #2 said No. When asked she wanted to go to the hospital, Resident #2 said No and went back to sleep. The DON talked to the resident's nurse, reviewed her vitals, did not see any major changes, then called the medical director who was on call for the resident's primary care physician (PCP), and let him know what was going on. He ordered a one-time dose of Oxycodone and set up a Telehealth with the PCP that morning. The DON explained this to Resident #2, and she was okay with that. The DON said, She did not get the Oxycodone. We didn't get it due to a mix-up with (the pharmacy). She said Resident #2 had pain a good deal of the time. She did have some Tylenol which was ineffective at 4:45 a.m. At 1:30 a.m. she was given 100 mg of [MEDICATION(S)] and it was documented as effective. The resident's pain was ,d+[DATE]. The DON said the pain location was not documented. The DON said the facility process for acquiring emergency pain medications was: the physician calls in the prescription, they send a form requesting an E kit pull, get a code from them and pull the medication from the E-kit. She said her follow-up if the authorization was not received, Depends. I generally call 10 to 15 minutes later and follow up on it if I'm giving the medication, but I'd passed it on (to the nurse for follow-up). (The pharmacy) didn't get the call from us. I'm not sure if she continued to have pain but she never got the oxy (Oxycodone). The DON said the day shift nurse came on, she told her what she had done for Resident #2 and the night shift nurse gave her report. The DON said she did not see Resident #2 again before she went to the ER. Registered nurse (RN) #1 was interviewed on [DATE] at 1:30 p.m. She said when she arrived on [DATE] at 6:00 a.m., Resident #2 was still in bed sleeping. She awoke around 7:40 a.m. and was calling out for help, which she sometimes would do even on her best of days. I checked on her and she said she was having pain in her leg. I looked at her leg, she didn't really want me to touch it, it was comfortably positioned on a pillow. RN #1 said she had learned from report that the resident had had some pain in her leg and they had made arrangements for a Telehealth appointment because this leg pain was new, unusual. After the PCP decided to send the resident to the ER for evaluation, RN #1 observed the resident seemed to be in pain, so she called her daughter, who said yes, going to the ER was fine. Resident #2 said her left leg was hurting and she suddenly said my arm my arm! so I was thinking heart attack? I assessed her again, took vitals, asked if her jaw was hurting and she said no. I told her I'm in the process of getting you to the hospital. The resident was transferred to the hospital at around 11:20 a.m. RN #1 said the Oxycodone script was never sent by the physician to the pharmacy. The nursing home administrator (NHA), assistant DON and corporate consultant were interviewed on [DATE] at 5:44 p.m. The NHA said if an emergency medication was ordered and not received in a timely manner, nursing staff should call the pharmacy and see if they got the script, then problem solve with the pharmacy or doctor. She said their process was to contact the physician, the physician gives the order, E-scripts it to the pharmacy, the pharmacy processes it, then gives the facility the authorization to pull the medication from the E-kit. The process takes roughly 30 minutes to an hour, and you want to stay on top of it. V. Facility follow-up During the interview on [DATE] at 5:44 p.m., the NHA provided a QAPI (quality assurance process improvement) action plan dated [DATE] at 8:37 a.m. A problem/concern identified was Timely intervention for residents who are experiencing pain - the community had an incident where ordered pain medication was not available in a timely manner and no further interventions were implemented when staff documented pain medication not effective. Corrective actions were documented as follows: The community will provide re-education and training to nursing staff on pain management policy and procedure. -The community will review MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -The community will run a report to review any routine or pain medication to ensure medication is effective. -The every shift pain scale to ensure pain is well controlled per resident's pain goal threshold. -Staff will be educated to call the MD back if controlled substances are not able to be obtained for a non opioid pain medication alternative. -No additional documentation related to the action plan was provided by the exit of survey on [DATE].

Based on record review and interviews, the facility failed to ensure two (#5 and #6) of three residents reviewed out of six sample residents were free from staff-to-resident verbal and physical abuse. Specifically, Residents #5 and #6 stated they were verbally abused and physically mistreated by certified nurse aide (CNA) #1. Cross-reference F610, failure to thoroughly investigate and follow up appropriately regarding allegations of abuse. Findings include: I. Facility policy The Abuse Policy, revised 10/28/2020, provided by the nursing home administrator (NHA) on 11/23/21 at 4:50 p.m., revealed the facility did not condone resident abuse and took every precaution possible to prevent resident abuse by anyone. Every resident had the right to be free from verbal and physical abuse. II. Resident #5 A. Resident status Resident #5, age 98, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 11/11/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She had no [CONDITION(S)] or behavioral symptoms including care rejection, and needed extensive assistance with most activities of daily living (ADLs). B. Abuse allegation and facility investigation Review of a facility investigation dated 11/12/21 revealed Resident #5 alleged she was abused by CNA #1 on the morning of 11/11/21 at 12:21 p.m. when night staff (CNA #1) grabbed her right arm strongly. Resident #5 reported that CNA #1 pushed her on the toilet, and would leave her on the toilet 30 to 40 minutes when the resident asked her to please stay in the room. Resident #5 reported that after going to the bathroom, she was scared to death to use her call light to bother CNA #1. The police department report dated 11/12/21 identified the victim as Resident #5 with cognitive status intact and the suspect as CNA #1. The narrative on police report revealed: on 11/11/21 the resident reported to the nurse that when she was ambulating to the bathroom, one of the night shift staff members grabbed her right arm strongly. When she told the staff member that her grip was too strong, staff loosened the grip. A staff interview completed by LPN #6 for another staff member who was not identified by title revealed: Resident reported to me on ambulation to bathroom night staff grabbed her right arm strongly. Resident verbalized to staff that the grip was too strong and staff loosened the grip. III. Resident #6 A. Resident status Resident #6, age 83, was admitted on [DATE] and discharged on [DATE]. An MDS assessment was not readily available. The resident was alert and oriented. B. Abuse allegation and facility investigation Review of facility investigative reports revealed Resident #6 reported on the morning of 11/12/21 that CNA #1 was rude and rough with her. The NHA interviewed Resident #6 who said CNA #1 was her CNA last night. I rang my light once and she came in and said 'what do you want?' in a rude tone. I've been constipated and needed to use the bathroom. I had an accident and she said 'you made a mess.'I had to ring the call light a total three times. I hated even having to call her but I needed help. She was not abusive but rough. I was really shocked by how rude she was. She was snappy and not friendly at all. I am not afraid of her and I do not feel abused. The NHA asked Resident #6 about the statement she made to the nurse about being pushed onto the toilet. Elder voiced I am not sure that she pushed me she just was rude and rough. The NHA asked about the long call light wait times. The resident said it seemed to take a long time to have to wait. The NHA asked the resident if she was afraid of CNA #1. The residents said no I'm not afraid I just hated to have to bother her again. Elder asked the resident to discuss the CNA slapping her while applying lotion. My back was so itchy I asked her to please put some lotion on my back. NHA asked did she slap you? The resident said it was more rough. I guess it was not really a slap. The NHA asked did it hurt when she applied the lotion to you? No, said the resident, just was not gentle. A PTA, two LPNs and two CNAs were interviewed. The PTA said the resident reported to the therapist the following statements during our therapy session: I had a rude person last night. I used my call bell they came in the room and stated what do you want? I needed to be changed. Person stated what a mess to me. Patient also reported the staff member slapped lotion on my back when asked to put lotion to her skin. Staff member stated per resident really are you going to be here for Thanksgiving. Patient reported to the therapist I don't want to make any complaints, I don't want anyone to get in trouble and I don't want them to know it was me. The police department report dated 11/12/21 reiterated the resident's allegation as above and documented the facility was investigating. CNA #1 had been removed from the schedule pending investigation. No other facility actions or findings were documented. There was no documentation of whether the allegations were substantiated or not. IV. Staff interviews CNA #1 was interviewed by phone on 11/23/21 at 11:06 a.m. She said her last day in the facility was 11/11/21 and she did not leave by choice. She said the DON called and said she did not want her to come back to work, because there was a report she was rude and abrupt with staff. She said she would never be rude to her residents. She said she asked her recruiter, who also did not know why her contract was ended at the facility. The NHA and ADON were interviewed on 11/23/21 at 5:44 p.m. The NHA said she thought verbal abuse and being rude were substantiated. She said that was not how she wanted staff to talk to their residents. She said when Resident #5 reported that CNA #1 grabbed her, she said that's too tight and CNA #1 let go. The NHA said Resident #6's statements were a little different to different people. She said CNA #1 was snappy, said she was not afraid of her, she did not feel abused, she said she was not sure that CNA #1 actually pushed her, she was just rude and rough, moving quickly, not taking her time. She had to wait for a long time, it seemed like a long time to have to wait. The slapping motion on her back when she applied lotion, I didn't like that either. She said it was more just rough, not really a slap I guess. I think that's just not appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Although Residents #5 and #6 alleged physical and verbal abuse, the NHA said they only substantiated verbal abuse.

Based on observation, record review and resident and staff interviews, the facility failed to provide two (#101 and #32) of 29 sample residents the necessary care and services to attain and/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 assess and manage resident #101's chest pain, and -The facility failed to assess and manage resident #32's abdominal pain. Due to the facility's failure to assess resident #101's complaint of chest pain, and provide the [MEDICATION NAME] medication that was ordered by the physician and requested by the resident, the resident had increased chest pain. The facility's failure to provide resident #32 with medication in a timely manner that was ordered by a physician and requested by the resident, caused an increase in the resident's abdominal gas pain on 7/8/15. The findings include: A. Facility Policy and Procedure regarding Condition Changes On 7/21/15 at 3:55 p.m., the staff development coordinator provided the facility's policy and procedure titled Changes in Resident Condition, dated 9/26/13, which included in pertinent part: Purpose: The resident, attending physician and legal representative or interested family member are notified when changes in condition or certain events occur. -Communication with the IDT (interdisciplinary team) and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. -A facility must immediately inform the resident, consult with the resident's physician; and if known, notify the residents' legal representative or an interested family member when there is . a significant change in the resident's physical, mental, or psychosocial status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical) . -Changes of condition are communicated from shift to shift through the 24 hour report management system. -Changes in the resident status that affect the problem(s)/goal(s) or approach on his/her plan of care are documented as revisions and communicated to the IDT team. -Examples of clinical condition changes are such things as . significant change in behaviors . any change in resident from resident's baseline/onset of new concern/incident . -Immediate notification to physician would include but not limited to . acute changes in cardiac status . Document in the resident's medical record: -Date and time of change of condition - who (physician/family member/responsible party) was notified regarding the condition change -Information communicated -Response and/or orders received -Assessment of resident condition and ongoing monitoring of resident condition -Care provided -Document the time emergency personnel arrived and took over the care of the resident, if applicable -Update the care plan as needed. Document on the 24 Hour Report-Resident name and the condition change and any other pertinent information. B. The policy and procedure on Pain Management documented in pertinent part: Pain is subjective and is what the resident says it is, existing when and where the resident says it does. -Procedure: All residents will be assessed for pain by utilizing a pain assessment tool. The pain assessment will be completed upon admission, readmission, quarterly, and with any significant change of condition. -The pain assessment includes the following: location, quality, intensity, associated symptoms, precipitating, aggravating and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain and their degree of effectiveness. C. Failures in response to resident condition changes 1. Resident #101 Resident #101, age 57, was admitted to the facility on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 6/9/15 included a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. He had adequate hearing, clear speech and impaired vision, and no rejection of care or physical or behavioral symptoms directed toward others. He was independent with bed mobility, transfers, dressing, eating and toilet use. Resident Interview: On 7/15/15 at 12:53 p.m., the resident was interviewed and was visibly upset, speaking loudly and emphatically. He explained that on 7/14/15 at approximately 5:15 p.m., he and his roommate were seated at a table in the main dining room during the evening meal, and were approached by the social services director (SSD). The resident said she sat down at their table and confronted him in a common area for making fun of another resident and implied that resident #101 had called a resident a derogatory name. Resident #101 denied that he had made fun of the other resident and said he felt that she had accused him of this unjustly, and this upset him. (Cross-reference F241, failure to treat residents with dignity and respect.) -The resident explained that after the SSD left, he continued to be upset and began to develop chest pain. He stated, I had to ask the cook to go and find the nurse to give me my medicine. He said the nurse that evening was licensed practical nurse (LPN) #38. He said, When my heart starts hurting like that, they give me my [MEDICATION NAME], but he said LPN #38 did not give it to him after he had asked for it. -The resident said he became more agitated and he was sweating really hard because I was upset, and certified nurse aide (CNA) #24 came to my table and said that my face was red and said the nurse had already given me my pills for my heart. He clarified that he had been given medications earlier, but not his heart medication. -The resident said LPN #38 approached him in the dining room approximately 10 minutes later, and he told her again that he was having chest pain, and she told me to go to my room and lay down. She never gave me my [MEDICATION NAME]. He explained that he required a dose of [MEDICATION NAME] once every three weeks or so. -At 3:39 p.m., the resident was asked if the staff had checked his vital signs or followed up with him after he went to his room. He responded, No, they didn't. And I was sweating pretty bad last night because my heart was hurting. Record Review: The resident's care plan, initiated 3/25/15, identified, Pain: (Resident #101) complains of pressure/pain to his head which he states he has been experiencing since his surgery first week of February (2015). Also has complained of chest pain. Physician aware. -The goal was that (resident #101's) risk for inadequate pain relief will be minimized through the review date. -The approaches included: Administer pain medications as per orders . Evaluate the effectiveness of pain interventions . Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria, nausea, vomiting, dizziness and falls. Report occurrences to the physician . Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Physician orders [REDACTED]. -Pain scale assess and record pain every shift using the 0-10 scale, started 3/5/15. -[MEDICATION NAME] Tab(s) 0.4 MG (milligrams), dissolve 1 tab under tongue every 5 minutes for chest pain up to 3 doses. The Medication Administration Record [REDACTED] -Pain Scale Assess and Record Pain every shift using 0-10 scale. This was documented on three shifts each day. However, all days except three, including 7/14/15 when the resident's chest pain incident occurred in the dining room, were recorded as zeros. -[MEDICATION NAME] ([MEDICATION NAME]) 0.4 MG, dissolve 1 tablet under tongue every five minutes for chest pain up to three doses. This was not documented as given on 7/14/15 when the resident complained of chest pain and requested the medication. -[MEDICATION NAME] 20 milliliters (ML) by mouth every six hours as needed for heartburn. This was given to the resident on 7/14/15 and documented as Late entry: 1700 (5:00 p.m.) [MEDICATION NAME] 20 ML. Resident request for heartburn. No complaints. 1800 (6:00 p.m.) The medication was signed out by LPN #55, not LPN #38. Resident Observation: On 7/15/15 at 4:15 p.m., LPN #38 was observed during her medication pass to administer insulin to resident #101. The LPN approached the resident in his room where he was lying down in bed and she made multiple attempts to awaken him, but he appeared sleepy and difficult to arouse. She spoke to the resident in a loud voice and informed him of whom she was and that she was there to give him his insulin. He remained groggy, opened his eyes slightly, and said, I know who you are. Don't hurt me. She informed him that she was not going to hurt him and proceeded to inject the insulin into his right lower abdominal area. Staff Interviews: On 7/15/15 at 3:43 p.m., the nursing home administrator (NHA) and director of nurses (DON) were informed of resident #101's complaint of chest pain on 7/14/15, that he was not assessed or medicated for the pain by his nurse after she was informed he was having pain, and no vital signs or follow up was done with him. The NHA said they would talk to LPN #38 who was currently working, and follow up immediately. -At 4:20 p.m., the NHA and DON reported that they had talked with (CNA #24) and the activities person that (resident #101) had talked to. They said CNA #24 confirmed to them that he went down and told (LPN #38) about his chest pain so this is totally confirmed. So what we are going to do is put (LPN #38) on administrative leave while we investigate. The NHA said, Prior to this incident, we had another resident complaint that (LPN #38) was short with him, so we are going to investigate that and we are going to follow up with (resident #101), and let the doctor know, and do an assessment and treat it as an incident. -The NHA stated That is not how we function and is not how we expect our residents to be treated. They were informed of the recent observation at 4:15 p.m., and that resident #101 was difficult to arouse, and the DON stated, That is normal for him; he cycles up and down. The NHA stated, We need to make sure it's not cardiac. The DON said they would do a full assessment on resident #101 immediately. -LPN #38's Employee Timecard Report documented that she left the facility that day at 4:50 p.m. On 7/16/15 at 9:50 a.m., activity aide #5 was interviewed and asked to explain the events she observed with resident #101 on 7/14/15. She said she heard him raising his voice and he was in a bad mood after (the SSD) talked to him. She said, (CNA #24) was over there talking to him, and (resident #101) started cursing (CNA #24) and I told him 'You don't need to use that language'and the resident became more and more upset. She said, I don't know what (CNA #24) was talking to him about, and I told him he didn't need to use that language, and he told me to 'shut up.' So I said 'OK' and just walked away. -The activity aide was asked if, after seeing that resident #101 was upset, she had informed his nurse. She said, Yes, I went and told (LPN #38) that he was upset and informed her of what happened. She explained, I had no idea he was having chest pain. If I would have, I would have let the nurse know. On 7/16/15 at 1:35 p.m., CNA #24 was interviewed and asked to explain the events he observed with resident #101 on 7/14/15. He said the first thing that happened was one of the activity aides came to him and asked me where the nurse was. I didn't know so I walkied (walky-talky) her and she was in a different room, so I waited. The aide had told me that (resident #101's) hand was hurting, and his chest. She wanted to find the nurse. The CNA clarified that the activity aide informed him that resident #101 was having chest pain. -CNA #24 stated I finally got a hold of the nurse (LPN #38) and told her that his hand and his chest were hurting and she said 'I've already given him his medication for that so wait 30 minutes.' I went back to (resident #101) and relayed the message. (Activity aide #5) was standing there, and (resident #101) stated 'That's (expletive),' and he told me a couple other foul language words, so I said 'I just relayed the message but I will let her know that you want to talk to her.' So I went back and told (LPN #38) that he wanted to speak to her. -CNA #24 said he immediately went back to LPN #38 and informed her resident #101 wanted to speak to her, and she told him that resident #101 wasn't the only resident she had to take care of, and said to give him 30 minutes because she gave him the medication. The CNA was unable to recall what medication the LPN had given to the resident and said he thought it was [MEDICATION NAME]. These events were not documented or addressed in the progress notes or any other form of documentation in the resident's clinical chart. Additional Observations and Staff Interviews: On 7/16/15 at approximately 10:40 a.m., an announcement was made over the facility's public announcement system that a nurse was needed in the dining room. Resident #101 was observed sitting in his wheelchair during a Bingo activity when he became sleepy and difficult to arouse, and two staff members propelled him from the dining room to his room. The NHA explained that the staff was in the process of checking his vital signs and blood sugar and calling the resident's physician. At 10:47 a.m., the NHA reported that resident #101 agreed to go to the emergency room (ER), probably for a cardiac work up. On 7/16/15 at 2:26 p.m., LPN #33, who was resident #101's nurse that day, was interviewed and asked to explain the events that occurred during the Bingo activity that morning. She stated, I went into Bingo and he was not responding to anyone, and his eyes were closed and he had been chewing on a straw and his mouth was closed around it. She demonstrated that his hands were pronated inward towards his chest and his fists were clenched. She explained that the NHA had performed a sternal rub on him and nothing changed. The DON got there at that point and I went to get the blood sugar kit, and he was still in the dining room at that time. She explained that the resident was escorted to his room with the DON, NHA and staff development coordinator while she called the resident's physician to see if he wanted to send him out (to the ER) at that time. -The LPN explained that the resident's blood glucose (BG) level was 363 (according to the American Diabetes Association website at www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/checking-your-blood-glucose.html <http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/checking-your-blood-glucose.html>, accessed on 7/23/15, a normal BG checked one to two hours after the beginning of a meal is less than 180 milligrams per deciliter). She was unable to recall what his other vital signs were and stated, I know his blood pressure was a little bit elevated. -The LPN said she obtained the resident's [MEDICATION NAME] medication and took it back to his room where he was in his wheelchair, and his hand was on his chest, and asked him to nod his head if he could hear me, but his hands and feet were shaking. She said she asked him if his chest hurt and he nodded his head (yes), and we gave him Nitro at 10:45 a.m., and then he continued to have his mouth (she demonstrated that his mouth was clenched) because I couldn't open his mouth, possibly having a [MEDICAL CONDITION]. -The LPN explained that after a few minutes had passed, he said he was still hurting so I gave him his second Nitro and at that point the EMS (emergency medical services) got here too. She explained that the resident's physician was unsure what was going on and needed to send him out for evaluation. -The LPN said the doctor from the ER called her and asked her some questions like Has he had a [MEDICAL CONDITION] before, and asked her to explain what she had seen resident #101 do. She said half an hour later, another physician called her and asked basically the same questions: 'What did you see? Has he ever done this before?' and he said that resident #101 was fully aware and he was telling him he did not want to stay at the ER, and they wanted to keep him overnight for evaluation, and he was refusing to stay. She said the resident would probably be returned to the facility that day and follow up with a neurologist at a later date. On 7/16/15 at 4:28 p.m., resident #101 had been returned to the facility and was observed sitting in his wheelchair in his room. He was awake and alert and said he was feeling better. On 7/20/15 at 1:28 p.m., LPN #37, who was resident #101's nurse on day shift, was asked if he had complained of chest pain that day. She said, No. In fact, I just listened to his lungs and they sound good. Additional record review: The progress notes dated 7/15/15 at 5:00 p.m. documented, (Resident #101) complained of pain to the left of midline chest area under left arm in the pit area. BP (blood pressure) 130/86, P (pulse) 85, Spo2 (peripheral capillary oxygen saturation) 95% on room air. No sweating or pain in the back of his neck, jaw pain denied, no SOB (shortness of breath), color pink. Requested [MEDICATION NAME] for this discomfort, refused to go to the ER. Will notify the doctor. Another progress note with same dated and time of 7/15/15 at 5:00 p.m. documented Communication sent to (doctor), resident's PCP (primary care physician). Relayed resident complained of left chest pain at this time and had episode last evening as well that he received [MEDICATION NAME] for with no further complaints last evening. Was encouraged at this time to allow nursing staff to perform cardiac assessment and after declining, resident did reluctantly agree to allow auscultation and vital signs to be obtained . The note was written by the DON. The progress notes dated 7/15/15 at 5:36 p.m. read in part, Dr. wishes for no further orders and to monitor resident for next 72 hours and offer Nitro sublingual with further complaints not relieved with [MEDICATION NAME]. Will place on 72 hour charting for cardiac signs and symptoms. The note was written by the DON. The progress notes dated 7/15/15 at 9:41 p.m. read, Resident complained of pain in right shoulder radiating to the back. Upon attempt (to) assess cardiac status resident becomes angry and strongly refuses assessment. Resident is persuaded to allow this nurse to listen to heart and palpate pulse. No irregular rhythm auscultated or palpated. Apical pulse 71. Resident refuses vital signs and Nitro. Strongly declines transport to hospital. Resident states 'I will come tell you if it gets bad; it's ok now.' Continue to monitor. The progress notes dated 7/15/15 at 9:46 p.m. documented, Approached resident to assess chest pain. Resident states 'My arm hurts,' pointing to his left shoulder. Resident continues to refuse further intervention. He understands he could be having heart issues. The progress notes dated 7/15/15 at 10:21 p.m. documented, Elder complained of pain in left axillary area down through left arm and also left hip down left leg. Elder is not clammy. Skin pink and dry. Given scheduled pain medications. Apical pulse 82, RRR (respiratory rate regular), denies SOB or trouble breathing. Also denies jaw pain. This nurse asked elder if he would like to be evaluated in ER, elder refused. Elder stated I talked to SSA (unknown abbreviation) and told her I don't want to do anything anymore. I'm tired of being in the hospital.' The ER summary dictated 7/16/15 at 11:23 a.m. was brief and included a list of tests and procedures that were performed including laboratory tests and diagnostic studies. The instructions provided to the resident included: Follow-up with: (physician), Neurology (phone number and address). Reason for referral: follow up after EEG (electroencephalogram) for possible [MEDICAL CONDITION]. Documentation and Follow-up Regarding LPN #38: On 7/21/15 at 9:35 a.m., LPN #38's employee record was reviewed in the presence of the NHA and the admissions coordinator (#7), revealing the following: -Hire date: 11/21/14 -The two Applicant Reference Check forms were void of documentation, which indicated no references were obtained or verified prior to LPN #38 starting work at the facility. The admissions coordinator stated, It looks like neither one of her references called back and there is no documentation on it. She confirmed that she would expect reference checks to be completed prior to a new employee starting to work at the facility and stated, Yes, we try to get as many completed as we can. We try to get at least one to two. She confirmed that no reference checks were obtained prior to LPN #38 working at the facility. -A 90-Day Evaluation form was completed on LPN #38 on 1/29/15 that documented her commitment to quality, quantity of work/ use of time/ initiative, resident relations/ customer service, compliance/ safety/ attendance and adaptability/ teamwork/ coping skills were all satisfactory. The document was signed by the facility's previous assistant director of nurses who was no longer employed at the facility. -The Employee Memorandum form used with employees in cases involving employee corrective disciplinary counseling action, including verbal warnings for LPN #38, reiterated the details of the incident with the resident, and noted she would be suspended for three days. The form was signed and dated 7/15/15 by LPN #38, the DON and NHA. -A form titled Individual Employee Education Record that had been crossed out with an ink pen documented education was performed by the DON for LPN #38. The form, which was undated and not signed by either the LPN or DON, included the following: Resident asked for [MEDICATION NAME] at 5:00 p.m. prior to going to dining room. Resident then complained to (CNA #24) upon arriving in dining room prior to conversation and said his chest hurt and (CNA #24) related to nurse and nurse relayed he just received [MEDICATION NAME]. Went to dining room and he spoke with (SSD) in dining room and he was upset about [MEDICAL CONDITION] and that 'his heart hurt' due to his son's passing away and was tearful. Late entry to be done by (LPN #38) as she did not document. The employee's statement read, Conversation was approximately 5:30-6:00p.m. after supper was done and were cleaning up. Nurse had been escorting resident to south hall for music event. Additional Staff Interviews: On 7/21/15 at 2:58 p.m., the DON, NHA and corporate nurse consultant were interviewed. The DON was asked what her expectation was if a resident complained of chest pain, and she stated, Get vital signs. Do a cardiac assessment. Assess for any shortness of breath, radiating pain, headache. She confirmed that this should be documented in the resident's progress notes and the physician should be notified. She explained that if a resident had an order for [REDACTED]. -The DON was aware that these interventions were not performed surrounding resident #101's episode of chest pain on 7/14/15, and explained that the facility would do a corrective action and (educate on) how to respond to different issues. -The NHA stated, We will probably not be bringing (LPN #38) back. -The corporate nurse consultant stated, Because of the severity, we will be (terminating LPN #38) and reporting her to the Board of Nursing. -The DON and NHA were not currently employed at the facility when LPN #38 was originally hired, and were not aware that she did not have reference checks completed prior to starting her employment at the facility. The corporate nurse consultant explained that the facility's human resources department performed an evaluation and did an audit in February 2015 and an action plan was put in place to address the concerns. 2. Resident #32 Resident #32, age 57, was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident Status: According to the 7/8/15 MDS, the resident had a BIMS score of 15 out of 15, indicating he was cognitively intact, with no behavioral symptoms. He required total assistance of two persons with bed mobility, transfers, dressing, toilet use, bathing, and personal hygiene. He used an electric wheelchair. He was always incontinent of bowel. He received a scheduled pain medication regimen and received as-needed pain medications. He had a pressure reducing device for his chair and a pressure reducing device for his bed. He had [MEDICAL CONDITION], and was on a routine turning and repositioning program. Care Plans: The care plan related to pain, dated 4/4/15 and revised 6/24/15, identified acute and chronic pain related to a history of traumatic bilateral [MEDICAL CONDITION] resulting in [MEDICAL CONDITION]. -Goals were for the resident's risk for inadequate pain relief to be minimized, risk of side effects with the use of [MEDICATION NAME] to be minimized, and risk to display behaviors related to inadequate pain control such as facial grimacing to be minimized through the next review date. -Interventions included: Administer pain medications per orders; evaluate effectiveness of pain interventions; review for compliance, alleviating symptoms, dosing schedules and resident satisfaction with results, and impact on functional ability cognition. 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. Report occurrences to the physician. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. Offer non-pharmacological interventions for pain. The care plan related to activities of daily living (ADLs), dated 4/9/15, identified self-care deficit related to [MEDICAL CONDITION]. -The goal was for the resident to maintain his current level of function. -Interventions included: The resident used an electric wheelchair for mobility and was able to operate it independently with supervision. The resident was totally dependent on staff for bathing, repositioning and turning every two hours, and for his personal hygiene care. The resident was totally dependent on two staff members for being checked and changed. The resident was always incontinent of bowel and had a suprapubic catheter. Resident Interview: Resident #32 was interviewed on 7/14/15 at 6:30 p.m. He said he had asked LPN #38 to give him his routinely needed suppository on 7/8/15. He said at 6:40 p.m. the CNA came into the room and told him that the nurse was to be one hour getting down to his room with the suppository because she was going on her lunch break. The resident was upset because he was already uncomfortable when he asked for the suppository, and the abdominal gas was building up. -The resident said that by the time LPN #38 came down to administer his suppository, he was in pain and he cursed her. He told her to get out and send another nurse in for him. -The resident said the other nurse (#34) was new or new to him and at 8:00 p.m. she gave him his medications including his suppository. -He said the SSD was instructed to come down the next day and talk to him about his language with the nurse. He said the SSD told him the facility was not going to do anything about the suppository issue and LPN #38. Record Review: The pain evaluation assessment, dated 7/8/15, documented the resident had chronic pain and at times his pain was worse. Additional symptoms associated with pain included irritability. The pain evaluation assessment form did not address pain and discomfort related to constipation. According to the July 2015 MAR, the resident was on routine medications including [MEDICATION NAME] mg every 12 hours for pain, [MEDICATION NAME] 5 mg three times a day for pain, and [MEDICATION NAME] 600 mg as needed for pain. The resident also had [MEDICATION NAME] 75 mg three times daily for anxiety; [MEDICATION NAME] 50 mg at bedtime for [MEDICAL CONDITION]; [MEDICATION NAME] 5 mg four times daily for muscle spasms; and [MEDICATION NAME] 5 mg, one tablet every four hours as needed for pain. --According to Mosby's 2013 Nursing Drug Reference, all the pain medications listed above have side effects including constipation. Additional medications included [MEDICATION NAME] suppository 10 mg every day as needed for constipation; milk of magnesia 1200 mg/15ml, 1 tablespoon every day as needed for constipation; [MEDICATION NAME] Sodium capsules one twice daily for constipation: Humalog Kwikpen insulin per sliding scale for diabetes; [MEDICATION NAME] 22 units subcutaneously at bedtime for diabetes; [MEDICATION NAME] 300 mg three times daily for nerve pain; Xarelto 20 mg daily for history of [MEDICAL CONDITION]/[MEDICAL CONDITION]; [MEDICATION NAME] 10 mg at bedtime for [MEDICAL CONDITION]; potassium chloride 20 meq twice per day as supplement; magnesium oxide 400 mg each day as supplement; polyethylene [MEDICATION NAME] 17 gms dissolved in water as needed for constipation; and fleet enema one daily as needed for constipation. According to the July 2015 MAR, the resident received PRN [MEDICATION NAME] suppositories on 7/1, 7/9 and 7/10/15. The administration and documentation for the suppository administered on 7/1 and 7/9 revealed no evidence of results. The suppository administered on 7/10/15 was void of documented results. There was no documentation a suppository was administered on 7/8/15. (See resident interview below regarding request for suppository on 7/8/15.) Nurse's Note: A nurse's note, documented by LPN #38 on 7/8/15 at 7:39 p.m., read that she was notified during her supper break that the resident wanted a suppository. She instructed the CNA to inform the resident that she (LPN #38) would administer the suppository when she returned from supper. LPN #38 walked into the resident's room at approximately 7:20 p.m. with the suppository and the resident yelled get out of my room, (expletive), so the nurse then asked him if he would like his medications. The resident said he wanted a different nurse to give him his medications. LPN #38 called and reported the issue to the DON and notified the SSD. LPN #38 documented the incident as a resident behavior. Concern/Complaint Form: A Concern/Complaint/Compliment Form dated 7/9/15 documented that the resident wanted to talk with the ombudsman to voice his complaints/concerns and he thought no one cared about his needs. The ombudsman and the resident spent time alone on 7/9/15 to discuss his concerns related to his complaint with the facility's lack of response to his needs. -The form further revealed on 7/14/15 that the ombudsman had another meeting with the resident and had requested from the facility copies of some of the resident's medical records. The facility Concern/Complaint/Compliment Form also documented that the management team had a meeting and made the decision to provide the staff additional training regarding customer service. The DON documented she had provided re-education to LPN #38 on 7/9/15 (see DON interview below). Staff Interview: CNA #24 was interviewed on 7/16/15 at 3:30 p.m. He said he was working the night of 7/8/15 and had been out with the resident in the smoking area, and on the way into the building at approximately 6:30 p.m.; he stopped and told LPN #38 that t

Based on observation, record review and family and staff interview, the facility failed to ensure one (#30) of two residents reviewed for pressure ulcers out of 35 sample residents received necessary treatment and services to prevent pressure ulcers from developing, and to promote healing of pressure ulcers. Specifically, the facility failed to: -Ensure the resident did not develop unstageable bilateral heel pressure ulcers; -Conduct a thorough initial wound assessment of new bilateral heel wounds on the day they were first observed to have developed (5/29/15); -Consistently and accurately assess, stage, and document information on the resident's bilateral heel ulcers; -Consistently ensure pressure relief of the bilateral heel ulcers; -Update the care plan when wounds developed and worsened; and -Consistently and completely document wound assessments. These failures contributed to the development and worsening of unstageable pressure ulcers to both of the resident's heels. The findings include: A. Professional Reference regarding Pressure Ulcers The National Pressure Ulcer Advisory Panel, NPUAP Pressure Ulcer Stages/Categories 2014, http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stages-categories (2/2015), read in pertinent part: International NPUAP-EPUAP Pressure Ulcer Definition -A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Pressure Ulcer Stages/Categories Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Suspected Deep Tissue Injury - depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. B. Resident #30 Resident #30, age 88, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], the resident had both short- and long-term memory problems and wandering behavior. She required extensive assistance of one or two persons with bed mobility, transfers, dressing, toilet use, personal hygiene, and with ambulating in her wheelchair to move on or off the unit. The number of pressure ulcers present on admission was none. As of 6/24/15, she had two stage 2 pressure ulcers that remained unhealed. The number of unstageable pressure ulcers due to coverage of the wound bed by slough and /or eschar was documented as none. The family or significant other participated in the resident's assessment. (However, see the wound /skin sheets below dated 6/12/15, which documented a wound bed with black/brown eschar. This indicated unstageable ulcers at the time of the MDS assessment.) Care Plan: The Skin care plan, initiated 6/23/15 and revised on 6/30/15 and 7/16/15, identified the resident had a blister on each heel related to using her lower extremities to self-propel her wheelchair. (See nurses' notes below - the date the blisters were first observed was 5/29/15, indicating the care plan was not initiated until 25 days after the facility was aware of the resident's bilateral heel blisters.) The goal was the resident's risk for complications related to blisters would be minimized and blisters resolved by 10/8/15. Interventions included: -The resident would have her heels floated at all times when she was in bed (date initiated 6/23/15, almost a month later). -Nursing staff was to monitor/document location, size, and treatment of [REDACTED]. -Report abnormalities, failure to heal, signs/symptoms of infection and maceration to the physician. - A padded protective covering was to be applied to both heels, and changed daily and as needed and with bathing. - The resident did not use her upper extremities to propel her wheelchair and the family was aware. The care plan was not updated to include that the resident had heel blisters that changed into brown and black eschar. The care plan was also void of interventions to prevent additional pressure to the resident's heels while she was up in her wheelchair. Record Review a. Nurse /Interdisciplinary Team Notes: Interdisciplinary team (IDT) meeting notes dated 5/26/15 included information that the resident was being monitored for weight loss and the dietary department had interventions in place. On 5/27/15 the resident's dietary supplement had been increased. A nurse's note dated 5/29/15 documented the resident was found to have new blisters of the right and left heels, consistent with pulling herself along in the wheelchair. The physician and family were notified. The note was void of a complete assessment of the blisters to include: measurements, color, odor, drainage, color of surrounding skin, and stage of the wound/blisters. The first facility Wound/Skin Healing Record was dated 5/31/15, two days after the bilateral heel blisters were first observed (see below). On 6/25/15 the dietary/nutrition note documented the resident had weight loss. She was being reviewed at the weight meeting to help maintain her weight, and for continued care in wound healing. b. Wound/Skin Healing Records, left heel The facility Wound/Skin Healing Record related to the resident's left heel was first dated 5/31/15 (two days after the wound was initially observed) and read as follows: wound stage = 2, size in cm length x width = 4 cm x 4 cm, depth=n/a, exudate = (void of documentation), odor = (void of documentation), surrounding skin color = (void of documentation), surrounding tissue wound edges = (void of documentation). The family, dietary, and physician all were notified on 5/31/15. The form was void of the date of onset. -On 6/3/15, wound stage = 2, size in cm length x width = 2cm x 1.5cm, depth= none, exudates type = none, odor = none, exudates amount = none, wound bed = normal for skin, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -6/12/15, wound stage = 2, size in cm length x width = 3cm x 2 cm, depth = none, exudates type = none, odor = none, exudates amount = none, wound bed = black/brown eschar, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -6/16/15, wound stage = 2, size in cm length x width = 2cm x 2cm, depth = none, exudates type = none, odor = none, exudates amount = none, wound bed = black/brown eschar, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -6/23/15, wound stage = 2, size in cm length x width = 1.78 cm x 2 cm, depth = none, exudates type = none, odor = none, exudates amount = none, wound bed = black/brown eschar, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -6/30/15, wound stage = 2, size in cm length x width = 2 cm x 1 cm, depth = none, exudates type = none, odor = none, exudates amount = none, wound bed = black/brown eschar, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -7/7/15, wound stage = 2, size in cm length x width = 1.9 cm x 1 cm, depth = (void of documentation), exudates type = none, odor = none, exudates amount = none, wound bed = black/brown eschar, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -7/14/15, wound stage = 2, size in cm length x width = 1.9 cm x 1 cm, depth = none, exudates type = none, odor = none, exudates amount = none, wound bed = wound, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -7/21/15, wound stage = unstageable, size in cm length x width = 2.5 cm x 1.3 cm, depth= unstageable, exudates type = serosanguineous, odor = none, exudates amount = scant, wound bed = black/brown, surrounding skin color = pink, surrounding tissue wound edges = rolled edges. The form was void of the date of onset. c. Wound/Skin Healing Records, right heel -5/31/15, wound stage = 2, size in cm length x width = 5 cm x 5 cm, depth = none, exudates type = none, odor = none, exudates amount = none, wound bed = normal for skin, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -6/3/15, wound stage = 2, size in cm length x width = 5 cm x 5 cm, depth= none, exudates type = none, odor = none, exudates amount = none, wound bed = normal for skin, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -6/12/15, wound stage = 2, size in cm length x width = 5.5 cm x 5.5 cm, depth= none, exudates type = none, odor = none, exudates amount = none, wound bed = black/brown eschar, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -6/16/15, wound stage = 2, size in cm length x width = 5.5 cm x 5.5 cm, depth= none, exudates type = none, odor = none, exudates amount = none, wound bed = black/brown eschar, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -6/23/15, wound stage = 2, size in cm length x width = 5.4 cm x 5.5 cm, depth = none, exudates type = none, odor = none, exudates amount = none, wound bed = black/brown eschar, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -6/30/15, wound stage = 2, size in cm length x width = 5.4 cm x 5.5 cm, depth= none, exudates type = none, odor = none, exudates amount = none, wound bed = black/brown eschar, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -7/7/15, wound stage = 2, size in cm length x width = 5.3 cm x 5.4 cm, depth= none, exudates type = none, odor = none, exudates amount = none, wound bed = black/brown eschar, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form was void of the date of onset. -7/14/15, wound stage = 2, size in cm length x width = (void of documentation), depth= none, exudates type = none, odor = none, exudates amount = none, wound bed = normal for skin, surrounding skin color = normal for skin, surrounding tissue wound edges = normal for skin. The form documented the date of onset was 5/29/15, right heel original stage 2 was dusky and cloudy. -7/21/15, wound stage = unstageable, size in cm length x width = 3.5 cm x 4.0 cm, depth= unstageable, exudates type = serous, odor = none, exudates amount = scant, wound bed = black/brown eschar, surrounding skin color = pink, surrounding tissue wound edges = hardness / induration, rolled edges. d. Physician Orders The physician order [REDACTED]. Review of the facility medication and treatment administration records revealed the physician's orders [REDACTED]. There were no additional physician orders [REDACTED]. On 6/25/15 a new physician order [REDACTED]. On 7/17/15 the physical therapist noted the facility was to have the resident seen by an orthotist for evaluation of the possibility of orthotic footwear so the resident would be able to bear full foot weight to improve standing balance and gait and take pressure off healing heel sores. An undated, unsigned physician order [REDACTED]. The order was written on the same order sheet as the physical therapist order above, dated 7/17/15. Observations/Interviews: On 7/15/15 beginning at 11:55 a.m., observations were made in the West dining area. The resident was observed sitting at her table, eating independently while sitting in her wheelchair. Her wheelchair continuously moved backwards away from the table and the resident was continuously repositioning herself up to the table in the wheelchair using her feet. She was wearing white socks with some sort of padding underneath the socks. On 7/15/15 at approximately 1:00 p.m., the resident was observed in the common area of the west dining area and living room, moving about independently in her wheelchair using her feet that were covered with some padding and white socks. On 7/15/15 at approximately 4:58 p.m., the resident was observed at the dining table. She continued to wear the padded white socks and use her feet to reposition herself at times, back up to the table. On 7/16/15 at 10:16 a.m., the resident's family member was interviewed. She said the resident had not had a change of condition within the past several months. She said the staff told her that her mother had blisters on her heels and that she thought the resident should wear shoes when she was up in her wheelchair, not just socks. On the morning of 7/20/15, the director of nurses (DON) was interviewed about the resident's pressure sores. The DON said she thought the cause of the pressure ulcers was that the resident had slipped out of her wheelchair and possibly caused a deep tissue injury to her heels when she slipped. She said the blisters appeared about two days after she had slipped out of the wheelchair. On 7/20/15 at 11:54 a.m., the resident was observed sitting in her wheelchair at the dining table. She was wearing regular white socks with padding underneath. On 7/20/15 at approximately 1:30 p.m., the resident was moving about in her wheelchair using her feet. She was wearing white socks with padding underneath. On 7/21/15 at approximately 10:00 a.m., the wound nurse (nursing staff #42) and registered nurse (RN) #40 were observed as they assessed the resident's bilateral heel wounds (refer to wound/skin/healing record above). The resident did not have an air mattress on her bed but her heels were floated on a pillow. Wound nurse #42 and RN #40 said they did not know what had caused the pressure ulcers and that this was the first time they had ever observed the wounds. Wound nurse #42 said the resident's heels were floated on pillows to prevent pressure when the resident was in bed. She wrapped [MEDICATION NAME] around both feet and heels, which she said was to pad and protect the pressure ulcers. Wound nurse #42 said a specialist would be out the following day to assess the wounds for special shoes or some device for offloading pressure of the resident's heels. (However, see above - the order for evaluation of the need for an orthotic device was first requested 7/17/15, more than four days prior.) On 7/21/15 at 11:53 a.m., the resident was observed in bed with her heels resting on the pillow. Her heels were not floated. Certified nurse aide (CNA) #56 was asked about the resident's heels and the need for floating. The CNA said the pillow was to float the heels, but the resident moved her feet around and crossed her legs over at the ankles. The CNA said she usually used two pillows to elevate the resident's feet and float her heels. She said that someone else had helped the resident to bed and used only one pillow, but that she was going to add one more pillow, reposition her legs and float her heels.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision to prevent accidents for one (#29) of 29 sample residents. Specifically, the facility failed to: - Thoroughly assess and implement fall prevention measures; - Provide supervision and assistance to a new resident who was admitted with known fall history and continued risk; - Assess and identify fall risk associated with use of multiple medications; - Develop and implement an interim fall prevention care plan; - Ensure the resident's level of assistance needs was comprehensively assessed; - Ensure the resident was consistently provided with the necessary assistance for transfers, ambulation and toilet use to prevent falls; and - Conduct a thorough status [REDACTED]. These failures contributed to the resident experiencing a fall resulting in a fractured neck and hospitalization . The findings included: A. Facility Policy The facility policy on Fall Management, dated [DATE], read in pertinent part as follows: The purpose of this fall management policy is to modify or eliminate risk factors and thereby reduce the likelihood of future falls. A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs . identify risk factors, followed by timely and appropriate interventions, is the key to a successful program . -To be effective, a fall reduction program is characterized by four components. 1. Fall risk assessment; 2. Care planning and implementation of interventions; 3. Ongoing evaluation process (quality assurance committee); and 4. A strong commitment by all caregivers to make it work. -If a resident has experienced a fall within the last thirty days prior to admission and is assessed by the facility as a fall risk the facility will provide education to the resident and/or responsible party about the potential use of personal protective devices. If the resident and/or responsible party consents to use of devices, the facility will proceed with implementation of such devices for a week observation period and then reassess the resident . -Individualized care plan interventions will be implemented for those residents found to be at high risk for falls . -Assess the environment and make appropriate changes, e.g. bed in lowest position, placement of furniture, lighting, personal items within reach, non-slip footwear, night light, walkers, wheelchair within reach. -CALL BELL AND FLUIDS MUST ALWAYS BE WITHIN REACH OF THE RESIDENT. -Offer frequent toileting or follow individualized toileting schedule. -Encourage resident to request assistance when needed - place a Safety Awareness sign in the room if applicable . -Therapies assess for wheelchair modifications (drop seat, pommel cushion) or use of a merry walker . -Complete thorough analysis of fall - time of day, location of fall, causative factors. Identify whether the interventions were in place at the time of the fall, i.e., interview staff and resident if able to identify potential causative (factors) . -The facility will review all falls daily (Monday through Friday) during the morning QA&A meeting. Falls review will include the following: a) Review the incident report to ensure complete and appropriate parties have been notified regarding the incident; b) Review the post fall investigation to ensure complete and appropriate interventions have been implemented; c) Review that a care plan has been initiated; and d) Provide revisions to the plan of care as necessary. -Monthly the QA&A Committee will review the Facility Quality Measures/Indicator Report to identify any resident who triggers with a new fracture or prevalence of falls. The DNS or designee will also complete a summary of residents who experienced a fall during the month to include a tracking and trending report for the committee to review. B. Resident #29 Closed record review revealed resident #29, age 87, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the [DATE] admission minimum data set (MDS), the resident's BIMS (cognition) score was 11 out of 15, indicating moderate cognitive impairment. -She required limited assistance of one for transfers, ambulation, personal hygiene and bathing. -She required extensive assistance of one for bed mobility, dressing and toilet use. -She was unsteady but able to stabilize without staff assistance for surface to surface transfers, and used a walker for ambulation. -She had sustained a fall within the last two to six months prior to admission. -She required oxygen therapy as her respiratory treatment. The resident's admission orders [REDACTED]. The Interdisciplinary Therapy Screen form read, PT (physical therapy) screened and found no rehab potential for skilled PT at this time. This note was signed on [DATE]. The form further read, PT not showing rehab potential at this time. This note was signed on [DATE] (the day the resident died in the hospital). There were no further notes on the therapy screen form, and no further therapy notes in the resident's medical record. Fall Risk Assessment: The fall risk evaluation dated [DATE] (the day of the resident's fall and ten days after admission) read that resident #29 had periods of confusion; sustained one to two falls in the past 90 days; had balance problems while standing and walking; had decreased muscular coordination; displayed a gait problem when walking through a doorway; had gait problems, such as jerking, unstable when turning, unsteady gait, shuffling gait; took three or more medications that could increase confusion or lethargy; and had three or more [DIAGNOSES REDACTED]. Room Observation: The room the resident had resided in was observed on the afternoon of [DATE]. The room was located in a hallway cul-de-sac of three rooms, close to the nurse's cart and where staff charting occurred. Record Review Care Plans: The care plans, provided by the MDS Coordinator on [DATE] at 2:03 p.m., were reviewed. The care plans were initiated on [DATE]. However, there was no care plan addressing falls, although the facility was aware that the resident had fallen at home prior to admission and required extensive assistance with toilet use (see MDS above). Medications: The [DATE] medication administration record (MAR) revealed the resident received the following medications: [REDACTED] - Sulfamethoxazole/Trimethoprim tab(s) ,[DATE] mg (sulfa antibiotic medication), one tablet every 12 hours for seven days, ordered [DATE] and discontinued on [DATE]; - Buspar (anti-anxiety), 10 mg twice a day for 14 days, ordered [DATE] and discontinued [DATE]); - Dicyclomine HCL (anti-cholinergic for gastrointestinal disorders), 20 mg three times a day; - Diltiazem HCL (antihypertensive), 240 mg every day; - Fluoxetine HCL (anti-depressant), 20 mg twice a day. The resident was admitted with this order. On [DATE] (the day prior to the fall), an order was written to decrease the medication to 20 mg daily for 3 days, then discontinue. - Ativan (anti-anxiety), 0.5 mg every 8 hours as needed. This was ordered on [DATE] and an order was written on [DATE] to increase the Ativan to 1 mg every 6 hours as needed. - Seroquel (anti-psychotic), 25 mg every night. This was ordered on [DATE] and increased to 50 mg every night on [DATE]. (According to Saunders Nursing Drug Handbook 2014, side effects from the above six medications include sedation, drowsiness, dizziness, orthostatic hypotension, loss of strength, tremor, blurred vision, fatigue and/or lightheadedness.) The June MAR also noted that resident #29 required oxygen at 2 liters per nasal cannula at night for her [DIAGNOSES REDACTED]. Interdisciplinary Progress Notes: The pertinent IDT progress notes read as follows: - [DATE]: Elder was transported to (local hospital) this morning for a change of condition. She became unarousable and right arm became rigid. Has new orders for Benadryl, Ativan, and Seroquel. Is to no longer receive sulfa drugs. - [DATE]: Initially, resident would not respond, O2 via nasal cannula was placed on resident's face at 3. Oxygen sats were 60%, within approximately one minute she sats at 97%, adjusted to 2%. Neuros (neurological checks) were started: right pupil no constriction, left pupil rapid constriction. Resident was not initially able to squeeze with her left hand, right hand strength was within normal limits, continued neuros Q 15 (every 15 minutes), with improved constriction in right pupil. Contacted physician's office, received verbal order to transport immediately, contacted family and was not able to speak to anyone. left a message. Resident departed facility at 2108 (9:08 p.m.) via ambulance. - [DATE]: .Spoke with (registered nurse) on neuro trauma unit . elder had passed at 2130 (9:30 p.m.) this night. (These were the only pertinent progress notes found in the resident's computer chart.) Fall Investigation: The fall investigation, dated [DATE] and revised [DATE], read in pertinent part, Unwitnessed fall: upon entry at 2020 (8:20 p.m.) into resident's room, observed on floor in front of the bathroom lying face down without her oxygen on her face. LPN (licensed practical nurse) contacted nurse and aides for assistance. Resident stated 'I was walking to the bathroom and slipped on the floor.' Resident later stated 'I was walking to the bathroom and passed out.' It noted that resident #29 suffered an abrasion on top of her scalp and was lethargic. Resident #29 was noted to be confused, displayed poor impulse control and poor safety awareness, ambulated without assist, was on her way to the bathroom, had a recent room change, a fall in past 30 days, impaired memory, and a recent change in medications. -The investigative report did not document the resident's footwear, whether the resident's call light was going off, whether it had been within her reach, or when staff had last checked on her and assisted her to the toilet. Neurological Checks: -The Glascow Coma Scale/Pupil Response Evaluation dated [DATE] showed that at 7:50 p.m., the resident's right pupil was non-reactive; at the following times of 8:05 p.m., 8:20 p.m., 8:35 p.m. and 8:50 p.m., the right pupil was sluggish. Her blood pressure was ,[DATE] at 7:50 p.m. and was ,[DATE] at 8:50 p.m. Telephone Order: -The telephone order dated [DATE] at 8:30 p.m. was to transport to hospital now. Hospital Record: The records from the local hospital dated [DATE] read in part, Has retropharyngeal (behind the pharynx) swelling at the level of the nasopharynx (nose and pharynx), pushing the soft tissue forward with a bluish hue and purplish swelling to the mucosa consistent with a retropharyngeal [DIAGNOSES REDACTED] (swelling) at the site of her fracture narrowing her nasopharyngeal airway. It is patent. She is able to breathe through her nasopharynx. Passing the scope more distally, the oropharynx (pharynx below the soft palate and above the epiglottis), tongue base, vallecula (between the base of the tongue and epiglottis), epiglottis, laryngeal inlet is normal. The vocal cords are fully mobile, healthy, clear and normal appeared. -Impression: 1. Retropharyngeal swelling at the site of her C-spine fracture with mild obstruction of her nasopharyngeal airway.; 2. C ,[DATE] (neck vertebrae) fracture, treating conservatively with a collar . -Plan: .I think she ought to be on some moist oxygen per face tent to keep her sats up. She is breathing easily. She is not stridorous (harsh vibrating sound with respiration indicating air passage obstructions). She is in no airway acute distress. I would keep her for observation for another 24 hours and if things look good tomorrow, I think it would be safe to send her home in her current situation with her collar (soft) on for conservative management of her c-spine fracture per (physician) with the mist mask on with warm humidified air for management in the nursing home. This does not need active intervention. This hematoma and the subsequent soft tissue edema should resolve. Her nasopharyngeal airway should improve with time. Death Certificate: The death certificate that the facility received on [DATE] read in pertinent part, Describe how injury occurred: fell in bathroom, striking head and neck. Immediate cause (of death): Spinal Cord Compression; Vertebral Fractures C1-C2; Impact to neck due to fall. The death certificate was issued [DATE]. A letter from the facility's medical director dated [DATE], provided by corporate consultant #47 on [DATE] at 4:45 p.m., read in pertinent part, (Resident #29) recently suffered a fall while at (the facility) on [DATE], which resulted in a cervical spine fracture. She was not identified as a fall risk on admission following a therapy screen. She had been ambulating independently with a walker. Unfortunately, there were issues with anxiety and she did have recent medication adjustments made by her primary care physician on the day prior to her fall. Staff Interviews: The director of nursing (DON) was interviewed on [DATE] at 1:44 p.m. The DON stated the fall resident #29 suffered on [DATE] had nothing to do with her death. She stated that the resident died of end stage dementia and co-morbid diagnoses. She stated that the resident was attempting to transfer herself in her room. A copy of resident #29's hospital records were requested at this time (see above). The DON and social services consultant were interviewed together on [DATE] at 3:15 p.m. They reviewed the fall investigation (above) dated [DATE] and revised on [DATE]. When asked about the revision, the DON said she thought maybe someone added a note to the original investigation. A copy was requested but not provided, as they stated it was quality assurance documentation. -They said resident #29 liked to go to bed around 8:00 p.m. every evening. They acknowledged that the resident's footwear at the time of the fall was not addressed in the fall investigation. The DON stated that the resident was confused, but was ambulating without a restrictive device. The DON stated that this was the only fall the resident sustained [REDACTED]. She stated the facility's initial assessment was completed on [DATE] and that the resident required total assistance upon admission, but began ambulating and transferring herself as her nursing home stay continued. The nursing home administration (NHA) was interviewed on [DATE] at 9:46 a.m. She stated the facility was located between two different counties and they were having difficulty obtaining the death certificate. She stated that the facility had just received resident #29's death certificate on [DATE] and stated, We were just so deflated when we finally got the copy of the death certificate. She declined to continue the conversation until corporate consultant #47 entered the room. A copy of the death certificate was then provided (see above). Two corporate nurse consultants (#47 and #48) were interviewed with the DON on [DATE] at 10:19 a.m. Consultant #48 had put a timeline together related to resident #29's fall, which was as follows: -The resident was admitted on [DATE], she was sent to the local hospital for change of condition (she was not able to be aroused) on [DATE]. She said that, from the chart, it looked like resident #29 may have had an allergic reaction to sulfa drugs and the resident returned that same day with an order to no longer receive sulfa drugs. -Resident #29 was sent out to the hospital again on [DATE], after becoming non-responsive after sustaining a fall in the facility. She stated that on [DATE], a facility nurse placed a call to the hospital and was told the resident was resting comfortably with a neck collar. -They stated the resident had sustained a neck fracture in the facility from a fall in the bathroom on [DATE]. -The DON stated she did not believe the resident was unconscious when transferred to the hospital. -Consultant #47 stated the resident was responsive and could recall the event. They shared that the resident originally stated that she fell , but then the resident told someone that she passed out, which caused her fall. -Consultant #47 then read the hospital report, which stated in pertinent part, [AGE] year-old admitted to emergency department on [DATE] with C,[DATE] fracture, after having fallen in the bathroom (unwitnessed) and hitting her head and neck. She did not lose consciousness and remembers the event. CT scanning at (local hospital) revealed no intracranial traumatic injury. -The DON stated that the PT/OT screen stated that resident #29 was independent, safe, and ambulatory, even with her dementia. (However, the DON provided no documentation to support this statement, which contradicted the therapy screen above.) -The DON stated that they spoke with their medical director and resident #29 was seen by one of his partners in the hospital. -Consultant #47 stated that resident #29's fall at home prior to admission was due to the resident's family giving her more Ativan for anxiety than was ordered. She stated she had physician's documentation on that and would research to see if the resident was receiving the same high dosage as prior in their facility. The consultant stated that, according to the hospital records, resident #29 was not receiving Ativan. -When asked if they would have expected a care plan addressing falls for this resident, since she had fallen at home prior to admission, they stated the resident was so new, the care plans had not been finished yet. -When asked if they expected to see an interim care plan or something on the CNA cardex related to resident #29's history of falls, they did not respond. -Asked if they expected to see the resident's footwear addressed in the post fall investigation, consultant #47 said that would have been addressed if they felt it was relevant. She stated she was uncertain if footwear had been addressed in the fall investigation already conducted, and she would have to check. Consultant #47 stated the facility staff really thought resident #29 would be returning to their facility. Certified nurse aide (CNA) #23 was interviewed at approximately 3:30 p.m. on [DATE]. She said she was not working on the resident's hall the night of the fall. CNA #23 stated she knew the resident used a wheelchair and she had always seen resident #29 wearing slippers or slipper socks, and had never seen her ambulating with bare feet. She was uncertain if there was a fall mat present or what position the resident's bed was in. CNA #22 was interviewed on [DATE] at 5:34 p.m. She stated that a nurse had found resident #29 in her room, in the bathroom's doorway, on the floor. The nurse called for a CNA and CNA #54 responded first and CNA #22 arrived shortly after. She stated that the resident was cyanotic. She stated that after a quick assessment, the staff repositioned the resident to further open her breathing way. She stated that they got the oxygen on the resident, as her nasal cannula had apparently fallen off during the fall. CNA #22 stated she thought the resident was on four to six liters of oxygen or a heavy flow of oxygen. The CNA stated that resident #29 then actually started to talk to us and was recovering fairly quickly in relation to her cognition. She stated that CNA #54 stayed with the resident to obtain vitals every 15 minutes. The staff tried to reassure the resident, who stated that she thought there was something really wrong and that she had broken her neck. -CNA #22 stated that resident #29 was pretty independent, but acknowledged that at times, the resident required limited assist of one to transfer safely. She stated that resident #29 was admitted to the facility with both a walker and a wheelchair. She stated that resident #29 would often walk without her walker. CNA #22 could not recall for certain, but was fairly sure that the resident's walker was fairly close when she fell . She stated that various staff was in and out of the resident's room area quite frequently prior to the actual fall and that the resident had been in bed. She assumed that the resident had gotten up to go to the toilet. She stated that it was approximately four or five feet from the resident's bed to the bathroom doorway. CNA #22 recalled that the resident's bed was in the low position and that they had not received any order for a fall mat yet for this resident. This CNA could not recall any other interventions that the facility had in place that could have prevented a fall. CNA #54 was interviewed on [DATE] at 5:54 p.m. She stated that the nurse paged CNAs to the resident's room number, and she was the first CNA to arrive. She found resident #29 face-down on the floor and both nurses working were present at the time. She stated that CNA #22 came in shortly after. She stated that the staff was making sure that the resident was okay and they slightly turned her for oxygen placement. She stated, It was kind of hectic and there was a lot going on. The nurses were trying to figure out what was going on. CNA #54 then called for a third nurse, who arrived to make sure that everything was okay. CNA #54 stated the staff finally got (resident #29) on her back for an assessment. She stated that a pillow was placed under the resident's head and they took the resident's vitals every 15 minutes and stayed with the resident for reassurance. She stated that resident #29 was mentally responding and was alert and oriented. She shared that the resident stated that she felt like her neck was broken. The CNA said they also placed pillows under her legs for comfort and did not allow her to get up and into bed, as the resident wanted to do. CNA #54 recalled that the resident was wearing socks at the time of the fall, but was uncertain what kind. She could not recall an ambulatory device being near the resident and that the resident seemed pretty ambulatory. This CNA could not recall what the care plan said or if there was a care plan related to falls in place. She did not believe there was a fall mat on the floor, but thought she recalled the bed being in the lowest position with the head of the bed elevated. The DON #52 was interviewed on [DATE] at 11:58 a.m. and she stated that there was no place in the CNA kiosk for the staff to document how often they were checking in on this resident. On [DATE] at 11:40 a.m., the nursing home administrator (NHA) shook her head and acknowledged that there were some facility failures, such as having no care plan addressing falls and the fact that footwear was not addressed in the post fall investigation. A final interview was conducted with corporate nurse consultants #47 and #48 and the NHA on [DATE] at 1:49 p.m. Consultant #47 stated she had misquoted something and wanted to make sure that the record was correct. She stated there was documentation that resident #29's daughter was giving her mother Ativan (an anti-anxiety medication) TID (three times per day). She stated that the resident did come to their facility with that order, per resident and family request. She stated that the attending physician wanted to get rid of the Ativan and try resident #29 on Buspar (another anti-anxiety medication), but the resident and family wanted her to stay on the Ativan, as she had been receiving that medication for years. -Consultant #47 stated that physical therapy did an evaluation and deemed the resident safe. She stated that the facility looked at the resident's constellation of medications, but acknowledged that was not documented anywhere. The consultant acknowledged that the facility did not have a care plan addressing falls for this resident. -She stated that this resident was wearing appropriate footwear, per interview with the nurse, and that the resident was doing everything that she was doing in the community. The consultant reiterated that the facility was now restraint free. The NHA stated that anything that was attempted with this resident to prevent falls may have increased the resident's level of anxiety in that she was so independent with her ambulation. Consultant #47 said she felt the facility had put interventions into place, saw no decline in the resident from admission, and did not identify any changes of condition with this resident.

Based on record review and staff interview, the facility failed to adequately screen staff prior to hire, investigate, report, and protect three of 10 sample residents (#7, #8 and #9) from abuse. Two staff members reported an improper transfer, mistreatment and verbal abuse by certified nurse aide (CNA) #1 involving resident #9 on 6/4/14. Two other staff members reported resident #7 had complaints about mistreatment by CNA #1 in early to mid August. On 8/15/14, resident #8 sustained a [MEDICAL CONDITION], skin tears, hematoma/bruising and pain after an improper transfer by CNA #1. The facility failed to adequately investigate allegations of abuse and injuries of unknown origin involving CNA #1 and residents #7, #8 and #9, failed to report abuse allegations and injuries of unknown origin to the proper authorities including the police department, and failed to protect residents from abuse during and after facility investigations. CNA #1 continued to work on a hall where most of the residents were unable to speak for or defend themselves; the facility did not remove CNA #1 from resident care until after being notified by the district attorney that CNA #1 was under investigation regarding resident #8. Cross-reference F323, improper transfer resulting in injury Findings: I. Failure to adequately investigate allegations of abuse and injuries to resident #8 A. Facility Expectations The facility corporate "Abuse Policy," dated 8/15/14, assigned accountability to the NHA and responsibility to the social services director (SSD), director of nursing (DON) and nursing department, and provided in pertinent part: -"Employees have a unique position of trust with vulnerable residents." -"Residents must not be subjected to abuse by anyone." -"Identification of abuse shall be the responsibility of every employee." -"Staff is encouraged to talk with Guides, Nurses, Social Services, or the Administrator about residents or situations they find difficult to manage, stressful, or frustrating." -"Residents at risk for abusive situations are identified and appropriate care plans are developed." -"A Concern/Complaint Report form is reviewed at orientation with all staff, for use in reporting any concerns or complaints to the Administrator. The Administrator or designee maintains a file showing community action on each concern or complaint." -"The community will take action when identifying events such as suspicious bruising or skin tears occur. Occurrences, patterns and trends that may constitute abuse will be identified and appropriate action taken." -"The Police Department is notified in all cases or suspected cases of physical abuse, sexual abuse or misappropriation of resident property." -"In addition to an investigation by the Police Department, the community conducts an internal investigation. That investigation includes interviewing any staff members, residents, or family members who may have knowledge of the incident." -"When an employee of the community abuses or is suspected of abuse of a resident, the employee is placed on immediate suspension while the matter is under investigation. When the investigation shows that abuse did not occur, the employee is reinstated. A report of those findings will be available to any persons or agencies notified of the allegations as required." -"When the investigation shows violation of a policy other than abuse, the employee will be subject to disciplinary action appropriate to the violation." -"Screening: All employees shall be screened with background screening. In addition, employee behavior shall be assessed at the time of employment, and 90 days following employment." -"If abuse happens: 1) Separate the assailant from the victim; 2) Isolate the assailant to protect others; 3) Assess and treat the victim; 4) Notify the Administrator on duty." B. Resident #8 1. Closed record review revealed resident #8, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was a hospice patient with a primary [DIAGNOSES REDACTED]. 2. Resident Status According to her 6/30/14 Minimum Data Set (MDS), resident #8 had a BIMS (cognition) score of three, indicating severe cognitive impairment. No behavioral symptoms were documented. She required extensive, two-plus person assistance with transfers. Her balance was unsteady, and she was only able to stabilize with staff assistance. She used a wheelchair for mobility. She was 58 inches tall and weighed 91 pounds. The care plan dated 7/8/14 identified behavioral symptoms "as evidenced by her refusing personal care assistance, yelling, cursing, combative with others, restlessness, kicking out and biting, spitting at others and increased physical aggression during moments of frustration when she is unable to clearly communicate her wants, wishes and needs with others or when others ask her complicated questions she cannot answer." Psychosocial well-being was also identified in the care plan. Interventions included: -"Always approach (resident) in a calm and friendly manner. When speaking with (resident), get down to her level and talk at her, making eye contact during the conversation. Ask simple yes and no questions." -"Explain all procedures to (resident) before starting and allow the resident to adjust to changes." -"(Resident's) triggers for her behavioral symptoms involve loud and noisy areas, moments when (resident) is unable to understand what is being asked of her. The resident's behavior is de-escalated by 1:1 conversations, redirection, toileting frequently, offer foods and fluids and participating in group activities." -"Allow (resident) time to answer questions and to verbalize feelings, perceptions and fears." -"Encourage participation from resident who depends on others to make own decisions." -"Provide opportunities for the resident and family to participate in care." -"When conflict arises, remove residents to a calm, safe environment to allow to vent/share feelings." The resident's eight-page care plan included activities, hypnotic medication use, name preference, behavioral symptoms, discharge planning, [MEDICAL CONDITION] medication use, psychosocial well-being, and a [DIAGNOSES REDACTED]. Although she was noted as having behavioral symptoms directed toward others, she had no care plan for risk for abusive situations. (See facility expectations above) 3. Transfer with Injuries 8/15/14 Facility record review (nurses' notes 8/15 - 8/21/14) revealed the resident sustained [REDACTED]. During change of her incontinence brief after the transfer, the resident yelled out in pain and, upon subsequent assessment, she was unable to flex her left leg. X-rays were obtained and revealed a comminuted (broken, splintered, or crushed into a number of pieces) [MEDICAL CONDITION] femoral neck and intertrochanteric fracture. Following hospital evaluation, the resident returned to the facility. The resident continued to experience pain and additional bruising was discovered. On 8/21/14, the resident was transferred to an inpatient hospice facility for pain management. Cross reference F323 for further details. 4. Hospice Medical Record -On 8/21/14 at 1:45 p.m., hospice clinician narrative notes documented in pertinent part, "Phone call with RN CM (registered nurse case manager name). She reports the 'story' is that an 'incident' occurred Friday at the (long term care) facility. An xray on Saturday showed a [MEDICAL CONDITION]. (The local hospital) on Saturday night identified a hematoma to the head. Xrays yesterday showed likely fractures to the elbow and knee. Per RN CM, the facility reports (resident) attempted to strike a staff member who ducked, and (resident) struck herself causing the hematoma. Then, she suffered the fractures when transferring her to her bed." "(RN CM) reports the facility investigated and found no fault on the CNA's part and closed the investigation. (RN CM) reports (local agency representatives were notified and) will be investigating. A report to APS (Adult Protective Services) is required by law when injuries occur due to possible abuse or neglect in caregiving. SW (social worker) discussed that the injuries sound extreme for the 'story' that (long term care facility) has reported. This is the first this SW has learned of the 'story.'" -Hospice physician notes dated 8/21/14 at 1:30 p.m. in pertinent part stated, "Transfers (to hospice inpatient facility) today with pain issues related to left femur fracture. I am told by staff that authorities are involved in this case due to apparent concerns of abuse ..." "Of note, xrays are now available and show no new fractures; does have displaced femoral neck fracture on L ... Ongoing signs of pain present. Granddaughter at bedside ... Bedbound frail appearing elderly female lying in bed ... Yellow-green bruising on L forehead with hematoma evident ... Grimaces and moans with light palpation of L hip area. No observed signs of pain with palpation L shoulder, L arm, L forearm, L elbow, L knee, L foot ... Temporal muscle wasting, overall lack of muscle tone evident, cachexia ... Full skin assessment not done at time of MD rounds due to obvious patient discomfort with movement ... Please see Xray reading from (mobile Xray) for full report: 8/16/14: Left [MEDICAL CONDITION] (report states displaced [MEDICAL CONDITION] femoral neck). 8/20/14: L elbow: negative study. L knee: moderate [MEDICAL CONDITION] arthritis. L shoulder: negative for acute fracture or dislocation, moderate [MEDICAL CONDITION] arthritis, previous surgery and old healed fracture..." "Assessment/Plan: [AGE] year old female with Alzheimer's type dementia, failure to thrive; now with L [MEDICAL CONDITION] and bruising from traumatic injury (etiology not known to me and is reported to be under investigation, SW to verify that appropriate entities are aware). Patient transferred to (hospice inpatient care) status for pain management; granddaughter at bedside confirms goals are for comfort. Pain, severe, somatic related to L [MEDICAL CONDITION], requiring [MEDICATION NAME] opioids for management. Overall prognosis poor. Symptoms management: [MEDICATION NAME] (dosage) prn pain/dyspnea/or prior to repositioning, [MEDICATION NAME] (dosage) prn anxiety/nausea, [MEDICATION NAME] (dosage) prn nausea/agitation..." -On 8/22/14 at 12 noon, a hospice post mortem note documented verification of the resident's death. The coroner was notified due to "suspicious death," and it was noted an autopsy would be performed. (As of 9/22/14, the coroner/autopsy report and police investigative findings were pending and unavailable.) 5. Facility investigation of 8/15/14 incident The investigative report, dated 8/21/14, was provided by the nursing home administrator (NHA) on 8/25/14. It documented in pertinent part: "At approximately 9:30AM on Saturday morning 8/16/14 I was called regarding a possible abuse situation involving one of the residents of (the facility, resident #8), and an aide (CNA #1). This incident occurred approximately 7:00 PM the night before. Since this was a potential abuse situation, an investigation was initiated immediately by myself and the Director of Nursing (DON). The following is the result of this investigation." "According to the testimonies and interviews with every staff member working with the resident in question at the time of the incident the following is the chain of events." "(Resident #8) was observed the day of 8/15/14 to be agitated with staff throughout the day, particularly in the evening. Due to her heightened agitation the staff were attempting to calm her down before attempting to settle her down into bed for the night. Finally she seemed to be calm and was appearing to doze off in her wheelchair so one of the aides (CNA #1) working the West hall decided to go ahead and attempt to get her into bed." "While in the process of transferring (resident #8) from her wheelchair to her bed, she immediately became elevated and agitated with the aide. As she stood in front of her wheelchair with (CNA #1's) hands around her waist, she doubled up her fist and attempted to strike (CNA #1) with her fist. While attempting to duck out of the way, (CNA #1) inadvertently pulled (the resident) toward him. In doing so the hand which was in the process of attempting to strike (CNA #1) was also pulled forward. This caused her to strike herself in the left forehead with the doubled up fist. (CNA #1) then fearing further injury to (the resident) helped her into her bed and called to the nurse and other aides on the hallway. During the transfer into bed she was still agitated and resistant to cares but ultimately was placed into bed in a safe position." "The nurse working that hall, (LPN #1), then came into the room along with another aide on the hall (CNA #2). (LPN #1) assessed (the resident) and immediately noticed the bruise on her forehead which she described as being the size of a quarter when she observed it. She did not notice any further injury but did hear complaints from (the resident) that her left leg was hurting her." "(LPN #1) at this time radioed for the charge nurse on that night, (RN #1), to help her assess the leg pain. Together they assessed the leg. (RN #1) was able to move the leg and compared it to the right leg and was able to determine that similar responses were given for both legs. She seemed to have good range of motion, no signs of one leg being shorter than the other, and (RN #1) also noticed that (the resident) complained of pain in the right leg same as the left when the leg was manipulated. This was also consistent with previous encounters with (the resident) where she would voice distress anytime she was touched. At this point the nurses did not feel there was any kind of injury so as to require further action. Due to the head injury though neuro checks were initiated and found to be within normal limits." "Later on during the night, (the resident) was still observed to be restless and agitated and was checked on by the nurses and aides. During 3:00AM rounds the nurse (LPN #2) noticed 2 skin tears to (the resident's) left arm which were not noted to be present during 1:00AM rounds. (LPN #2) also noticed at this time that (the resident's) leg seemed to not be laying just right. They placed a pillow between her legs and gave her some medication. She then fell asleep and rested comfortably the rest of the night." The NHA noted he was notified at 9:30 a.m. "the next morning of the incident and came to investigate." He found the resident seemed "lethargic looking in her wheelchair and a significant looking bruise on her forehead." He was notified by the nurse that the resident had complained of leg pain. The DON arrived and hospice was notified and an Xray requested "to rule out any kind of break." The hospice nurse arrived and the portable Xray was ordered. The NHA noted, "At this time I performed multiple interviews with staff and residents to determine what witnesses observed." The Xray company arrived at about 4 p.m. and results around 8:30 p.m. revealed a left femoral neck fracture. The family and physician were notified and decided to have the resident sent to the ER for further evaluation; she returned to the facility with pain medication. "On Tuesday 8/19/14 I was called to the DON office as (the resident's) granddaughter was there and was requesting information as to how and what had happened. With all of the interviews and reports we stated the incident as we were able to piece together:" "(The resident) was combative and aggressive throughout the day ... She attempted to strike the aide during a transfer to which he attempted to avoid thus causing her to strike herself in the head. At this point (CNA #1) transferred (the resident) to her bed and notified the nurse. During the night due to her unrest and agitation she was somehow able to cause a skin tear to her arm. The fracture we believe occurred during the transfer from the chair to her bed. Given her level of agitation and aggressiveness, it is possible that (CNA #1) unintentionally caused the fracture due to the turning and twisting motion of the transfer. This was determined by asking (CNA #1) to re-enact the scene with myself and the DON. The stress that was placed on (the resident's) leg while she was combative during her transfer to bed we believe was the cause of the fracture." "(The resident's) granddaughter was concerned and stated that she had a hard time believing the incident as we described it." The NHA wrote that they assured the family that the resident would be well cared for, work closely with hospice, and "I also informed her that we had not removed the aide from the hall that had worked with (the resident) that night, but that he was going in with a partner as he was nervous following the incident. She did not voice displeasure with this course of action..." "On the morning of 8/20/14 a new bruise was identified on (the resident's) left knee which was not noted on any incident report beforehand. An additional X-ray was ordered to ensure further damage was not present in (the resident's) leg. The granddaughter was also notified of this finding. Later the granddaughter came to the facility and informed us with the hospice that she was moving (the resident) to a hospice facility..." "In conclusion we did not find in our investigation that there was the element of intent to injure (the resident) on behalf of (CNA #1) or any other aide working with her. (CNA #1) was not reckless and did not knowingly injure (the resident). She was unfortunately injured but much to her own devices. Since there was not intent to injure this is not a reportable occurrence and thus is not being reported to the state." The investigative report included a written statement from the facility medical director, dated 8/21/14, that he had read the resident's chart, that she had a "history of repeated combative behaviors ... Apparently, the elder swung at the CNA (who) deflected the punch, and the elder struck her head, resulting in a hematoma on the forehead. In an effort to maintain the safety of the patient, the CNA continued to hold on to the elder, which resulted in some twisting and torqueing of the femur ... My review does not reveal any wrongdoing on the part of the CNA ... It does appear that (the facility) conducted a thorough investigation into this event. Additionally, I did speak with several members of the nursing staff that do corroborate that the computerized records do reflect an accurate summary of this unfortunate incident." The report also included copies of the 8/16/14 Xray report, the 8/17/14 diagnostic imaging report for the hip/pelvis CT which noted a "fall"; the 8/17/14 diagnostic imaging report for the head CT which noted "fell hit head and left hip pain"; the 8/20/14 left elbow/knee/shoulder study which were negative although the left shoulder had moderate [MEDICAL CONDITION] arthritis, previous surgery with two orthopedic anchors and an "old healed fracture." Interviews with five residents were included. They were asked if they were fearful of anyone at the facility, if anyone had handled them roughly or hurt them, if they had seen anyone handled roughly, and if there were any other concerns they would like to share. The residents were noted to have responded "No" to all the questions. Written statements from eight staff members were included in the investigation. -CNA #1 wrote on 8/16/14 that on 8/15/14, "I was working with (the resident). She had been very agative (stet) after dinner. (CNA #2 was) my coworker on west hall for the night. Had gotten her into PJ, and had tried to get her into bed. I do know for sure that she got her into a night shirt, but was not able to get her into bed. She (told) me what she was doing to stop her from finishing getting her to bed. I told her I will give it a try, and we had no luck, we will do it together." "I got her up and from her wheelchair. She started to fight me, I got her turned. I saw that she was about to punch me. I ducked the punch to avoid getting hit. She then hit herself in the forehead. I thought it would be best to get her in a safe place first, then call for help. I got ahold of (LPN #1) the nurse for that hall. She came down to check her out, and I informed her what had happened. I went and started getting a set of vitals on her. I did not notice any skin tears on her, but I was not looking either. I know that she got one of the other nurses to look her over. (RN #1) the nurse looked her over. From there I do not know what happened." -CNA #2 wrote on 8/16/14, "Last night between the time of 7:00PM and 9:00PM there was an incident with (resident #8). I was scheduled to work West hall but (was assisting on a different hall because the CNA was working by herself). (CNA #1) called over the walkie that he needed (LPN #1) to come to (resident #8's) room. (LPN #1) proceeded to (the resident's) room and I finished care with (the other resident). I then went and spoke to (the CNA on that hall and LPN #1)." "I then proceeded to (resident #8's) room. When I went in (CNA #1) showed me the goose egg on her forehead and said that when he was transferring (the resident) that (the resident) swung at him and as he backed his head up (the resident) punched herself in her head." "I then helped (CNA #1) change (the resident) and she was consistently screaming about her leg hurting. After changing (the resident) I went and spoke to (LPN #1) about (the resident's) leg and (LPN #1) also had (RN #1) check her out. The goose egg continued to grow as I frequently went and checked on (the resident)." "While I was charting at the computer she was repeatedly yelling that her leg was hurting and at one point shouted that she wanted it chopped off. When (RN #1) came down the hall while I was charting I told him again that she was persistently complaining about her leg. I did privately ask (CNA #1) if she fell and he told me no." "When the NOC (night) shift came on I was doing report to (LPN #2) and told her what happened. (CNA #1) was in the room and (LPN #2) asked if she was on neuros and he said 'no because it was witnessed she is not on neuros.' I looked at him like 'Who witnessed it?' and he said 'It was witnessed so there is not neuros.' (LPN #2) then was called to the nurses station for a phone call so that was the end to that conversation. Please let me know if you have further questions." (Review of neuro check documentation revealed neuro checks were not documented until 8/16/14 beginning at 7:15 a.m., almost 12 hours after the resident's forehead injury, and then were done in keeping with the timing set out on the Neurocheck form.) -LPN #1 wrote on 8/15/14 that she was "called to (the resident's) room ... Res had hand on head. This nurse removed her hand & found hematoma on L forehead, Neuros were completed & were WNL. Res complained of left leg hurting. This nurse assessed leg at this time. This nurse then got another nurse to assess same leg for second opinion. Cold cloth was applied to res head at this time. To the best of my knowledge this is what I saw." -RN #1 wrote on the night of 8/15/14, "Floor nurse asked if I could take a look at (the resident). Nurse said that she had a goose egg to left forehead above eye. When entering room, I found pt lying in bed talking to self. In looking at pt found bruised goose egg over left eye. Pupils equal but equally sluggish. Pt was able to move both arms. As she tried to slap this nurse. In examining the lower body, pt did scream as I touched her left leg. I then touched her right leg and got the same response. Pt was moving both legs. Did ROM to both legs after looking at them both visually and finding no shortening of limbs, no internal or external rotation. Pedal pulses were present. I then did ROM and found limbs and joints could freely move. No grinding or other non-anatomically weird skeletal movements. Pt was yelling at this nurse to get out of room and swinging at this nurse once in awhile." "Upon the results of this exam I found no injuries other than the goose egg over the left eye. When asked, the aide (CNA #1) said pt had swung at him when transferring her and he had ducked and she missed. This resulted in her hitting herself in the head. Floor nurse was already writing this incident up." -RN #2 wrote on 8/16/14, "I was first in (resident #8's) room around 12 MN to give resident (non-interviewable roommate) her nebulizer. At that time I observed (resident #8) being changed by (CNA #3). (The resident) was very agitated as she can be and I spoke with her as she was being changed. Myself and the other staff looked at the injury on (the resident's) head, looked at her hips and repositioned her with a pillow. At that time I did not recall seeing any skin tears on her left arm." "Later in the shift around 2:30ish, (LPN #2) asked if I could give (resident #8's roommate) a PRN neb since she seemed congested and could we do something for pain for (resident #8). I took (the resident) Tylenol, and Kerforpen cream down to her room, turned the light on and at that time I noticed the very obvious skin tear on her left elbow. (LPN #2) came in the room right behind me. I asked her if she had noticed if (resident #8) had the skin tears earlier and she had not seen them either. After I gave (the resident) her Tylenol, cream, and PRN [MEDICATION NAME], she went to sleep and appeared to be comfortable the remaining part of the shift." -LPN #2 wrote on 8/16/14, "I came on shift @ 10pm on 8/15/14. I was a CNA & took report from the West hall aide (CNA #1). He stated that (resident #8) had been combative with cares & swung her fist at him. He stated he ducked & she hit herself in the forehead causing a 'goose egg.' When I saw it she was lying in bed & it was dark. I saw an abrasion around 3 AM, the nurse & I went in to give her pain medication. We then noticed 2 skin tears to her left elbow. I also noticed her L knee/leg looked displaced/not right. We placed a pillow between her knees. She seemed in pain at this time. After she was medicated, she fell asleep & looked comfortable. She had been agitated most of the night." -CNA #3 wrote in an undated statement: "The night of the incident I received report from (CNA #1) for West, at that time I didn't notice whether or not the resident's arm had a skin tear or not, as the only injury I saw was the knot on the resident's head that (CNA #1) was pointing out to me." "I went in on rounds and explained to the resident I was going to change her brief, she began to yell out as I was taking the blankets off of her, about that time (RN #2) and (LPN #2) came into the room, I told the nurse the resident had been yelling and I thought she may need some pain medication for her hips, there was no draw sheet or pad underneath the resident so I rolled the resident towards me using her shoulder and behind her knees, at about (1:30 a.m., RN #2) called me back in the room and asked me had I seen the skin tear on the resident's arm while I was changing her, I said no, I had not seen it at that time. The nurses told me they had not seen it either, and that we would each need to write up a written statement for the incident." -CNA #4 wrote on 8/16/14, "I was not working on that side last night at all. I worked only on South." Three incident reports were included in the investigative report: (1) On 8/15/14 at 8 p.m., LPN #2 noted a "bruise," and that "CNA stated resident doubled up fist & tried to hit while doing cares. CNA stated he ducked & res hit self on left side of forehead. Quarter size hematoma appeared." There was no drawing on the body map. The pain assessment was blank. The physician notification was blank and family member notification was 1630 (4:30 p.m.) The DON noted reviewing the incident on 8/18/14. Treatment was noted as "cold cloth" and action taken was noted as "staff re-education" and "2 person transfer, de-escalation education." (2) On 8/16/14 at 2:30 a.m., a skin injury of unknown origin was noted, with no drawing on the body map, no description of the location, and no measurements of the injuries. The description read, "On rounds resident noted to have two separate areas possible bruises that were open with (illegible)." The pain assessment was blank, but pain management intervention was checked "yes." Physician notification was documented as 3:30 a.m., no family notification was noted, the document was completed by RN #2, with no review sign-off or dates from nursing management. Treatment was "first aid," action taken was "staff re-education" and "geri sleeves offered & encouraged." (3) On 8/20/14 at 10:45 a.m., an unidentified staff person who did not print their name or title documented, "Green/yellow bruising noted on anterior and medial aspect of L knee. Measures 6x7cm and there is a small scab/abrasion on patella - measures 0.7x1.5cm." A large circle was drawn around the left knee on the body map picture. The treatment was "assessment" and the action taken was "Xray of knee done." The pain assessment noted, "No s/sx of pain to L knee w/ gentle palpation." The hospice nurse was notified at 11:25 a.m. and the family at 11:30 a.m. There were no signatures from the DON, medical director or NHA. 6. Facility Failures in Response to Incident 8/15/14 a. Failure to report violations of potential abuse See facility policy above, indicating that the Police Department is notified in all cases or suspected cases of physical abuse, sexual abuse or misappropriation of resident property. Although the incident was investigated as potential staff to resident abuse (see facility investigation above), the resident's family member as well as the resident's hospice providers and staff (see below) expressed concern and doubts about the circumstances of the resident's injuries, the facility did not report resident #8's injuries to the police, the state health department, or other government/advocacy agencies/entities as required by facility policy (see above). b. Failure to thoroughly investigate circumstances surrounding the 8/15/14 transfer. There was insufficient evidence of investigation of the circumstances involved in the transfer; specifically, whether or not a gait belt was used and how the resident's multiple injuries were sustained. Resident #8, per MDS, required extensive two-plus person assistance for transfers, but CNA #1 transferred her alone, unassisted. -Although the CNA said when interviewed on 8/26/14 at 4:06 p.m. (see below) that he used a gait belt, the investigative report said he had his hands on the resident's waist. And, see below; CNA #2 when interviewed 8/27/14 at 3:45 p.m., said she did not see a gait belt in the room. There was no evidence in the facility investigation about the CNA's use of a gait belt or why, even with a gait belt, he was transferring the resident in a manner inconsistent with her assessed needs. -Moreover, record review showed the resident was a frail [AGE] year-old with muscle weakness and a history of pain and injury to her shoulders. She was under five feet tall and weighed approximately 90 pounds. CNA #1, per observation and employee record review, was over six feet tall and weighed more than 250 pounds. There was insufficient evidence in the facility's investigation to show how the resident could sustain such significant and varied injuries (see above) given her physical state and the abilities of the CNA, given his physical state, to protect her from self-harm. Several staff members (CNAs #5, #6, #7, #9, #11, #12, and RN #3, interviewed on 8/27/14, LPN #2 interviewed on 8/28/14 and and LPN #1 interviewed on 9/2/14), who knew resident #8, said that although resident #8 was combative, they did not believe she had ever injured anyone, or that she was capable of self-inflicting the forehead injury that she sustained. c. Failure to conduct comprehensive interviews of residents, staff, family, and hospice staff Resident interviews: It was noted that resident interviews should be conducted by social services, according to the instructions on the resident interview forms. However, the dates and times the interviews were conducted, and the persons conducting the interviews, were not documented. Both social services staff me

Based on record review and staff interview, the facility failed to ensure one of ten sample residents (#8) received adequate supervision and assistance to prevent accidents. Specifically: Resident #8, per assessment, required two-plus-person extensive assistance for transfers. On 8/15/14, a certified nurse aide (CNA #1) transferred the resident from her wheelchair to bed without assistance from another staff member. The resident was discovered with a number of injuries after the transfer including a fractured hip, bruising, and skin tears as well as experiencing pain. On 8/21/14, the resident was transferred to inpatient hospice for "pain management." Findings: Closed record review revealed resident #8, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Resident Status According to her 6/30/14 Minimum Data Set (MDS), resident #8 had a BIMS (cognition) score of three, indicating severe cognitive impairment. No behavioral symptoms were documented. She required extensive, two-plus person assistance with transfers. Her balance was unsteady, and she was only able to stabilize with staff assistance. She used a wheelchair for mobility. She had one fall since admission or prior assessment, and two falls without injury. She was 58 inches tall and weighed 91 pounds. She had a life expectancy of less than six months and received hospice care. 2. Transfer with Injuries Facility record review revealed the resident sustained [REDACTED]. During change of her incontinence brief the following morning, the resident yelled out in pain and was unable to flex her left leg. X-rays were obtained and revealed a comminuted (broken, splintered, or crushed into a number of pieces) fracture of the left femoral neck fracture and intertrochanteric fracture. Following hospital evaluation, the resident returned to the facility. The resident continued to experience pain and additional bruising was discovered. On 8/21/14, the resident was transferred to an inpatient hospice facility for pain management. a. 8/15/14 - 8/17/14 (1) Facility nurses' notes revealed the following: -On 8/15/14 at 11:41 p.m., a licensed practical nurse (LPN #1) documented: "CNA (#1) stated resident doubled up her fist and tried to hit him while doing cares. CNA stated he ducked and resident hit self on left side of forehead. Quarter size hematoma appeared. Neuros (neurological checks) were WNL (within normal limits). Cold cloth applied. Resident tolerated fairly well. Will continue to monitor." -On 8/16/14 at 3:30 a.m., a registered nurse (RN) wrote: "Resident found to have two skin tears on left arm. One on the forearm and one on the elbow, about the size of a quarter with the one on the forearm slightly bigger. Resident was very agitated this shift and appeared to be in pain. Medication given with some improvement. Physician and family notified." At 4:36 a.m., the RN noted, "Resident is currently resting quietly, appears to be sleeping and pain free." -On 8/16/14 at 8:20 a.m., an LPN noted, "CNAs call this nurse in to room for elder yelling out in pain during brief change. This nurse in to assess. Elder holding hand on L (left) hip and unable to flex L leg when asked. L leg slightly rotated inward. Attempted to perform ROM (range of motion), unable as elder is screaming in pain. Bruising on L side of forehead is approx 3x3.5cm round dark red, with blue colored bruising extending back into hairline. Elder has facial grimacing during breakfast, and has not eaten any breakfast without help. This nurse has placed a call to Hospice regarding L hip pain, awaiting call back. Elder medicated with tylenol as scheduled for pain, will continue neuros and to monitor." -On 8/16/14 at 1:54 p.m., the same LPN noted, "Rec'd orders from hospice (physician and RN) to have X-ray of L hip taken. This nurse spoke with DON (director of nursing) regarding orders and it was decided to have (a mobile Xray company) come and perform x-ray in facility. This nurse placed call to (the Xray company) ... Elder given PRN (as needed) tylenol for signs of pain. Elder calm now." -On 8/17/14 at 12 midnight, LPN #1 noted, "(Mobile Xray company) came to facility at about 4:15 (p.m.), to Xray resident's left hip. Granddaughter was called and informed of Xray being done. We received results and resident has fracture of left hip. Hospice nurse and family were informed. Hospice nurse called on-call (physician, who) said to contact family and see what they wanted to do. Granddaughter wanted resident sent to hospital, sent to (local) hospital for evaluation of left hip. Resident was transported via ambulance to hospital at 10:45 (p.m.)." (2) Hospital documentation revealed the following: On 8/17/14 at 12:40 a.m., the emergency room physician documented: "Chief complaint: left hip fracture ... Hospice patient since 2012 for dementia ... Pt (patient) unable to provide history secondary to dementia, she is from (the long term care facility) - apparently she fell yesterday pm and struck her head and left hip. She had an xray done this afternoon which revealed a displaced left femoral neck fracture. She was sent here for further evaluation. She is currently a hospice patient and has a DNR (do not resuscitate order). She is not on a blood thinner as can be ascertained from her medical chart from (the LTC facility)." -"Differential Diagnosis: [REDACTED]." -"CT head read by radiologist and reviewed by me, no acute intracranial hemorrhage. CT left hip/pelvis ... positive for comminuted (broken, splintered, or crushed into a number of pieces) left femoral neck fracture and intertrochanteric fracture." -"Pt is not a surgical candidate at present, she is under hospice care." -"(Granddaughter) did have questions as to the nature of her accident - I am aware through our RN who spoke with nursing home that patient had fallen Friday night while being assisted by aide and struck her head and left side ... Pt is nonverbal and unable to provide history." An emergency room nursing note documented on 8/17/14 at 1:27 a.m., "Per the nursing staff at (LTC facility), yesterday (8/15/14) around 2130 (9:30 p.m.) the male aide was getting the pt into bed and says the pt was combative and the aide stepped back and hit herself in the forehead. She also got skin tears to her L arm, and fell fracturing the L hip..." (Hospital documentation revealed the fracture was not treated.) (3) Record review and staff interviews revealed resident #8 experienced pain following her injuries 8/15/14 Staff interviews: -RN #1, who worked the evening of 8/15/14, stated in interview at 2:19 p.m. on 8/25/14, that after assessing the resident following her injury, "I told the nurse (LPN #1) to give her Tylenol..." -LPN #1, interviewed at approximately 9 a.m. on 9/2/14, said, "(CNA #1) said at one point that (resident #8) she was complaining of her leg hurting ... I went down there at least every 30 minutes, maybe not quite on the 30-minute mark, but I did go check. She was saying her head hurt. I put the cold cloth on it and that seemed to help..." -CNA #2, who worked the evening of 8/15/14, was interviewed at 3:45 p.m. on 8/27/14. CNA #2 said that (on the evening of 8/15/14), the resident "was screaming her leg was hurting and I asked why, and (CNA #1) said, 'I don't know...' He was in the middle of putting her brief on. She already had her night shirt on. She wasn't ready for bed. He was changing her brief when I walked in. When she was screaming about her leg ... I told (LPN #1) she was complaining about her leg. (LPN #1) said she'd go check on her. I saw her go in there and saw (RN #1), the charge nurse, in there checking on her." "I continued to chart probably 30 minutes after that, and was cattycorner from her room. She was continuously complaining about her leg, so I reported that again to (LPN #1 and RN #1). It was a good 30 minutes where she kept saying her leg was hurting ... She just kept saying, 'My Leg, My Leg,' but as the night went (on) I reported it again, because she was screaming, 'My Leg Hurts,' and it was getting worse with her agitation over that. When I left for the night everyone was trying to figure everything out." -LPN #2, who worked with resident #8 on 8/16/14, was interviewed by phone at 2:25 p.m. on 8/28/14. She said, "Between 2 and 3 a.m. (on 8/16/14) she was kind of agitated and was saying that her leg hurt, so I asked the nurse should we go ahead and give her her ketaprofen gel that they usually rub on her hips and it helps with the pain ... When we went to put the gel on and pulled the covers back, her pillow wasn't there. I was like 'wow her leg looks really distorted.' Every time I've seen her she's been on her side with the pillow between her legs, and I didn't know if that was normal for her or not. We put on the gel, put her pillow back between her legs, and it seemed to kind of hurt when we put the pillow back..." Record Review: Review of resident #8's pain assessments and medication administration record revealed the resident's pain was documented as: 6/10 (10 being the worst possible pain) on 8/15/14 on the night shift; 8/10 on 8/16/14 on the day shift (resident administered Tylenol 325 mg - no time noted). Pain assessments for 8/17 - 8/20/14 were either illegible or blank. (Prior to 8/15/14, the resident's pain was rated at 0 on all three shifts, except once on 8/5/14 when it was rated 4/10). See above; the resident was transferred to the emergency roiagnom on [DATE] at 12 midnight for evaluation of her left hip fracture. b. 8/17/14 - 8/21/14 (1) Facility nurses' notes revealed: -On 8/17/14 at 4:45 p.m., "Elder arrived at facility approx (9:30 a.m.) via ambulance from (local emergency room ), transferred to bed, stated that her leg hurts, elder positioned and made comfortable, received new med orders from (ER physician) ... vicodin 5-325 1 po (by mouth) q4-6h (every 4-6 hours) prn. POA (power of attorney) contacted by phone, left message for ... caseworker and notified hospice of elder's arrival, asked for and received order for liquid morphine from hospice nurse." -On 8/18/14 at 12:04 a.m., "Elder has returned from hospital and has been sleeping. CNAs requested pain meds prior to changing her bed and cleaning her up." -On 8/18/14 at 11 a.m., the staffing development coordinator (SDC) noted, "IDT (interdisciplinary team) review of bruise on left side of forehead. She was being transferred to bed when she was having behaviors at that time she did double her fist and attempted to hit CNA, that were (stet) he stated he ducked and she hit her head with her fist causing this bruise to form. She does have a dx (diagnosis) of dementia with behaviors. Will do staff education on how to help de-escalate the situation and two person transfers with her." -On 8/18/14 at 11:45 p.m., "Elder was resting comfortably throughout the shift. (Family) was at bedside during the shift. Pain meds were given at (8 p.m.)." -On 8/19/14 at 7:14 a.m., "Resident resting quietly throughout night shift. Medicated with prn MS04 (morphine) prior to cares this AM at 0445 (4:45 a.m.). Resident yelling out during movement and repositioning. Resident fell asleep after repositioned and appears without pain. Will continue to monitor and provide comfort care." -On 8/20/14 at 9:52 a.m., the SDC noted, "IDT review of the skin tears that we found on her left arm, will have education with staff about don on (stet) derma/geri sleeves." -On 8/20/14 at 10:51 a.m., an RN noted, "CNA reports to this nurse resident uncomfortable with am cares and arm twitching upon assessment. Left arm noted with spasm type movements that lasted about 1 min., facial grimacing noted, prn medicated for pain, resident appears comfortable, no grimacing noted, drsg to left arm changed per sdc, v/s 86/55, 131, 98.9, 24, 90 RA, message left to notify hospice nurse, awaiting return call, will cont to monitor." -On 8/20/14 at 10:57 a.m., the SDC noted, "Came in to help reposition elder and noted on anterior and medial aspect of left knee diffuse areas of green and yellow bruising are measuring 6cm x 7cm with a 0.7cm x 1.5cm scabbed area in the middle, no pain with gentle palpation on the knee noted. Also changed dressing to left elbow skin tear, it was cleaned, no signs of infection, area is very tender to touch, elder is guarded while any movement to left arm is done, due to pain in left upper extremity, going to request xray of shoulder and elbow and the bruising to the knee request as well the left knee via mobile xray. (POA) was notified of what we are requesting and give her an update." -On 8/20/14 at 3:19 p.m., "PRN pain medication administered for s/sx (signs/symptoms) of pain, grimacing, moaning with movement, resident in bed at this time." -On 8/21/14 at 12:53 a.m., "Elder had an x-ray done and was transferred via (medical transport) after to hospice (locally) per hospice ... orders at (4:55 p.m.). MS (x2) and Ativan were given prior to, also per hospice orders." The resident was noted to leave the facility at 5:05 p.m. Nursing Discharge Notes, Inter-Facility Transfer Form, Post-Discharge Plan of Care, Recapitulation of Stay, and Final Summary of Stay forms, dated 8/21/14, documented the resident had the following injuries to her left side: Hematoma to forehead, lacerations to upper arm/elbow, fractured hip, bruising to the knee. The discharge [DIAGNOSES REDACTED]." The resident was noted as severely cognitively impaired, dependent for all ADLs, non weight-bearing, and bed-bound. (2) Hospice Medical Record -On 8/21/14 at 1:45 p.m., hospice clinician narrative notes documented in pertinent part, "Phone call with RN CM (registered nurse case manager name). She reports the 'story' is that an 'incident' occurred Friday at the (long term care) facility. An xray on Saturday showed a fractured hip. (The local hospital) on Saturday night identified a hematoma to the head. Xrays yesterday showed likely fractures to the elbow and knee." "Per RN CM, the facility reports (resident) attempted to strike a staff member who ducked, and (resident) struck herself causing the hematoma. Then, she suffered the fractures when transferring her to her bed. (RN CM) reports the facility investigated and found no fault on the CNA's part and closed the investigation. (RN CM) reports (local agency representatives were notified and) will be investigating. A report to APS (Adult Protective Services) is required by law when injuries occur due to possible abuse or neglect in caregiving. SW (social worker) discussed that the injuries sound extreme for the 'story' that (long term care facility) has reported. This is the first this SW has learned of the 'story.'" -Hospice physician notes dated 8/21/14 at 1:30 p.m. in pertinent part stated, "Transfers (to hospice inpatient facility) today with pain issues related to left femur fracture. I am told by staff that authorities are involved in this case due to apparent concerns of abuse..." "Of note, xrays are now available and show no new fractures; does have displaced femoral neck fracture on L ... Ongoing signs of pain present. Granddaughter at bedside ... Bedbound frail appearing elderly female lying in bed ... Yellow-green bruising on L forehead with hematoma evident ... Grimaces and moans with light palpation of L hip area. No observed signs of pain with palpation L shoulder, L arm, L forearm, L elbow, L knee, L foot ... Temporal muscle wasting, overall lack of muscle tone evident, cachexia ... Full skin assessment not done at time of MD rounds due to obvious patient discomfort with movement ... Please see Xray reading from (mobile Xray) for full report: 8/16/14: Left hip fracture (report states displaced fracture of the left femoral neck). 8/20/14: L elbow: negative study. L knee: moderate degenerative arthritis. L shoulder: negative for acute fracture or dislocation, moderate degenerative arthritis, previous surgery and old healed fracture..." "Assessment/Plan: [AGE] year old female with Alzheimer's type dementia, failure to thrive; now with L hip fracture and bruising from traumatic injury (etiology not known to me and is reported to be under investigation, SW to verify that appropriate entities are aware). Patient transferred to (hospice inpatient care) status for pain management; granddaughter at bedside confirms goals are for comfort. Pain, severe, somatic related to L hip fracture, requiring parenteral opioids for management. Overall prognosis poor. Symptoms management: Morphine (dosage) prn pain/dyspnea/or prior to repositioning, Lorazepam (dosage) prn anxiety/nausea, Haloperidol (dosage) prn nausea/agitation..." (3) Staff interviews confirmed resident #8 continued to experience pain from her injuries 8/17/14 - 8/21/14; record review revealed PRN pain medication, ordered 8/17/14 and 8/18/14, was given infrequently. Staff Interviews: CNA #10, who worked with resident #8 on 8/20-8/22/14, was interviewed by phone at 9:15 p.m. on 8/27/14, and said, "I think she was (in pain after her injury) ... You would touch her and she would scream. When they transferred her from the bed to the gurney (when she was transferred from the facility), you could tell she was in pain." RN #3, who worked with resident #8 on 8/20/14, interviewed at 10:20 a.m. on 8/27/14, said when she first came back on duty and saw resident #8, "She had the bruise on her forehead ... I was concerned about her (left) arm, the way she was holding it ... She was keeping it stationery and I noticed a little twitch to it. Pain? Yes, I gave her morphine ... It helped ... She was resting after that." Record Review: Morphine Sulfate, ordered 20 mg/1ml (5 mg) (0.25ml) PO SL (sublingual) q 6 hrs prn pain or shortness of breath (order date not noted on MAR) and changed on 8/18/14 to Morphine Sulfate 20 mg/1ml (5mg) SL/PO q 2 hrs PRN pain, give 0.25 ml, per the MAR, was ordered 8/17/14, and given once that day and twice 8/18/14. Although the order was increased to every two hours on 8/18/14, it was only given once on 8/19 at 5:45 p.m., and was given only three times on 8/20/14 at what appeared to be 9:30 a.m., 1:50 p.m. and 4 p.m. 3. Facility Failure to Ensure Resident #8 was as Free from Accident Hazards as Possible a. Failure to care plan and update care plan on resident #8's assistance needs See above; the 6/30/14 MDS identified the resident as unsteady and with a history of falls, and assessed her as requiring extensive, two-plus person assistance with transfers. Review of the resident's comprehensive care plan revealed, however, the resident had no care plan addressing her fall history, fall risk, and no plan to communicate to staff, across all shifts, the resident's need for two-plus person assistance during transfers as identified in the 6/30/14 MDS. The facility investigation (see below) included three incident reports, following discovery of the resident's forehead bruise/hematoma (8/15/14 at 8 p.m.), discovery of the resident's skin tears (8/16/14 at 2:30 a.m.) and discovery of bruising on the resident's left knee (8/20/14 at 10:45 a.m.). The first two of the incident reports referenced re-education of staff on the resident's transfer needs (2-person assist) and use of geri-sleeves. However, there was no documentation of this education or update to the resident's care plan regarding "2 person transfer" and geri-sleeves. b. Failure to ensure resident #8 was transferred, as assessed, with two-plus persons on 8/15/14. Review of the facility investigative report and interview with CNA #1 revealed on 8/15/14, the resident was transferred from her wheelchair to bed by one staff. The 8/16/14 investigative report completed by the nursing home administrator (NHA) documented in pertinent part: "(Resident #8) was observed the day of 8/15/14 to be agitated with staff throughout the day, particularly in the evening. Due to her heightened agitation the staff were attempting to calm her down before attempting to settle her down into bed for the night. Finally she seemed to be calm and was appearing to doze off in her wheelchair so one of the aides (CNA #1) working the West hall decided to go ahead and attempt to get her into bed." "While in the process of transferring (resident #8) from her wheelchair to her bed, she immediately became elevated and agitated with the aide. As she stood in front of her wheelchair with (CNA #1's) hands around her waist, she doubled up her fist and attempted to strike (CNA #1) with her fist. While attempting to duck out of the way, (CNA #1) inadvertently pulled (the resident) toward him. In doing so the hand which was in the process of attempting to strike (CNA #1) was also pulled forward. This caused her to strike herself in the left forehead with the doubled up fist. (CNA #1) then fearing further injury to (the resident) helped her into her bed and called to the nurse and other aides on the hallway. During the transfer into bed she was still agitated and resistant to cares but ultimately was placed into bed in a safe position." CNA #1 interview: CNA #1 was interviewed on 8/26/14 at 4:06 p.m. He said the night resident #8 was injured: "She was wound up, having behavioral issues. (CNA #2), who was working with me, attempted to put her into bed first, and was not successful, but was successful with getting a pajama top on her. All we needed to do was get her into bed and do a check and change on her. About 50 percent of the time you can get her into bed if you leave her alone, let her wind down a little bit. The other 50 percent it just doesn't happen." "Some time went by, I attempted to get her into bed, I thought she was calmed down, got her stood up, got her transferred halfway. Once I got to the halfway point, she just started winding up again. I saw her getting ready to throw a punch towards me. I leaned left, my right elbow up, and she hit herself in the head. Immediately after, I thought I needed to get her to a safe spot where she wasn't going to hurt herself. I got her into bed and called my nurse for backup. It was somewhere between 7 and 9 p.m. It was a very busy night. That hall usually has behavioral issues due to sun-downing." When asked to describe again what happened, he said, "Her arm was down, I saw her ball up (her fist) and immediately try to go for my face. That's when she hit herself in the head - I'm not sure what part of her fist." Asked if the resident needed one or two person assistance, he said, "She's really a one person assist. She can stand very short (time periods) but she is very unstable on balance and you definitely have to guide her. I had a gait belt. She was halfway between the bed and the chair. She'd started to stand and pivot, and that's when she started to wind up, ball up her fist, and that's just where I leaned and pulled up my elbow. I just moved her the rest of the way into the bed. She was a one person assist usually." Additional staff interviews: Additional interviews with staff familiar with resident #8 revealed that, despite the lack of care planning, eight direct care staff members were aware the resident required two-person transfer assistance because of her shoulder pain and behavioral issues. -LPN #2, interviewed by phone at 2:25 p.m. on 8/28/14, said, "... I'm not sure how many people she requires for transfers. For check and change, it depended on if she was in a good mood and not agitated one person could change her themselves. Because of her combativeness I'd always have the aide go with me..." -RN #3, interviewed at 10:20 a.m. on 8/27/14, said, "She was a two-person assist." -CNA #5, interviewed the morning of 8/27/14, said, "(Resident #8) was a two-person transfer because her shoulder was kind of contracted or constricted. Her mobility is very limited to both arms. ... And she's a double transfer. Most definitely two people should have been in there. Her transfer status is not because she can't bear weight - it has nothing to do with that. It's not because she's huge. It's simply because of her back and shoulders. It's impossible to do a safety transfer with just one person (for resident #8) and with her cognition impairment, she might stand well one second and the next second she could not. So a two person transfer is what you have to do. We tried a sit-to-stand and it went over horribly. It scared her." -CNA #6, interviewed the morning of 8/27/14, said, "(Resident #8) would get combative sometimes ... it was also one of the rules that if she was combative, you'd let her be, check back with her in 30 minutes and see how her mood was then. If we were in the middle of a transfer, I'd try to put her back in the safest position ... I thought (resident #8) was a two-person transfer. So you should not have been transferring her by yourself." -CNA #7, interviewed the afternoon of 8/27/14, said, "For transfers, it depends, usually one or two (person assist) with a gait belt." -CNA #2, who worked with resident #8 and CNA #1 on 8/15/14, was interviewed on 8/27/14 at 3:45 p.m. She said, "(Resident #8) is a two person (transfer) with a gait belt. I didn't see one in there, but I was looking at the goose egg on her head." The CNA said, "I've never tried to transfer (resident #8) by myself, ever, because she does better with two people ... It's getting her from one spot to the next that she'd sometimes get agitated. That's why she's a two person transfer." -CNA #11 was interviewed on 8/27/14 at 4:15 p.m. She said, regarding resident #8, "She's two-person assist for transfers." -CNA #12 was interviewed on 8/27/14 at 4:30 p.m., and said, "She was a two person if not a Hoyer assist for transfers from wheelchair to bed. I have used a Hoyer with her, but for me, very seldom. The Hoyer or sit to stand is always two-person as well." -CNA #10 was interviewed by phone at 9:15 p.m. on 8/27/14. She said resident #8 needed two-person assistance for transfers. c. Failure to thoroughly investigate the incidents prior to 8/15/14, as well as the incident on 8/15/14 involving CNA #1. The facility failed to adequately screen staff prior to hire, investigate, report, and protect three of 10 sample residents (#7, #8 and #9) from abuse. Two staff members reported an improper transfer, mistreatment and verbal abuse by CNA #1 against resident #9 on 6/4/14. Two other staff members reported resident #7 had complaints about mistreatment by CNA #1 in early to mid August. On 8/15/14, resident #8 sustained a fractured hip, skin tears, hematoma/bruising and pain after an improper transfer by CNA #1. The facility failed to adequately investigate allegations of abuse and injuries of unknown origin involving certified nurse aide (CNA) #1 against residents #7, #8 and #9, failed to report abuse allegations and injuries of unknown origin to the proper authorities including the police department; and failed protect residents from abuse during and after facility investigations. CNA #1 continued working on a hall where most of the residents were unable to speak for or defend themselves. The facility did not remove CNA #1 from resident care until after being notified by the district attorney that CNA #1 was under investigation regarding resident #8. See F225 for further details.

Based on interviews and record review, the facility failed to ensure two of 28 sample residents (#10, #28) and one supplemental sample resident (#50) received care and services in a manner to promote dignity and respect. Specifically: Resident #28 reported an episode of bowel incontinence that made her "feel bad," while waiting for staff to respond to her call light. Resident #50, who was frequently incontinent, said she waited several hours for her bath, and finally asked staff to go ahead and dress her without first bathing, leaving her feeling "dirty" because of her incontinence. Residents #28 and #10 also reported delays in staff response after falling/sliding to the floor, as well as other delays in or the absence of other services. The findings included: 1. Resident #10 Resident #10, a [AGE] year-old female, was re-admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The PPS 5-day minimum data set (MDS) reflected the resident was fully cognitively intact for daily decision making. She was independent with set-up for eating. She required limited assistance of one for bed mobility and ambulating in her wheelchair. She required extensive assistance of one for transfers, dressing, toileting, and personal hygiene. She required one person assisting during her bathing. The resident was occasionally incontinent of both bowel and bladder. Resident #10 was interviewed on 5/5/14 from 10:35 a.m. through 11:00 a.m. -She stated that she felt the facility did not have enough certified nurse aides (CNAs). She stated that both she and her roommate had fallen recently. She stated that she fell within the past two weeks and waited at least 25 minutes for assistance. She stated that her roommate was currently in the hospital following a fall in which she broke her hip. She stated that her roommate's fall happened in the middle of the night and resident #10 stated that her roommate just laid there and cried while waiting for assistance; she said it took staff longer than 15 minutes for staff to come and help. -She stated that "when accidents happen, all the CNAs are involved, so are not available to help others." She stated that she has often waited until 10:00 a.m. for assistance with dressing and, on occasion, had not gotten her breakfast because of this. -She stated that the CNAs are now assisting with meals, which took even more time away from CNAs providing direct resident care. Resident #10 said she had to ask to have her bed made that morning. She said, "Each shift is supposed to pass water, check vitals, and check the oxygen equipment," but she added that usually no staff member ever checked her oxygen concentrator when she had a recent bout of pneumonia that she was just recovering from. -She stated "they keep hiring office help, but we (the residents) feel neglected." Resident #10 was interviewed again on 5/6/14 at 1:26 p.m. -She stated that she waited 20 minutes "the other day" for her call light to be answered. She stated, "It was in the morning and I had slid off the cushion and out of my wheelchair and was lying on the floor by the fireman's pole and was trapped in a small corner by my wheelchair. This was in the morning between 7:00-8:00 a.m. and the CNAs were all busy getting others ready and down to breakfast." -She stated, "It did not feel great sitting on my butt for that long in the corner." She stated, "We just don't have enough well trained CNAs. Two or three are perfect, but the rest could use some additional training." 2. Resident #28 Resident #28, a [AGE] year-old resident, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed the resident was fully cognitively intact for daily decision making. She required limited assistance of one to ambulate with either her walker or her wheelchair. Section H0400 of the MDS read that the resident was "always continent" of bowel. Resident #28 was initially interviewed on 5/6/14 at 9:20 a.m. She stated she had to wait a long time for her call light to be answered. She stated that she had a fall the night of 5/4/14 and had a long wait for assistance to help her. Resident #28 was interviewed again in the evening on 5/7/14. -She reiterated that it usually took a long time for her call light to be answered, and that she fell at the foot of her bed in the middle of the night on 5/4/14 while attempting to transfer herself to the bathroom after her call light went unanswered for some time. -She said, "It takes quite awhile; sometimes an hour, sometimes longer for her call light to be answered and I'm almost blind." -She said that one time she had an episode of bowel incontinence which made her feel "very bad." 3. Resident #50 Resident #50, an [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The quarterly MDS dated [DATE] revealed the resident was fully cognitively intact for daily decision making. This MDS stated that this resident was independent with set up for eating. She required limited assistance of one to ambulate with her wheelchair. She required extensive assistance of one for bed mobility and dressing. She required extensive assistance of two+ for transfers. Finally, she was totally dependent of one for her bathing needs and frequently incontinent of urine and occasionally incontinent of bowel. Resident #50 was interviewed on 5/8/14 at 2:56 p.m. -She stated that recently she did not get her daily tub bath. She stated that the staff initially told her that they were too busy and that she would have to wait. Resident #50 stated that she laid in bed for several hours while waiting for her bath. She stated that finally she just told the staff that if she could not have her bath soon, to just go ahead and put her clothes on because she could not lie in bed any longer. She stated this was upsetting to her and she felt dirty the remainder of the day because of her toileting patterns. CNA #11 was interviewed on 5/8/14 at 2:13 p.m. She said one female resident (resident #50) was very upset the other day because she did not get her regular bath. The resident was told there was only one CNA on duty and they could not give her the bath. This upset the resident's daily routine. Furthermore, CNA #11 stated that the other CNA, who was by herself, did not even offer a bed bath to the resident. CNA #11 stated that this occurred on 5/4/14. 4. Staff interviews Ten certified nurse aides (CNAs) revealed staff confirmed delays with resident cares as well as other delays in or the absence of other services, and indicated delays had contributed to resident incontinence. See F353 (staffing) for further details.

Based on resident interviews, family interview, staff interviews, and record review, the facility failed to provide sufficient nursing staff to meet the needs of the residents on all four halls/neighborhoods in the facility, including five of 28 sample residents (#10, #19, #28, #34, #70) and two supplemental sample residents (#50, #75). This failure contributed to resident #28 experiencing an episode of bowel incontinence that made her "feel bad," while waiting for staff to respond to her call light. Resident #50, who was frequently incontinent, said she waited several hours for her bath, and finally asked staff to go ahead and dress her without first bathing, leaving her feeling "dirty" because of her incontinence. Staff interviews revealed other incidents of bowel and bladder incontinence related to staff's inability to provide timely assistance to residents. Cross reference F241 The findings included: 1. Expectations The facility's nurse consultant was asked for a policy in relation to staffing on 5/8/14 at 3:20 p.m. She stated that they do not have a facility policy and that they follow the federal guidelines for staffing. 2. Resident Care Needs per Census and Condition Report According to the Resident Census and Condition Report provided by the Minimum Data Set (MDS) Coordinator on 5/5/14, the facility census was 62. Resident needs were documented as follows: Regarding activities of daily living: - For bathing, 48 residents needed assistance by one or two staff, and 14 residents were totally dependent; - For dressing, 49 residents needed assistance, and six were totally dependent; - For transferring, 45 residents needed assistance, and eight were totally dependent; - For toilet use, 42 residents needed assistance, and ten were totally dependent; and - For eating, 26 residents needed assistance, and eight were totally dependent. Regarding bowel/bladder status and mobility: 52 residents were occasionally or frequently incontinent of bladder; 29 residents were occasionally or frequently incontinent of bowel; two residents were bedfast all or most of the time; 36 residents were in a chair all or most of the time; and 27 residents had contractures. Regarding mental status: 12 residents had behavioral healthcare needs and 29 residents had dementia. Regarding special care: 14 residents received hospice care, 30 residents received respiratory treatment, and two residents received tube feedings. 4. Resident Interviews Residents #10, #28, #50, #75, #19, #34 and #70 were interviewed on 5/5/14, 5/6/14 and 5/7/14. All of the residents were assessed as cognitively intact per their MDS assessments. a. Resident #50 Resident #50 was interviewed on 5/8/14 at 2:56 p.m. She stated that recently she did not get her daily tub bath. She stated staff initially told her that they were too busy and that she would have to wait. Resident #50 stated that she laid in bed for several hours while waiting for her bath. She stated that finally she just told the staff that if she could not have her bath soon, to just go ahead and put her clothes on because she could not lie in bed any longer. She stated this was upsetting to her and she felt dirty the remainder of the day because of her toileting patterns (frequent incontinence). See F241 for further details. b. Resident #28 Resident #28 initially was interviewed on 5/6/14 at 9:20 a.m. She stated that the facility was short of nursing help and that she had to wait a long time for her call light to be answered. She stated that she had a fall the night of 5/4/14 and had a long wait for staff to come and assist her. Resident #28 was interviewed again the evening of 5/7/14. She reiterated that she felt the facility was short of help, that it usually took a long time for her call light to be answered, and that she fell at the foot of her bed in the middle of the night on 5/4/14 while attempting to transfer herself to the bathroom after her call light went unanswered for some time. When asked what the usual wait time was for her call light to be answered, she stated, "It takes quite awhile; sometimes an hour, sometimes longer and I'm almost blind." Resident #28 stated that once she was incontinent of bowel while waiting for her call light to be answered and it made her feel "very bad." c. Resident #10 Resident #10 stated she felt the facility did not have enough certified nurse aides (CNAs). She stated that both she and her roommate had fallen recently. She stated that she had fallen within the past two weeks and waited at least 25 minutes for assistance. She stated that her roommate was currently in the hospital following a fall in which she broke her hip. She stated that her roommate's fall happened in the middle of the night, and resident #10 stated that her roommate just laid there and cried while waiting for assistance. She stated it took staff longer than 15 minutes to come and help. Resident #10 stated the CNAs are now assisting with meals, which takes them away from direct resident care. She stated "they keep hiring office help, but we (the residents) feel neglected." Resident #10 stated "when accidents happen, all the CNAs are involved, so (they) are not available to help others." She stated that she has often waited until 10:00 a.m. for assistance with dressing and, on occasion, had not gotten her breakfast because of this. She shared that it was hard to get ice water consistently and stated, "Each shift is supposed to pass water, check vitals, and check the oxygen equipment," but she added that no staff member had checked her oxygen concentrator when she had a recent bout of pneumonia. Resident #10 was interviewed again on 5/6/14 at 1:26 p.m. She stated that she waited 20 minutes "the other day" for her call light to be answered. She stated, "It was in the morning and I had slid off the cushion and out of my wheelchair and was lying on the floor by the fireman's pole and was trapped in a small corner by my wheelchair. This was in the morning between 7:00 and 8:00 a.m. and the CNAs were all busy getting others ready and down to breakfast." She stated, "It did not feel great sitting on my butt for that long in the corner ... She stated, "We just don't have enough well trained CNAs. Two or three are perfect, but the rest could use some additional training. d. Resident #75 Resident #75 was interviewed on 5/6/14 at 10:35 a.m. She stated that there was not enough staff assistance, but especially during meals because so many residents needed extra assistance with feeding. She said there are residents who cannot feed themselves and they need help just to eat and it take staff time to transport residents to and from the dining area. e. Resident #19 Resident #19 was interviewed on 5/5/14 at 11:25 a.m. She stated that it took staff "awhile for them to come answer my call light" because there were so many other residents who lived there and needed help. f. Resident #34 Resident #34 was interviewed on 5/5/14 at 2:50 p.m. She stated there is not enough staff. She stated the length of time for staff to respond to her call light depended on where the staff was located. She said night shift staff (usually two CNAs) work all the hallways and "they can't be (on her hallway and down on (another hallway) too." She thought there should be more CNAs at night. Resident #34 also stated that the facility did not have adequate staff on the weekends. Resident #70 was initially interviewed on 5/5/14 at 3:31 p.m. Resident #70 had a BIMS score of 15, which meant she was fully cognitively alert for daily decision making. She stated that she felt the facility could use more nursing staff. g. Resident #70 Resident #70 was interviewed again on 5/8/14 at 9:40 a.m. in the presence of a family member. The family member stated, "We've seen times where there is only one CNA plus a floater." She said she each of the neighborhoods should have consistent staff, especially on the south and the memory wings so that residents get to know staff better and there's more rapport, trust, and feelings of safety and security. Resident #70 stated it takes about 15 minutes for her call light to be answered. She stated that one time "it felt like forever because I was waiting for the bathroom." The resident's family member stated that they had received calls from resident #70 during the middle of the night. The family stated that the resident would call when she had an "urgent need and no one was answering her call light." Resident #70 said she thought that she waited about 20 minutes for her call light to be answered during before she picked up the phone to call her family. Resident #70's family member said, and it was observed, that resident #70's room was located in an alcove and the call light was not visible from the main hall. The resident's family member said they felt that the facility did not have enough staff available during the mornings when all the residents were asking to get up at the same time. 5. Staff Interviews a. The nursing home administrator (NHA) and the staff development coordinator (SDC) were interviewed together on 5/7/14 at 1:50 p.m. They stated that the facility staffed by census and not to acuity. They stated that they went by the federal guidelines for staffing numbers. The NHA stated that the facility was trying to build each "household" or hall according to their specific needs and each household would be budgeted differently. He stated that the North Hall was their skilled rehabilitation unit and staffing would be expected to be somewhat higher on that unit. East Hall was their long-term care unit for their most "established" residents who had lived there for some time. The South Hall was also for long term care, but offered private rooms. The NHA stated that West Hall was the hall in transition now, which would be their secured unit. He stated that more staff would need to be hired before this unit opened, but he anticipated having a ratio of approximately one skilled staff member for every five to six residents. He stated that there would also be a program manager for that unit solely. He stated that this unit would have the highest staff to resident ratio. The SDC stated the current staffing expectation was: South Hall: 3 CNAs and 1 nurse day and evening shifts; West/East Halls: 3 CNAs and 1 nurse day and evening shifts; North Hall: 2 CNAs and 1 nurse day and evening shifts; and Night shift: 3 CNAs and 2 nurses for the entire building. The SDC stated that the facility was staffing the night shift with three CNAs and 1 nurse until approximately mid-April of 2014. The NHA stated that this time last year, the facility had much higher staffing than was needed. In transitioning to the household set-up, some CNA duties were changed and more work has been required, which has been difficult for some staff to transition to. He felt that residents were hearing these conversations and had been responding to staff stress and "chatter." He stated, "I feel very confident that resident's needs are being met." He stated the facility still had a strong budget for staffing. He stated they were "promoting the blended role. We want everyone trained as a CNA if possible, but will grandfather in some older staff members. There will continue to be both homemaker staff and skilled staff positions." b. CNA #2 was interviewed on 5/7/14 at 10:46 a.m. She said she did not feel the facility had enough nursing staff to ensure that all residents got the care they required in a timely manner. She stated, "I just feel like if you're having a demanding day, there is not enough CNAs to make sure all residents are adequately cared for." When asked how she organized resident care on a demanding day, she stated "I care for the (residents) first before other things get done. Since it's a blended role, we are doing housekeeping and dining. I would prioritize housekeeping being last, including vacuuming, sweeping and mopping in the dining rooms." She stated that resident's care came first. She stated that charting would be her lowest priority. She stated, "Being a CNA is a hard job, then throw the blended role into it and it became overwhelming." She stated that one particular resident had been telling her for months now that the facility did not have enough staff. She stated, "I think a lot of the (residents) feel that way and they feed off the staff stress." She admitted she has had to tell residents she cannot assist them right then, but will touch base with them, turn off their call light, and tell them that she will return when she can. CNA #2 said it usually took five to ten minutes to get back to the resident to assist. She stated the facility had five or six residents on south hall, six residents on east hall, five residents on west hall, and an unknown number of residents on north hall who required two-person transfers and it was difficult finding a second staff member to transfer the residents safely. She stated that within the past few months she recalled at least one instance of bladder incontinence and one instance of bowel incontinence in residents that were usually continent while they were awaiting their call lights to be answered. She also admitted falls had been occurring quite a bit with residents trying to transfer themselves after and getting tired of waiting for their call lights to be answered. CNA #2 stated many evening shift CNAs were feeling over-worked and were feeling that administration was not listening to them. c. CNA #3 was interviewed at approximately 1:30 p.m. on 5/7/14 and stated that from what she had seen, the facility did not have enough nursing staff. She stated day shift is more staffed than evening shift when she had worked evenings on north hall and it was very hard with only one CNA. She stated there was only one CNA on each hall plus one float for the evening shift and she felt the facility should have another (CNA assigned, not floating) on these halls. She stated that today had two CNAs on the west hall, but yesterday they only had one CNA on that hall. She stated that yesterday morning, water was not passed but they were able to pass water this morning because of the additional CNA. CNA #3 stated that she had heard of a female resident falling yesterday on the west hall while waiting for her call light to be answered. She stated that the facility did not have enough walkie-talkie's for all staff who needed them. d. CNA #4 was interviewed on 5/7/14 at 2:50 p.m. She said resident cares are getting met timely, but more staff are needed. She stated staff was getting burned out and the residents sense this. She stated that she has had residents and families tell her that they did not feel the facility had enough staff. She stated she has had to tell residents that she could not assist them immediately, but would be back as soon as she could. She stated that it usually took her an additional five to ten minutes to get back to them. She stated that only two days ago, a resident who was usually continent, had an episode of urinary incontinence while waiting for a call light to be answered. She stated that there were currently five two-person transfers on her hall and that it took time to find the second staff member for the transfer. She stated that daily, or at least every other day, the facility is "scampering" for coverage and they approach her on almost a daily basis to cover for someone who called off. e. CNA #6 was interviewed on 5/7/14 at 3:31 p.m. She said there is not enough nursing staff to meet residents' needs in a timely manner. She said, "We are going to the household model and blending jobs...I've seen this happen with the south hall. Everyone is a CNA, now they are adding housekeeping, dietary, and activities ... They have 3.5 (staff) for 26 (residents) and CNAs cannot get everything done." When asked how she prioritizes her work, she stated she makes sure direct patient care gets done and "if I don't get the floor mopped, I don't get the floor mopped. We have let restorative go a lot of times due to not having enough time. We try to get bed changes done; (the beds) may not get changed every bath day, but they don't go longer than one week. We try to ensure water is passed, but it doesn't always get done." She said a resident told her the facility needed to get more staff. She stated that it normally took the CNAs she works with 10-15 minutes to answer the call lights initially. She said she works with a resident on west hall who requires a two-person transfer and it usually takes her an additional ten or 15 minutes just to locate a second CNA to assist with the transfers. CNA #6 stated there were currently six residents on her hall that required two-person transfers. She stated that she had to tell residents on a daily basis that she could not assist them immediately, but would get back to them as soon as she could; she stated the longest it has taken her to get back to a resident was approximately another 10 minutes. She stated that a few weeks ago, residents had incontinent episodes of both bowel and bladder while awaiting their call lights to be answered. She also stated residents had fallen as a result of insufficient staffing. f. CNA #7 was interviewed on 5/7/14 at 4:37 p.m. She stated, "I do not feel there is enough staff. I feel that way because a lot of our (residents) require extensive care and staffing is not sufficient to do everything. We have had drastic changes in a short period of time. Months of change were expected in just about a month. I think the night shift suffers the most due to being shorter staffed just for the nights. The west hall also suffers a lot; upper management does not seem to understand the acuity on that unit with the dementia and the wandering ...The busiest time is 6:00 p.m. to 10:00 p.m. and they could use more staff then. That's when people start sun-downing. There is currently only 1 CNA for 11 or 12 residents." She stated that she has been told by residents that they did not feel facility has enough staff working. She stated that the longest she'd taken to answer a call light was 10 or 11 minutes and that she has had to tell a resident she could not assist them immediately, but would return when she could. She stated that it usually took her another five or six minutes to assist that resident on top of the 10 or 11 minutes it took to answer the call light initially. She stated that currently her hall had eight out of 26 residents that required two-person transfers. She stated that it was very hard to find another person for the transfer and often took approximately 15 extra minutes to locate a peer to assist with the transfer. When asked how she organized her work she stated, "I prioritize (resident) before housework and getting the mopping done." She stated that residents who are normally continent of urine were having occasions of bladder incontinence on a daily basis. She stated that one resident fell while awaiting assistance about two months ago; she stated the call light was not on, but the resident's alarm was sounding. She said residents' "TLC (tender, loving care) needs are not getting met and residents are showing this by becoming more needy." g. CNA #8 was interviewed on 5/8/14 at 10:08 a.m. She stated that she has been working extra hours to cover for others and that she had been doing this quite a bit lately. She stated that there were not enough CNAs to cover the floor; she stated that her hall currently had three day-time CNAs for 22 residents. She stated that the two-person transfers were an issue, as it limits the number of aides left on the floor to answer call lights. She stated, "It really bothers me when I can't take care of them (the residents) like I'd like to; they are my family. I can't be in two places at once, even though I try. My residents come first; if a resident is having a bad day, I will give them an extra five minutes rather than mopping the floor." She stated that the only thing they have consistent trouble with was having fresh linens available in the mornings: she stated that was the night shift's responsibility. CNA #8 stated residents have told her they feel that the facility needs more staff. She stated the longest she had seen a call light take to be answered was 30 minutes when she was working a night shift. She stated that on days, she had seen lights take 15-30 minutes to be answered. She stated that residents have been incontinent of both bowel and bladder and had fallen while awaiting their call light to be answered. She stated that she has had to tell a resident that she could not assist them immediately, but would return to assist when she had time. She admitted that it had taken her an additional 15 minutes on top of the initial waiting period for a resident's call light to be answered. She stated that there were currently 6 out of 22 residents on her hall that required two-person transfers. h. CNA #10 was interviewed on 5/8/14 at approximately 1:30 p.m. She stated, "We do need more staff. Sometimes you get harder (residents) to care for. We have breakfast from 7:30 a.m. to whenever and we often assist in the dining room until 10:00 or 10:30 a.m. When questioned on how she organizes her work, she stated that her lowest priority was charting. She stated that sometimes the CNAs will also try to save some time by giving a quick bed bath, if need be, rather than taking the resident down to the bath house. She stated her highest priorities were toileting, changing, feeding, passing hydration (especially on east), and repositioning the residents. She stated that they had a bath list for day and evening shifts and that sometimes they give two to three baths per day. She stated that they strip and re-make three to five beds per day, as well as ensure the resident's rooms are neat and clean, including their closets. She stated that residents and families have told her that they do not feel the facility has enough nursing staff working the floors. She stated that when there are only three CNAs available, the average call light response was "maybe five to eight minutes." She stated that on the hall she was working , eight out of 14 residents required two-person transfers. i. CNA #11 was interviewed on 5/8/14 at 2:13 p.m. She stated there are not enough CNAs on the floor. "We are stretched very thin." She stated that one some days, if there is only one CNA, the residents do not get their actual bath in the bath house; they get a brief bed bath. She shared that one female resident, resident #50, was very upset the other day because she did not get her regular bath. The resident was told there was only one CNA on duty and they could not give her the bath. This upset the resident's daily routine. Furthermore, CNA #11 stated that the other CNA, who was by herself, did not even offer a bed bath to the resident. CNA #11 stated that this occurred on 5/4/14. CNA #11 stated "We don't get to do 1:1's with residents, their nails and the little things that the residents like to get done. A lot of times there is only one of us to assist in the main dining room. We are responsible for the whole dining room, but are "hands on" for two separate tables." The CNA stated that one table needed total assistance for eating and the other table was for those residents who required verbal cues to finish eating. This CNA admitted that water did not get passed consistently if there was only one CNA on duty and that the CNAs may or may not get to passing water. She stated that restorative exercises and activities had not been getting done all the time and that residents have asked her about the lack of restorative services. She stated, "It makes me sad when a resident tells me that I don't have to do something for them because they know we're so busy." She stated that she even had one resident tell her, "You're too busy. I don't want to finish eating." She stated that she triages what she can and cannot get done and her highest priorities were resident's baths, nails, cleaning rooms, and making the beds immediately after getting the residents up. She stated her lowest priorities were restorative exercises and fresh towels in each resident's room. She admitted that she had been told by residents and families that there was not enough help, with comments such as "I see you're alone again today." When asked how long it took CNAs to answer call lights, she stated that during their last CNA meeting, 72 minutes was mentioned. She stated that upper management and nurses are supposed to assist them with answering call lights, but they do not. She stated that back in February, there was an issue with residents being left soiled with bowel due to insufficient staffing. She stated that the issues still continue; residents are found saturated in urine, one resident who was usually incontinent did not have an incontinent brief on, and another resident was found covered in bowel from head to toe. She stated there have been residents that were usually continent having issues with bladder incontinence and one episode of bowel incontinence because the CNAs were assisting in the dining room and could not get to them in time. She stated that she recently heard about a resident falling on another hall because all three CNAs were assisting other residents. The CNA stated the resident's call light was on when she fell . She stated that she has had to tell residents that she could not assist them immediately, but would return to them when she could. She stated that it could take up to 10 minutes to get back to that resident. She stated that there was a significant issue with two-person transfers. She stated that currently there were 8 out of 14 residents that she cared for that required two-person transfers and that due to staffing, it may take her 15 minutes just to find a second staff member to assist with the transfer. j. CNA #12 was interviewed on 5/8/14 at approximately 2:35 p.m. CNA #12 said, "90% of the time, I'm on the hall by myself." She stated that towards the end of their shift was when they were supposed to sweep and mop and that those tasks do not get done five out of seven days of the week. She stated that residents and families have complained about not having enough staff. She said this affects residents who often do not ask for what they really need because they were aware that the facility is short of staff and the available staff was short on time. She stated that she ensures that beds are made and fresh linens are passed out and her lowest priorities were sweeping, mopping, and charting. She admitted that there were days that the residents did not receive their bath because of insufficient staffing. When asked how long it was taking for call lights to be answered, she stated, "Anywhere from ten to 20 minutes, depending on what's going on." Asked how many two-person transfers she was responsible for, she said there were at least six on east and five on west. She stated that it was very hard to find a second staff to assist with the transfer and it took up to 25-30 minutes just to locate a second person available. k. Staff Member #13, who wished to remain anonymous, was interviewed on 5/8/14 at 11:28 a.m. This staff member stated that they did not feel that the facility had enough nursing staff for all residents to get residents' care needs met in a timely manner. They stated, "When you have four people on one hall that are two-person transfer assists, plus 10 other residents with various needs, and two CNAs ...How can you get everything done? You may have the four two-person assists, need to assist in the dining room with feeding, while some residents choose to have room trays ...How can you be everywhere at the same time?" This staff member stated that possibly not everything on the residents' care plans are being done. Staff Member #13 stated, "CNAs don't have time to do their regular job, now they are doing housekeeping, activities, and restorative on top of everything." l. On 5/8/14 at 3:58 p.m., the NHA stated that he had a resident ask him why they hired a human resources position instead of another CNA and his response was that a human resources position would make for better employees. When informed of resident and staff concerns about staffing the NHA said, "I know it's the transition." He went on to state that he always had to explain his staffing pattern/ratio to everyone. The facility's nurse consultant who was present stated the facility building had one of the highest staff to resident ratios that she had seen. 5. Record Review The Resident Council Minutes were reviewed in their entirety from 8/1/13 through 5/1/14. The notes of 5/1/14 stated in pertinent part that the residents did have concerns about staffing during meal times. The NHA told the resident council that he would make sure there were two or three CNAs in the dining room with one additional CNA being available to answer call lights. The facility's Daily Nursing Staff Schedules were reviewed in their entirety from 2/2/214 through 5/8/14. Out of 28 days in February, staff shortages were documented eight days. Out of 31 days in March, staff shortages were documented 20 days. Out of 30 days in April, staff shortages were documented 20 days. From May 1 - 8, 2014, staff shortages were documented 2 days. Specifically: - On 2/13/14, the facility was short one licensed practical nurse (LPN) from 6:00 a.m. to 2:30 p.m. on the East/West Hall. - On 2/14/14, the facility was short one CNA from 2:00 p.m. to 10:30 p.m. on the South Hall. - On 2/16/14, the facility was short one nurse from 10:00 p.m. to 6:30 a.m. for the entire facility. - On 2/18/14, the facility was short one CNA from 2:00 p.m. to 10:30 p.m. on the South Hall. - On 2/24/14, the facility was short one CNA from 10:00 p.m. to 2:00 a.m. for the entire facility. - On 2/25/14, the facility was short one CNA from 2:00 p.m. to 10:30 p.m. on the South Hall. - On 2/26/14, the facility was short one CNA from 10:00 a.m. to 2:30 p.m., one CNA from 2:00 p.m. to 6:00 p.m., and one CNA from 2:00 p.m. to 10:30 p.m., all on the South Hall. This date the facility was also short one nurse from 10:00 p.m. to 6:30 a.m. for the entire facility. - On 2/27/14, the facility was short one CNA from 10:00 a.m. to 2:30 p.m. on the South Hall. - On 3/1/14, the facility was short one CNA from 10:00 a.m. to 2:30 p.m. and one CNA short from 2:00 p.m. to 10:30 p.m. on the South Hall. The facility was short one CNA from 10:00 a.m. to 2:15 p.m. and short one CNA from 2:00 p.m. to 6:00 p.m. on the East/West Hall. - On 3/3/14, the facility was short one nurse from 10:00 p.m. to 6:30 a.m. for the entire facility. - On 3/5/14, the facility was short one CNA from 10:00 p.m. to 6:15 a.m. for the entire facility. - On 3/8/14, the facility was short one CNA from 6:00 a.m. to 10 a.m. on the East/West Hall. - On 3/10/14, the facility was short one CNA from 10:00 a.m. to 2:15 p.m. on the North Hall. - On 3/13/14, the facility was short one CNA from 2:00 p.m. to 10:30 p.m. on the East/West Hall. - On 3/15/14, the facility was short one nurse from 10:00 p.m. to 6:30 a.m. for the entire facility. - On 3/16/14, the facility was short one CNA from 6:00 a.m. to 10:00 a.m. on the North Hall. The facility was short two CNA's on the East/West Hall: one from 6:00 a.m. to 2:15 p.m. and another from 2:00 p.m. to 10:15 p.m. - On 3/17/14, the facility was short two CNA's on the East/West Hall: one from 6:00 a.m. to 2:15 p.m. and another from 2:00 p.m. to 10:15 p.m. - On 3/18/14, the facility was short one CNA from 10:00 p.m. to 6:15 a.m. for the entire facility. - On 3/20/14, the facility was short one CNA from 10:00 p.m. to 6:15 a.m. for the entire facility. - On 3/23/14, the facility was short two CNA's on the East/West Hall: one from 6:00 a.m. to 2:15 p.m. and another from 2:00 p .m. to 10:15 p.m. - On 3/24/14, the facility was short one homemaker staff from 6:00 a.m. to 2:30 p.m. on the South Hall. - On 3/25/14, the facility was short one CNA from 6:00 a.m. to 2:15 p.m. on the East/West Hall. - On 3/26/14, the facility was short one CNA from 2:00 p.m. to 10:15 p.m. on the East/West Hall and another CNA from 10:00 p.m. to 2:00 a.m. for the entire facilit

Based on observation, staff and resident interviews and record review, the facility failed to ensure one of 32 sample residents (#12) who entered the facility without pressure sores did not develop. Specifically: -The facility failed to assess and implement treatment in a timely manner to prevent three pressure ulcers from developing and worsening. As a result, the resident acquired three stage 4 pressure ulcers and infection to her left foot. The findings included: I. Facility Expectations A. Facility Policy and Procedure on Pressure Ulcer Prevention: Purpose: "The purpose of this policy is to establish protocols for care of residents who are at risk of developing pressure ulcers to ensure that a resident does not develop a pressure ulcer unless clinically unavoidable". Overview: "A pressure ulcer can occur whenever pressure has impaired circulation to the tissue. Critical steps in pressure ulcer prevention and healing include: identifying the individual resident at risk for developing pressure ulcers, identifying and evaluating the risk factors and changes in the resident's medical condition, identifying and evaluating factors can be removed or modified, implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors, monitoring the impact of interventions, and modifying the interventions as appropriate. It is important to recognize and evaluate each resident's risk factors and to identify and evaluate all areas at risk of constant pressure." Procedure (in pertinent part): "The facility will then complete a Pressure Ulcer Risk Assessment tool upon admission. The facility will then continue to complete this assessment tool quarterly, annually and with any significant change in condition thereafter. The facility will complete a thorough comprehensive weekly skin assessment on all residents. A skin assessment may be completed more frequently if deemed necessary by nursing management or plan of care." B. Facility Policy and Procedure on Diabetic Management: Purpose: "Diabetic management involves both preventative measures and treatment of [REDACTED]. Routine Care (partially included): "Diabetic foot care is provided during daily routine care. Residents are monitored for signs and symptoms of complications. Any identified complication is reported timely to the physician." II. Resident #12 Resident #12 was admitted [DATE] with [DIAGNOSES REDACTED]. According to her 5/6/13 significant change Minimum Data Set (MDS), the resident had a BIMS (cognition) score of nine, indicating moderate cognitive impairment. She had no behavioral symptoms. She required limited assistance with activities of daily living. She was at risk for pressure ulcers, had a stage 1 or greater unhealed pressure ulcer, two unstageable pressure ulcers, one with suspected deep tissue injury, sized at 2.3 cm long x 2.0 cm wide, no depth noted. The most severe pressure ulcer had necrotic tissue. The pressure ulcers were not present on the prior assessment, there was infection to the resident's foot, and she was taking antibiotic medications. The Braden Scale for Predicting Pressure Sore Risk was completed on 12/26/12 with a score of 17, 2/8/13 with a score of 18, and on 5/6/13 (after the development of the skin ulcers) with a score of 17. All indicated the resident was at mild risk. A. First mention of the resident's pressure ulcer - failure by facility to adequately assess and monitor the resident's skin between 3/5 and 4/21/13 Documentation on 3/5/13 indicated the resident went to a foot and ankle specialist for "diabetic shoe dispense, nail fungus, DFC (acronym unknown), ingrown nail, and dry skin." Documentation of the specialist's Assessment and Plan indicated the following foot/ankle conditions: -diabetes with neurological manifestations, type 2 or unspecified type -dermatophytosis of foot -[MEDICAL CONDITION] -ingrowing nail -dermatophytosis of nail -Pressure Ulcer Stage 1 -difficulty in walking -bunion -acquired deformities of toe -hallux valgus (acquired) -The foot and ankle specialist indicated the resident had a stage 1 pressure ulcer, but did not specify the location. The 707.21 code was used for this diagnosis, which indicated a stage 1 pressure ulcer. The resident did not return to the foot/ankle specialist until 5/29/13, when the specialist was informed of the resident's new and worsening wounds (see below). B. Failures in facility response 1. Failure to assess, monitor skin condition, and identify pressure areas until six weeks after the foot/ankle clinic diagnosis - failure to adequately assess wounds after they were identified There was no evidence the facility adequately assessed the resident's skin after the specialist visit above. Weekly skin assessments documented no issues with the resident's skin condition between 3/5/13 and 4/21/13 (below). The facility Wound/Skin Healing Record documented the following: - The skin assessments, after the wounds were identified, and other than the documentation below, involved simply initializing on the daily MAR indicated [REDACTED]. *Left Medial Foot - stage 2, onset 4/21/13 (six weeks after the foot/ankle specialist assessment above) - facility acquired. No measurements or detailed assessment was noted. -On 4/24/13 indicated the size to be 2.4 x 2.6 cm, unstageable -On 5/14/13 indicated the size to be 1.3 x 1.0 cm, unstageable -On 5/21/13 indicated the size to be 1.4 x 1.4 cm, unstageable -On 5/29/13 indicated the size to be 1.5 x 1.5 cm, unstageable -On 6/5/13 indicated the size to be 1.8 x 1.8 cm, unstageable -On 6/12/13 indicated the size to be 2.2 x 2.1 cm, unstageable -On 6/19/13 indicated the size to be 1.8 x 0.5 cm, now a stage 2 *Left toe-unstageable, onset 4/21/13 - facility acquired -On 4/24/13 indicated the size to be 2.4 x 2.6 cm, unstageable -On 5/12/13 indicated the size to be 1.2 x 1.4 x 0.2 cm, stage 4 -On 5/14/13 indicated the size to be 1.2 x 1.4 x 0.2 cm, unstageable -On 5/21/13 indicated the size to be 1.5 x 1 cm, unstageable -On 5/29/13 indicated the size to be 1.4 x 1.2 cm, unstageable -On 6/5/13 indicated the size to be 2 x 2 cm, unstageable -On 6/12/13 indicated the size to be 2.0 x 1.6 cm -On 6/19/13 indicated the size to be 2.4 x 2 cm, unstageable *Left ankle-deep tissue, onset 4/21/13 - facility acquired -On 4/24/13 indicated the size to be 0.5 x 0.5 cm, unstageable -On 5/14/13 indicated the size to be 0.5 x 0.5 cm -On 5/21/13 indicated the size to be 0.7 x 0.7 cm, unstageable -On 5/29/13 indicated the size to be 1 x 1 cm, unstageable -On 6/5/13 indicated the size to be 1 x 1 cm, unstageable -On 6/12/13 indicated the size to be 0.9 x 0.9 cm, unstageable -On 6/19/13 indicated the size to be 0.8 x 0.9 cm, unstageable Dietary Progress Notes: -A progress note on 4/23/13 indicated a stage 3 to left 1st metatarsal, stage 2 on left medial foot, and a stage 1 to left ankle related to new shoes. -A progress note on 5/2/13 revealed a 4 pound weight loss "this week, but [MEDICAL CONDITION] reported in feet." Weekly Nursing LTC Assessment: -Documentation on 4/14/13 indicated no concerns with the resident's skin. -Documentation on 4/28/13 indicated under skin concerns: intact coccyx, left foot has open sores. Dressing intact. [MEDICAL CONDITION] to left leg 4+ and right leg 3+ pitting tight-rash. 2. Failure to notify the physician of the stage I pressure ulcer identified at the foot/ankle clinic, and to assess for possible causes Physician Orders for Wound Care: A physician order on 3/5/13 indicated "compression stocking stage 1 (stocking stage 1), apply daily." There was no evidence the physician was notified of the stage 1 pressure ulcer identified at the foot/ankle clinic. - On 4/20/13, "apply [MEDICATION NAME] to pressure sores to left foot and ankle areas, change every 3 days and prn (as needed)." - On 4/22/13, "[MEDICATION NAME] to left great toe, stage 3, change every 3 days and prn." - On 4/23/13, "treatment medial aspect of left foot and ankle area with skin prep bid, continue with [MEDICATION NAME] to left great toe for autolytic debridement." - On 4/25/13, "treatment of [REDACTED]. Border change daily. Treatment medial left foot wound with xerifoam with foam change daily." - On 4/25/13, "bactrim ds bid (antibiotic twice daily) x 10 days." - On 5/3/13, "change wound treatment to left great toe. Apply collagen to wound bed, cover with foam each day, medial foot apply santyl and catalgunate, cover with foam, change each day, continue with skin prep to left ankle each day." - On 5/3/13, "multivitamin daily and juven packet bid mix with water x 21 days breakfast and dinner for healing." - On 5/9/13, "change covering of left toe and medial wound to abd instead of foam due to maceration and concern of added pressure at site, continue with other pieces of treatment." - On 5/13/13, "change treatment to left foot, to apply santyl to wound beds, alginate cover with abd change q day and prn." - On 5/20/13, "bactrim ds po bid x 10 days for foot wound infection. Ok to refer to wound clinic." - On 5/21/13, "foot care to be followed by wound doctor." - On 6/9/13, "culture wound on foot and send c & s (culture and sensitivity). Start bactrim ds po bid x 10 days. Clean foot wounds left foot." - On 6/11/13 stated "cleanse wound with wound cleanser then apply silver alginate, foam, [MEDICATION NAME] and setopress to ulcers left foot." - On 6/11/13, "juven pack bid, vitamin c 500 mg bid." - On 6/19/13, "wound therapy to left great toe, left medial foot and left ankle. Cleanse with wound spray, apply santyl with [MEDICATION NAME] powder to 100%, apply calcium alginate cover with foam and [MEDICATION NAME] wrap with setopress on in am, off in pm." - On 6/21/13, "clarification wound vac: appy to left foot wounds when slough resolved." Faxed Physician Documentation: An original faxed note to the physician on 4/20/13 stated: "has 3 pressure ulcers to side left foot - 2 are unstageable and 1 stage 1. Applied a thick [MEDICATION NAME] - may we continue with this tx and change every 3 days and prn." The doctor approved the order. - On 4/24/13, a request to treat the resident's medial wound, now open, with xeroform and foam and change daily. A note also indicated that the resident was going to the ankle and foot specialist on the following Tuesday for a follow up regarding her diabetic shoes. The physician signed acknowledgment on 4/25/13. physician progress notes [REDACTED]. Bath Skin Documentation: -Documentation done for each bath or shower to indicate any skin concerns documented: -3/3/13-"nothing new " -3/8/13-"nothing new " -3/17/13-no note of skin concerns to the foot or leg -3/24/13-no note of skin concerns to the foot or leg, "nothing new". -3/29/13-no note of skin concerns to the foot or leg -4/3/13-no note of skin concerns to the foot or leg -4/10/13-no note of skin concerns to the foot or leg -4/14/13- "nothing new " -4/19/13- "nothing new " -4/21/13- red spot on left foot; slight [MEDICAL CONDITION] bil legs; open spot on left foot. Swelling noted -4/24/13-open sore with dressing; red sore on left ankle -4/26/13-dressings noted to left foot -4/28/13-more [MEDICAL CONDITION] left foot and ankle; [MEDICAL CONDITION] 3+ pitting; open sore left foot, dressing in place; tight 4+ [MEDICAL CONDITION] from left knee to toes; swelling bil ankles and foot noted -5/1/13-bandaged left foot; swollen -5/3/13-swollen left knee to foot; bandaged open area to left foot 3. Documentation did not indicate daily skin evaluations, except when bathing occurred. No documentation in the resident record was found prior to the three pressure ulcers on the left foot and ankle, with [MEDICAL CONDITION]. Nurses' Notes: A nurse note on 3/22/13 indicated the resident had a new order for a [MEDICATION NAME] to left hip daily for hip pain/discomfort. The next nurse note was not documented until a month later, on 4/22/13: "IDT review of 3 pressure ulcers on left inner aspect of foot. First pressure ulcer left 1st metatarsal stage 3 with 95% slough periwound hyperkeratotic. Medial aspect of foot stage 2 1x1 cm, dimpled white [MEDICATION NAME]. Left ankle area 1.2 x 1.2 cm DT (deep tissue) dark blue-purple center with periwound redness. Noted diabetic shoes have a ridge directly overlying sites. Shoes removed and staff CNA and nurses educated to use old diabetic shoes. Elder has 1+ [MEDICAL CONDITION] left foot. Compression stockings in place." They left a message for the family. An appointment with transport was made for the resident to have a follow up with the foot and ankle specialist for her shoes. A nurse note on 4/24/13 included in part: "continue with ankle medial ulcer now unstageable due to slough in wound bed with depth. Elder encouraged to wear non skid socks, no shoes over compression stockings. Elder to see ankle and foot specialist on Tuesday, will request surgical debridement to left great toe, abi with consult on diabetic shoes. Noted elder has internal rotation of inside of foot left when ambulating. Will request follow up on gait pattern as well related to left hip osteo(arthritis) and djd ([MEDICAL CONDITION] joint disease)." A nurse note on 5/15/13 included in part: "elder returned from appt with new diabetic shoes and gel sock (compression) and off loader pads to aide in internal aspect of left foot." Ankle and Foot Specialist Wound Care: Progress notes from the specialist on 5/29/13 indicated a visit due to a chief complaint of requiring diabetic foot care. "Trauma as a result of ambulation and tight shoes." The modifying factors: "debridements improves condition, pressure worsens condition shoes that are tight worsens condition and walking worsens condition." Timing, onset/frequency: "onset is with pressure ... She does reveal a history of ulceration, slow healing wounds". Orthopedic exam: "the musculoskeletal exam reveals no deformities. The gait is observed to be normal". Vascular exam: "2/4 [MEDICAL CONDITION] present left". Assessment: "diabetes 2 with [MEDICAL CONDITION], ulcer pressure primary [DIAGNOSES REDACTED]." Care Plans: -A care conference was held on 5/14/13 related to a significant change in condition. Documentation indicated "new pressure ulcers have made her a significant change in condition - has 3 on left foot, and infection ... At risk for further skin breakdown, falls." *The resident's care plan, initiated 8/29/12, identified potential for skin breakdown and delayed healing related to [DIAGNOSES REDACTED]. -"She requires setup to limited assist with ADLs (activities of daily living). Her Braden Score on admit 8/6/12 -'23'. Need: to have no skin breakdown. This was revised on 5/13/13: has 3 pressure ulcers on left foot from diabetic shoes rubbing. Need: for current pressure ulcers to heal and to have no additional skin breakdown. Approaches initially included: Monitor skin during daily cares and bath times. Weekly head to toe skin assessments. Approaches were revised: on 4/22/13, Podiatrist referral for assessment of her diabetic shoes/wounds. On 4/24/13, removed all of shoes/slipper-socks only. Request ABI and surgical debridement and eval of gait on left foot." -No documentation of daily skin monitoring during cares was noted in the resident record. *Care plan initiated on 9/20/12 for "potential for dehydration/fluid imbalance related to use of diuretic prn for increased [MEDICAL CONDITION]." Interventions included: "offer fluids frequently with meds, snacks, activities, and prn; draw and monitor labs as ordered by physician; monitor for increased temp, dry mucous membranes, poor skin turgor, etc prn; notify physician of any changes." -No intervention to monitor for excessive [MEDICAL CONDITION] was noted, and no documentation in the resident record to indicate regular monitoring of excessive [MEDICAL CONDITION] was found. Resident Observations: The resident was observed during survey, 7/1 through 7/4/13, wearing velcro slippers with padding to accommodate the bandaging to her foot. Resident Interview: An interview with the resident on 7/4/13 at 9:40 a.m. revealed that the resident had structural problems with her foot for a long time, but had "never had wounds before." The resident confirmed that she had some new diabetic shoes recently that never fit very well. She stated that she did not know if staff noticed that the shoes weren't fitting properly. The resident stated that leading up to the development of the open pressure ulcers, her left foot was getting swollen and very red, and she could not think of any other reason she developed the wounds. Staff Interviews: An interview with a licensed practical nurse (LPN) on 7/3/13 at 11:40 a.m. revealed that the resident had received new diabetic shoes about a month or two before they noticed skin breakdown. The LPN stated the resident was not considered a high risk for skin breakdown, as her Braden score was a 20. "I received the incident report that the ulcers were found during a bath. When found, there was one stage 3, one stage 2, and one stage 1 on the left metatarsal, medial aspect of the left foot, and just below the ankle bone. We determined that we don't know why it took so long after getting the shoes to develop (the ulcers), but that talking to the doctor she does have an inversion of her hip and her other shoes were loose fitting. The new ones weren't tight, but tighter. With the [MEDICAL CONDITION], it probably occurred fairly rapidly. We currently have one stage 2 and two stage 3's." An interview with a certified nursing assistant (CNA) on 7/3/13 at 2:35 p.m. stated that the resident had diabetic shoes that did not fit. The CNA thought they might have ordered the resident new shoes since the ulcers developed, but didn't know for sure. The CNA thought the wounds developed quickly. "I noticed her leg was getting swollen about a month before I noticed the wounds. I know that a CNA doing the baths did make note of the change in her foot but nothing was really done about it until it was too late and it was a bigger wound". An interview with an LPN on 7/3/13 at 2:55 p.m. revealed that the resident had gained 8 pounds of weight leading up to the wounds, and that the facility attributed the weight gain specifically to [MEDICAL CONDITION]. The LPN confirmed that the resident's diabetic shoes contributed to the wounds and were related to [MEDICAL CONDITION] (however, this doctor documented these wounds as pressure ulcers). The LPN stated the doctor was informed that the resident had wounds from her shoes, and her predisposed foot deformity and the occurring [MEDICAL CONDITION] contributed. The LPN revealed that there should be a care plan related to potential for skin breakdown and that the resident wore ted hose. An interview with a CNA on 7/3/13 at 3:35 p.m. revealed that she often bathed resident #12 2 or 3 times a week. She stated that the resident was getting more and more [MEDICAL CONDITION] prior to the development of the wounds. The CNA confirmed the resident had been continuing to wear the diabetic shoes during this time because she liked them, "but they didn't fit right". The CNA stated that "I usually am really good about documenting (skin assessment during bathing), but I saw the leg/foot getting swollen and I noticed what appeared to be calluses developing on both sides of her left foot. I thought they started to go away, but I should have been more diligent about watching them. I told the nurse when I saw the wounds in the shower room. I sure thought I documented concerns more than that." An interview with another LPN on 7/4/13 at 9:20 a.m. revealed that the resident was developing [MEDICAL CONDITION] and swelling of her left leg. The LPN stated that the resident has had left hip pain for awhile and "was at an angle on her foot." The LPN stated the doctor ordered a compression stocking on 3/5/13 because the resident was having [MEDICAL CONDITION] and was developing a stage 1, or redness, to her left foot. The LPN also confirmed that there should be more documentation between the development of [MEDICAL CONDITION] and the order for a compression stocking, and the observation of the pressure ulcers. The LPN also stated that the resident received medication for [MEDICAL CONDITION] because she was specifically at the facility due to an ongoing [MEDICAL CONDITION] problem. The LPN stated that the resident's older diabetic shoes were contributors to the pressure ulcers she developed. The director of nursing, interviewed on the afternoon of 7/4/13, said, regarding the resident's current skin condition, that she now had one stage 2 and two stage 3 pressure sores. The DON provided no response when asked why there were no nurses' notes for the month leading up to the development of the resident's open wounds. The DON said the resident had deformities to her foot, and combined with that and her shoes, the wounds "just developed practically overnight."

The facility must ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. This requirement is not met as evidenced by: Based on observations, record review and staff interview, the facility failed to initiate timely and effective interventions for resident #23 to prevent falls. Specifically: The facility failed to: - provide adequate supervision and provide an environment as free of accident hazards as is possible. -provide increased supervision and care and services to prevent a fall, resulting in a fracture, for this resident with a history of multiple falls. -update the care plan to include the placement of a low to the floor bed. -document rationale and time for the use of an anti-anxiety medication that was ordered PRN (as needed). -timely reevaluate resident #23's medications as a possible factor that could have contributed to her fall risk. Resident #23 Resident #23, a [AGE] year-old-female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS) The MDS dated [DATE] (the MDS prior to fall) documented that resident #23 had a BIMS (brief interview of mental status) score of 6= severe cognitive impairment, required extensive assistance of two persons with bed mobility, transfers, required extensive assistance of one person with toileting, not steady and only able to stabilize with human assistance when moving from seated to standing position, resident had one fall since her prior MDS assessment, required oxygen therapy, did not receive physical, occupational, or restorative therapy in the past 7 days, and no behavior issues documented. According to the MDS dated [DATE] resident #23 did not have behavior issues, required extensive assistance of two persons with bed mobility and transfers, had a fall since prior MDS assessment (the MDS question related to fracture in the past 6 months was void of documentation and the resident had a fall on 4/29/12 with a fracture of the ankle), antipsychotic and antidepressant medications were used in past 7 days, did not receive physical, occupational, or restorative therapy in the past 7 days. Care Plan The care plan dated 9/6/11 documented in part; Problem- Resident #23 is at risk for drug related side effects, potential for falls related to history of falls resulting in hip fracture and poor safety awareness. Goal- Resident will not have drug related side effects of medications and will not have significant injuries from a fall through next review. Approaches- Resident #23 needs assistance of 1-2 persons with transfers using a walker, keep call light within reach and encourage resident to use, routinely toilet resident throughout the shift, Elder educated of safety, on 2/24/12 grabber bar provided and trained to use it by physical therapy, on 3/16/12 phone removed from sight per request of daughter, physical therapy evaluation for safety with transfer, CNA to stay with elder when in bathroom, on 4/30/12 bed alarm placed on residents bed for safety, on 3/2/12 resident is continent of bowel and frequently incontinent of bladder and wears brief. (The care plan was void of documentation related to the low bed). Record Review Review of the MAR (medication administration record) for the month of April revealed that on 4/29/12, the resident was administered routine medications to include: Zoloft 50 mg every day, Amitriptyline HCL 25 mg daily at night time, Risperdal 0.5 mg by mouth twice per day, and Ativan PRN (as needed). The Ativan 0.5 mg by mouth documented as administered on 4/29/12 (time and reason unknown). Nurses Notes, Post Fall Evaluation notes: On 2/23/12 the Post Fall Evaluation documented resident was found on floor at 4:05 p.m. next to the wheelchair in her room. The resident expressed that she was reaching down to pick something up off the floor. (February 2012 and early Nurses Notes had been purged from the current medical record). Nurses notes documented in part: On 3/7/12 at 5:15 p.m., Elder found on floor sitting with her back against the side of the bed. On 3/14/12 at 10:00 p.m. Resident was in the bathroom (per MDS resident required 2 person for transfers) and did not use her call bell for assistance, resident was calling out verbally for help, the staff CNA tried to assist but resident's hands slipped on the rail and she was lowered to the floor. On 4/10/12 resident had no signs of infection of the skin tear on her left arm. On 4/11/12 through 4/28/12 there was no documentation in the nurse's notes. On 4/29/12 the resident was medicated with Ativan per MAR (there was no documentation of what time or reason it was administered). On 4/29/12 at 3:30 a.m. resident found on floor sitting on a pillow with right leg buckled under her. Resident complained of right ankle pain. On 4/29/12 resident returned to facility from hospital with [DIAGNOSES REDACTED]. On 4/30/12 at 9:00 p.m. a bed alarm was placed on the bed for fall precaution. Physician notes and orders: On 4/14/12 a physician order [REDACTED]. On 4/30/12 a faxed physician order [REDACTED]. On 5/3/12 a faxed physician order [REDACTED]. The Nursing Data Collection Tool dated 5/24/12 documented in part; Resident #23 had potential for bowel or bladder retraining total score of 18= good candidate for formal bowel and bladder program (per staff interview resident #23 was not on a formal bowel and bladder program). Observations On the morning of 6/27/12 the resident was sitting in her room in the wheelchair looking out the window of her room. The bed was observed to be low and near the floor, a bed alarm was in place, the bedside commode was not near the bed and there was no phone on her bedside table. On the morning of 6/28/12 at 10:45 a.m., the resident was observed in her room sitting in the wheelchair near the window of her room, her call light was observed attached to the linens on the bed (approximately 4 feet behind her), she was calling and moaning out for someone to come, a staff nurse was in the room on the other side of the curtain providing care to the roommate. The staff nurse came over after she was finished with care to the roommate, she asked the resident if she wanted to go back to bed, she (nurse) expressed she would find some help to come get her into bed. When the surveyor asked about the call light placement the nurse removed the call light from the bed and placed it within reach for the resident and expressed the resident could use it at times. Interviews On 6/27/12 at 2:30 p.m. the staff CNA on the South Hall was interviewed related to resident #23. She expressed that after the ankle fracture the facility had placed the resident on a low bed and a bed alarm. She expressed the resident was on an every 2 hour turning and repositioning schedule and check for incontinence and offer of toileting. On 6/28/12 at 2:15 p.m. a family member was interviewed. She expressed that the resident did have one of the old hand crank type of bed prior to her fall with the ankle fracture and then they put in the new bed that was electric and would lower down near to the floor and they also put a bed alarm on the bed after the ankle fracture. She expressed the staff did monitor the resident more often after the ankle fracture. On 6/28/12 at 2:45 p.m. the Director of Nurses (DON) and two consultants (facility management group) were interviewed, they expressed that after the resident fell in February the facility intervention was to provide the resident with a reacher. They also expressed, "The daughters are literally here all the time". After the fall on 3/7/12 they stated the intervention was to remove the phone from the bedside. On 3/14/12 additional interventions of re-educating the staff CNA to not leave the resident unattended on the toilet was put into place. They went on to say, with the fall on 4/29/12 we discussed that a low bed could promote her to crawl out of bed even more and her daughters are here 18 hours a day. They also shared the facility has a new form now that is to get to the root cause of a fall. The facility management group was informed of the lack of increased supervision for the resident, when asked how often they thought the resident should be checked on they did not answer that question. When the facility management group was asked if the resident had been provided physical/Occupational/Restorative therapy they expressed they would call the former therapy director/manager. When the facility group was asked if a medication review related to falls had been completed they expressed they would have to check and see. At the time of this writing (7/2/12) no additional information had been provided.

Based on medical director/staff interviews and record review, the facility failed to provide adequate care and services for pressure ulcer prevention and management for two (#2, #45) of 33 sample residents. Specifically, the facility failed to ensure resident #2, who entered the facility without a pressure ulcer, did not develop a pressure ulcer; and failed to ensure resident #45 received necessary treatment and services to promote healing, to prevent new ulcers from developing and prevent the existing pressure ulcer from worsening. The findings included: Professional Reference The National Pressure Ulcer Advisory Panel's (NPUAP) February 2007 guidelines, found at the website: http//www. npuap.org. provided the following definitions: Pressure Ulcer Definition: A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction . . . Pressure Ulcer Stages Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . . . Stage II: 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 . . . Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable: 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. 1. Resident #45 Closed record review revealed resident #45, a [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was discharged home with home health nursing care for his pressure ulcer on 2/28/11. A. Record review The admission minimum data set (MDS) assessment dated [DATE] revealed resident #45 had a BIMS (mental status) score of 4 that indicated he was severely impaired in cognitive skills for daily decision-making; he required two-person assistance for bed mobility and transfers, dressing, toileting and bathing; one-person assist for walking , eating and personal hygiene, he used a walker and a wheelchair; was incontinent of bowel and bladder; was at risk for developing pressure ulcers, had a stage one ulcer and a stage II ulcers and the date of the oldest stage II ulcer was 2/16/11. (The pressure ulcer information was incorrect as resident #45 was admitted on [DATE] with a stage I ulcer that on 2/12/11 became a stage II ulcer and also developed a stage II ulcer (blister) on 2/17/11.) The MDS also reported that resident was 66 inches tall and weighed 133 pounds. Hospital Discharge Summary In the hospital's discharge summary dated 2/8/11, the physician did not note any skin issues other than the incision site on his left hip. Admission Assessment Nursing Report on New Admission form dated 2/8/11 included, "Skin issues identified staples left hip, decub (pressure ulcer) right gluteal fold. Stage I, non-blanchable, [MEDICATION NAME] (applied)." Admitting Orders Review of the physician's admission orders [REDACTED]. Braden Risk Assessment Scales On 2/8/11 the nursing staff assessed resident #45 to score 16 where "15 or 16 = low risk." On 2/11/11 he scored 12 where "12 or less = high risk," on 2/18/11 he scored 15 and on 2/25/11 he scored 14 where "13 or 14 = moderate risk." The nursing staff was inconsistent in their Braden Scale assessments of resident #45's risk for developing pressure ulcers. Care Plan Resident #45's plan of care dated 2/8/11 identified skin as a "Problem/Need/Concern" as he had "Potential for skin breakdown related to left [MEDICAL CONDITIONS], decreased mobility and dementia." The approaches included, "1. Skin assessment weekly. 2. Frequent position changes 3. Roho cushion in wheelchair 4. Air mattress (provided by facility) 5. Wound care per facility protocol 6. Ensure one can TID in milkshake with peanut butter. Braden Score=16." B. Chronological Development of Pressure Ulcers. 2/8/11 - Nurses Notes, "74 y/o male in wheelchair admitted to facility ... post left total hip 2/4/11 ... Transferred into bed with 2 persons and slide board ... Dressing applied over pressure area on right buttocks. 11:00 p.m. Air mattress on bed secondary to pressure ulcer. Repositioned every 2 hours for comfort and skin breakdown." - Faxes to MD - None. There were no faxes to the physician to advise him of and/or request treatment orders for the pressure ulcer. - Telephone Orders - None. There were no orders from the physician to treat the stage I pressure ulcer present upon admission to the facility. - Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 2/9/11 - Daily Assessment - Wound: "Addressed per wound committee." - Pressure Ulcer Weekly Report - Identified "Stage I, gluteal crease, length 3.9cm, width 1.8cm, no drainage, status - red/purple in color, non-blanchable, intact; peri-wound blanchable. Suspect DTI (deep tissue injury)." Identified current treatment as: 'Air mattress, cleanse skin with skin prep, apply [MEDICATION NAME]. Change Q 3-5 days and PRN until resolved. Roho in wheelchair ... admitted with ulcer on 2/8/11." - Faxes to MD - None. There were no faxes to the physician to advise him of and/or request treatment orders for the pressure ulcer. - Telephone Orders - None. In spite of the nursing staff treating the pressure ulcer with skin prep and [MEDICATION NAME], there were no orders from the physician to treat the stage I pressure ulcer present upon admission to the facility. - Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 2/10/11 - Daily Assessment - Wound: (blank) - Faxes to MD - None. There were no faxes to the physician to advise him of and/or request treatment orders for the pressure ulcer. - Telephone Orders - None. There were no orders from the physician to treat the stage I pressure ulcer present upon admission to the facility. - Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - Skin Management Team Progress Notes: "Elder admitted to facility 2/8/11 with left [MEDICAL CONDITION]/staples left hip C/D/I (clean/dry/intact). Coccyx with red/purple non-blanchable area intact. Suspect DTI. Per spouse elder had area on coccyx red and non-blanchable prior to fall. Post fall, spouse reports seeing purple areas on coccyx. Spouse states "I think he fell on his butt." Area cleansed, skin prep applied and [MEDICATION NAME] placed with protection. Air mattress and Roho (cushion in wheelchair) in place. Frequent position changes being offered. Elder's Braden Scale score is 16." Note that there were no orders for the placement of [MEDICATION NAME]. 2/11/11 - Daily Assessment - Wound: "Decub - redness of skin - buttocks." - Treatment Administration Record (TAR) ". . . Groin/buttocks excoriated red. Coccyx had open areas X2, one small open area to right inner buttock. Coccyx cleansed [MEDICATION NAME] applied; other areas with moisture barrier cream . . ." Note that this is the first documentation that the pressure ulcer had deteriorated to a stage II and that the physician was not notified. - Telephone Order - at 10:45 a.m. "Per (facility) wound protocol: Cleanse coccyx, apply skin prep, cover with [MEDICATION NAME]. Change Q 3-5 D and PRN." Of note is that these were the first orders for treatment by the physician - three days after resident #45 was admitted with stage I pressure ulcer. Also these orders were obtained after they were documented as being performed by staff on 2/9/11 and 2/10/11. 2/12/11 - Daily Assessment - Wound: "Decub Stage II coccyx, applied Allevyn and Calazyme." Of note is the nurse did not follow the physician's orders [REDACTED]. 2/13/11 - Daily Assessment - Wound: (blank). Notes: ". . . Dressings to coccyx and left hip (incision site) clean, dry and intact." - Fax to MD: "Concern: apparent allergy/sensitivity to adhesive tape and [MEDICATION NAME]. May we change the dressing protocol for his coccyx pressure ulcer to 'Clean area with wound cleanser spray. Apply antibiotic ointment to red/open areas. Cover with ABD pad and use [MEDICATION NAME] tape to secure. Change dressing QD and PRN?' . . ." Note that the fax to the MD still did not identify the pressure ulcer as a stage II. 2/14/11 - Daily Assessment - Wound: "Coccyx peri area. Notes: Peri-area and coccyx red, excoriated with open area over coccyx (5cm) " - Fax to MD - " ... Also have had to change dressing to coccyx frequently d/t dressing not staying. May we have order to treat wound per protocol so we can change to appropriate treatment? "Again, did not notify the MD that the pressure ulcer was now a stage II pressure ulcer. - Telephone Order - "Clean area with wound cleanser spray. Apply antibiotic ointment to red/open areas. Cover with ABD pad and use [MEDICATION NAME] tape to secure. Change dressing QD and PRN." - MAR - There was no evidence on the MAR indicated [REDACTED]. 2/15/11 - Daily Assessment - Wound: "Stage II coccyx. Notes: ". . . Continues to have large amount of red excoriation peri- rectal area and Stage II pressure area (small) over coccyx. [MEDICATION NAME] & [MEDICATION NAME] cream to affected areas. . ." Note that neither of the creams was ordered by the physician to treat the resident's pressure ulcer, thus again the nursing staff did not follow physician orders [REDACTED]. - MAR - There was no evidence on the MAR indicated [REDACTED]. 2/16/11 - Daily Assessment - Wound: (blank). "Notes: ... Peri-rectal area red with small open area. Continue to use [MEDICATION NAME] & [MEDICATION NAME] cream to affected areas. . . "Again, note that this treatment with the two creams was not ordered by the physician, thus the nursing staff did not follow physician orders [REDACTED]. 2/17/11 - Daily Assessment - Wound: only identified left hip incision. Notes: there was no documentation about the resident's two pressure ulcers by nursing staff. - Pressure Ulcer Weekly Report - Identified, "Stage 2 right medial buttock, length 5.5cm X 2.5 cm with drainage; current status: superficial open area with blanchable peri-wound, wound bed with granulation tissue, minimum sero-sanguinous drainage without signs/symptoms of infection, peri-wound light red in color; current treatment: cleanse, skin prep peri-wound, apply [MEDICATION NAME]. Change daily and PRN until resolved ... acquired ulcer dated 2/16/11." And it identified second pressure ulcer, "Stage 1 right lateral buttock 1.4cm X 3.5 cm, no drainage; current status: blister, red in color, not open, peri-wound blanchable; current treatment: skin prep daily, air mattress, frequent repositioning, Roho (cushion) to wheelchair ... acquired (in facility) 2/16/11." The second pressure ulcer, the "blister" was inaccurately staged as I rather than accurately as a stage II (see NPUAP guidelines above). Also the stage II "blister" was never mentioned again in the Daily Assessments nor were any physician orders [REDACTED]. - Skin Management Team Progress Notes: "1:35 p.m. Elder with Stage II to right medial buttocks. 5.5cm X 2.5cm area, superficial with minimal sero-sanguinous drainage. Wound bed 100% granulation tissue. Peri wound red, intact and blanchable. Right lateral buttock with blister 1.4cm X 3.5cm. Peri-area intact. Irritation noted to buttocks after [MEDICATION NAME] placed. Stage II to be treated with [MEDICATION NAME] and changed daily. Blister to be treated with skin prep daily. Current interventions to continue." 2/18/11 - Daily Assessment - Wound: only identified left hip incision. Notes: There was nothing documented about either of the resident's pressure ulcers. - Fax to MD: "2/18/11 Elder now with Stage II to right medial buttock 5.5 cm X2.5cm. Peri-wound with red blanchable areas. Right lateral buttock with blister appearing area 1.4 cm X 3.5cm. Buttocks appear to be irritation/reaction to [MEDICATION NAME] as the areas appeared after placing [MEDICATION NAME]. Per wound committee recommendation, may we have treatment order for the following: Cleanse right medial buttock. Apply skin prep peri-wound. Apply thin layer of Hydrogel to wound bed. Cover with [MEDICATION NAME] dressing. Change daily and PRN until resolved?" - Telephone Order - "Cleanse right medial buttock. Apply skin prep peri-wound. Apply thin layer of Hydrogel to wound bed. Cover with [MEDICATION NAME] dressing. Change daily and PRN until resolved." 2/19/11 - Daily Assessment - Wound: only identified left hip incision. Notes: There was nothing documented about either of the resident's pressure ulcers. - Treatment Administration Record (TAR): ". . . Coccyx has large open area, approximately 5cm X 3cm, irregular shaped edges, pink center tissue, minimal drainage. New dressing applied." 2/20/11 - Daily Assessment - Wound: only identified left hip incision. Notes: There was nothing documented about either of the resident's pressure ulcers. 2/21/11 - Daily Assessment - Wound: only identified left hip incision. Notes: " ... coccyx, red open with yellow slough, small amount sero-sanguinous drainage. Skin prep after cleaning, then gauze 2X2's covered with bordered foam dressing." Again, nursing staff did not follow physician's orders [REDACTED]." 2/22/11 - Daily Assessment -Notes: " ... coccyx area red open with yellow slough over base of wound. Cleaned and redressed ... " 2/23/11 - Daily Assessment -Notes: "Open area on coccyx, unstageable with yellow slough at base of wound. Wound care changed to clean with wound spray. Apply collagen dressing and cover with bordered foam dressing. Redness around open area on coccyx and open area (unreadable) than last week. Continues to need turning every two hours to keep off coccyx." - Pressure Ulcer Weekly Report: Identifies two pressure ulcers. The first, "unstageable right gluteal fold, 3.6cm X 2.0cmX<0.2cm with drainage; current status: 90% slough to wound bed, moderate amount sero-sanguinous drainage, without signs/symptoms of infection, peri-wound blanchable; current treatment: cleanse, skin prep peri-wound, collagen to fit wound, cover with [MEDICATION NAME] dressing, change daily and PRN." The second, "Stage I right lateral buttocks, 2cm X 1.6 cm, current status: red, blister area, intact, non-blanchable wound, peri-wound blanchable; current treatment: skin prep daily, air mattress, Roho wheelchair cushion, daily baths." - Telephone Orders: "Per wound protocol: 1. Discontinue current treatment to right buttocks wound and change to: 2. Cleanse right gluteal crease wound, peri-wound with skin prep. Apply collagen to fit wound bed. Cover with [MEDICATION NAME]. Change daily until healed (change after daily bath). 3. Daily bath" and "Home health at discharge for coccyx wound care." 2/24/11 - Daily Assessment - Notes: No documentation relating to pressure ulcers. "Plan discharge to home 2/28/11." - Skin Management Team Progress Notes: "Elder with unstageable (pressure ulcer) to right medial buttocks/gluteal crease. Area now with slough 90% and moderate amount of sero-sanguinous drainage. Without signs/symptoms of infection. Peri-wound blanchable. Right lateral buttock red blister non-filled area. 2.0cm X 1.6cm. Area intact - non blanchable. Area noted with irritation after [MEDICATION NAME] placed. Treatment now with collagen and [MEDICATION NAME] dressing. Will change daily and PRN. Prior interventions to continue." - Telephone Orders: "Discharge to home 2/28/11 with home health care for coccyx wound and PT." 2/25/11 - Daily Assessment - Notes: No documentation relating to pressure ulcers. - Treatment Administration Record (TAR): " ... Coccyx has open area with yellow slough; elder getting daily baths and daily dressing change to coccyx." 2/26/11 - Daily Assessment - Notes: No documentation relating to pressure ulcers. 2/27/11 - Daily Assessment - Notes: "Coccyx wound, dressing changed last evening." 2/28/11 - Nursing Notes: "Resident discharged with meds and narcotics to son and wife. Transport per family to home. Bathed prior to discharge and new dressing applied right gluteal fold; improved." - Recapitulation of Stay/Post Discharge Information included: "Discharge home 2/28/11; Narrative Statement: admitted to (SNF) for skilled care/PT/OT with L [MEDICAL CONDITION], L total hip, acute [MEDICAL CONDITION], Alzheimer's dementia and [MEDICAL CONDITION] ... Wound care R medial buttock improved. Area with QD (every day) dressing changes." - Final Summary of Resident Stay dated 2/8/11 included: "Skin ... 3cm X 3cm superficial open area R medial buttock; Special Treatment/Procedures: Dressing change QD R gluteal fold." - Resident Post-Discharge Plan of Care included: Special Treatment/Procedures - "Cleanse right gluteal crease wound, apply skin prep peri-wound, collagen to fit wound, cover with [MEDICATION NAME] and change daily; has been receiving daily bath's to promote wound healing." C. Receiving Agency Pressure Ulcer Assessment The facility Wound Nurse submitted the home health agency's Wound Flow Sheet/Pressure Ulcer Scale for Healing for review on 3/23/11 at 12:05 p.m. It stated in pertinent part: "3/1/11 (the day after discharge from the facility) Wound #1, location: coccyx, type: pressure ulcer - Stage III, size 3.8cm X 2.1cm X 0.26cm, with slough, moderate amount serous exudate, pink/red surrounding skin, edges of wound - diffuse/irregular, no odor, tunneling or undermining edges ... " D. Interviews 1. Medical Director Interview The facility's Medical Director was interviewed on 3/21/11 at 12:02 p.m. During the interview the Medical Director stated, "In our QA (quality assurance) meetings each month we talk about the residents with pressure ulcers ... Notification to the attending physician? Yes, I think it is important as an 'FYI' (for your information) or to obtain orders ... As a physician, I would like to be notified in order to be aware of and monitor them (pressure ulcers) ... It would be my expectation that the nursing staff follow the orders that I write." When asked about the facility's wound protocol, the Medical Director responded, "Yes, I'm aware they have them ... No, I don't know the exact details." 2. Staff Interviews The facility's Wound Nurse, a Registered Nurse, was interviewed at 8:27 a.m. on 3/23/11. She stated, "I do weekly wound rounds and pressure ulcer measurements and treatments ... The facility's wound protocol? No, we don't have a specific wound protocol. We have a wound nurse consultant that comes in ... Yes, I would expect the nurses to obtain MD orders for treatments of pressure ulcers ... I check to make sure treatments are being done. It is a struggle with the nurses and I have been working with them. I had an inservice for them in December or January ... Stage I is a reddened, non-blanchable area and Stage II is where the skin is open." When asked how she would stage a blister, the Wound Nurse replied, "Stage I ... Oh, I didn't realize it should be staged as a II ... The consultant told me if you have slough and you don't know what is underneath it is considered unstageable ... Training? I was trained with one of the nurses here that had done it for one year; I trained with her for one day." The Wound Nurse acknowledged she felt her training to be the wound nurse for the facility was insufficient. The Wound Nurse said, "I am working on educating the CNAs and nurses on accuracy of the Bath Reports. If there is something on there I don't know about, I talk with the nurse that signed off on it. The nurses are responsible for the bath sheets to be correct ... Measuring the depth of the pressure ulcer? Yes, I understand that it should be (measured) if it is a stage II or greater ... It is important to identify deep tissue injuries (DTI) because they could turn into a stage IV overnight ... I suspected a DTI with him ... I know he had a Roho cushion for his wheelchair, it was too big then PT got one that fit better ... When a pressure ulcer develops we notify the doctor ... Absolutely, the doctor should have been notified the day the stage II was observed to request treatment orders." On 3/23/11 at 2:20 p.m., the Wound Nurse submitted agendas from two inservices regarding pressure ulcer/wound prevention and management dated 11/24/10 and 1/12/11. During an interview on 3/23/11 at 10:06 a.m. with a facility RN, she stated, "We were told to always write that (per facility wound protocol) on every physician's orders [REDACTED]." The director of nursing (DON) and the nursing home administrator (NHA) were interviewed on 3/23/11 at 11:59 a.m. When the DON was asked for the "wound protocol" the facility's policy and procedures for pressure ulcer prevention and management were submitted. When asked what "per wound protocol" meant when the nurses documented it, the DON said, "The nurses have been told to document all orders with 'per wound protocol' preceding them as they are developed specifically by the wound team and the orders are obtained from the physician." After being advised of the identified failures of the facility with respect to pressure ulcer prevention and management, the NHA stated, "That's why we added that (wound nurse) position ... within the last year." E. Policies and Procedures On 3/22/11 at 12:02 p.m. the DON submitted the facility's policy and procedure #NURS.600.1, revised 9/20/09, titled, "Pressure Ulcer Prevention and Management Program" for review; it stated in pertinent part: "A. Purpose: To identify residents at risk for pressure ulcers and to define early interventions for prevention ... C. Policy: The primary purpose of this facility's pressure ulcer management and prevention program is to reduce the occurrence of pressure ulcers through the following steps: 1. Goals of care are established. 2. Education needs are identified and implemented. 3. Nutrition and fluid management. 4. Correct body position is evaluated and monitored. 5. Turning and repositioning per plan of care. 6. Support surfaces are utilized. 7. Skin care is provided as appropriate. 8. Monitoring changes in risk status. 9. Interdisciplinary Team process occurs in management and prevention of pressure ulcers. F. Resident Failures In providing services and caring for resident #45 the facility failed to: - Accurately assess resident for the pressure ulcer. On the MDS the wounds were staged incorrectly and the dates of development were incorrect. - Consistently/accurately assess the resident's risk of developing a pressure ulcer. The Braden Scales were inaccurate and inconsistent. - Accurately/consistently measure the pressure ulcers. The depth of the pressure ulcer was measured only once. - Identify and track the Stage II/III pressure ulcer on his coccyx separately from the stage II (blister) on his right buttock. They were two distinct areas that should have both been monitored and tracked independent of each other on any documentation. There was no follow-up or resolution documentation on the stage II (blister) pressure ulcer. In addition, multiple site names were given to the same pressure ulcer, i.e., gluteal crease, gluteal fold, coccyx and right medial buttock; this caused some confusion in communication. - Develop a care plan with approaches that were specific to the resident with measurable interventions and identification of the meaning of "per facility protocol." - Implement interventions such as repositioning the resident every two hours or as necessary to ensure that his pressure ulcer status did not deteriorate and monitor to ensure the interventions were implemented. - Notify the physician of the development of the pressure ulcer from a stage I to a stage II and then "unstageable" in a timely manner. The nursing staff delayed seven days (from 2/11/11 to 2/18/11) to notify the physician that the resident's pressure ulcer worsened and became a stage II ulcer. Further, it was never documented, when the resident's pressure ulcer became unstageable, that the physician was notified. - Accurately assess a "blister" as a stage II pressure ulcer. The nursing staff assessed the blister to be a stage I pressure ulcer. - Consistently administer appropriate care and follow physician's orders [REDACTED]. Some treatment was administered without physician's orders [REDACTED]. These failures culminated in the degeneration of resident #45's stage I pressure ulcer to a stage III/ unstageable pressure ulcer for which he had to receive post-discharge treatment in his home from a home health nursing agency. 2. Resident #2 Closed record review revealed resident #2, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. MDS The MDS dated [DATE] documented that the resident makes self understood and can usually understand, needs extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Her height is 60 inches, weight 84 pounds, no known weight loss, stage one pressure ulcers, no other pressure ulcers present. Care Plan The care plan dated 10/7/10 documented in part as follows: - Problem- Potential for skin breakdown related to current stage one of the toes bilateral. On 10/15/10 stage two on coccyx. - Goal- Resident will have no skin break down through (no date noted). - Approach- Keep Elder's shoes off and replace with non skid slipper socks, apply skin prep to toes, boost 120cc three times per day, Rojo in wheelchair and recliner, on 10/14/10 Rojo on back of wheelchair, multiple vitamin daily, air mattress provided by facility (no date noted), cradle to bed, Elder up for meals and therapy only until coccyx healed. Care plan dated 10/22/10 documented: - Problem- Unstageable sacral wound - Goal- (blank) - Approach- Apply [MEDICATION NAME] and change every three to five days. 10/28/10- clean sacral wound, apply santyl to wound bed, cover with spot dressing and change daily. Record Review a. Skin Management Team Progress Notes dated 10/7/10: multiple stage one to right toes request multivitamin. On 10/14/10 Elder continue with stage one open areas, to wear non-slip socks, bed cradle over the foot of the bed. Sacrum with non-blanchable area reddened area 7.5 x 1.7, [MEDICATION NAME] applied with skin prep and change every three days. Elder with Rojo in wheelchair to bottom and one for back. Rojo to be used in recliner too. Air mattress provided. b. Physician Orders The physician orders [REDACTED]. - On 10/2/10 may have flavored Boost 120cc TID c med passes. - On 10/5/10 May treat per wound protocol. - On 10/7/10 orders MVI po wound healing. - On 10/8/10 physician orders [REDACTED]. - On 10/15/10 open area to coccyx, bed cradle, air mattress, (bed rest). Elder up for meals and therapy only until coccyx healed...Rojo cushion in wheelchair and recliner. - On 10/22/10 Change wound care to sacral stage two, clean sacrum, apply skin prep around wound and cover with [MEDICATION NAME], change every 3-5 days until healed. (However, according to the care plan dated 10/22/10 above, the sacral wound was unstageable.) - On 10/28/10, change wound treatment to sacrum, begin santyl to wound bed, apply spot dressing and change daily. Although the resident was admitted on [DATE] with a reddened coccyx (see nursing admission assessment below), no interventions were ordered until three weeks after her admission. Further, her medical record did not reveal a formal, documented, turning and repositioning schedule c. Physician Communication Faxes Documentation in part as follows: - On 10/14/10 per facility fax to the physician, resident #2 coccyx area "3-4 inches surrounding area excoriated with two open areas." - On 10/27/10 per facility fax to physician, wound on sacrum is 1.2 x 1 x UTD (undetermined), wound bed with 100% yellow slough, minimal serosanguinous drainage, unstageable wound, and clinical wound nurse specialist consulted. Suggestion was to try santyl to wound bed, apply spot dressing and change daily. d. Braden Scale The Braden Scale dated 9/23/10 documented resident #2 had a total score of 17 (16 or less = at risk of developing pressure ulcers). - The Braden scale did not identify the resident at high risk although she was admitted with a reddened coccyx and a [MEDICAL CONDITION]. e. Pressure Ulcer Reports (Weekly) The facility documentation on the pressure ulcer sheets revealed in part the following: - The first report date was 10/6/10 and documented red blanchable skin on the resident's left 4th and 5th toe and on the right 2nd, 3rd, 4th, and 5th toes. There was no mention of the sacrum/coccyx. - On 10/13/10, nonblanchable reddened skin, acquired 10/6/10, intact 7.5cm x 1.7cm on gluteal fold/sacrum. Toes on left 1st, 2nd, 3rd, 4th, and 5th with blanchable reddened area. Toes on right 1st, 2nd, 3rd, 4th, and 5th with blanchable reddened area. - On 10/20/10 Stage 2, sacrum 0.9 x 2.1 x 0 depth, minimal serosanguinous drainage, 100% yellow slough in wound bed. - On 10/20/10 Stage 2, coccyx/gluteal fold, 0.2 x 0.2 x 0 depth, no drainage, no signs of infection. - On 10/27/10 Unstageable sacrum, 1.2 x 1 x ? no odor, minimal serosanguinous drainage. f. Nurse's Notes The nurse's notes documented in part as follows: - On 9/23/10 the nurse's admission assessment (11 page) data collection tool documented resident #2 had redness on the coccyx area on admission to the facility. The nurses' documentation was void of information related to any type of pressure reduction or pressure-relieving mattress on the resident's bed. - On 10/11/10 Rojo cushion in her chair to prevent skin breakdown. - On 10/12/10 Barrier cream applied to redness on her bottom, Rojo cushion in recliner. - On 10/15/10 Elder with Stage 2 areas on coccyx. Refer to the skin progress notes. - On 10/18/10 Pressure ulcer on coccyx, stage 2, nickel size. - On 10/23/10 Resident encouraged to get out of bed for awhile onto Rojo cushion to relieve pressure. - On 10/24/10 Dressing to coccyx changed. Open area noted, circular, quarter size. Scant amount of serous drainage noted. Area cleaned with wound spray, skin prep applied to wound edges and [MEDICATION NAME] applied. Resident repositioned from side to side throughout shift every two hours related to area with sore, no odor noted. - On 10/26/10 Dressing to coccyx changed. Open area on coccyx quarter size. Small amount of serous drainage noted. Skin prep applied to wound edges and [MEDICATION NAME] applied to wound. - On 10/26/10 Elder continues to complain of weakness. Requiring more assistance. Decreased intakes, physician called. Open area on sacrum with [MEDICATION NAME] intact, stage 2. (See skin assessment above dated 10/27/10 where the pressure ulcer was noted as unstageable.) g. Lab Results The laboratory results dated [DATE] documented in part as follows: Low results on calcium at 8.0, sodium low at 132, chloride low at 99, total protein low at 4.7, low [MEDICATION NAME] at 2.6, other labs were within normal limits. h. Medications - On 9/23/10 the admission medications orders for resident #2 in part as follows: [MEDICATION NAME] 20mg daily, aspirin 325mg daily, [MEDICATION NAME] 4mg, HCTZ 12.5mg daily, [MEDICATION NAME] 20mg daily, [MEDICATION NAME] 2.5mg daily, [MEDICATION NAME] 50mg every 6 hrs if needed, [MEDICATION NAME] 15mg