Every finding on record at Creekside Village Rehabilitation and Nursing LLC

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure the kitchen was maintained in a sanitary manner. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 8/10/26, read in pertinent part,Nonfood-contact surfaces of equipment should be kept free of an accumulation of dust, dirt, food residue, and other debris (4-601.11),The physical facilities should be maintained in good repair (6-501.11),The physical facilities should be cleaned as often as necessary to keep them clean (6-501.12),Intake and exhaust air ducts should be cleaned and filters changed so they were not a source of contamination by dust, dirt, and other materials (6-501.14); and,The premises should be free of items that were unnecessary to the operation or maintenance of the establishment (6-501.114).II. Facility policy and procedureThe Preventative Maintenance Program policy, dated 4/11/25, was provided by the chief compliance officer on 8/5/26 at 4:25 p.m. The policy revealed a program should be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The maintenance supervisor was responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment were maintained in a safe and operable manner. If preventative maintenance was required, the MS should decide what tasks needed to be completed and how often to complete them. The MS should develop a calendar to assist with keeping track of all tasks. Documentation should be completed for all tasks and kept in the MS's office for at least three years.III. Kitchen observationsDuring the initial kitchen tour on 8/4/26 at 7:24 a.m. the following was observed:-Upon entrance to the kitchen from the dining room hallway, the left entrance wall had four unpainted sheet rock patches. The right wall had several unpainted sheet rock patches and five missing wall tiles. -The ceiling to the right of the stove had several areas of chipped paint and unfinished sheet rock patches. -There were three missing floor tiles to the left of the stove. -There were approximately 17 floor tiles that were missing grout (thick paste or liquid mortar made of water, cement, and sand) and contained debris (loose waste, rubbish, or food fragments) where the grout was missing. -The convection oven was greasy (fat or full oil), dirty (unclean or unwashed) on the front and right side. The top surface of the oven was greasy and contained dust. -The plate warmer was greasy. -The metal serving tables, lower shelves and support metal pipes were greasy with debris on them. -The trash can by the serving tables did not have a lid and contained various debris items. The large upright mixer was not covered. -The floors in the large area past the cooking area had debris underneath including spaghetti, one set of blue gloves, two plastic cup lids, three paper towels, two sugar packets, and two small single service milk cups. -The floor under the three compartment sink was greasy. There were rags on the floor under the three compartment sink. The white drain under the three compartment sink was rusty, and contained debris. The white plastic pipes under the three compartment sink were greasy. The wall above the three compartment sink contained 12 small holes and one small area (approximately six inches) where the paper had torn off the sheetrock.-The beverage room had approximately 30 floor tiles with missing grout and contained debris where the grout was missing. -There were three single serving milk cups and eight sugar packets on the floor in the beverage room. The corners of the room contained debris. -The two ceiling air vents were dusty in the beverage room.-The spice room had one non-function light, one white glove on the floor, the floor had areas covered with spilled spices and there were two plastic containers on the floor that were filled with various items including cups, plates and utensils. Two of the four walls contained 14 small holes. There was a large red unused fire suppression canister sitting on the floor. The alcove (recessed space) was dusty.-The small exit room adjacent to the walk-in refrigerator had several areas of torn linoleum.-The walk-in freezer had large amounts of ice built up under the two functional fans. -The dish room entrance door frame from the kitchen had unpainted metal corner protectors, bent/protruding metal corner protectors (sharp to the touch), missing corner wall laminate corner protectors and sheet rock damage on both sides of the door frame. There were approximately 100 floor tiles with missing grout that contained debris where the grout was missing. There were two rags on the floor, two yellow gloves on the floor, and two plastic cup lids on the floor. Two of the four walls were dirty. There were 26 small holes in two of the walls. There were two sections of missing cove base tiles. There was missing [NAME] at the junction of the wall and the stainless steel components of the dish washing machine. There was a black substance on the wall behind the dish washing machine. There was a black substance on the wall adjacent to the dish washing machine two compartment spray sink.The metal air exhaust hood over the dish washing machine was greasy and contained a black substance.The kitchen was observed a second time on 8/5/26 at 7:31 a.m. The same conditions existed for cleanliness and environmental repairs. IV. Staff observations and interviewsThe nursing home administrator (NHA) was interviewed on 8/6/26 at 9:42 a.m. The NHA said the kitchen was to be cleaned daily. The NHA said the kitchen staff were responsible for the cleanliness of the kitchen. The NHA said he had previously talked with the kitchen staff on the necessity of keeping the kitchen clean and sanitary. The NHA said he went into the kitchen once or twice each week to ensure it was kept clean. The NHA said he was ultimately responsible for the cleanliness and environmental condition of the kitchen. The NHA said there were no work orders for the environmental repair issues in the kitchen.The maintenance supervisor was interviewed on 8/6/26 at 2:21 p.m. The maintenance supervisor said the kitchen staff were responsible for the clearing/sanitizing the kitchen. The maintenance supervisor said the kitchen staff were responsible for developing work orders for any needed environmental repairs in the kitchen. The maintenance supervisor said he did not have any work orders in the past two months for any environmental repairs in the kitchen. The maintenance supervisor said he did not actually walk through the kitchen to look for environmental repairs.

Based on record review and interviews, the facility failed to ensure residents received the required therapy services which were ordered by the physician for one (#10) of 10 residents reviewed for therapy services out of 17 sample residents. Specifically, the facility failed to ensure Resident #10 was evaluated to determine if she required specialized rehabilitative services as ordered on admission to the facility.Findings include:I. Facility policy and procedureThe Specialized Rehabilitative Services policy, revised 9/10/25, was provided by the chief compliance officer on 8/6/26 at 11:52 a.m. It read in pertinent part, The facility shall provide or obtain services from an outside resource for specialized rehabilitative services if required by the resident's comprehensive assessment and care plan. These services will assist them in attaining, maintaining, or restoring their highest practicable level of physical, mental, functional and psychosocial well-being. Specialized rehabilitative services include but are not limited to the following: physical therapy, speech-language pathology, occupational therapy, respiratory therapy, specialized services for mental illness or intellectual disability and mental health rehabilitative services for mental illness and intellectual disability or services of a lesser intensity (those services to be implemented by facility staff regardless of whether or not they are required to be subject to the PASARR - preadmission screening and resident review, process). Specialized rehabilitative services will be provided under the written order of a physician by qualified personnel. Specialized rehabilitative services are considered a facility service and included within the scope of facility services, therefore, if services are not enumerated in the State plan, the facility will not charge a Medicaid recipient for specialized rehabilitative services.II. Resident statusA. Resident #10Resident #10, age less than 65, was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included respiratory failure, heart failure, chronic pain, depression and perirectal abscess (including wound care) with colostomy.The 7/19/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #10 was dependent on staff for toileting and transferring, required substantial assistance with oral and personal hygiene and moderate assistance with positioning in bed.The MDS assessment revealed Resident #10 did not receive therapy services at least 15 minutes a day on one or more days in the past seven days.B. Resident interviewResident #10 was interviewed on 8/5/26 at 11:00 a.m. Resident #10 said she had not received physical or occupational therapy since she was admitted to the facility. She said the hospital had said she was supposed to receive physical therapy at this facility upon admission. Resident #10 said she asked for physical therapy when she arrived at the facility. She said she had been told she was on a list for rehabilitation services and the reason she did not receive treatment was because her insurance would not cover it. Resident #10 said no one from the facility had discussed the plan for rehabilitation services with her.C. Record reviewReview of Resident #10's activities of daily living (ADL) care plan, initiated 7/15/26, revealed the resident was at risk for decline in ADL function.Review of Resident #10's August CPO revealed the following physician's orders:May obtain an evaluation for the following-SLP (speech language pathology). May provide treatment and perform additional modalities as deemed necessary by a qualified therapist, ordered 7/13/26.Occupational therapy (OT) evaluation and treatment as needed, ordered 7/13/26.Physical therapy (PT) evaluation and treatment as needed, ordered 7/13/26.-However, review of Resident #10's did not reveal documentation indicating the resident received any consultation for therapy services until 8/5/26 (during the survey, see therapy encounter note and interviews below).A physician's progress note on 7/14/26 at 1:03 p.m. documented Resident #10 was admitted to the facility for continued rehabilitation and conservative management following intensive care unit (ICU) admissions for respiratory failure, heart failure and fluid overload. A nurse practitioner (NP) note on 7/15/26 at 11:53 a.m. documented Resident #10 required assistance with mobility, which included a wheelchair. The note documented Resident #10 was previously bedbound, the resident had chronic wounds, was admitted to the facility for rehabilitation and continued wound care.An NP note on 7/31/26 at 12:05 p.m. documented Resident #10 was previously ambulatory prior to hospital admissions and had become deconditioned and wheelchair dependent. A document titled Occupational Therapy Treatment Encounter note from 8/5/26 (during the survey) was provided by the nursing home administrator (NHA) on 8/6/26 at 12:53 p.m. The note read in pertinent part,The resident presented with a new colostomy and urinary catheter, resulting in an increased need for training in self-care management, ADL performance and compensatory strategies to safely manage daily routines. The OT evaluation identified deficits in strength, coordination, balance, activity tolerance and functional independence with ADLs, transfers, and self-care tasks. The note documented the resident would benefit from OT to address upper extremity strengthening, functional mobility, ADL retraining, colostomy and urinary catheter management, safety awareness and energy conservation techniques to maximize independence and reduce caregiver burden prior to discharge. The note documented the resident had good tolerance in the treatment session.D. Staff interviewsThe director of rehabilitation services was interviewed on 8/5/26 at 5:15 p.m. The director of rehabilitation services said the facility had placed a standing physician's order for OT and PT evaluation upon admission. She said prior to receiving services, there was a wait for the business office to process the resident's insurance. The director of rehabilitation services said Resident #10 was on a list for evaluation of OT or PT needs. She said her department was short staffed in July 2026 and had not had the time to evaluate Resident #10's needs. She said it was possible that Resident #10 could have declined in her ADL abilities due to not continuing therapy services that she had received at the previous acute care facility.The NHA was interviewed on 8/6/26 at 8:30 a.m. The NHA said there was not communication from the hospital upon Resident #10's admission that she needed PT or OT services. The NHA said Resident #10's representative told him on 8/1/26 that the hospital had informed the resident and family that Resident #10 would receive PT/OT services at the facility. The NHA said he did not know who was responsible for determining whether a PT or OT evaluation was needed at the facility and he would obtain additional information.The NHA was interviewed a second time on 8/6/26 at 9:20 a.m. The NHA said there was an order for every resident to have at OT and PT evaluation as needed at admission. The NHA said different disciplines of staff, including nursing, could initiate a request for OT or PT evaluation. The NHA said Resident #10 probably should have been evaluated at admission to see if she needed a PT or OT evaluation.The director of rehabilitation services was interviewed a second time on 8/6/26 at 9:40 a.m. She said upon admission, all residents at the facility had an OT and PT evaluation, as needed, physician order. She said the therapy services department was responsible for determining if an OT or PT evaluation was needed. The director of rehabilitation services said residents who were at the facility for skilled services were prioritized for evaluation, however all residents should be reviewed by someone from the therapy services department to determine if an evaluation was needed. She said Resident #10 should have been evaluated earlier for PT and OT services.The regional director of therapy operations was interviewed on 8/6/26 at 10:48 a.m. She said residents should be reviewed by the therapy department at admission to determine if they need evaluation and treatment. She said the therapy department should have reviewed Resident #10's record at admission to make this determination.Licensed practical nurse (LPN) #1 was interviewed on 8/6/26 at 12:07 p.m. LPN #1 said Resident #10 had told her a week ago that she had been asking to receive physical therapy services. LPN #1 said she was told the resident was waiting to find out if her insurance would cover the physical therapy.

Based on record review and interviews, the facility failed to provide choices for preference of bathing schedule for two (#10 and #3) of two residents reviewed for self-determination out of 17 sample residents. Specifically, the facility failed to ensure Resident #10 and Resident #3 received their showers or baths per their preferences. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADLs) policy, revised 6/19/26, was provided by the chief compliance officer on 8/5/26 at 9:44 a.m. It read in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: bathing, dressing, grooming and oral care, transfer and ambulation, toileting, eating to include meals and snacks, and using speech, language or other functional communication systems. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. II. Resident #10 A. Resident status Resident #10, age less than 65, was admitted on [DATE]. According to the August 2026 computerized physician orders (CPO), diagnoses included respiratory failure, chronic pain, depression and rectal abscess with colostomy. The 7/19/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #10 was dependent on staff for toileting and transferring, required substantial assistance with oral and personal hygiene and moderate assistance with positioning in bed. B. Resident interview Resident #10 was interviewed on 8/5/26 at 11:00 a.m. Resident #10 said she preferred bed baths instead of showers due to her immobility. Resident #10 said she received a bed bath the previous day (8/4/26) and prior to that had not received a bath in two weeks. Resident #10 said she felt dirty when she had to wait for such a long time to be bathed. C. Record review Resident #10's ADL care plan, initiated 7/15/26, documented Resident #10 required assistance with bathing. The bathing task record documented Resident #10 preferred to be bathed on Tuesdays and Fridays. The bathing task record did not include documentation of any showers/baths given to Resident #10 since admission. The Shower/Hygiene Care form for Resident #10 was provided by the regional director of clinical services on 8/5/26 at 2:18 p.m. The document revealed Resident #10 received three baths since her admission [DATE], 7/21/26 and 8/4/26). Resident #10 received bathing on three out of six opportunities. D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 8/6/26 at 8:45 a.m. CNA #4 said Resident #10 was scheduled for baths on Tuesdays and Fridays. CNA #4 said Resident #10 did not refuse baths. She said there were days when the facility did not have enough staff to get all of the showers and baths completed and some residents did not get bathed. CNA #5 was interviewed on 8/6/26 at 8:55 a.m. CNA #5 said the shower aide position that was scheduled from 6:00 a.m. to 2:00 p.m. had been eliminated by the facility. She said most residents received their showers or baths, but sometimes there was not enough time to get everyone's baths done. The director of nursing (DON) was interviewed on 8/6/26 at 11:10 a.m. The DON said Resident #10 should have had six to seven baths since her admission. The DON said she had encouraged the CNAs to come to her to tell her if showers did not get done. She said the CNAs should try to do the showers at night if they were unable to do so during the day. The DON said the CNAs should document in the resident's electronic medical record (EMR) and on the Shower/Hygiene Care form whether residents had or did not have and if they refused their showers. The DON said she was in process of educating the CNAs about documenting and immediately reporting to her the reasons why a shower or bath had not been completed. The DON said it was important for residents to have showers or baths for cleanliness and for mental health purposes, as it helped residents feel better and it aided in their psychological well being. III. Resident #3A. Resident status Resident #3, age less than 65, was admitted on [DATE]. According to the August 2026 CPO, diagnoses included multiple sclerosis, neuralgia, neuritis, chronic obstructive pulmonary disease, low back pain, muscle weakness, and the need for assistance with personal care. The 6/19/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident had functional limitations of range of motion of the lower extremities (hip, knee, ankle and foot) on both sides. The MDS assessment revealed a shower had not been attempted with the resident during the seven day assessment period. B. Resident interview Resident #3 was interviewed on 8/4/26 at 10:34 a.m. Resident #3 said he did not get a minimum of two showers each week. He said he wanted at least two each week per his preference. He said there had been a few times he refused. C. Record review The care plan for functional abilities/self-care/mobility revealed the resident had a performance deficit related to multiple sclerosis, weakness, decreased sensation/decreased mobility of lower extremities, and incontinence. Pertinent interventions included the resident was dependent on staff for showers/baths. The resident's shower documentation from 5/1/26 to 7/31/26 was provided by the chief compliance officer on 8/5/26 at 9:03 a.m. The shower documentation revealed: -Resident #3 received zero baths out of eight opportunities for May 2026. It indicated the resident refused once. -Resident #3 received zero baths out of eight opportunities for June 2026. It indicated the resident refused once. -Resident #3 received zero baths out of eight opportunities for July 2026. It indicated the resident refused once. D. Staff interviews The DON was interviewed on 8/6/26 at 11:48 a.m. The DON said Resident #3 was dependent on staff for showers. The DON said Resident #3 was scheduled to have his showers on Monday and Thursday in the evenings. The DON said the residents should receive two or more showers each week if they want them. The DON said the shower documentation was not applicable (N/A) and she was not sure what that meant. The DON said the use of the word no in the documentation meant that a shower had not been given. The DON said if a resident refused a shower, the CNA should offer the resident a different time and/or date. The DON said the CNA would tell the resident's nurse of the shower refusal and how many times the resident refused. The DON said the documentation of showers provided or refused should be documented in the resident's electronic medical record (EMR) by at least the end of each shift. The DON said resident's showers were also documented on a paper form. The DON said showers should be provided as scheduled to help prevent infections, and any psychosocial benefits such as a resident's positive mental health, and to help the resident feel better. CNA #6 was interviewed on 8/6/26 at 5:48 p.m. She said she provided showers to residents. She said she documented a resident receiving or refusing a shower in the EMR and also on a paper form. CNA #6 said she documented at least by the end of her shift. She said she did not know what N/A meant in regards to showers. She said the use of the term no, meant that a shower was not given. CNA #6 said she had the ability in the EMR and on the paper form to document if a resident refused a shower. CNA #5 was interviewed on 8/6/25 at 5:58 p.m. She said she provided showers to residents. She documented a resident receiving or refusing a shower in the EMR and also on a paper form. CNA #5 said she documented at least by the end of her shift. She said she did not know what N/A meant in regards to showers. CNA #5 said the term no, meant that a shower was not given. She said she had the ability in EMR and on a paper form to document if a resident refused a shower. CNA #5 said if a resident refused a shower, the CNAs were to ask the resident two to three times and then tell the nurse of the refusal. She said a resident should be offered a different time and date if they refuse.

Based on record review and interviews, the facility failed to ensure the facility had a designated designated registered nurse (RN) acting as the director of nursing (DON). Specifically, the facility utilized the DON as a floor nurse and certified nurse aide (CNA) several times when the facility's average daily census was over 60 residents. Findings include:I. Facility policy and procedureThe Nursing Services and Sufficient Staffing policy, not dated, was provided by the nursing home administrator (NHA) on 4/30/26 at 3:08 p.m. It read in pertinent part, The Director of Nursing (DON) may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. The facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The facility is required to provide licensed nursing staff 24 hours a day, along with other nursing personnel, including but not limited to nurse aides.II. Record review The daily assignment sheets were provided by the NHA on 4/30/26 at 9:20 a.m. The daily assignment sheets showed the DON worked the following shifts: On 4/13/26 the DON worked a day shift as a charge nurse/medication nurse. On 4/16/26 the DON worked an overnight shift as a CNA.On 4/18/26 the DON worked a day shift as a CNA.On 4/19/26 the DON worked a day shift as a charge nurse/medication nurse. On 4/22/26 the DON worked a day shift as a charge nurse/medication nurse. On 4/27/26 the DON worked an overnight shift as a charge nurse/medication nurse. The facility assessment was provided by the NHA on 4/27/26 at 9:15 a.m. The facility assessment revealed the facility's current occupancy was 80 residents on 4/27/26.III. Staff interviewThe NHA was interviewed on 4/27/26 at 8:55 a.m. The NHA said the census as of midnight on 4/26/26 was 80. Licensed practical nurse (LPN) #3 was interviewed on 4/28/26 at 11:50 a.m. LPN #3 said the DON resigned mid April 2026. She said the IDON filled in on the overnight shift when there were not enough nurses. LPN #3 said the assistant director of nursing (ADON) was a LPN.The DON was interviewed on 4/29/26 at 2:30 p.m. The DON said she had accepted the DON position on 4/16/26. She said she worked an overnight shift as a CNA on 4/16/26. The DON said she worked a night shift as a registered nurse on 4/27/26, assigned to a medication cart. She said she was assigned to work on a medication cart or as a CNA when she needed to fill in, due to not having a licensed nurse or CNA to work a shift.

Based on observations and interviews the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the two of two nourishment refrigerators.Specifically, the facility to ensure safe and appropriate food storage of food items in the nourishment refrigerators. Findings include:I. Professional referenceThe Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/5/26 read in pertinent part, Commercially processed food: open and hold cold, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, the day the original container is opened in the food establishment shall be counted as day one and the day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. 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 as specified under. (3-501.17)The [NAME] Uncrustable Sandwiches Website Frequently Asked Questions, retrieved from https://www.smuckersuncrustables.com/frequently-asked-questions We suggest keeping our products frozen until ready to thaw. Thaw for 30 to 60 minutes at room temperature for the best results and consume within 8 to 10 hours. We do not recommend microwaving these sandwiches as the filling can become very hot and pose a safety hazard. Uncrustables(R) sandwiches should not be thawed and refrozen. Once thawed, Uncrustables(R) sandwiches may be refrigerated for up to 24 hours. However, refrigerating may dry out the bread. For best flavor and experience, we recommend eating within 8 to 10 hours of thawing. II. Facility policy and procedureUse of Storage of Food Brought in by Family or Visitors policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 4/27/26 at 5:23 p.m. It read in pertinent part, It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator; the prepared food must be consumed by the resident within three days; if not consumed within three days, and food will be thrown away by facility staff. All items not maintained are subjected to being thrown away if not removed by the resident and/or resident representative.The Kitchen Sanitation policy, dated 12/22/25, was provided by the NHA on 4/30/25 at 3:30 p.m. It read in pertinent part: It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects. The sanitation program will provide inspections to be conducted of the food service areas. Sanitation inspections will be conducted in the following manner:Daily: Food service staff shall inspect refrigerators/coolers, freezers, storage area temperatures and dishwasher temperatures daily. Weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulation. Inspections will be conducted but not limited to the following areas: dry storage, freezer, refrigerator, dish room, pot wash, main production area, food preparation area, general dietary observations.III. ObservationsOn 4/28/26 at 4:15 p.m. the following was observed in the 300 hall nourishment refrigerator and freezer:-There was a plastic pitcher that contained red colored liquid which was not labeled or dated. -There was a plastic pitcher that contained yellow colored liquid which was not labeled or dated. -There was a plastic pitcher that contained white colored liquid that was not labeled or dated. -There were five thawed Uncrustables sandwiches in the refrigerator not dated.On 4/28/26 at 4:28 p.m. the following was observed in the 600 hall nourishment refrigerator:-There were two juice bottles, with the same resident name, one bottle expired 1/26/26 and the other bottle expired 2/10/26. -There was a plastic container of grapes with no name or date. The grapes had wrinkled skin with brown stems and there was brown fluid in the plastic container.-There was a bottle of chocolate milk with a resident's name and an expiration date of 4/26/26. The chocolate milk appeared to contain brown chunks in the bottle.-There were seven Uncrustable sandwiches, not dated. -A resident's pizza box dated 4/8/26. -A resident's pizza box dated 3/29/26.-A resident's pizza box dated 4/20/26. -A resident's pizza box dated 4/21/26.On 4/30/26 at 1:50 p.m. the following was observed in the 300 hall nourishment refrigerator:-A resident's personal food containing store bought sliced meat that had a film covering over the meat and dripping fluid coming out of the container, was not dated.-Five thawed Uncrustable sandwiches with no date.-Two juice pitchers with no label or date. -Nineteen health shakes with no pull dates. On 4/30/26 at 2:00 p.m. the following was observed in the 600 hall nourishment refrigerator:-Four thawed Uncrustable sandwiches with no dates.-Four residents' pizza boxes.-Three thawed health shakes with no pull date. IV. Staff interviewsLicensed practical nurse (LPN) #3 was interviewed on 4/28/26 at 4:28 p.m. She said the night shift was supposed to clean out the nourishment refrigerator/freezer. The NHA was interviewed on 4/30/26 at 10:12 a.m. The NHA said the certified nurse aides (CNA) should be cleaning out the nutrition refrigerators as needed. The NHA said all items in the refrigerators and freezers should be labeled and dated and expired food should be cleaned out. The dietary manager (DM) was interviewed on 4/30/26 at 2:10 p.m. The DM said he was not sure who should be cleaning out the nourishment refrigerators. He said the dietary staff were responsible for taking the drinks and snacks to the units. He said it would be important to clean out the refrigerators so residents were not served expired foods or drinks. The DM said all items in the refrigerators and freezers needed to be labeled and dated. He said the Uncrustables sandwiches should not be in the refrigerators longer than three days.

Based on record review and interviews, the facility failed to employ an infection preventionist (IP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to employ an infection preventionist (IP) with specialized training in infection prevention and control. Findings include:I. Record reviewThe facility provided a certificate of infection prevention training with an expiration date of 2024 for the current IP.II. Staff interviewsThe IP was interviewed on [DATE] at 3:00 p.m. The IP said she was the assistant director of nursing (ADON). She said she was combining responsibilities of the ADON and the IP. She said she did not realize her certification had expired. She said she started doing the training online, but was not able to complete the training to receive her certification. The chief nursing officer was interviewed on [DATE] at 5:00 p.m. She said she did not realizethat the IP was not certified. She said she did not have an infection prevention certification. The chief nursing officer said the IP needed to complete her training and certification.

Based on interviews, record review and observations the facility failed to ensure residents consistently received food that was palatable, attractive and at an appetizing temperature.Specifically, the facility failed to ensure residents' food was palatable in temperature. Findings include:I. Facility policy and procedureThe Food Preparation Guidelines, 4/11/25, was provided by the nursing home administrator (NHA) on 4/30/26 at 3:30 p.m. It read in pertinent part, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. Food shall be prepared by methods that conserve nutritive value, flavor and appearance. This includes, but is not limited to: Minimizing holding time prior to meal service. Food and drinks shall be palatable, attractive and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: Serving hot foods/drinks hot and cold foods/drinks cold and addressing resident complaints about foods/drinks.II. Resident interviewsResident #42 was interviewed on 4/27/26 at 11:00 a.m. Resident #42 said the food was a bummer. She said the food was delivered warm sometimes. She said half the time it was delivered cold.Resident #12 was interviewed on 4/27/26 at 11:30 a.m. Resident #42 said the food was delivered sometimes warm and sometimes not, about half and half. Resident #5 was interviewed on 4/27/26 at 12:44 p.m. Resident #5 said the food was not usually warm when it was delivered.Resident #7 was interviewed on 4/27/26 at 1:46 p.m. She said the food was often served cold and it made her feel aggravated.Resident #1 was interviewed on 4/27/26 at 2:45 p.m. Resident #1 said her food was not delivered warm.Resident #54 was interviewed on 4/28/26 at 9:00 a.m. Resident #54 said the food was not warm when it was delivered. He said most of the time it was cold. III. Resident group interviewFive residents (#15, #39, #51, #67, and #78) were identified as alert and oriented by facility and assessment and were interviewed on 4/28/26 at 1:00 p.m. All of the residents frequently attended the resident council meetings. Resident #15 and Resident #51 said the food was room temperature when it was delivered in the dining room. Resident #67 said the food was cold when delivered to the room. The group said they had brought this issue up at previous resident council meetings. IV. Record reviewResident council meeting notes, dated 1/6/26, documented residents reported food at breakfast and lunch was cold. The minutes documented a grievance form was completed.-The facility's response for the 1/6/26 grievance form did not address food temperatures. The February 2026 culinary council meeting minutes documented concerns about food being served cold. The facility's response was acknowledging the concern and advised the residents the staff was working on improving food temperature consistency. Resident council meeting notes, dated 2/9/26, documented prior concerns from January 2026 would be addressed in the resident council meeting scheduled for March 2026. The March 2026 culinary council meeting minutes documented concerns regarding food temperature. The NHA and dietary manager (DM) provided updates that improvements were in progress to address timely meal service. Resident council meeting notes, dated 3/3/26, documented residents reported the food was cold.-The grievance form written from the 3/3/26 resident council meeting did not address food temperatures. V. Test trayOn 4/28/26 at 11:45 a.m. the meal trays were being prepared for cart trays. The food carts were lined up, none of the food carts were plugged. On 4/28/26 at 11:47 a.m. the meal trays for the 600 hall were being prepared. The cart tray was delivered to the 600 hall at 11:55 a.m.At 11:57 a.m. the first tray was delivered to the resident's room.At 12:03 p.m. the test tray was removed from the cart after the last resident had been served their room tray. At 12:04 p.m. the test tray was immediately evaluated by three surveyors.The test tray consisted of honey glazed pork loin, herb stuffing, steamed carrots,and red velvet bar for dessert. Each item was placed all on one plate and covered. The red velvet bar was in a separate cup.-The stuffing registered a temperature of 118.7 degrees F.-The steamed carrots registered a temperature of 115.6 degrees F.-The red velvet bar registered a temperature of 82.6 degrees F.VI. Staff interviewsThe DM was interviewed on 4/28/26 at 11:11 a.m. The DM said he was aware of the concerns regarding cold food. He said he checked the temperatures before service began and when the service was completed. The DM said he continued to work with the dietary staff on being more efficient with plating the meals and getting the meals in the cart. The DM said the carts were delivered to the halls and the certified nurse aides (CNA) were responsible for disturbing the trays. The DM said the meals should be passed out as soon as the carts were on the unit. The NHA was interviewed on 4/30/26 at 9:00 a.m. The NHA said he had not heard the resident had complained of cold food. The NHA said the facility used a name brand insulated top and bottom combination for room trays. He said the facility also incorporated a plate warmer to raise the temperature of the plates prior to the plating of the residents' food. The NHA said the facility transported the foods to resident rooms with an enclosed metal tray-serving cart, which was plugged into an electrical outlet while it was in the kitchen. The NHA said this would help keep the food warm during room tray preparation. The NHA said the staff did not plug the cart into an electrical outlet once it left the kitchen.-However, during kitchen observation on 4/27/26 and 4/28/26 the one metal tray-serving cart, which could be plugged in, was not plugged while it was in the kitchen (see observations above).

Based on observations, record review, and interviews, the facility failed to ensure that its medication error rate was not greater than five percent (%).Specifically, the facility had a medication error rate of 44%, which was 11 errors out of 25 total opportunities for error. Findings include:I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., 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 medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.II. Facility policy and procedureThe Medication Administration policy, revised on [DATE], was provided by the chief nursing officer on [DATE] at 6:42 p.m. Compare the medication source (bubble pack, vial) with the medication administration record (MAR) to verify the resident's name and medication name. Review MAR to identify medication to be administered. Administer within 60 minutes before or after the scheduled time unless otherwise ordered by the physician. Identify expiration date. If expired, notify nurse manager. Sign MAR after administration. For those medications requiring vital signs, record vital signs on the MAR. Ensure that the six rights of medication administration are followed:a. Right residentb. Right drugc. Right dosaged. Right routee. Right timef. Right documentation Insulin and Diabetes Agents: Must be timed precisely around meals to manage glucose levels effectively.II. Observations and record reviewA. Resident #93On [DATE] at 11:32 a.m. registered nurse (RN) #2 prepared and administered 40 units of Lantus and 12 units of insulin lispro to Resident #93.The physician's orders read:Lantus Subcutaneous Solution 40 unit/milliliter (ml) (Insulin Glargine) Inject 40 units subcutaneously two times a day for Type 1 Diabetes Mellitus. The order was scheduled to be administered at 7:00 a.m. to 9:00 a.m.-Lantus was administered at 11:32 a.m., which was two hours and 31 minutes after the medication administrator window. RN #2 did not prime insulin pen prior to administering the insulin. Insulin Lispro Injection Solution 12 unit/ml (Insulin Lispro). Inject 12 units subcutaneously three times a day for Type 1 diabetes mellitus. Give before meals. The order was scheduled to be administered at 7:00 a.m. to 9:00 a.m.-RN #2 administered insulin Lispro at 11:32 a.m., which was two hours and 31 minutes after the medication administrator window. RN #2 did not prime insulin pen prior to administering the insulin. B. Resident #6On [DATE] at 9:09 a.m. the assistant director of nursing (ADON) prepared and administered two 500 mg tables of acetaminophen to Resident #6. The physician's orders read:Acetaminophen oral packet 500 milligrams (mg). Give 1000 mg by mouth three times a day for pain. The order was scheduled to be administered at 7:00 a.m., 2:00 p.m. and 9:00 p.m. -The ADON administered the acetaminophen in the wrong form and one hour outside the allowed medication administration window. C. Resident #68On [DATE] at 10:15 a.m. the ADON prepared and administered the following medications to Resident #68:Farxiga oral (medication used to treat diabetes) tablet 10 mg;Metoprolol Succinate (to treat high blood pressure) oral capsule 25 mg extended release (ER) 24 hour; Lisinopril oral tablet (to treat high blood pressure) 10 mg; and,Oxycodone HCl oral tablet (pain medication) 5 mg.Review of Resident #68's [DATE] computerized physician's orders (CPO) revealed the resident's physician's order: Farxiga oral tablet 10 mg. Give 10 mg by mouth one time a day at 7 a.m. to 9 a.m. Hold if glucose was less than 70 milligrams per deciliter (mg/dl).-However, the ADON administered the medication one hour and 15 minutes outside the allowed medication administration window, and she did not check the resident's blood sugar to ensure it was above 70 mg/dl. Metoprolol Succinate Oral Capsule ER 24 Hour Sprinkle 25 mg. Give one capsule by mouth in the morning for Hypertension. The medication was scheduled to be administered from 7:00 a.m. to 9:00 a.m.Lisinopril oral tablet 10 mg. Give one tablet by mouth in the morning for hypertension. The medication was scheduled to be administered from 7:00 a.m. to 9:00 a.mOxycodone HCl oral tablet 5 mg. Give one tablet by mouth every morning and at bedtime for pain The medication was scheduled to be administered from 7:00 a.m. to 9:00 a.m. -However, the ADON administered the medication one hour and 15 minutes outside the allowed medication administration window. D. Resident #73On [DATE] at 10:03 a.m. RN #4 prepared and administered the following medications to Resident #73Amlodipine Besylate oral tablet (to treat high blood pressure) 10 mg.Review of Resident #73's [DATE] CPO revealed the resident's physician's order: Amlodipine Besylate oral tablet 10 mg. Give 10 mg by mouth one time a day for hypertension. The medication was scheduled to be administered from 7:00 a.m. to 9:00 a.m.-However, RN #4 administered the medication one hour outside the allowed medication administration window. E. Resident #8On [DATE] at 10:57 a.m. RN #4 prepared and administered the following medications to Resident #8:Insulin Glargine Solution 50 units;Humalog KwikPen Subcutaneous Solution Pen-injector 6 units; and, Sertraline HCl oral tablet 100 mg Review of Resident #8's [DATE] CPO revealed the resident's physician's order: Insulin Glargine Solution 55 units subcutaneous. The medication was scheduled to be administered from 7:00 a.m. to 9:00 a.m.-However, RN #4 administered the medication one hour and 57 minutes outside the allowed medication administration window and administered 50 units instead of 55 units per physician's orders.HumaLOG KwikPen Subcutaneous Solution per sliding scale to be administered from 7 a.m. to 9 a.m. -However, RN #4 administered the medication one hour and 57 minutes outside the allowed medication administration window.Sertraline HCl Oral Tablet 25 MG (Sertraline HCl). Give 25 mg. This medication was scheduled to be administered from 7:00 a.m. to 9:00 a.m.-However, RN #4 administered 75 mg above the physician's order and administered the medication one hour and 57 minutes outside the allowed medication administration window. III. Staff interviewsRN #2 was interviewed on [DATE] at 11:35 a.m. RN#2 said she would notify the physician of the late administration of insulin. RN #2 said she forgot to prime the insulin pen prior to administering. The ADON was interviewed on [DATE] at 10:50 a.m. The ADON said she was not familiar with the medication cart, and that was why she was administering medications late. She said she would notify the physician once she had a complete list of residents with late medications. The ADON said she did not realize that Resident #68 needed a blood glucose check.RN #4 was interviewed on [DATE] at 2:49 p.m. RN#4 said he was behind giving medications because he was assisting with dental appointments. RN #4 He did not realize he was five units short when he prepared to administer the insulin. He said he administered Sertraline 100 mg, because that was the dose in the bubble pack from the pharmacy. He said the physician's order indicated to administer 25 mg instead of 100 mg. RN #4 said he should have been looking at the MAR more closely and had fewer distractions.The chief nursing officer was interviewed on [DATE] at 3:00 p.m. She said she had done education in the morning hours with the nursing staff for medication administration. The chief nursing officer was aware that the nursing staff were struggling to give residents their medications on time. She said she would be educating the nursing staff again on the importance of the six rights of medication administration. The chief nursing officer said Sertraline was administered correctly. She said the order recently was reduced from 125 mg to 100 mg. The order was transcribed inappropriately and the order for 100 mg was discontinued in error, leaving an active order for 25 mg. She said MAR was immediately corrected to ensure the resident was receiving the appropriate dose.

Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for two of three medication carts. Specifically, the facility failed to: -Ensure inhaler medications and ophthalmic solution were marked with the date when the medications were opened;-Ensure insulin was labeled with the date they were opened;-Ensure there were no loose pills in the medication cart; and,-Ensure that expired medications were disposed of properly. Findings include:I. Professional referenceAccording to the manufacturer recommendations Latanoprost 0.005% ophthalmic solution prescribing information read in pertinent parts, Once opened, manufacturers recommend discarding eye drops after 28 days. Latanoprost 0.005% eye drops must be discarded four to six weeks after opening, regardless of the expiration date on the bottle. According to the Spiriva Respimat (tiotropium bromide) inhaler package insert, retrieved on 5/5/26 from https://pro.boehringer-ingelheim.com/us/bipdf/spiriva-respimat-us-pi After assembly, the Spiriva Respimat inhaler should be discarded, at the latest, three months after first use or when the locking mechanism is engaged, whichever comes first.The Food and Drug Administration (FDA) Insulin Storage and Effectiveness (revised 9/19/17), was retrieved on 5/6/26 from fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-switching-between-products-emergency. It read in pertinent part, Insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 (degrees) Fahrenheit (F) and 86 F for up to 28 days and continue to work.The United States Food and Drug Administration (USDA) Don't Be Tempted to Use ExpiredMedicines (revised 10/31/24), was retrieved on 5/6/26 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth, and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed, there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it.II. Facility policy and procedureThe Medication Storage policy, not dated, was provided by the chief nursing officer on 4/29/26 at 6:42 p.m. It read in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. All drugs and biologicals will be stored in locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Any discrepancies that cannot be resolved must be reported immediately as follows: Notify the director of nursing (DON), charge nurse, or designee, and the pharmacy. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, illegible, or missing labels.III. ObservationsOn 4/27/26 at 9:18 a.m. the medication cart was observed with registered nurse (RN) #2 on hallway 300 and 700. The following medications were found:-Olopatadine Hydrochloride ophthalmic solution 0.2% was not labeled when it was opened.-Latanoprost ophthalmic solution was not labeled when it was opened.-Latanoprost 0.005% was not labeled when it was opened.-Symbicort 160/45 inhaler was not labeled when it was opened.-Ventolin HFA (albuterol inhaler) 90 micrograms was not labeled when it was opened.-Fluticasone propionate (Flovent inhaler)was not labeled when it was opened.-Spiriva inhaler was not labeled when it was opened.-Forty four loose unidentified medications were found in the medication cart.On 4/27/26 at 9:45 a.m. observation of the medication cart for the hallway 100 and 400 with licensed practical nurse (LPN) #2 The following medications were found:-Prednisone (steroid) 20 mg pack that expired on 3/25/26-Prednisone 20 mg pack that expired on 4/7/26.-Six medications were found loose at the bottom of the drawer in the medication cart. IV. Staff interviewsRN #2 was interviewed on 4/27/26 at 9:40 a.m. RN #2 said she was not sure who was responsible for cleaning out the medication carts and she would to ask the assistant director of nursing (ADON). LPN #2 was interviewed on 4/27/26 at 9:55 a.m. LPN #2 said the night nurse was responsible for cleaning the medication cart. LPN #2 said she did not know who completed the monthly chart audits of medication cart cleaning. The chief nursing officer was interviewed on 4/27/26 at 10:10 a.m. She said each nurse was responsible for cleaning and maintaining the medication cart. She said the cart should be cleaned during their shift. She said if the nurse dropped a medication in the drawer, they should pick it up and dispose of it correctlyThe director of nursing (DON) was interviewed on 4/29/26 at 2:30 p.m. The IDON said the medication carts were cleaned by everybody working on that medication cart. The IDON said the night shift should also be cleaning them at night. She said the pharmacy completed medication cart audits. The DON said all medication should be labeled and dated when opened.

Based on record review and interviews the facility failed to ensure meals were served according to the resident's preferences on three of four units. Specifically, the facility failed to provide menus to residents in order for the residents to choose their meals and honor food preferences. Findings include:I. Facility policy and procedureThe Food Preparation Guidelines policy and procedure, dated 4/11/25, was provided by the nursing home administrator (NHA) on 4/30/26 at 3:30 p.m. It read in pertinent part: Food and drinks shall be palatable, attractive and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: Honoring resident preferences, as possible, regarding foods and drinks. Staff shall accommodate resident allergies, intolerances, and preferences, providing appropriate alternatives when needed.II. Resident interviewsResident #5 was interviewed on 4/27/26 at 12:44 p.m. Resident #5 said she was not offered menus at night. She said a few times since her admission the night certified nurse aides (CNA) took her meal order for the next day, which was nice so she knew what she was going to have for her meals. Resident #5 said if she did not fill out the meal ticket she would not know what she was going to be served, because they just provided the main option. Resident #5 said she preferred to choose her own meals, so she could order what she liked. She said she did not always eat the full meal because it was not something she would have ordered for herself and would like the opportunity to order different items. She said she was aware of the alternate menu and would choose items off of that menu. She said she did not ask for anything different when her meal was passed because she would rather try to eat what was served than have to wait for anything else. Resident #1 was interviewed on 4/27/26 at 2:45 p.m. Resident #1 said the menus were not available the night before so she would not know what she would receive until the meal was served. She said she was not happy about that and would like to be able to choose her own meals. She said it takes too long to wait for an additional meal if she requested another meal. Resident #42 was interviewed on 4/27/26 at 3:22 p.m. Resident #42 said the food was a bummer for her, because she did not choose her meals daily. She said the CNAs used to pass out and assist with the menu selection the night before, but that was not happening very often anymore. Resident #42 said when she did not fill out her menu she was served the main meal for the day and would not know what that was until she received it. Resident #42 said who knew what you would get, and said she would prefer to choose her meals. Resident #42 said it was frustrating not choosing her meal. Resident #54 was interviewed on 4/28/26 at 10:00 a.m. Resident #54 said he was not getting the option to choose his meals and got what he got. He said he was served the main meal, which was not always what he would choose for himself so he just would not eat it. He said if asked for something else it would take too long so he would wait until the next meal and maybe have a snack. Resident #54 said he was not provided the menu options the night before like he used to be. III. Resident group interviewFive residents (#15, #39, #51, #67, and #78) were identified as alert and oriented by facility and assessment and were interviewed on 4/28/26 at 1:00 p.m. All of the residents frequently attended the resident council meetings. Resident #15 and Resident #51 said the CNAs were not consistently getting the menu tickets filled out for the following day. Residents#15 and Resident #51 said they did not always know what they were going to be served the next day, because they did not choose their meals. Resident #51 said the CNAs used to take the orders the night before, but that was not happening all the time. Residents #15 and Resident #51 said it was upsetting not being able to order what they wanted.IV. Record reviewResident council meeting minutes, dated 1/6/26, revealed the residents in attendance had concerns that the dietary staff were not reading the meal tickets. The facility did not have a response documented on the resident council minutes. Resident council meeting minutes, dated 3/3/26, revealed the residents in attendance continued to voice concerns about kitchen staff were not reading the meal tickets. The facility's response was that the dietary manager (DM) would re-educate the staff. Resident council meeting minutes, dated 4/7/26, revealed the residents in attendance continued to voice concerns about the kitchen staff not reading the meal tickets. The facility's response was that the DM would re-educate his staff. V. Staff interviewsThe DM was interviewed on 4/28/26 at 11:11 a.m. The DM said the menus were to be completed the night before by the CNAs. The DM said the CNAs were to take the menu to the rooms, review the menus and alternates and fill out the meal ticket. The DM said the CNAs were to return the meal tickets by 5:30 a.m. the next morning. The DM said he was not sure if the tickets were completed with the residents or filled out by staff.CNA #4 was interviewed on 4/29/26 at 6:06 p.m. CNA #4 said it was the CNAs' responsibility to go room to room with the menus and assist, if needed, residents to fill out their menu ticket for the next day. She said if she was unable to get the task done the morning shift would fill out the menu tickets. CNA #3 was interviewed on 4/29/26 at 6:18 p.m. CNA #3 said the CNAs' received the menu tickets for each hall. CNA #3 said the CNAs went over the menu and alternate menu with the resident, then filled out the ticket with the residents. CNA #3 said the tickets were returned to the kitchen for the next day's meal. CNA #3 said it had happened only a few times that she was unable to complete tickets because it was a busy shift.

Based on record review and interviews, the facility failed to honor resident choices for two (#5 and #54) of 18 residents reviewed out of 40 sample residents. Specifically, the facility failed to ensure Resident #5 and Resident #54 received showers consistently according to the residents' preferences and plan of care. Findings include:I. Facility policy and procedureThe Resident Showers policy, dated 12/4/25, was provided by the nursing home administrator (NHA) on 4/30/26 at 3:30 p.m. It read in pertinent part, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards or practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident preferences and safety.II. Resident #5A. Resident statusResident #5, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included lymphedema, morbid obesity with alveolar hypoventilation (slow breathing), and muscle weakness.The 4/13/26 minim data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for lower body dressing and required maximal assistance with upper body dressing. She was partial to moderate assistance with showers. Resident #5 was dependent for mobility.The MDS documented the resident did not refuse care.B. Resident interviewResident #5 was interviewed on 4/27/26 at 12:44 p.m. Resident #5 said she wanted one shower a week. She said since she was admitted on [DATE] she had one shower, which was on 4/26/26. She said she was not asked about getting a shower and went two and half weeks without a shower. She said she felt dirty and her hair felt greasy. C. Record reviewThe activities of daily living (ADL) care plan, initiated 4/19/26 and revised 4/23/26, revealed the resident had a risk for decline in ADL function related to activity intolerance, respiratory disease, and morbid obesity. Pertinent interventions included, Resident #5 required assistance with bathing.Resident #5's point of care (POC) response history for the bathing task revealed Resident #5 preferred shower day was Sunday during the day shift after lunch. Review of Resident #5's POC response history for the bathing task from 4/8/26 to 4/26/26 revealed the resident had one shower on 4/26/26. III. Resident #54A. Resident status Resident #54, age less than 65, was admitted on [DATE]. According to the April 2026 CPO diagnoses included paraplegia, pressure ulcer right buttock, stage 4, left buttock pressure ulcer, stage 4, neurogenic bowel, neurogenic bladder, infection and inflammatory reaction due to other urinary catheter, initial encounter and other chronic osteomyelitis left thigh.The MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #54 required touching assistance to setup or clean- up assistance with ADLs. B. Resident interviewResident #54 was interviewed on 4/28/26 at 10:00 a.m. Resident #54 said he had refused a couple of showers because of not feeling well or he had pain. He said his preference was to shower three times a week during the day shift, but he was not asked three times a week. Resident #54 said if he declined, he was not offered a bed bath, a shower at a different time or a different day. He said he went many days without a shower. C. Record reviewThe ADL care plan, initiated 11/22/24 and revised 11/28/24, revealed the resident had an ADL self-care performance deficit related to activity intolerance, weakness and paraplegia. Pertinent interventions included encouraging the resident to discuss feelings about self-care deficit, encouraging the resident to participate to the fullest extent possible with each interaction, and monitoring/documenting/reporting as needed any changes, any potential for improvement, reasons for self care deficit, expected course, declines in function. Resident #54's POC response history for the bathing task revealed Resident #54 preferred showers on Monday, Wednesday and Friday during the day shift. Review of Resident #54's POC response history for the bathing task from 3/30/26 to 4/24/26 documented the resident received one shower out of nine opportunities. The documentation on the POC response history for the bathing task revealed the following:The POC documentation revealed the staff documented on 3/30/26 that the resident was not scheduled for a bath that shift. -However, 3/30/26 was a Monday which was one of Resident #54's preferred days. The POC documentation revealed on 4/1/26 Resident #54 refused a shower.-However, the progress note dated 4/1/26 at 4:04 p.m. had no reason for the refusal or that a shower was offered at a different time. The 4/3/26 progress note documented at 5:32 p.m. revealed the resident agreed to a shower. The note documented the resident continued to delay the shower during the day and then left the building and not return until after the certified nurse aide's (CNA) shift ended. The POC documentation revealed on 4/20/26 the resident had a shower.The POC documentation revealed on 4/22/26 the resident refused a shower. -However, there was no further documentation for the reason for the refusal or that the resident was offered a shower at a different time.The POC documentation revealed on 4/24/26 the resident was not available-There was no documentation from 4/3/26 to 4/8/26, regarding the resident's showers and from 4/27/26 to 4/28/26. The resident was in the hospital from [DATE] to 4/18/26. IV. Staff interviewsCNA #2 was interviewed on 4/29/26 at 3:20 p.m. CNA #2 said there was a bath aide scheduled and the bath aide provides the showers. If there was not a bath aide available then the CNAs were responsible for completing the scheduled showers for that day. CNA #2 said the CNAs were to document when a shower was given and to notify the nurse when a resident refused to have a shower. The assistant director of nursing (ADON) was interviewed on 4/29/26 at 2:25 p.m. The ADON said if a bath aide was not scheduled then the CNAs were responsible for completing the showers for their residents. She said a bath aide was not always scheduled and sometimes the bath aide was pulled to the floor to work a shift. The ADON said the CNAs were responsible for documenting when the showers were completed. The ADON said the facility did not have an issue with completing showers for the residents.

Based on record review and interviews, the facility failed to ensure one (#15) of 18 residents reviewed for abuse were kept free from abuse and neglect out of 40 sample residents.Specifically, the facility failed to protect Resident #15 from physical abuse by Resident #10. Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, implemented 4/11/25, was provided by the nursing home administrator (NHA) on 4/28/26 at 1:10 p.m. The policy revealed, the facility provided protections for the health, welfare and rights of each resident by developing/implementing written policies/procedures that prohibited/prevented abuse, neglect, exploitation and misappropriation of resident property. Abuse was defined by the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident-to-resident altercations. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical abuse included but was not limited to hitting, slapping, punching, biting, and kicking. It also included controlling behavior through corporal punishment. The facility would make efforts to ensure all residents were protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples included, but were not limited to, responding immediately to protect the alleged victim and integrity of the investigation and examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed. The facility would increase supervision of the alleged victim and residents and offer room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. The facility would provide protection from retaliation and provide emotional support and counseling to the resident during and after the investigation, as needed. The facility would revise the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences changed as a result of an incident of abuse.II. Incident of physical abuse by Resident #10 towards Resident #15 on 3/19/26 A. Facility investigationThe 3/19/26 facility investigation, documented at 7:46 p.m., revealed Resident #15 was observed on the floor in the dining room. Resident #15 reported that Resident #10 hit him and then pushed him out of his wheelchair. Resident #15 was assessed by a nurse and assisted back into his wheelchair. The investigation documented the incident was not witnessed by staff, but there were other residents present in the dining room at the time of the incident. The investigation documented the other residents were interviewed and said Resident #10 was upset about a paper that had information about $400.00 dollars on it. The residents collectively said Resident #10 came up behind Resident #15 and hit him on the right side of the face. Resident #10 then proceeded to tip Resident #15's wheelchair over. The investigation documented a nurse assessed Resident #15 and observed a small red mark above his eyebrow. Resident #15 denied any pain. Resident #15 said that Resident #10 came up from behind him and said he took his paper. Resident #15 said Resident #10 swung at him from behind and above his right eye. The investigation documented Resident #10 was interviewed and said Resident #15 took a paper from him and this made him mad. Resident #10 said that Resident #15 told him that he did not know anything about the paper. Resident #10 said Resident #15 tried to back his wheelchair into him. Resident #10 said he grabbed Resident #15's wheelchair and dumped him out. Resident #10 said that he did not hit Resident #15. The conclusion of the investigation revealed that based on resident reports and witness statements, Resident #10 made physical contact with Resident #15, which resulted in Resident #15 being on the floor.B. Resident #15 (victim)1. Resident statusResident #15, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included cerebral infarction without residual deficits, chronic kidney disease stage 3, major depression disorder and lack of coordination.According to the 3/19/26 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15.The resident utilized a wheelchair for ambulation. The resident required substantial/maximal assistance from staff for toileting, upper body dressing, lower body dressing and personal hygiene.2. Resident interviewResident #15 was interviewed on 4/30/26 at 1:50 p.m. Resident #15 said he was in the dining room at his usual spot (on 3/19/26). Resident #15 said Resident #10 came up to him and punched in the right side of face, pulled him out of his high-backed wheelchair and he fell to the floor. Resident #15 said he did not hit Resident #10 back. He said Resident #10 accused him of stealing some paper. Resident #15 said he did not know what paper Resident #10 was talking about. Resident #15 said he was not afraid of Resident #10. Resident #15 said this was the first altercation with Resident #10. Resident #15 said he had no pain after being hit in the face and he did not have to go to the hospital. 3. Record reviewA nurse note, dated 3/19/26 at 7:45 p.m., revealed Resident #15 was found lying on the floor on his left side. The resident was oriented to person, place, time and situation. The resident had a small red bump above his right eyebrow and the skin was intact. The resident was able to move all of his extremities. The resident had no complaints of pain or discomfort. Resident #15 said that Resident #10 hit him and he (Resident #10) hit like a girl. Resident #15 was assessed and vital signs were obtained with no obvious injuries observed. A Hoyer (mechanical lift) was used to lift the resident off the floor and back into his wheelchair.An event note, dated 3/23/26 at 9:54 a.m., revealed the event occurred on 3/19/26 at 7:45 p.m. Resident #15 was found lying on the floor on his left side. The resident was alert and oriented times three. The resident had a small red bump above the right eyebrow. The resident's skin was intact with no noted reddened areas. The resident was able to move all extremities well. The resident had no complaints of pain or discomfort. The root cause identification was Resident #15 had cognitive decline at baseline, was wheelchair bound, had lack of coordination at baseline. Resident #10 was the aggressor and felt that his items (candy wrappers in the trash) had been taken by Resident #15 and he retaliated. The note documented preventative measures included psychosocial support by nursing and social services. Staff were to watch for signs and symptoms of delayed injury and neurological assessments. Staff were to separate Resident #15 from Resident #10 at all times. Staff were to ensure close supervision in common areas as indicated. Staff were to assess for fear, anxiety, withdrawal, or behavioral changes following the incident. Resident #15's care plan for being the victim of a resident-to resident altercation, including being struck in the face, tipped in a wheelchair, placing resident at risk for injury, fear, and psychosocial distress was initiated on 3/23/26. The interventions included assessing the resident for fear, anxiety, withdrawal, or behavioral changes following the incident and providing reassurance and emotional support, ensuring the resident was not left in high-risk areas unattended if vulnerability was identified, and separating Resident #15 from Resident #10 at all times and ensuring close supervision in common areas as indicated.Resident #15's Kardex (an electronic quick-reference tool that provided a concise summary of essential resident information, care plans and medical orders), printed on 4/30/26 at approximately 3:00 p.m., revealed staff were to ensure the resident was not left in high-risk areas unattended if vulnerability was identified. Staff were to separate Resident #15 from Resident #10 at all times and ensure close supervision in common areas as indicated.C. Resident #10 (assailant)1. Resident statusResident #10, age less than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included diabetes mellitus type 2, personal history of traumatic brain injury, cognitive communication deficit, dementia, disorientation and adjustment disorder with mixed anxiety and depressed moods.According to the 3/20/26 MDS assessment, the resident was severely cognitively impaired with a BIMS score of six out of 15. The resident had inattention continuously present and did not fluctuate. The resident also had disorganized thinking continuously present and did not fluctuate. The resident had no physical or verbal behavioral symptoms directed toward others. The resident had no impairments in functional limitation in range of motion for either the upper or the lower extremities. The resident required partial/moderate assistance from staff for toileting, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene.2. Resident interviewResident #10 was interviewed on 4/30/26 at 10:22 a.m. Resident #10 said he did not remember any altercation with Resident #15. Resident #10 said he was not afraid of any residents or staff. Resident #10 said sometimes he was looking for a fight. He said this occurred when he became anxious. Resident #10 said he did not like it when people talked a lot. He said if the other people were happy, he could walk away from the incident. He said he was not afraid of Resident #15.3. Record reviewThe event note, dated 3/23/26 at 9:38 a.m., revealed an altercation occurred on 3/19/26 at 7:45 p.m. Resident #10 was observed in a physical altercation with Resident #15. Resident #10 hit Resident #15 and knocked him to the floor. Resident #10 was very angry and tried to exit-seek out the front door. Resident #10 sat in a chair in the front foyer of the facility. The risk factors and root cause identification were Resident #10 was at baseline confusion and recently had increased psychosis with a history of dementia. The preventative measures in place prior to the incident were to minimize the risk of agitation, refer to psychological counseling, staff were to interact in an empathetic/supporting manner and document behavioral events. New interventions were for Resident #10 to be placed on one-to-one caregiver supervision for safety. Staff were to monitor for signs of agitation, provide personal space during periods of agitation and redirect the resident away from peers when signs of escalation were noted. Staff were to administer medications as ordered and monitor for effectiveness and adverse side effects.A behavior care plan was initiated on 3/19/26 related to Resident #10's behaviors (paranoid thoughts, aggression, irritability often triggered by minor annoyances). The care plan documented the resident had sudden outbursts, low frustration tolerance and verbal or physical aggression. The resident had disinhibition (lack of restraint or poor self-regulation, where an individual acts impulsively without considering consequences or social norms) or a lack of filtering (cognitive distortion where an individual focuses exclusively on negative details of a situation while ignoring the positive aspects) which leads to socially inappropriate behavior. The resident had impulsivity (tendency to act swiftly on a whim without forethought, planning or consideration of negative consequences) with poor decision-making and taking risks without thinking of the consequences. The resident had egocentricity (state of being self-centered, focusing solely on one's own needs, perspectives, and interests while ignoring or failing to understand the viewpoints of others). The resident had a self-centered attitude, showing lack of empathy (ability to understand and share the feelings, thoughts, and perspectives of another person from their frame of reference, rather than one's own) or awareness of how their actions affected others. The resident had memory impairment leading to making false allegations against others and misplacing items. The interventions included assessing the resident for triggers and patterns related to accusations such as misplacement of items, time of day and staff interactions. Staff were to assist the resident with locating missing items promptly to reduce distress and reinforce trust. The staff would ensure the resident remained safe and demonstrated reduced episodes of agitation/aggression toward others through the review period. Staff would monitor the resident for signs of agitation, aggression, irritability, pacing, yelling, threatening behavior, or other escalation each shift and as needed. Staff were to redirect the resident away from peers/situations when signs of escalation were noted. Staff were to provide personal space and decrease environmental stimuli during periods of agitation. The alert note, dated 3/21/26 at 9:38 p.m., for a resident to resident altercation revealed Resident #10 was peacefully in his room with a one-to-one caregiver. Resident #10 believed that people were stealing from him and at this time he seemed calmer. The resident was started on Zyprexa (antipsychotic medication) at 2.5 milligrams (mg) after the situation (with Resident #15).III. Staff interviewsThe chief nursing office was interviewed on 4/30/26 at 8:00 a.m. The chief nursing officer said this was the first altercation between Resident #10 and Resident #15.The NHA was interviewed on 4/30/26 at 9:52 a.m. The NHA said this was the first altercation between Resident #10 and Resident #15. The NHA said the physical altercation occurred in the dining room. The NHA said the root cause was that Resident #10 said he had some papers that had $400.00 in them. The NHA said to his knowledge, Resident #10 did not have the money. The NHA said Resident #10 felt that Resident #15 took the money. The NHA said no staff members witnessed the incident. The NHA said some residents in the dining room at the time of the incident collectively said that Resident #10 hit Resident #15 on the side of the face. The NHA said Resident #15 did not have to go to the hospital. The NHA said Resident #10 was placed on a one-to-one caregiver because his paranoia caused him to escalate and he became fixated on an issue. The NHA said Resident #10 de-escalated when staff talked with him. The NHA said the resident would suddenly calm down and offer an apology. The NHA said Resident #10 and Resident #15 did not live in the same room and did not live in the same hallway. The NHA said when interviewed, neither of the two residents were afraid of each other. The NHA said the one-to-one caregiver for Resident #10 was continued until 4/7/26.

Based on record reviews and interviews, the facility failed to ensure one (#9) of eight residents out of 40 sample residents received treatment and care in accordance with professional standards of practice.Specifically, the facility failed to:-Ensure physician's orders for wound care were continued after a hospitalization for Resident #9; and,-Ensure Resident #9's wound was addressed in a timely manner by the wound care physician. Findings include:I. Resident #9A. Resident statusResident #9, age [AGE], was admitted on [DATE], was discharged to the hospital on 4/7/26 and returned to the facility on 4/9/26, discharged to the hospital on 4/11/26 and returned to the facility on 4/13/26. According to the April 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with diabetic chronic kidney disease, muscle weakness, morbid obesity, hypo-osmolality (water retention) and hyponatremia (low sodium), and dependence on renal dialysis.The 4/21/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She was partial to moderate assistance with dressing upper and lower body and with showers. She was substantial to maximum assistance with toileting and was incontinent of bowel and bladder. The MDS assessment did not indicate Resident #9 had a wound.B. Resident interviewResident #9 was interviewed on 4/27/26 at 4:00 p.m. The resident said she had skin issues on her bottom and a newer one on her abdomen. Resident #9 said she had treatment for her abdomen now after she saw another physician, but it took a few weeks. Resident #9 said she notified the nurse about the abdomen skin issue a few weeks ago, but nothing was done and now she had a hole in her side. C. Record reviewThe 3/29/26 progress note documented the resident complained of a cyst to the left abdomen. The area was measured at 1 centimeter (cm) by 0.5 cm. The note documented no drainage was observed, barrier cream was applied. The 3/30/26 progress note documented a certified nurse aide (CNA) alerted the nurse to an open area on Resident #9's abdomen. The resident said no one had looked at it and it had been there a few days. The assessment included a measurement of 2 cm by 1 cm open area with yellowish/white center with no drainage. The note documented the surrounding area was slightly red and cool to the touch. The area was cleaned and a dressing was applied. The physician and wound care team were notified. -However, the assistant director of nursing (ADON), who was also the wound nurse, said she was not aware of the wound until she worked a shift as a CNA on 4/16/26 (see interview below).The 3/30/26 physician progress note documented a new wound measuring 2 cm by 2 cm under the pannus (lower abdominal area). The resident agreed to have the wound care team evaluate. The physician recommended the wound care team to evaluate and to monitor for signs of infection to include erythema (redness), drainage and fever.The 3/31/26 progress note documented new interventions to include wound care referral, clean, dry and temporary bandage applied with monitoring orders in place. Review of the April 2026 CPO revealed the following physician's order: Monitor the wound to the abdomen every shift and keep the area clean and dry. Notify the physician with any changes, ordered on 3/31/26 and discontinued on 4/9/26, the date the resident returned from the hospital. -Review of the resident's electronic medical record (EMR) revealed the resident was admitted to the hospital on [DATE] and returned to the facility on 4/9/26. The resident was admitted to the hospital for a laceration to her scalp after a fall in the facility.The 4/9/26 nurse practitioner (NP) note documented to continue with wound care protocol and monitor for infection for the wound under the pannus. -However, the treatment assessment record (TAR) documented the order to monitor wound to abdomen every shift and keep area clean and dry and notify the physician with any changes was discontinued on 4/9/26. The 4/10/26 wound general note documented the resident was not present in the facility for wound rounds. She was not seen by the wound care physician. -Review of the resident's EMR revealed the resident was admitted to the hospital on [DATE] and returned to the facility on 4/13/26. The resident was sent to the hospital from her dialysis appointment due to low sodium.-Review of the April 2026 revealed the facility failed to obtain new wound care orders for the resident's wound on her abdomen when she was readmitted to the facility on [DATE].The 4/14/26 wound general note documented the resident was not in the building for wound rounds. She was not seen by the wound care physician. The 4/18/26 weekly skin check evaluation documented the resident had a left iliac crest site (near the left hip bone) that had a mediplex covering (foam dressing) the area with erythema and small drainage present, no odor, and no periwound (skin surround a wound) ecchymosis (bruising). The 4/20/26 progress note documented the resident had an open area to the abdomen. The 4/21/26 progress note documented the resident had an open area to the abdomen. The 4/24/26 wound care management progress note documented the resident told the physician the left lower wound was a boil that drained yellow fluid. The physician debrided the wound and ordered silver alginate (wound care dressing pad) dressing to the wound bed, border gauze topper one time a day every Monday, Wednesday and Friday. -However, review of the resident's EMR revealed the facility failed to obtain and provide treatment orders for the resident's wound after she was readmitted from the hospital on 4/13/26 until 4/24/26.The 4/24/26 wound weekly observation tool documented there was a popped boil or cyst on the left lower abdomen with 100 percent (%) slough pre sharp debridement (removal of dead, damaged or infected tissue to promote healing), 100% biofilm (bacteria) reduction post sharp debridement. The wound had moderate serous drainage (fluids from wounds) . The wound measured 1.5 cm by 0.8 cm by 0.3 cm. The wound was deeper around the two o'clock position. Sharp debridement was performed. D. Staff interviewsThe ADON was interviewed on 4/29/26 at 2:25 p.m. The ADON said when a new skin issue was identified the nurse communicated this by writing in a wound care binder located at the nurses' station. The ADON said the binder informed the ADON of any new issues that needed to be addressed. The ADON said she assessed new skin issues without the wound care physician. The ADON said on 4/16/26 she worked Resident #9's hall as a CNA and notified the nurse there was a wound on Resident #9's abdomen. She said this was the first time she was aware of the abdomen wound. The ADON described the wound as having slough on 4/16/26. She said at that time the mediplex was changed to border gauze. She said she removed the mediplex covering that was placed when the resident was in the hospital and returned on 4/13/26. She said the facility needed a new order for a change in mediplex. -However, review of progress notes and physician's orders revealed there was no documentation of the wound covering being changed or communication with the physician requesting an order for a new dressing.The ADON said the wound care physician was in the building once a week. She said rounds were dependent on the physician's schedule and cannot be changed. She said however the visit could be rescheduled if the ADON was unable to attend, but was not changed for residents' schedules. The ADON said Resident #9 was seen on 4/24/26 by the wound care physician and the wound was stable, there was a deep area, it was open and there was slough present.The wound care physician was interviewed on 4/30/26 at approximately 11:40 a.m. The wound care physician said Resident #9 did have a wound on the abdomen when she assessed her on 4/24/26. She said she did not know if the wound started as a boil as she only saw it when it was opened. She said she would have expected the wound to be monitored for infection, cleansed and covered if it was draining until she was able to assess the wound.

Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infectious diseases on four out of six hallwaysSpecifically, the facility failed to ensure blood sugar glucometers were disinfected appropriately between residents. Findings include: I. Professional referenceAccording to the centers for disease control (CDC), Conditions for Blood Glucose Monitoring and Insulin Administration, retrieved on 5/6/26 from https://www.cdc.gov/injection-safety/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html Clean and disinfect blood glucose meters after every use, per the manufacturer's instructions. Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place.Dedicated meters should be stored in a manner that prevents cross-contamination and inadvertent use for the wrong patient. Establish responsibility for oversight of infection control activities. Provide infection control training for staff members who assume responsibilities for fingersticks and injections.II. Facility policy and procedureThe Glucometer Disinfection policy date revised 1/21/26, was provided by the chief nursing officer on 4/29/26 at 6:42 p.m. Glucometers will be cleaned and disinfected after each use and according to the manufacturer's instructions, regardless of whether they are intended for single resident or multiple resident use.Using the first wipe, clean first to remove heavy soil, blood, and/or other contaminants left on the surface of the glucometer. After cleaning, use a second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry.III. ObservationsOn 4/28/26 at 11:10 a.m. registered nurse (RN) #2 performed a blood glucose test on a resident and failed to clean the glucose monitor before placing it in a plastic bag that was labeled with the resident's name. On 4/29/26 at 4:02 p.m. the assistant director of nursing (ADON) performed a blood glucose test on a resident and failed to clean the glucose monitor before placing it in a plastic bag that was labeled with the resident's name and securing it in the medication cart. On 4/30/26 at 10:41 a.m. RN #4 performed a blood glucose test on a resident and failed to clean the glucose monitor before placing it in a plastic bag that was labeled with the resident's name. IV. Staff interviewsRN #2 was interviewed on 4/28/26 at 11:22 a.m. RN #2 said she should have cleaned the glucose monitor before putting it away. The ADON was interviewed on 4/29/26 at 4:12 p.m. The ADON said she planned to clean all the glucose monitors at the end of her shift. She said she should have cleaned the glucose monitor after each use.The chief nursing officer was interviewed on 4/29/26 at 5:30 p.m. The chief nursing officer said the glucometers needed to be disinfected after each use. She said she reminded the nurses earlier in the morning to ensure the glucometers were disinfected after each use and was providing education. RN #4 was interviewed on 4/30/26 at 11:10 a.m. RN #4 said he should clean the glucose monitor after each use. He should have cleaned it before securing it in the plastic bag and placing it in the medication cart.V. Follow upThe chief nursing officer provided documentation on 4/29/26 at 6:42 p.m. that indicated education was provided to the nurses on 4/29/26 regarding cleaning the glucometers. The education read, Properly cleaning and disinfecting your glucometer is essential to prevent the spread of bloodborne pathogens like Hepatitis B, Hepatitis C, and HIV. While cleaning refers to removing visible dirt or blood, disinfecting is the process of killing germs and microorganisms.Frequency: Meters must be cleaned and disinfected after every use. The glucometers will be disinfected with a wipe pre-saturated with an EPA-registered healthcare disinfectant that is effective against Human Immunodeficiency Virus HIV), Hepatitis C, and Hepatitis B virus. Ensure glucometers are allowed to sit for the appropriate dwell time.

Based on record review, interviews, and observations, the facility failed to ensure that residents received adequate supervision and were kept free from elopement for one (#13) of three residents at risk for elopement out of 24 sample residents.Specifically, the facility failed to provide Resident #13 with the supervision necessary to prevent elopement.Resident #13 had severe cognitive impairments and was assessed to require supervision to substantial assistance from staff for most activities of daily living. He needed supervision to touching assistance to walk ten feet, had a history of wandering and exit-seeking, and was at high risk of falling.Record review revealed that in October 2025, the resident began exhibiting exit-seeking behavior, packing his clothes, wandering, and pacing, and on 11/1/25 at 2:30 p.m., a nurse was notified by another resident that Resident #13 was outside and was walking away from the facility, approximately 20 minutes after he was last seen. The nurse on duty followed Resident #13, spoke with him, and, with another staff member, was able to redirect him back into the facility. Resident #13 was placed on 15-minute checks, and the resident's hospice provider and the nursing home administrator (NHA) were notified. No other interventions were implemented.Record review continued to reveal the resident exhibited exit-seeking behaviors, and on 12/13/25 at approximately 12:40 a.m., a certified nurse aide (CNA) heard someone outside the locked door at the end of the hallway. The CNA discovered Resident #13 was attempting to come into the building. The CNA said she had not heard the alarm for the door go off, and that the door was locked and functioning properly. Resident #13 was interviewed and said he was going out to do his laundry. Resident #13 attempted to leave several more times that night but was redirected. Fifteen-minute checks were implemented, and line-of-sight observations were conducted for the remainder of the night.Record review revealed the facility did not develop a resident-centered care plan to prevent elopement following either of the elopements above, despite evaluating the resident at high risk for elopement after the 11/1/25 elopement, and despite progress notes and hospice notes documenting the resident's continued exit-seeking behaviors. When, on 1/20/26, an elopement risk evaluation assessed the resident at an even higher risk for elopement than on 11/1/25, the facility still failed to initiate a resident-centered care plan that informed staff of the level of supervision he required for his safety. Further, staff interviews revealed the resident often sat in the front lobby with the unlocked front door, an area that was infrequently visited by facility staff. The facility's failure to address Resident #13's increasing risk for elopement through interventions that would ensure adequate supervision created the likelihood for a serious adverse outcome. Findings include:I. Immediate JeopardyA. Situation of immediate jeopardyThe facility's failure to address Resident #13's increased risk for elopement and to provide adequate support and supervision to prevent elopement was likely to result in a serious adverse outcome. The facility was located on the corner of a busy street, and the resident had cognitive and physical impairments that made being unsupervised outside of the facility hazardous to his health and safety. B. Imposition of immediate jeopardyOn 2/4/26 at 5:45 p.m., the nursing home administrator (NHA) was notified that the facility's failure to take steps to ensure Resident #13 received adequate supervision to prevent elopement created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardyOn 2/5/26 at 11:29 a.m., the facility submitted a plan to remove the immediate jeopardy.The removal plan read:1. Corrective actionResident #13 was placed on one-to-one supervision by facility staff and would remain on one-to-one supervision indefinitely. On 2/4/26, Resident #13's care plan was reviewed and updated by the director of nursing (DON) to reflect current wandering and elopement risk and person-centered interventions, including implementation of a one-to-one supervisor, and providing redirection as needed when he exhibited wandering behaviors.2. Identification of othersAn audit was completed by the DON on 2/4/26 to evaluate each [resident] in the facility and identify residents who were at high risk for elopement. The residents identified during the audit were reviewed to ensure appropriate and effective elopement prevention measures were in place and documented in their care plans.3. Systemic changesBeginning on 2/4/26, the DON or a designee would educate all staff members in all departments on resident-centered interventions for residents at high risk of elopement, the facility policy on reducing wandering and elopement risk, and reporting of any increased exit-seeking behaviors prior to working their next scheduled shift. New staff members would receive this education during orientation.The interdisciplinary team (IDT) was educated on 2/4/26 on conducting root cause analyses of significant events to ensure appropriate actions were taken to prevent reoccurrence.The Elopement and Wandering Residents policy was reviewed by the NHA and DON on 2/4/26. Beginning 2/4/26, the DON or a designee would ensure progress notes for the 24 hours preceding would be reviewed each day for all residents during the clinical stand-up meeting to address any changes in behavior including wandering, exit seeking, or expressions of wanting to leave the facility. Concerns identified will be addressed by the IDT team to include non-pharmacological interventions and a care plan review.3. MonitoringResidents would be reevaluated by the IDT team quarterly and any time increased exit-seeking symptoms were noted to ensure appropriate elopement prevention measures were in place and effective, beginning 2/4/26. Staff would be informed of any changes through in-servicing, care plan updates and updates to the resident's Kardex.The DON or designee would audit new admissions for elopement risk and ensure appropriate interventions were in place starting 2/4/26. This audit would occur daily for four weeks, then five times per week for four weeks, then three times per week for four weeks. The audit would be documented on an audit form.D. Removal of the immediate jeopardyThe NHA was notified that the immediate jeopardy was removed on 2/5/26 at 12:32 p.m. based on the facility's removal plan (see above). However, the deficient practice remained at a D level, no actual harm, and potential for more than minimal harm that is not immediate jeopardy.III. Facility policy and procedureThe Elopements and Wandering Residents policy, revised 4/30/25, was provided by the NHA on 2/9/26 at 9:15 a.m. It read in pertinent part, The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The IDT will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. The effectiveness of interventions will be evaluated, and changes will be made as needed.IV. Resident #13A. Resident statusResident #13, age [AGE], was admitted on [DATE] and discharged to another facility on 2/9/26. According to the February 2026 computerized physician orders (CPO), diagnoses included neurocognitive disorder with Lewy bodies (a progressive neurodegenerative disorder caused by abnormal protein deposits (Lewy bodies) in the brain, affecting thinking, movement, sleep, and mood), parkinsonism, orthostatic hypotension (a sudden, significant drop in blood pressure upon standing or changing positions which can cause dizziness, lightheadedness, blurred vision, and fainting) and repeated falls.The resident's cognition care plan, revised 9/15/26, revealed Resident #13 was at risk for impaired cognitive function or impaired thought processes due to dementia. Pertinent interventions included cuing, reorienting, and supervising Resident #13 as needed, and presenting him with just one thought, idea, question, or command at a time.The resident's psychotropic care plan, initiated 11/19/25, revealed Resident #13 received psychotropic medications for his Lewy body dementia. Pertinent interventions included administering medications as ordered and monitoring for side effects and efficacy each shift.The resident's fall care plan, revised 12/1/25, revealed Resident #13 was at risk for falls due to his diagnosis of Lewy body dementia, history of falls, unsteady gait, and hypotension. Pertinent interventions included frequent safety checks and ensuring his call light was within reach.The most recent minimum data set (MDS) assessment, dated 1/20/26, revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) assessment score of four out of 15. The assessment documented that the resident required supervision to substantial assistance from staff for most activities of daily living. The assessment documented that the resident needed supervision to touching assistance to walk ten feet. The assessment indicated the resident had not exhibited any wandering behavior during the assessment look-back period.B. Resident history of elopements in the facility1. Resident #13's representative's interviewResident #13's representative was interviewed on 2/5/26 at 2:58 p.m. The resident representative said there was an incident when Resident #13 went outside when he was first admitted to the facility. The resident representative said it was late at night when Resident #13 walked out, and the staff went outside and brought him back inside. The resident representative said there was another incident where it sounded like Resident #13 was going outside, but the facility staff saw him leave. The resident representative said Resident #13 had not had any elopement attempts since those incidents, and thought his medications were working better at the moment.2. Facility investigation of elopementsRecord review revealed Resident #13 eloped from the facility on 11/1 and 12/13/25.The facility investigation of Resident #3's elopement, dated 11/1/25, was received from the NHA on 2/4/26 at 10:25 a.m. and revealed the following:-An interview with certified nurse aide (CNA) #9, undated, revealed CNA #9 had finished giving another resident a shower and went to assist him with a meal. CNA #9 saw Resident #13 in his room as she was walking through the hallway at approximately 1:15 p.m. to 1:20 p.m. The last time CNA #9 had checked on Resident #13's roommate was approximately 2:10 p.m. to 2:15 p.m. At approximately 2:30 p.m., another resident alerted the nursing staff that Resident #13 was outside the facility. CNA #9 said Resident #13 was outside for approximately 15 minutes before the nursing staff helped him back into the facility and placed him on 15-minute checks.-An interview with registered nurse (RN) #2, undated, revealed RN #2 last saw Resident #13 around 1:30 p.m. RN #2 said another resident notified her that Resident #13 was outside the facility, so she went out to help bring him back inside. RN #2 said Resident #13 stopped in the middle of the street's crosswalk while they were trying to bring him back inside, and began asking people to call the police.The facility's investigation of Resident #13's elopement, dated 12/13/25, was received from the NHA on 2/4/26 at 10:25 a.m. and revealed the following:-An interview with Resident #13, dated 12/13/25, revealed that Resident #13 said he was leaving the facility to go do his laundry. Resident #13 said his family (who typically washed his laundry) had not come in for a while, and he had clothes that needed to be washed.-An interview with CNA #9, dated 12/13/25, revealed CNA #9 had last seen Resident #13 in his room around 12:20 a.m. on 12/13/25. At around 12:40 a.m., CNA #9 said she heard someone at the door at the end of the hallway and saw Resident #13 standing outside the door wearing long pants, a jacket, and shoes. CNA #9 said she had not heard the alarm for the door at the end of the hallway going off, and that the door was locked and functioning properly. (Review of the resident's 15-minute check sheet revealed that on 12/13/25 from 12:00 a.m. to 1:00 a.m., Resident #13's whereabouts were not documented and left blank.)C. Record review An elopement assessment shortly after Resident #13's admission on [DATE] revealed the resident was not at risk of wandering. The assessment documented Resident #13 was cognitively impaired and was able to ambulate independently, but documented that he did not have any memory or decision-making impairments and did not verbalize wanting to leave the facility. The resident had a score of two, with any score greater than seven indicating a high elopement risk.However, record review (progress notes and hospice notes below) revealed that beginning in October 2025, the resident began exhibiting exit-seeking behaviors (wandering, pacing, confusion, agitation) and eloped twice; once on 11/1/25 and again on 12/13/25 (see above). Although elopement evaluations thereafter (11/1/25 and 1/20/26) revealed the resident was at high risk for elopement, record review revealed the facility failed to develop a resident-centered care plan with effective, nonpharmacologic interventions that informed staff of the level of supervision the resident consistently required for his safety until 2/4/26 during the survey (see below).Record review revealed:A progress note, dated 9/25/25 at 8:06 p.m., revealed Resident #13 was found by a facility staff member wandering in the back hall of the facility, pushing his wheelchair and approaching the elevator. Resident #13's stated intention was to ride the elevator back to his room. The staff member guided Resident #13 back to his room. Resident #13 was monitored frequently throughout the remainder of the daytime shift.A progress note, dated 9/28/25 at 9:20 p.m., revealed Resident #13 was found lying on the floor in the hallway. Resident #13 said he was going to find his way out and said he did not have his driver's license. Resident #13 was weight-bearing on both lower extremities but was slightly off-balanced. Resident #13 was frequently monitored per facility policy.An IDT note, dated 9/30/25 at 9:44 a.m., revealed the IDT team reviewed Resident #13's fall on 9/28/25. The IDT note documented that the root cause and risk factors for the fall were Resident #13's baseline cognitive decline and poor safety awareness due to his Lewy body dementia and progressive memory decline. Resident #13 also had orthostatic hypertension at times. New interventions included frequent rounding on the resident by nursing staff and reminding him to use his walker for ambulation.Progress notes on 10/5/25 at 7:37 p.m., 10/6/25 at 8:06 p.m., 10/7/25 at 6:30 p.m., 10/12/25 at 10:56 p.m., and 10/13/25 at 3:56 a.m. revealed Resident #13 was administered as-needed doses of lorazepam (an anxiety medication) due to increased agitation. A progress note, dated 10/13/25 at 11:14 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam as he was presenting with anxiety and pacing all over the facility. A progress note, dated 10/14/25 at 7:48 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam as he was presenting with anxiety and was pacing.A physician note, dated 10/14/25 at 3:45 p.m., revealed Resident #13 was seen by his physician at the request of his hospice provider. The hospice provider requested a urinalysis to evaluate Resident #13 for increased confusion and altered mental status. The hospice provider was concerned for Resident #13's disease progression, but wanted to rule out a urinary tract infection.A physician note, dated 10/17/25 at 11:15 a.m., revealed Resident #13 was seen by the physician to review his urinalysis results and behaviors. The note documented that Resident #13's urinalysis came back without any concerns. Resident #13 continued to have aggressive behaviors and agitation, so the physician would reach out to the hospice provider for them to consider reviewing his medication management.A progress note, dated 10/18/25 at 12:38 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam for increased agitation.A progress note, dated 10/20/25 at 8:28 p.m., revealed Resident #13 was administered an as-needed dose of Seroquel (an antipsychotic medication) for his increasing behaviors. Resident #13 was walking up and down the hallway, packing and unpacking his clothes and belongings, and attempting to enter other residents' rooms.A physician note, dated 10/21/25 at 3:08 p.m., revealed Resident #13 was seen by the physician per the hospice provider's request. Resident #13's as-needed lorazepam order had been discontinued, and the nursing staff noticed increased behaviors from the resident, including toileting in his laundry basket. The hospice provider would add the as-needed lorazepam back into Resident #13's orders.-However, the physician did not address Resident #13's wandering, packing, or pacing behaviors or suggest nonpharmacologic interventions.A physician note, dated 10/24/25 at 8:56 a.m., revealed Resident #13 was seen by the physician to follow up on the resident's medication changes. Resident #13's behaviors had improved per the nursing staff after adding scheduled Seroquel to his medication regimen. The physician documented that the hospice provider would continue prescribing lorazepam as it seemed to help with Resident #13's behaviors.A progress note, dated 10/28/25 at 7:30 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam. Resident #13 was exhibiting signs of restlessness and anxiety, including pacing, quick breathing and agitation.A progress note, dated 10/28/25 at 11:58 a.m., revealed Resident #13 was administered a second as-needed dose of lorazepam as he was still exhibiting signs and symptoms of anxiety.A progress note, dated 10/28/25 at 5:03 p.m., revealed Resident #13 was administered a third as-needed dose of lorazepam. Resident #13 was exhibiting signs and symptoms of anxiety. Resident #13 was pacing and going back and forth between standing and sitting in his chair.Progress notes on 10/28/25 at 11:53 p.m. and 10/29/25 at 2:21 a.m. revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation. A progress note, dated 10/29/25 at 7:40 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation and anxiety. Relaxation techniques including deep breathing and redirection were used with minimal results.A physician note, dated 10/30/25 at 2:10 p.m., revealed Resident #13 was seen by the physician per the nursing staff's request. The nursing staff reported Resident #13 seemed to have been in pain earlier that day. Resident #13 denied any pain, and no other concerns were identified or documented.A progress note, dated 11/1/25 at 3:12 p.m., revealed Resident #13 took a walk with his walker to the school across the street from the facility. When a nursing staff member approached him, Resident #13 accused everyone of trying to harm him, and stopped in the middle of the street in the crosswalk to ask people driving by to call the police. Resident #13 was persuaded to move onto the sidewalk and continued walking back to the property, where he was assisted back into the building. Resident #13 was placed on 15-minute checks, and the NHA and hospice provider were informed.A progress note, dated 11/1/25 at 4:45 p.m., revealed further information regarding the incident on 11/1/25 at 3:12 p.m. Another resident approached the nursing staff to tell them Resident #13 was outside walking away from the facility with his walker. The nursing staff went outside and approached the resident. Resident #13 said everyone wanted to kill him, and said he was not sure if he could trust the staff member. On his arrival back to the facility, Resident #13 was assessed and found to not have any injuries.A progress note, dated 11/1/25 at 5:35 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased anxiety and behaviors.An elopement risk evaluation, dated 11/1/25 at 8:23 p.m., revealed Resident #13 was at a high risk of elopement. The assessment documented that Resident #13 was cognitively impaired, had dementia, had verbalized wanting to leave the facility, and had memory and decision-making impairments. Resident #13 was known to wander inside the facility with and without his walker. The assessment documented that verbal redirection was ineffective, and Resident #13 could not find his room without hands-on assistance from staff. The assessment documented that the resident had a score of 11 (high risk).-However, no elopement care plan was developed with effective, nonpharmacologic interventions that informed staff of the level of supervision the resident consistently required for his safety.A progress note, dated 11/1/25 at 9:00 p.m., revealed Resident #13 was observed wandering in the hallway. Resident #13 said he was going to the curb to catch a cab. When the nursing staff attempted redirection, Resident #13 was resistant to changing his plan. One-to-one supervision was implemented to observe Resident #13's whereabouts for the next several hours until he went to sleep.A progress note, dated 11/1/25 at 9:35 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam, as he was agitated, wandering, exit-seeking, and said he wanted to go to the police station to report a bad dinner. Resident #13 was making verbal threats of harm to staff.A progress note, dated 11/2/25 at 8:48 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation and anxiety. Relaxation techniques including deep breathing and redirection were used with minimal results.A progress note, dated 11/3/25 at 12:02 a.m., revealed the resident was having increased agitation and aggression. Resident #13 was pacing in his room and pulling on several layers of clothing. Resident #13 resisted assistance and cares from staff.A progress note, dated 11/3/25 at 1:19 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation, anxiety and aggression. Resident #13 was resisting all cares and assistance from staff. Resident #13 was pacing in his room and going through his drawers.A progress note, dated 11/3/25 at 4:17 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to his anxiety. Resident #13 was pacing and determined to go home.A progress note, dated 11/4/25 at 7:44 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation and anxiety. Resident #13 was expressing frustration with not being able to leave the facility.An IDT note, dated 11/4/25 at 10:00 a.m., revealed Resident #13 was reviewed by the IDT team for his elopement on 11/1/25. Resident #13 was walking with his walker and had started to cross the street at a stoplight, stopped and asked drivers to call the police, and was redirected back to the facility. The root cause of the incident was determined to be confusion and paranoia. New interventions included initiating 15-minute checks.-However, the note did not indicate the duration of the 15-minute checks or that the intervention was placed on the resident's care plan for consistent implementation. Further, there were no new non-pharmacologic interventions on his care plans to address his confusion and paranoia.A progress note, dated 11/7/25 at 7:44 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation. Resident #13 was fixated on disliking his roommate and was pacing, rummaging through his belongings and displaying anger.A physician's note, dated 11/11/25 at 5:23 p.m., revealed Resident #13 was seen by his physician for a follow-up. Resident #13's hospice provider wanted to begin prescribing the resident donepezil (a medication used to improve cognitive function, used for people with dementia).-However, the physician did not address Resident #13's wandering, packing or pacing behaviors or his elopement on 11/1/25 or suggest nonpharmacologic interventions.A progress note, dated 11/13/25 at 1:12 p.m, revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation. Resident #13 was pacing, questioning who the staff were and questioning why they were doing things, and indicating suspicions of hidden actions by the staff.A progress note, dated 11/16/25 at 9:16 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased anxiety, restlessness and exit-seeking.A progress note, dated 11/17/25 at 7:43 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation. Resident #13 was pacing and fixated on the idea he was in a hotel and needed to check out.A progress note, dated 11/18/25 at 10:26 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation. Resident #13 was fixated on the idea his sister was stuck in the facility and he needed to get her out.A progress note, dated 11/23/25 at 7:37 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation. Resident #13 was paranoid, confused as to why he was in the facility and was pacing.A progress note, dated 11/24/25 8:43 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation and anxiety. Resident #13 was pacing, had increased tremors and was mumbling his speech.A progress note, dated 11/25/25 at 7:30 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased anxiety and agitation. Resident #13 was pacing and exit-seeking.A progress note, dated 11/25/25 at 5:48 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased anxiety, pacing and tremors.A progress note, dated 11/26/25 at 9:44 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation and exit-seeking.A progress note, dated 11/27/25 at 5:32 p.m, revealed Resident #13 was administered an as-needed dose of lorazepam due to his anxiety. Resident #13 was displaying signs of high anxiety, including hallucinations, increased tremor and pacing.A progress note, dated 11/28/25 at 5:16 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased anxiety. Resident #13 was wandering and making suspicious statements and was difficult to redirect. Staff encouraged Resident #13 to stay in his room for dinner.A progress note, dated 11/29/25 at 5:52 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam. Resident #13 was talking about suspicious people and was mumbling his speech.A progress note, dated 11/29/25 at 11:31 p.m., revealed Resident #13 had an unwitnessed fall and was found on the floor. Resident #13 was unable to tell the nursing staff what had happened.A progress note, dated 12/2/25 at 8:02 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to physical signs of anxiety. Resident #13 had an increased tremor and was hyper-fixated on leaving. A progress note, dated 12/3/25 at 9:07 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased agitation. Resident #13 had an increased tremor, mumbled speech and darting eyes.A progress note, dated 12/5/25 at 3:38 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam. Resident #13 was showing signs of a suspicious attitude toward staff, and had a history of sundowning with agitation and anxiety.A progress note, dated 12/7/25 at 4:45 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam. Resident #13 was showing signs of agitation, including increased tremor, mumbled speech and pacing.A progress note, dated 12/10/25 at 4:55 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased anxiety and agitation. Redirection, distraction and relaxation with breathing techniques were used with minimal effectA progress note, dated 12/10/25 at 5:40 a.m., revealed Resident #13 was anxious and agitated multiple times overnight. Resident #13 was pacing in his room, packing and unpacking his belongings. The nursing staff attempted relaxation techniques including speaking to Resident #13 in a calm soothing voice and distracting him with minimal effect. Resident #13's lorazepam was administered, and Resident #13 became calm and returned to bed. Frequent checks were made on Resident #13 to ensure his safety and his needs were met.A progress note, dated 12/10/25 at 12:49 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased anxiety. Resident #13 was pacing, rummaging through his belongings and mumbling his speech.A progress note, dated 12/10/25 at 4:51 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam due to increased anxiety. Resident #13 was pacing, rummaging through his belongings and mumbling his speech.A progress note, dated 12/13/25 at 8:07 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam. Resident #13 was showing signs of wandering and restlessness before breakfast.A progress note, dated 12/13/25 at 8:11 a.m., revealed Resident #13 left the facility without his walker between 12:30 a.m. and 1:00 a.m. on 12/13/25. Staff observed Resident #13 on the facility grounds at the back door attempting to reenter the building through the back door, which was locked. Resident #13 was escorted back into the building, assessed and found to have no injuries. 15-minute checks were implemented for him, and line-of-sight observations were made for the remainder of the night. Resident #13 attempted to leave several more times throughout the night but was redirected. The DON, hospice provider and Resident #13's representative were notified.-Despite repeated documentation in late November and early December of exit-seeking behaviors (wandering, packing, pacing, hyper-fixated on leaving, and his second elopement on 12/13/25, the facility failed to develop an elopement care plan with effective, nonpharmacologic interventions that informed staff of the level of supervision the resident consistently required for his safety.A progress note, dated 12/13/25 at 10:07 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam as he was anxious and restless.A physician note, dated 12/19/25 at 3:05 p.m., revealed Resident #13 was seen for a routine visit. The nursing staff did not report any acute concerns, and the physician documented Resident #13 seemed to have some improvements since his hospice provider started prescribing a low dose of Seroquel.-However, the physician did not address Resident #13's wandering, packing or pacing behaviors, his elopements on 11/1/25 and 12/13/25, or suggest any nonpharmacologic interventions. A progress note, dated 1/15/26 at 7:23 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam as Resident #13 had a new roommate and was walking frequently.A physician note, dated 1/16/25 at 9:17 p.m., revealed Resident #13 was seen to address a concern with his vision.The physician documented Resident #13 was doing well and his behaviors were stable.A progress note, dated 1/18/26 at 8:04 a.m., revealed Resident #13 was administered an as-needed dose of lorazepam for increased anxiety. Resident #13 was pacing, had wide eyes and was monitoring the hallway from his doorway.A progress note, dated 1/18/26 at 4:33 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam. Resident #13 was pacing and had a paranoid affect, and said he felt anxious.A progress note, dated 1/20/26 at 1:37 p.m., revealed Resident #13 was administered an as-needed dose of lorazepam for anxiety. Resident #13 was pacing, had an increased tremor and was exit-seeking.An elopement risk evaluation, dated 1/20/26 at 12:46 p.m., revealed R

Based on interviews and record review, the facility failed to ensure residents were free from any significant medication errors, affecting one (#11) of five residents out of 24 sample residents.Resident #11 was admitted on [DATE] with diagnoses of epilepsy (seizure disorder) and acute kidney failure that required dialysis three days a week.Resident #11 was prescribed phenobarbital (anti-seizure medication), valproic acid (anti-seizure medication), clobazam (anti-seizure medication) and Depakote (anti-seizure medication). From [DATE] to [DATE] the resident was hospitalized due to seizure activity. Within 24 hours the resident was sent back to the hospital for more seizure activity. While at the hospital, it was recommended to increase the clobazam to twice a day. The facility failed to administer the resident's anti-seizure medications consistently. On [DATE] the resident was hospitalized again due to seizure activity. Review of the medication administration record (MAR), revealed the facility failed to administer multiple doses of the resident;s seizure management regimen. During the hospitalization, it was recommended to add Tegretol (anti-seizure medication) three times a day. The hospital documented the resident's medication levels were below therapeutic levels.Upon return, the facility failed to administer multiple doses of the Tegretol medication. The resident was hospitalized again due to seizure activity on [DATE]. On [DATE] the resident elected palliative care and expired due to breakthrough seizures and seizure disorder.The director of nursing (DON) was aware that some seizure medications were not administered, and some were held on the dialysis days per facility practice, but did not complete a full audit of residents' medication administration records (MAR) for November and [DATE]. The facility did not conduct an audit to determine the extent of missed medications. In addition, the resident's neurologist and primary care physician (PCP) were not notified about missed medications. Specifically, the facility failed to ensure Resident #11 was administered his seizure medications per physician's orders. Findings include:I. Immediate jeopardyA. Situation of immediate jeopardy Resident #11 was prescribed four different seizure medications upon admission. In [DATE] resident was started on hemodialysis due to kidney failure. Between [DATE] and [DATE], some of the seizure medications were tapered, all four were not administered on dialysis days, and a new seizure medication (Tegretol) was started. In addition, the resident had a PRN order for Lacosamide in [DATE] and Phenobarbital in [DATE] to be given on dialysis days as he was experiencing an increase in seizure activity. The resident was hospitalized on [DATE] for seizures, where subtherapeutic levels (below the recommended level) of his seizure medications were detected. The resident returned to the facility and was started on Tegretol.The new order for Tegretol was supposed to start on [DATE]. However, the medication was not administered for a total of four doses as nurses were not able to locate the medication that was stored in a separate area. The nurses were unaware that medication was available and did not administer it. The resident was hospitalized again due to increased seizure activity, was placed on palliative care and passed away on [DATE].Due to the facility's failures, a serious adverse outcome occurred that required hospitalization. The resident continued to have seizures requiring hospitalization. B. Facility notice of immediate jeopardyOn [DATE] at 1:55 p.m., the nursing home administrator (NHA) was notified of the facility's failure to prevent a significant medication error by not ensuring Resident #11 received his seizure medication as prescribed created a situation of immediate jeopardy for serious harm. C. Facility plan to remove immediate jeopardyOn [DATE] at 4:48 p.m, the NHA presented the following plan to address the immediate jeopardy situation. It read in pertinent part,Identification of other residents affected or likely to be affected: the facility took the following actions to identify other residents that may be at risk on [DATE]The DON and ADON completed an audit to ensure all residents are getting medications as ordered. This audit included a review of each resident's medication administration record for the last 24 hours, and an audit of the medication carts to ensure the medications were available.The DON and regional clinical resource #1 audited all residents currently on dialysis to ensure administration of medications, per physician order, on dialysis days, for the last week.Actions to prevent occurrence/reoccurence:On [DATE] The Medication Administration policies were reviewed by NHA, the DON, regional clinical resource #1Beginning on [DATE] the DON educated all licensed nursing staff on the Medication Administration policy, properly following physician's orders and the process of notifying of medication errors. The education included the process of notifying providers when medications conflict with scheduled dialysis days. This education will be provided to all nursing staff prior to their next scheduled shift.The DON or designee will educate all new hire licensed nurses on medication administration and physician notification guidelines during orientation.The DON or designee will review MAR reports for all residents to ensure medications are administered as ordered, or the physician was notified appropriately if a medication was held. This audit will be completed daily for four weeks, then five times a week for four weeks.Beginning [DATE], all licensed nurses will be observed by the DON or designee administering medications to ensure competency. Observations will occur five times per week for four weeks, then weekly for eight weeks. Observations will occur across shifts and with various staff members. D. Removal of immediate jeopardyOn [DATE] at 5:45 p.m., the NHA was notified that, based on the plan for removal of immediate jeopardy, the plan was accepted and the immediate jeopardy situation removed. However, deficient practice remained at a G level, actual harm, isolated, that is not immediate. II. Facility policy and proceduresThe Medication Administration policy, revised on [DATE], was received from the NHA on [DATE] at 2:15 p.m. It read in pertinent part, The facility shall ensure that the medication will be administered according to the physician's orders. Errors in medication administration include medication omission. If an error has occurred, the nurse assesses the resident's condition and notifies the physician or health care practitioner as soon as possible. The Hemodialysis policy, dated [DATE] with no revision date, was received from the NHA on [DATE] at 2:15 p.m. It read as follows, The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment. Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.III. Resident #11A. Resident statusResident #11, age less than 65, was admitted on [DATE], discharged to the hospital multiple times and passed away on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included epilepsy, acute kidney failure (requiring dialysis), chronic gout, major depressive disorder, muscle weakness, bipolar disorder, and hypertension. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) assessment score of 15 out of 15. The resident was dependent on staff for all activities of daily living due to weakness, medication and disease process.B. Record reviewThe seizure care plan, dated [DATE], revealed Resident #11 had seizure disorder related to epilepsy. Interventions included to give medications as ordered and monitor for effectiveness. According to the medication administration record (MAR) for [DATE] and [DATE], Resident #11 was on the following seizure medications that were scheduled daily:-Phenobarbital oral tablet 48.6 milligrams (mg) to be given in the morning and 97.2 mg to be given in the evening; -Lacosamide oral tablet 100 milligrams (mg), given 200 mg by mouth in the morning and 250 mg by mouth in the evening; On [DATE], Lacosamide 100mg was increased to three times a day; -Clobazam oral tablet 15 mg twice a day; and,-Depakote oral tablet, delayed release 1125 mg given twice a day. In addition, the resident had as needed (PRN) order for seizures to be given after dialysis.-Phenobarbital oral tablet 32.4 mg as needed after dialysis between [DATE] and [DATE]. -Review of the MAR revealed this medication was not administered even though the resident continued to have seizures after dialysis, and -Lacosamide oral tablet 100 mg as needed, to be given immediately after hemodialysis, from 11/2 25 to [DATE]. This medication was not administered even though residents continued to have seizures after dialysis. B. Failure to administer seizure medications and multiple hospitalizations for Resident #11Review of the [DATE] MAR revealed:On [DATE] the resident was not administered Lacosomide 100 mg at noon and Depakote extended release 1000 mg in the evening per physician's orders. -Review of Resident #11's EMR did not reveal documentation indicating the resident's neurologist or PCP were notified of the missed doses of anti-seizure medication. The [DATE] emergency room progress note documented the resident presented for evaluation of increased frequency of breakthrough seizures. The note documented the resident had several seizures today in the emergency department. Intravenous ativan (anti-anxiety medication) was administered. The note documented the resident was prescribed Phenobarbital in the morning and evening, Vimpat (lacosamide) in the morning, afternoon and evening, and Depakote twice a day. The resident was on a complex dosage and scheduling because the resident received dialysis on Tuesday, Thursday and Saturdays. The note documented the resident often had a seizure after dialysis. The [DATE] hospital history and physical documented phenobarbital and valproic acid levels were subtherapeutic on admission . The note documented the plan was to request the MAR from the nursing facility to verify appropriate dosing of seizure medications. The note documented the resident also experienced acute encephalopathy (brain dysfunction) that was likely secondary to seizures.The [DATE] nursing progress note documented at 4:20 p.m. revealed the resident was discharged back to the nursing facility.The [DATE] nursing progress note documented at 2:23 p.m. (less than 24 hours since returning to the facility) the resident was admitted back to the emergency room due to a seizure during dialysis. Review of [DATE] MAR revealed: On [DATE] the resident did not receive the morning dose of all of his four seizure medications: Phenobarbital 48. 6 mg morning dose, clabazam 10 mg morning dose, Depakote extended release 1125 mg morning dose and lacosamide 100 mg morning dose. Additionally, the resident did not receive the evening doses of Depakote ER 1000 mg evening dose and lacosamide 100 mg evening dose. -Review of Resident #11's EMR did not reveal documentation indicating the resident's neurologist or PCP were notified of the missed doses of anti-seizure medication. The [DATE] hospital discharge summary documented the resident was stabilized in the hospital and discharged back to the nursing facility the same day ([DATE]) at 5:00 p.m. The note documented the clobazam medication was increased to 15 mg twice a day. The [DATE] at 12:23 p.m. emergency room note documented the resident presented to the hospital for evaluation after experiencing a possible seizure or whole body tremor episode lasting about an hour. The note documented there were unclear details regarding the duration or continuity of the seizure. The note documented differential diagnoses included breakthrough seizure and subtherapeutic medication usage. Review of the [DATE] and [DATE] MAR revealed that prior to hospitalization on [DATE] and before the hospitalization on [DATE] the following medications were not administered: On [DATE] the lacosamide 100 mg morning and evening dose;On [DATE] the lacosamide 100 mg morning and evening dose;On 11/16 the clobazam 10 mg morning dose;On [DATE] the lacosamide 100 mg noon dose;On [DATE] the clobazam 15 mg evening dose; On [DATE] the lacosamide 100 mg noon dose, On [DATE] the lacosamide 100 mg noon dose; and, On [DATE] lacosamide 100 mg noon dose.Further review of the [DATE] MAR revealed on the morning of [DATE] prior to the resident's hospitalization the resident did not receive his morning medications that included:Lacosamide 100 mg, clobazam 15 mg, and Depakote ER 1125 mg.-Review of Resident #11's EMR did not reveal documentation indicating the resident's neurologist or PCP were notified of the missed doses of anti-seizure medication. The [DATE] hospital note documented the resident was prescribed Tegretol 200 mg three times a day. The [DATE] nursing progress note documented the resident returned to the facility on [DATE] at 6:00 p.m.Review of the [DATE] MAR after the resident returned from the hospital on [DATE] revealed Tegretol was not administered on the following days:-[DATE] evening dose;-[DATE] all three doses;-[DATE] noon dose, and-[DATE] noon dose.-Review of Resident #11's EMR did not reveal documentation indicating the resident's neurologist or PCP were notified of the missed doses of anti-seizure medication. The [DATE] at 12:30 p.m. progress note documented resident was found with tremors and unresponsive, the provider was contacted and gave an order for Lorazepam administration. After the dose of Lorazepam, the resident became responsive and he was transferred to bed. The resident was assessed by the physician and sent to the emergency room due to intermittent partial seizures. The hospital admission records, dated [DATE], revealed the resident was admitted to the hospital at 3:46 p.m. due to unspecified convulsions. The record documented the resident presented after experiencing multiple seizures throughout the day despite adherence to his antiepileptic medications. He had received two doses of intravenous lorazepam.-However, review of the resident's EMR did not reveal the resident received the antiepileptic medications as ordered.The [DATE] hospital summary documented the resident's hospitalization was complicated by seizures, encephalopathy and severe weakness. He additionally experienced multiple episodes of hypotension and unresponsiveness. The resident transitioned to palliative care on [DATE] and passed away due to breakthrough seizures and seizure disorder. 3. ObservationsOn [DATE] at 10:00 a.m. registered nurse( RN) #2 was administering medications for Resident #25, in the 400 hallway. RN #2 was unable to locate Resident #25's Symbicort inhaler. RN #2 said the inhaler needed to be ordered and she did not have the medication to administer to the resident. The RN did not call the physician or write a progress note regarding the missed dose.IV. Staff interviewsRN #2 was interviewed on [DATE] at 11:39 a.m. She said on [DATE] around noon a certified nurse aide (CNA) reported that Resident #11 was having a seizure. RN #2 said she assessed the resident and implemented seizure precautions. She said she made sure he did not hit his head or injure himself. She said she timed the seizure activity. She said Resident #11 had a second seizure. She said the physician was in the building. She said the physician gave an order for Ativan and to transfer the resident to the hospital. She said she was unaware of any missed doses of medication. She said she did not do a change of condition form or get vital signs.LPN #1 was interviewed on [DATE] at 9:25 a.m. She said she worked with Resident #11 on [DATE] when he was hospitalized . She said CNAs told her that Resident #11 was not his usual self. She said she did not work with Resident #11 before and did not know what his baseline was. She said he appeared to be having a seizure and he was unresponsive. She said the resident's physician was in the building and sent the resident to the emergency room. LPN #1 said it was facility practice to hold medications when a resident was at dialysis as it was not physically possible to administer them when the resident was not in the building. The DON was interviewed on [DATE] at 10:30 a.m. She said on the days when the resident was out for dialysis, the EMR indicated the seizure medications and other medications were marked as not administered. She said it was a facility practice to hold medications when a resident was at the dialysis clinic. She said the orders for medications scheduled on the dialysis days were not clarified with the PCP or neurologist because both physicians already knew that the resident was in dialysis three times a week. The DON said she was aware four doses of Tegretol were not administered upon readmission on [DATE]. She said the facility educated nurses on the location of medications. She said she did not complete a full audit of resident's seizure medications and was not aware of any additional missed doses beside dialysis days. The DON said the PRN orders for lacosamide in [DATE] and phenobarbital in [DATE] that read to be administered after dialysis for breakthrough seizures. She said it was up to the dialysis clinic to decide and administer the medication. She said she did not clarify the order with the primary care physician or neurology as it was up to the dialysis clinic. The medical director (MD) was interviewed on [DATE] at 11:00 a.m. She said all seizure medications were managed by Resident #11's neurologist. She said she could not comment on any specifics about seizure medications. She said it was communicated to her that some seizure medications were missed for Resident #11. She said seizure medications should be given as ordered to prevent seizures. Resident #11's PCP was interviewed on [DATE] at 11:50 a.m. She said all seizure medications were managed by Resident #11's neurologist. She said since the resident started dialysis his seizure activity increased and the goal was to find a proper seizure medication that would not be removed (dialysed) during dialysis. She said for that reason the phenobarbital was titrated and resident was started on Tegretol.She said she did not know medications were not being administered on the days that the resident went to dialysis. She said she thought all of the scheduled seizure medications were administered except for one incident on [DATE] when four doses of Tegretol were not given. She said when nurses reported to her that Tegretol was not available on [DATE] and [DATE] her response to missed doses was a discussion with the IDT team. She did not give any new orders. Resident #11's PCP said said the PRN orders for lacosamide in [DATE] and phenobarbital in [DATE] read to be administered after dialysis for breakthrough seizures. She said it was up to the dialysis clinic to decide and administer the medication. She said she was aware that this resident had multiple seizure medications and was having an increase in seizure activity but it was not her role to manage, adjust or clarify any of seizure medications. She said the seizure medications were managed by the neurologist. On [DATE] at 1:02 p.m. an attempt was made to interview the neurologist. However, the neurologist was no longer working with the facility and was not available for an interview. A triage nurse at the dialysis clinic was interviewed on [DATE] at 2:15 p.m. She said the dialysis clinic did not administer any medications that were part of the nursing facility's orders. She said some residents who were able to administer their own medications were able to take them during or after dialysis. She said the residents who were not able to administer their own medications did not bring medications. She said if the resident was unable to administer their own medications, they were administered at the nursing facility before or after dialysis. The nephrology physician was interviewed on [DATE] at 3:30 p.m. He said he was a nephrology physician who worked with a dialysis clinic that Resident #11 visited three times a week in [DATE] and [DATE]. He said he was not aware that the dialysis clinic was expected to administer any medications to this resident. He said it was an unusual expectation from a nursing facility. He said the physician who signed orders in the nursing facility for Resident #11 was responsible for administration and clarification of the orders. The pharmacy consultant was interviewed on [DATE] at 4:40 p.m. She said she reviewed the residents' records monthly and submitted suggestions to the DON She said she did not identify any concerns with Resident #11's physician's orders. She said her suggestions were to check Depakote level in [DATE]. She said she was aware that the resident did not receive four doses of Tegretol on [DATE]. The pharmacy consultant said the dialysis clinic was responsible for administering the as needed lacosamide and the phenobarbital.

Based on record review, observations and interviews, the facility failed to ensure three (#4, #22, and #23) of six residents of 24 sample residents received food prepared in the form designed to meet their individual needs. Resident #4 diagnoses of dysphagia, oropharyngeal phase (difficulty swallowing), cerebral infarction (stroke), cognitive communication deficit, and unspecified dementia was admitted on [DATE]. Resident #4 had a physician's order for minced and moist diet texture (cannot bite off pieces of food but does have basic chewing ability). Resident #22 had diagnoses of dysphagia oropharyngeal phase, cognitive communication deficit, and other symptoms and signs involving cognitive functions and awareness was admitted on [DATE]. Resident #22 had a physician's order for soft and bite-sized texture (not able to bite off pieces of food safely but able to chew bite-sized pieces down into little pieces that are safe to swallow). Resident #23 had diagnoses of gastroesophageal reflux disease (GERD) without esophagitis, dysphagia, oral phase (difficulty chewing, manipulating, or transporting food from the mouth to the throat) was admitted on [DATE]. Resident #23 had a physician's diet order of soft & bite-sized texture. On 1/13/26 Resident #4 was served regular textured soft tacos on a tortilla, which was not altered to the correct diet consistency. The resident began choking on a piece of tortilla, which got stuck in his throat. A registered nurse (RN) attempted the Heimlich maneuver several times and was unsuccessful. The resident was able to clear the piece of tortilla by coughing and then required high-flow supplemental oxygen given by a mask. Observations during the survey revealed the facility continued to provide residents the incorrect modified textured diets. Resident #22 received a regular texture hamburger and a cookie. Resident #23 received a regular texture cookie. Specifically, the facility failed to ensure Resident #4, Resident #22 and Resident #23 received the correct modified food per physcian's orders. The facility's failure to ensure residents received the physician's ordered diet texture placed residents at risk for serious harm or death if not corrected immediately. Findings include:I. Immediate jeopardyA. Situation of immediate jeopardyThe facility failed to ensure Resident #4 was served the correct diet texture as ordered by the physician. Resident #4, who was diagnosed with dysphagia. Resident #4 had a physician's diet order for minced and moist texture. He required supervision and hands-on assistance for meals. On 1/13/26 Resident #4 was served a regular texture meal of soft tacos instead of the minced and moist texture as ordered by the physician. Resident #4 began choking and a nurse performed the Heimlich maneuver. After several attempts she was unable to dislodge the tortilla. The resident was moving air during the episode. After a few minutes, the resident was able to cough up the tortilla and supplemental oxygen was applied. Observations of the dinner meal service on 2/3/26 at 5:40 p.m., revealed two residents who were prescribed a soft and bite-sized diet texture received regular diet food items. Specifically, Resident #22 received a hamburger bun with a whole lettuce leaf and a whole cookie and Resident #23 received a cookie. The facility's failure to ensure residents received the physician ordered diet texture placed residents at risk for serious harm or death if not corrected immediately. B. Facility notice of immediate jeopardyOn 2/4/26 at 1:29 p.m., the NHA and the director of nursing (DON) were notified of the immediate jeopardy situation created by the facility's failure to ensure Resident #4, Resident #22 and Resident #23 received the physician's ordered diet texture. C. Facility plan to remove immediate jeopardyOn 2/4/26 at 5:05 p.m., the facility submitted a plan for immediate jeopardy. The plan read:1. Action planAll staff involved in meal preparation or service including the interdisciplinary team (IDT), nursing, dietary, activities received re-education on diet modifications and following physician orders using the International Dysphagia Diet Standardization Initiative (IDDSI) standards prior to their next scheduled shift. This education included a post-test to demonstrate understanding. All new IDT members, nursing, dietary and activities staff will receive this education during orientation. Education started on 2/4/26 and will continue until all staff are educated. Education provided by the DON or designee. All dietary staff received re-education on food preparation utilizing diet extensions and recipes to adhere to each resident's diet order prior to their next scheduled shift. All new dietary staff will receive this education during orientation. Education started 2/4/26 and will continue until all staff are educatedThe registered dietitian (RD) conducted an audit on 2/4/26 to ensure all dietary orders, recommendations, and documentation were accurate in the medical record and matched the dietary department's tray ticket information for each resident. 2. Systemic changesThe facility's pertinent menu and therapeutic diet policies were reviewed and revised on 2/4/26. The IDT received education on 2/4/26 on conducting root cause analysis of serious events, including choking incidents and to ensure appropriate actions are taken to prevent recurrence. The dietary manager (DM), the DON or designee will audit new admissions daily for three months to ensure the dietary orders/recommendations/documentation are accurate in the medical record and match the dietary department's meal ticket information for that resident and will document findings on an audit form. The DON or designee will review all new orders daily for four weeks then five times a week for four weeks then weekly for one month to monitor for changes to diet orders. Any changed orders will be communicated to the dietary department through a diet change communication form.3. MonitoringThe DON or designee will monitor food service at all three meals for all residents, and compare the meal being served to the physician order/documentation for that resident's dietary needs. Monitoring/auditing will continue daily for four weeks, then five times a week for four weeks, then weekly for one month and will document findings on an audit form.C. Removal of the immediate jeopardyOn 2/5/26 at 2:00 p.m., the NHA was notified that the facility's plan to remove immediate jeopardy was accepted based on the facility's plan to implement the measures above. However, the deficient practice remained at a D level, no actual harm with potential for more than minimal harm.II. Professional referencesThe IDDSI Patient Handout (January 2019), was retrieved on 2/10/26, from https://iddsi.org/Resources/Patient-Handouts It read in pertinent part, Level five minced and moist food may be used if you are not able to bite off pieces of food safely but have some basic chewing ability. Some people may be able to bite off a large piece of food, but are not able to chew it down into little pieces that are safe to swallow. Minced and moist only need a small amount of chewing and for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. It is important that minced and moist foods are not too sticky because this can cause the food to stick to the cheeks, teeth, roof of the mouth or in the throat. These foods are eaten using a spoon or fork. Level five minced and moist, for safety avoid these food textures that pose a choking risk for adults who need level five minced and moist food: Bread: no regular dry bread due to high choking risk.Level six soft and bite-sized textures are used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. Soft and bite-sized foods need a moderate amount of chewing, for the tongue to collect the food into a ball and bring it to the back of the mouth for swallowing. The pieces are bite-sized to reduce choking risk. Soft and bite-sized foods are eaten using a fork, spoon or chopsticks. An example of of level six soft and bite-sized: Meat cooked tender and chopped, so pieces are no bigger than 1.5 centimeter (cm) by 1.5cm lump size. If food cannot serve soft and tender, serve as minced and moist.Level six soft and bite-sized, for safety avoid these food textures that pose a choking risk for adults who need level six soft and bite-sized food:Bread (no regular dry bread, sandwiches or toast of any kind). Use IDDSI level five minced and moist sandwich recipe to prepare bread; use pre-gelled 'soaked' breads that are very moist and gelled through the entire thickness; Hard or dry food include nuts, raw vegetables, dry cakes, bread, dry cereal; Crumbly bits include dry cake crumble, dry biscuits (add sauce to make these suitable; 'Floppy foods' include lettuce, cucumber, baby spinach leaves; Large or hard lumps of food include casserole pieces larger than 1.5cm x 1.5cm, fruit, vegetable, meat, pasta or other food pieces larger than 1.5cm x 1.5cm.III. Facility policy and proceduresThe Therapeutic Diet Orders policy and procedure, implemented 4/11/25, was provided by the NHA on 2/9/26 at 9:15 a.m. It revealed in pertinent part, The facility provides all residents with food in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or addressed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat and thickened liquids. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: inadequate nutrition; nutritional deficits; weight loss; medical conditions such as diabetes; renal disease;or heart disease; swallowing difficulty. The reason for a therapeutic diet is to be documented in the medical record and/or indicated on the resident's comprehensive plan of care. All diet orders are to be communicated to the dietary department in accordance with facility procedures.IV. ObservationsV. Resident #4 A. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the February 2026 computerized physician's orders (CPO), diagnoses included dysphagia, oropharyngeal phase, cerebral infarction, cognitive communication deficit and unspecified dementia.The 11/8/25 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident required supervision or touching assistance for eating and was moderate to maximum assist with all his activities of daily living (ADL).The MDS assessment documented the resident was on a mechanically altered diet, which required a change in the texture of foods or liquids. B. Record reviewThe nutrition care plan, initiated 8/8/24 revised 1/16/26, documented Resident #4 had nutritional problems related to dementia, recent stroke, bipolar and was on hospice services. Pertinent interventions included ensuring food, utensils and liquids were kept on his right side visual field due to left sided vision deficit and providing and serving the diet as ordered. The care plan indicated the resident was to receive a level five minced and moist texture.The February 2026 CPO revealed the following physician's order:-Large portion diet level 5-minced and moist texture, regular consistency, ordered 11/26/25.A progress note, dated 1/13/26 at 5:46 p.m., documented the nurse was notified, by a certified nurse aide (CNA) that Resident #4 was choking from being served a soft taco. The note documented the resident was on a level five minced and moist diet. The nurse performed the Heimlich several times. The resident was moving air, but was unable to dislodge the tortilla. The note documented eventually, the resident was able to cough up the tortilla and oxygen was applied. Emergency medical services (EMS) were called but the resident declined to go to the hospital. The 1/14/26 at 9:11 a.m., event note, identified the risk factors and root cause as Resident #4 having dysphagia with cognitive decline and poor safety awareness and insight. The resident was served a regular texture meal for dinner, which included a whole tortilla. The note documented Resident #4 lacked the insight into safety regarding food intake. The preventative measure in place prior to the incident included confirming Resident #4 had an order level five minced and moist. The new interventions included the description of the event and reeducation to the CNA who served the meal despite the physician order of mince and moist texture.VI. Resident #221. Resident status Resident #22, age less than 65, was admitted on [DATE]. According to the February 2026 CPO diagnoses included dysphagia oropharyngeal phase, cognitive communication deficit, hemiplegia and hemiparesis following a cerebrovascular disease affecting the right dominant side, and other symptoms and signs involving cognitive functions and awareness.The 12/11/25 MDS assessment documented the resident was moderately cognitively impaired with a BIMS score of 10 out of 15. The resident required set-up assistance for eating and was substantial to touching assistance with ADLs. The MDS assessment documented Resident #22 was on a regular not on a therapeutic diet or mechanically altered diet at the time of the assessment. 2. Record reviewThe February 2026 CPO revealed the following physician's order:Level six soft and bite-sized texture, ordered on 1/12/26.The dietary care plan, initiated 6/10/25 and revised 1/14/26, documented Resident #22 had a potential for or presence of altered nutrition needs related to depression, diabetes, hemiplegia and hemiparesis. Pertinent interventions included downgrading the texture of diet per speech therapy and providing diet and food texture as tolerated regular diet, soft and bite-sized.VII. Resident #23A. Resident statusResident #23, age less than 65, was admitted on [DATE]. According to the February 2025 CPO diagnoses included gastroesophageal reflux disease without esophagitis, dysphagia, oral phase, cognitive communication deficit, cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage (brain bleed). The 12/26/25 MDS assessment documented Resident #23 was cognitively intact with a BIMS score of 14 out of 15. The resident required set-up assistance with all ADLs. The MDS assessment documented Resident #23 was on a mechanically altered diet which required a change in texture of food or liquids. B. Record review The nutrition care plan, initiated on 10/2/25, documented Resident #23 had a potential for altered nutritional needs related to anxiety, bipolar, GERD and heart disease Pertinent interventions included providing diet and food texture as tolerated soft and bite-sized texture (revised 2/9/26 -during the survey).The February 2026 CPO revealed the following physciain's orders:Level six, soft and bite sized, however the resident may have regular sandwiches and hamburgers, ordered on 11/17/25.-However, observations revealed Resident #23 was served a whole cookie which was not appropriate for the soft and bite sized diet.VIII. ObservationsOn 2/3/26 at 5:50 p.m. Resident #22 was served a regular textured hamburger on a bun with a whole lettuce leaf and a cookie. Resident #23 was served a whole cookie.-However, Resident #22 and Resident #23 were prescribed a level 6, soft and bite-sized diet.F. Staff interviews and observationsLicensed practical nurse (LPN) #2 was interviewed 2/3/26 at 6:03 p.m. LPN #2 said she received training on diet textures upon hire and every few months. LPN #2 said Resident #22 was on a soft and bite-sized diet. She said the resident was recently downgraded for his diet texture as he was recently hospitalized with a stroke and had dysphagia. LPN #2 entered Resident #22's room and looked at the resident's plate, which contained one whole lettuce leaf and a few 1 cm sliced onion pieces. LPN #2 asked Resident #2 what he had for dinner and the resident replied he had a hamburger. LPN #2 verified the resident's ticket said soft and bite-sized and said the resident should not have had lettuce or the lettuce leaf should have at least been cut up. LPN #2 was interviewed again at 6:10 p.m. LPN #2 said Resident #23 was on a soft and bite-sized diet texture because he had dysphagia. LPN #2 entered the resident's room and opened the resident's room tray lid and revealed three scoops of rice, small chunks of chicken in gravy and vegetable medley. The meal tray also contained a whole cookie. LPN #2 said the resident should not have a cookie with his diet texture. LPN #2 encouraged the resident to eat his meal, removed the cookie from the tray and asked if he wanted pudding or ice cream for dessert.CNA #7 was interviewed on 2/4/26 at 9:25 a.m. CNA #7, who was working on the secured unit at the time, said most of the residents on the secured unit eat their meals in the dining room. She said the CNA assisted residents with physical or verbal assistance when needed. CNA #7 said she read the meal ticket from the tray to match it with the meal on the tray before she served the meal. She said she had been provided education through their training site and again recently by the DON on diet textures. Registered nurse (RN) #2 was interviewed on 2/4/26 at 9:30 a.m. RN #2 said she received training on diet textures upon hire and as needed. RN #2 said she had received training on diet textures two weeks ago when they switched to the IDDSI diet textures. RN #2 said their training included what to look for for each diet texture and what each diet texture could and could not have. CNA #1 was interviewed on 2/4/26 at 9:40 a.m. CNA #1 said he received training upon hire for diet textures by the CNA who trained him. CNA #1 said the CNA who was training a new CNA would give them pointers on what to look for when passing trays. CNA #1 said the DON would occasionally quiz them on diet textures and they received reminders during staff meetings. CNA #1 said for soft and bite-sized the residents could have bread, and could potentially have cookies depending on how soft they were. CNA #1 said MM5 residents' food was usually pretty blended up and had sauce or gravy to make it easier to eat. CNA #1 said the CNAs passed trays and would check the resident's meal ticket and ensure the meal they were served matched the diet texture on the ticket. CNA #1 said if he noticed any issues he would take the meal to the kitchen and have them serve the appropriate diet texture.RN #1 was interviewed on 2/4/26 at 10:12 a.m. RN #1 said she was working on 1/13/26, but was not working on the secured unit where Resident #4 resided. She said on 1/13/26 a CNA came out of the secure unit looking for a nurse because Resident #4 was choking. She said the nurse assigned to the secured unit was not on the unit at the time of the incident.RN #1 said she entered the unit and saw Resident #4 in the dining room struggling to breathe. She said she performed the Heimlich maneuver several times without success. She said she continued to coach the resident to cough in order to remove the object. RN #1 said Resident #4 was eventually able to cough up the object, which was a piece of tortilla. RN #1 said as the resident was coughing up the object EMS arrived but the resident declined to go to the hospital. The DM was interviewed on 2/4/26 at 10:55 a.m. The DM said he was unaware of dietary extensions (document that indicates how to alter food items to the correct texture) prior to the choking incident on 1/13/26. He said he was new to the position and was still learning the responsibilities of the position. The DM said after the choking incident he had placed dietary extensions in the kitchen so the staff had access to them. The DM said he was not sure if the dietary staff had education on diet textures and extensions. He said a dietary aide plated the food using the resident's diet ticket. The DM said the ticket had the diet order and the food to be served for each meal. The DM said the staff member who served the food, which was typically the CNA but could be any staff member, should also check the diet ticket and the meal to make sure they match up prior to serving the meal. The DM said he did not know if all staff had been educated on the different diet textures prior to 1/13/26. The DM said he has been providing one-to-one verbal education to the dietary staff and the DON had provided training on the IDDSI textures since 1/13/26. The DM said the education was not documented.The RD was interviewed on 2/4/26 at 11:40 a.m. The RD said the residents' diets orders were put in the electronic medical record (EMR) and the kitchen was able to print out dietary tickets. The RD said the diet tickets matched the diet order. She said the ticket also included the resident's likes and dislikes, allergies, extensions and the specific food that should be plated for each meal. The RD said the dietary aides received education and visual tools to use while serving. -However, observations revealed the visual aide was posted on a bulletin board behind the serving station (see observations above). The RD said the staff member serving the meal, which could be any staff member, was also responsible for checking the meal against the diet ticket. The RD said education on the IDDSI diet textures was provided to all staff recently by the DON. The RD said Resident #22 should not have received the hamburger bun or piece of lettuce. The RD said Resident #22 and Resident #23 should not have received the cookies because those food items were not recommended on their ordered diets. The NHA and the DON were interviewed together on 2/4/26 at 11:56 a.m. The DON said she was present during the choking incident on 1/13/26. She said immediately after the incident she provided education to the secured unit staff regarding meal tickets matching the meal being served with the proper ordered diet. The DON said the education given that evening was not documented. The DON said she and the NHA had been providing education to all staff on the IDDSI diet textures. The DON said Resident #23 had received the right diet texture for his meal, but got the cookie. She said the cookie should have been cut up on 2/3/26 (see observations above). The DON said she did not know that Resident #22 received a regular textured hamburger and a cookie on 2/3/26 for dinner. The NHA said they had an issue with the tickets because the ticket said whole cookie rather than the soft and bite-sized cookie. He said there was a glitch with the computer program the evening of 2/3/26. The NHA said the root cause of the incident was a glitch with the ticket. He said the RD audited all the tickets and they match the physician's diet order and specifically went through the meal tickets for 2/4/26 to verify the menu items matched the tickets and diet orders. The NHA and the DON were interviewed again on 2/4/26 at 1:12 p.m. The DON said there were approximately 18 residents in the building on altered diets. The DON said the assistant director of nursing (ADON) audited the meals once a week. The DON said the ADON included three residents in her audit per week to ensure their diets were correct. The DON said three residents per week was not enough. The DON said the ADON did complete an audit form, however, the audit form did not include which meals were being audited. The DON said after the 1/13/26 incident she educated the staff on the IDDSI diet textures and conducted audits following the choking incident. The DON said their education was ongoing as some of their staff were out due to the recent gastrointestinal (GI) outbreak at the facility. The DON said the ADON had not found any concerns with the meal textures. The DON said she was not sure what meals had been audited. The DON said she would expect the ADON to audit different meals throughout the day. The DON said she had done multiple training sessions. She said she started with the staff who were involved with the choking incident. She said then another training on the 1/29/26 to capture more staff members. The DON said they had been educating the staff members as they returned to work prior to their next shift. The NHA said they spoke with the dietary aide (DA) #2, who plated the meals for 1/13/26 and 2/3/26. The NHA said DA #2 said he was flustered during the meal service on 1/13/26, because there was so much going on in the kitchen. The NHA said he had met with the DM and the dietary aides last night (2/3/26) and discussed the meal service. The NHA said there would be further education with DA #2 when his shift started.The DON and the NHA provided signed education sheets with no dates. The NHA said he should have a date on the education but all the education has been rolled out since the 1/13/26 incident.-However, the wrong texture meal was served to Resident #22 and Resident #23 after the education had been provided to all staff after the 1/13/26 choking incident (see observations above). CNA #11 was interviewed 2/5/26 at 10:59 a.m. CNA #11 said she had received education on diet textures this morning before her shift. CNA #11 said she checked the resident's meal tray against their diet texture on their meal ticket and looked at what they should have on their meal ticket versus what they were served. CNA #11 said she was educated on what the different diet textures should look like, the fork tine test and how level five minced and moist should look. CNA #4 was interviewed on 2/5/26 at 11:05 a.m. CNA #4 said she had received more education on diet textures on 2/4/26. She said she was educated to review the meal ticket against the plate to confirm the meal and ticket matched and the meal was the correct diet texture. She said she would get a new plate if the diet did not match. CNA #5 was interviewed on 2/5/26 at 11:10 a.m. CNA #5 said he had received more education on meal service on 2/4/26. He said he was to double check the meal ticket with the meal. He said if the meal ticket and meal were different, he would take the meal back to the kitchen. He said he had been educated on the different textures and to not rely only on the meal listed on the ticket but to check the diet order as well. RN #1 was interviewed on 2/5/26, at 11:26 a.m. RN #1 said she had received education regarding diet textures last night (2/4/26). RN #1 said the education reviewed what to look for with each diet texture, the staff should check each resident's meal to their meal tray ticket to verify it matched their physician ordered diet, and if the meal item did not match what was ordered to remove the item and bring it back to the kitchen to get the proper diet texture.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety.Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care. Findings include:I. Cross-referenced citationsCross-reference F 805: The facility failed to serve correct altered diet texture per physician order, resulting in an actual choking incident. The facility failed to ensure appropriate texture meals were served to multiple residents. Resident #4 was served a regular meal instead of a minced and moist diet on 1/13/26. He experienced a choking episode that required multiple attempts of Heimlich maneuver to dislodge the food from the airway. In addition, Resident #22 and #23 were served incorrect texture diets at the time of the survey. The facility's failure to serve an appropriate texture diet created an immediate jeopardy (IJ) situation with actual serious harm. Cross-reference F 689: The facility failed to prevent two elopement incidents for a resident who exhibited wandering behaviors. Resident #13 eloped from the facility on two different occasions. After the first incident, the facility did not implement interventions to prevent a second elopement. During the second incident, the resident left the facility without staff knowledge and was locked out outside. He was only noticed by staff when he was struggling to get through the locked door back into the facility. The facility's failure to ensure residents safety created an IJ situation with actual serious harm.Cross-reference F 760: The facility failed to ensure all medications were administered as ordered. Resident #11 was not administered his seizure medications on multiple occasions, and his seizure medication was not administered at all on days he went to dialysis. He experienced increased seizures and required multiple hospitalizations. The facility's failure to ensure residents were free from significant medication errors created an IJ situation with actual serious harm. II. Facility policy and procedureThe Quality Assurance and Performance Improvement policy and procedure, dated 4/11/25, was received from the nursing home administrator (NHA) on 2/9/26 at 3:12 p.m. It read in pertinent part, It is a policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.III. Repeat deficienciesReview of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies.F600 Abuse prevention: The facility failed to prevent multiple physical abuse situations on the secure unit. This deficiency was consistently cited on previous complaints on 2/25/25, 5/13/25, and 9/4/25. F760 Significant mediation error: The facility failed to be free from significant medication errors. This deficiency was cited on 5/13/25 and 6/11/24 at a D level scope and severity, potential for more than minimal harm, isolated.On 7/8/25 this deficiency was cited at a G level scope and severity, isolated, actual harm.IV. Staff interviewsThe medical director (MD) was interviewed on 2/4/26 at 92:57 p.m. The MD said she was notified about seizure medication error and she expressed her concern to staff. She said her concern was that seizure medications should be administered as ordered to prevent seizure activity. She said all seizure medications were managed by a neurologist and staff should have contacted the neurologist for clarification. The nursing home administrator (NHA) was interviewed on 2/9/26 at 3:10 p.m. The NHA said all cases of abuse allegations were reviewed during QAPI. Several interventions were in place such as one to one monitoring for residents who displayed aggressive behaviors. He said the goal was to increase the number of staff on the secure unit who will provide additional activities for residents.The NHA said he was aware of the significant medication error of the seizure medication. He said the facility completed the investigation, however he was not sure if any performance improvement plans were started.The NHA said he was not aware the kitchen was serving inappropriate diets even though he was aware of the choking incident on 1/13/26. The NHA said the facility was actively looking for a secured unit placement for Resident #13.

Based on record review, and interview, the facility failed to provide choices for preference of bathing schedule for one (#20) of five residents reviewed for self-determination out of 24 sample residents.Specifically, the facility failed to provide Resident #20 per his preference. Findings include:I. Failure to provide shower as scheduledA. Resident #20B. Resident statusResident #20, age over 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included fracture of left tibia, and type 2 diabetes. The 12/14/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 11 out of 15. The resident required partial to moderate assistance from staff for personal hygiene and showers. C. Resident interviewResident #20 was interviewed on 2/3/26 at 12:30 p.m. He said it was impossible to receive a shower at the facility. He said when he was initially admitted , he went several weeks without showers. He said staff would say the shower was due on the next shift and the next shift would give the same answer. He said he verbally complained to nurses, nursing aides, and managers, but his shower schedule was never fixed. He said one of the managers came into his room a few days ago and placed a sign on the end table that his shower days were Tuesdays, Fridays and Sundays. He said the sign did not solve the problem. His showers were not completed as scheduled. Resident #20 was interviewed a second time on 2/9/26 at 11:30 a.m. He said he did not receive his shower on Friday 2/6/26 or Sunday 2/8/26. He said staff kept saying it was not scheduled on their shift. D. Record reviewReview of the resident's comprehensive care plan did not include preferences or specific days for showers. Review of the resident's electronic medical record (EMR) revealed the resident's shower preferences were obtained on 12/8/25 and revealed the resident preferred his shoes twice a week on Tuesdays and Fridays evening. The 2/1/26 progress note documented the resident preferred to shower three times a week on Tuesdays, Thursdays and Saturdays. The note indicated the resident preferred to shower before 8:00 p.m. but after lunch.Shower records for the last 30 days, from 1/9/26 to 2/9/26 revealed the resident received showers on three occasions 1/18/26, 1/19/26, and 1/27/26.E. Staff interviewsCertified nurse aide (CNA) # 13 was interviewed on 2/9/26 at 2:30 p.m. She said she did not know when the resident received showers, she said it was not scheduled on her shift. She said it was confusing because at times the shower schedule was updated in the book but not communicated to CNAs. She said she did not know why the resident did not receive his shower on Friday or Sunday.Registered nurse (RN) # 1 was interviewed on 2/9/26 at 2:40 p.m. She said the resident had a very specific request that his shower was to be completed before 8:00 p.m. but not during the dinner time. She said at times it was difficult to accommodate due to the CNAs busy schedule. She said his schedule was changed multiple times and she was not sure what his most current schedule was. She said the resident did not refuse his showers unless it was offered after 9:00 p.m. when he was in bed. The director of nursing (DON) was interviewed on 2/9/26 at 3:50 p.m. She said she was not aware Resident #20 did not receive his showers. She said she asked nursing staff and came to the conclusion that staff were confused which shift was supposed to provide the shower. She said she educated staff where to locate the shower schedule. She said Resident #20 would receive a shower today.

Based on observations, record review and interviews the facility failed to ensure two (#2 and #4) of 23 out of 24 sample residents were free from abuse and neglect.Specifically, the facility failed to ensure Resident #2 and Resident #4 were kept free from physical abuse from Resident #1.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, implemented 4/11/25, was provided by the nursing home administrator (NHA) on 2/9/26 at 9:15 a.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes, but is not limited to hitting, slapping, punching, biting and kicking. It also includes controlling behavior through corporal punishment. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:-identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms;-assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment;-the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect;-addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and-assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors.II. Incident of physical abuse involving Resident #1 and Resident #2 on 10/29/25A. Facility investigationThe facility's abuse investigation, dated 10/29/25, was provided by the NHA on 2/3/25 at 10:00 a.m. The investigation revealed the following:On 10/29/25 a certified nurses aide (CNA) reported to the NHA she watched Resident #1 enter Resident #2's room. As the CNA was walking toward Resident #2's room to redirect Resident #1 out of the room, she heard Resident #2 say get out of my room and then heard what sounded like a punch. The CNA entered the room and was able to redirect Resident #1 out of the room. Resident #2 had a scratch on the left side of his neck. Resident #2 was interviewed by the NHA. Resident #2 said he was his bathroom when Resident #1 entered his room. Resident #2 said he told Resident #1 to get out of his room and then Resident #1 then punched him three or four times. Resident #2 said he did not know where he was hit because he did not have his glasses on. Resident #2 said Resident #1 had something sharp come out of his knuckles and felt like he was scratched. The NHA attempted interview Resident #1, but he did not respond to questions.-However Resident #1 was Spanish speaking, it was not clear if the NHA had an interpreter present. The investigation documented both residents resided on the secure memory unit.Interventions following the incident included putting a stop sign across Resident #2's door to help other residents from entering his room, however Resident #2 asked for the stop sign to be removed shortly after it was put up. There were no other interventions put in place. The facility concluded they could not substantiate or unsubstantiated the allegation of abuse. The facility found the evidence to be inconclusive. The facility documented Resident #2 could not recall if he was hit and there was no evidence as to how Resident #2 sustained the skin tear on his neck.-However, during the initial interview, Resident #2 said he was hit by Resident #1 and he had something sharp in his hand. Resident #2 also verbalized that he was struck by a resident when he was seen by his physician. The CNA also said they heard what sounded like a punch prior to entering the room.B. Resident #1 - assailant1. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included Alzheimer's Disease, anxiety disorder, cognitive communication deficit, and vascular dementia, unspecified with other behavioral disturbance. The 12/10/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. Resident #1 required set up assistance with all activities of daily living (ADLs).The MDS assessment documented Resident #1's preferred language was English, did not wander and did not exhibit any behavioral symptoms.2. Record reviewThe behavior care plan, initiated 8/20/25, documented to monitor Resident #1 for behaviors related to inappropriate touching, increase in behaviors, pain, tearfulness, self isolation, and angry outbursts. The pertinent interventions included placing the resident on 15 minute safety checks; maintaining close staff supervision during meals, activities and common areas; ensuring the resident was seated in a staff visible, low risk location during dining and group activities; assessing the possible increase in behaviors and removing any triggers; and redirecting the resident if increased behaviors occurred. -However the care plan did not identify effective redirection techniques. The cognition care plan, initiated 8/20/25, documented Resident #1 had a risk for impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease. The pertinent interventions included, using the resident's preferred name, identifying yourself at each interaction, facing the resident when speaking and making eye contact, reducing any distractions, asking yes or no questions in order to determine the resident's needs, providing the resident with necessary cues, stopping and returning if the resident was agitated and reorienting and supervising as needed. The communication care plan, initiated 8/20/25, documented Resident #1 had a communication problem related to a cognitive communication deficit. The pertinent interventions included being conscious of the resident position when in groups, activities, and the dining room to promote proper communication with others; allowing the resident adequate time to respond; repeating statements as necessary; not rushing the resident; requesting clarification from the resident to ensure understanding; facing the resident when speaking; making eye contact; turning off the television or radio to reduce environmental noise asking yes or no questions if appropriate; using simple, brief consistent words and cues; and using alternative communication tools as needed. -However the interventions do not identify the types of alternative communication tools that were effective for Resident #1. The communication care plan, initiated 8/20/25, documented Resident #1's primary language was Spanish. The pertinent interventions included providing Resident #1 with an interpreter.-However, the MDS assessment documented English as the resident's preferred language and he did not need or want an interpreter to communicate with a doctor or health care staff. The 10/29/25 progress note at 3:29 p.m., documented Resident #1 entered another resident's room. The other resident asked him to leave and Resident #1 started to hit him.C. Resident #2 - victim1. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the February 2026 CPO diagnoses included, unspecified psychosis, personal history of traumatic brain injury, dementia unspecified severity with other behavioral disturbance, cognitive communication deficit, and other symptoms and signs involving cognitive functions and awareness. The MDS assessment revealed Resident #2 was cognitively intact with a BIMS score of 13 out of 15. The resident required supervision or touching assistance for ADLs.The MDS assessment documented the resident did not exhibit physical or verbal behaviors toward others. 2. Record reviewThe mood and behavior care plan, initiated 6/23/25 and revised on 11/2/25 documented Resident #2 had a history of an alteration in mood or exhibition of behavioral symptoms related to Alzheimer's, dementia, depression and psychosis. Pertinent interventions included evaluating the resident for a referral to psychological counseling as recommended by physician, interacting with the resident in an empathetic and supportive manner, monitoring and documenting each behavioral event and offering psychosocial support as needed. A follow up progress note, dated 10/29/25 at 7:33 a.m. by the physician documented the resident had an altercation with another resident who scratched Resident #2 on the neck. Resident #2 sustained a small skin tear to the left side of his neck and was approximated with steristrips. Resident #2 said he was startled but otherwise was doing okay. III. Incident of physical abuse between Resident #1 and Resident #4 on 12/30/25A. Facility investigationThe facility investigation, dated 12/30/25, documented CNA #12 was assisting a resident in their room when she heard a disturbance in the hallway. She responded to assess the situation and found Resident #4 and Resident #5 in a verbal dispute. CNA #12 intervened and positioned herself between the residents to deescalate the situation. While CNA #12 was deescalating the situation Resident #1 approached and swung at Resident #4, it was unclear if there was any contact. -However, CNA #12's interviewed (see below) revealed Resident #1 made contact with Resident #4.Resident #5 said Resident #4 came toward him so he grabbed his wrists to stop him but then later denied any physical contact. Resident #4 said he was walking toward Resident #5 to stop him from running his mouth. He denied hitting anyone or being hit. Resident #1 denied being involved in the altercation and said he was not hit and did not hit anyone. -However, Resident #1 was Spanish speaking and there was no indication an interpreter was used for his interview. The investigation documented all three residents resided on the secure unit.B. Resident #4 - victim1. Resident statusResident #4, age less than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included dysphagia, oropharyngeal phase, cerebral infarction, cognitive communication deficit, and unspecified dementia.The 11/8/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. The resident required supervision or touching assistance for eating and was moderate to maximum assist with all his ADL.2. Record reviewThe cognitive function care plan, initiated 8/9/24 and revised on 11/4/24, documented Resident #4 had impaired thought processes related to dementia. Pertinent interventions included redirecting the resident away from other residents; providing structured and supervised activities to reduce unstructured roaming; providing increased checks due to reaction when other residents enter his room and being cursed at in Spanish;.ensure staff face the resident when speaking, making eye contact and reducing any distractions; and keeping the resident in direct line of sight while awake to prevent the resident from wandering into other residents' rooms.The behavior care plan, initiated 7/21/25 and updated 8/13/25, documented Resident #4 had an altered thought process and impulsive behavior due to dementia. Pertinent interventions included providing one to one supervision for safety, maintaining a calm and structured environment to reduce cognitive overload and frustration, monitoring for potential behavioral triggers such as unexpected intrusion into personal space, and providing de escalation support and redirection techniques when the resident appears agitated or defensive.-However, the care plan did not include any resident specific redirection techniques. A nursing progress note, dated 12/30/25 at 6:31 p.m, documented the nurse was notified by the CNA an altercation happened between Resident #4 and two other residents. Resident #4 was yelling at Resident #5 when Resident #1 walked by and punched Resident #4 in the face. Resident #4 denied being hit. Resident #4 was assessed and there were no apparent injuries. A nursing progress note, dated 12/31/26 at 9:54 a.m., documented the root cause of the altercation between Resident #5, Resident #1 and Resident #4 was cognitive decline and poor safety awareness. The preventative measure put in place was frequent safety checksIV. Staff interviewsCNA #4 was interviewed on 2/3/26 at 12:20 p.m. She said she had been trained on abuse through the facility's training program. She said she was aware of residents' triggers and what interventions to attempt through communication with other staff members. She said she received information at the morning unit meeting and through the facility communication application. CNA #6 was interviewed 2/3/26 at 3:35 p.m. CNA #6 said each shift provided a verbal report from the previous CNA about any behavior or mood changes in a resident. She said the unit had a staff meeting to discuss any resident changes. She said each resident's kardex (summary of resident care information) provided information on how to care for residents and included behavior triggers and interventions to attempt.CNA #12 was interviewed 2/4/26 at 4:00 p.m. CNA #12 said she was involved with the incident between Resident #4, Resident #5 and Resident #1. She said she was the only staff member in the secured unit since the nurse was on another unit. She said she was assisting a resident in their room when she heard two male resident voices escalating in the hall. She quickly finished with the resident she was assisting and went to intervene between the male residents (Resident #4 and Resident #5), but the situation had escalated. She positioned herself between the residents hoping to deescalate the situation. She said Resident #1 approached and swung with a closed fist, making contact with Resident #4's cheek. She tried to communicate to Resident #1, however she did not speak his primary language of Spanish. CNA #1 was able to get the residents separated, calmed down and Resident #1 to his room without further incident.CNA #8 was interviewed 2/9/26 at 11:30 a.m., CNA #8 said she was not the CNA who entered Resident #2's room at the time of the incident, however she was working the unit and walked in the room a few seconds later. CNA #8 said she heard a commotion and the was told by the CNA who did entered the room first, there was contact made between Resident #1 and Resident #2. She said Resident #2 had a scratch on this neck most likely from Resident #1's nail. She said Resident #1 only spoke Spanish and would become upset when he was not able to verbalize his needs. She said the staff tried to communicate with an interpreter application on their phones but it did not always work especially if the resident was agitated. The director of nursing (DON) was interviewed on 2/9/26 at 11:50 a.m. The DON said residents were placed on one to one supervision if behaviors escalated and resulted in an altercation. She said the one to one supervision could last a day up to several days. The one to one supervision was monitored by the interdisciplinary team (IDT) and when the IDT agreed it was no longer needed the resident was placed on frequent checks. The DON said the secured unit was staffed with one nurse, who was also assigned to another unit and one CNA. She said if a resident had a one to one supervision then there would be more than the two staff members assigned to the secured unit. She said the staff member who provided one to one supervision was not to assist with tasks on the unit and to stay with their resident. The DON said when the nurse was on the other assigned unit the CNA could be the only staff member on the secured unit. She acknowledged the staffing situation on the secure unit may not be safe and said the facility was going to add another CNA to the unit potentially in the next week. The DON said that administration staff rounded on the secured unit and provided assistance with the one to one supervision for the residents. The NHA was interviewed on 2/9/26 at 12:11p.m The NHA said he investigated both resident to resident altercations. He said the first incident involving Resident #1 and Resident #2 could not be substantiated or unsubstantiated due to the contact being not witnessed. He said there was no evidence on how Resident #2 received the scratch on his neck, however the investigation did not explore any alternatives as to the origin of the scratch to Resident #2's neck. The NHA documented on the investigation that CNA #12 was not clear if there was contact. -However, during the interview 2/4/26 interview, CNA #12 said contact was made with Resident #1 and Resident #4. The NHA said he was aware having only one staff member on the secured unit could be difficult for a staff member to assist residents and monitor behaviors. He said they had recognized this issue and would be hiring for an additional CNA for the unit. The NHA said there had been an employee from the activities department on the unit during some days providing activities, however this person was not on the unit full time and had resigned. The NHA said staff members were provided education on dementia and abuse on orientation and at least annually. He said new training had been rolled out to the staff specifically for behavior interventions on 2/6/26, and he expected those trainings to be completed within a week of the roll out.

Based on record review and interviews, the facility failed to ensure one (#7) of seven residents reviewed for medication management were free from significant medication errors out of nine sample residents. Resident #7 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebrovascular disease (a condition that affects the blood vessels in the brain). On 6/20/25 certified nurse aide with medication authority (CNA-Med) #1 administered another resident's medications to Resident #7, including apixaban and clopidogrel (used to prevent blood clots), isosorbide (used to relax and widen the blood vessels and manage chest pain), lisinopril (used to treat high blood pressure), propranolol (used to lower heart rate and blood pressure), quetiapine (used to treat mental health conditions), Percocet (pain medication) and Fioreicet (used to treat tension headaches). The resident began to experience severe hypotension (a dangerously low blood pressure), required supplemental oxygen and was sent to the hospital. The resident received intravenous (IV) fluids, administered medications and was monitored in the intensive care unit (ICU). Specifically, the facility failed to ensure Resident #7 did not receive another resident's (Resident #8) medications. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/7/25 to 7/8/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/23/25.I. Medication error on 6/20/25The facility failed to ensure a licensed nurse administered medications to the correct resident. Resident #7 was administered another resident's (Resident #8) medications, which caused the resident to experience a change in condition and the resident was sent to the hospital for treatment. II. Facility's plan of correctionThe corrective action plan the facility implemented in response to Resident #7's medication error incident on 6/20/25 was provided by the nursing home administrator (NHA) 7/7/25 at 4:02 p.m. The stated purpose of the plan was to address the significant medication error and prevent any additional residents from suffering any adverse outcome.The plan revealed the following:A. Identification of other residentsThe resident (Resident #7) who received the wrong medications was immediately transferred to the hospital.An audit of all residents was conducted to ensure a photo was present in the electronic medical record (EMR). Four residents were identified to have missing photos in their EMRs. The missing residents' photos were uploaded to their EMRs, completed 6/20/25.B. Systemic changesAll applicable facility policies and procedures were reviewed and revised.The director of nursing (DON) reeducated licensed nurses on the facility's policies regarding medication administration and medication error reporting. All nursing staff were educated prior to working their next shift, completed 6/23/25.The DON completed corrective action and one-to-one education with registered nurse (RN) #1, completed 6/21/25. All nurses and CNA-Meds received a competency observation related to medication administration prior to working their next shift, completed 6/23/25.C. MonitoringThe DON or designee would observe medication administration five times per week for four weeks, then weekly for eight weeks. Observations would occur across shifts and with various staff members.The activity director or designee would audit resident photos in the EMR weekly to ensure all newly admitted residents had photos in their chart. The NHA implemented a performance improvement plan as a means to gather and process information from the audit. Findings would be reported at the monthly quality assurance meetings for a minimum of three months.The facility's determined date of compliance was 6/23/25.III. Professional referenceAccording to [NAME], P.A., [NAME], A.G et.al,, Fundamentals of Nursing, 10th ed., Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications:1. The right medication2. The right dose3. The right patient4. The right route5. The right time6. The right documentation7. The right indication.IV. Facility policy and procedureThe Medication Administration policy, revised 6/20/25, was provided by the NHA on 7/7/25 at 4:02 p.m. It read in pertinent part, Identify resident by photo in the MAR (medication administration record).Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time and right documentation.V. Resident #7A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebrovascular disease, depression and arthritis.The 6/11/25 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) assessment score of 14 out of 15. The assessment documented the resident needed supervision to substantial assistance from staff for most activities of daily living (ADL).B. Resident interviewResident #7 was interviewed on 7/7/25 at 2:08 p.m. Resident #7 said he went to the hospital recently. Resident #7 said he had just woken up and a nursing staff member came into his room and had a medication cup in her hand. Resident #7 said he thought the nursing staff member had mentioned his name but he was not sure. Resident #7 said when he took the medications, he had a hard time getting them washed down. Resident #7 said he quickly felt out of it and really sleepy. Resident #7 said if Resident #8 had not said something to the nurses he would have been dead. Resident #7 said he felt like he had been slapped in the head with a hammer after taking the medications. Resident #7 said he was always worried something like the incident would happen again. Resident #7 said he was blind in his right eye and could not see very well, so he had no idea there were more medications than usual in his medication cup until he swallowed them. Resident #7 said he had started looking at the medication cups and asking the nursing staff if the medications were his since the incident occurred. Resident #7 said he was worried because the doctors at the hospital said his blood pressure dropped so low it could lead to damage to his organs in the future.C. Record reviewThe June 2025 CPO revealed Resident #7 had physician's orders for the following daily scheduled medications: atorvastatin (used to treat high cholesterol) 20 milligrams (mg), empagliflozin (used to manage diabetes) 25 mg, fluoxetine (used to treat depression) 40 mg, gabapentin (used to treat nerve pain) 600 mg and 900 mg, sitagliptin (used to manage diabetes) 100mg, hydrocodone-acetaminophen (used to treat chronic pain) 10-325 mg and loperamide (used to treat diarrhea) 2 mg.-Resident #7 did not have physician's orders for apixaban, clopidogrel, isosorbide, lisinopril, propanolol, quetiapine, Percocet or Fioricet. A progress note, dated 6/20/25 at 9:15 a.m., revealed Resident #7 had a change in condition. Resident #7 had a blood pressure of 68/42 millimeters of mercury (mmHg) and an oxygen saturation (level of oxygen in the blood) of 74 percent (%). Resident #7 was receiving oxygen via a mask. Resident #7 had an altered level of consciousness; the resident was hyperalert and drowsy. Resident #7 was assessed by a registered nurse (RN) at his bedside, was placed in the Trendelenburg position (a body position used to help stabilize blood pressure) and was receiving 15 liters of oxygen via a non-rebreather mask. Emergency services arrived, began intravenous (IV) fluids and Resident #7 was transferred to the hospital.A physician's note, dated 6/20/25 at 9:29 a.m., revealed the physician was contacted at 9:13 a.m. on 6/20/25 and was notified Resident #7 had been administered the incorrect medications. The physician was onsite at the time and met with the nursing staff to go over what medications were administered to Resident #7. Resident #7 was given his prescribed morning medications along with apixaban 5 mg, clopidogrel 75 mg, isosorbide 30 mg, lisinopril 20 mg, propranolol 10 mg, quetiapine 75 mg, Percocet 5-325 mg and 50-325-40 mg. The physician assessed Resident #7 and found he was diaphoretic (excessively sweating) and was not feeling well. Resident #7's systolic blood pressure was in the 70s over a diastolic blood pressure in the 50s, his pulse was 110 beats per minute (bpm) and his oxygen saturation on room air was 80%. The physician documented these symptoms were likely due to the vasodilatory effect (when blood vessels widen causing increased flow of blood) of isosorbide. The physician requested emergency services be called so the resident could be transferred to the hospital for blood pressure support. Resident #7 was provided with supplemental oxygen and ultimately required 15 liters of oxygen via a nonrebreather mask in order to maintain his oxygen saturation. Resident #7 was placed in the Trendelenburg position which brought his blood pressure up to 89/59 mmHg and his pulse to 102 bpm. The note documented the physician contacted poison control and discussed the medications Resident #7 was administered. The poison control center advised the physician tha the isosorbide likely caused the vasodilation (widening of the blood vessels) and lowered Resident #7's blood pressure. A progress note, dated 6/20/25 at 10:05 a.m., revealed at 9:10 a.m. on 6/20/25 Resident #7 had a low blood pressure of 68/42 mmHg and appeared diaphoretic and lethargic. Resident #7 was responsive to verbal stimuli and said he just felt very sleepy. The DON and Resident #7's physician was notified at 9:14 a.m. Resident #7 was placed in the Trendelenburg position and his blood pressure came up to 88/65 mmHg at 9:20 a.m. Emergency services were contacted at 9:26 a.m. and arrived at the facility at 9:40 a.m. The emergency services immediately began administering IV fluids. Resident #7 was transferred to the hospital at 9:55 a.m. for hypotension (low blood pressure). A progress note, dated 6/21/25 at 11:38 a.m., revealed Resident #7 arrived back to the facility from the hospital and was assessed by the RN upon arrival. Resident #7 said he felt well and was happy to be back at the facility.Hospital notes, dated 6/21/25, revealed Resident #7 was admitted to the hospital on [DATE] after receiving the wrong resident's medications. Resident #7 was administered a number of medications in addition to his normal morning medications. Resident #7 was treated for iatrogenic shock (a life-threatening condition where blood pressure is too low to deliver enough oxygen to organs) and required pressor support (medications administered intravenously to increase blood pressure in patients experiencing hypotension or shock) to maintain adequate blood pressure for less than 24 hours. Resident #7 felt okay with returning to the facility despite the error. An interdisciplinary team (IDT) note, dated 6/23/25 at 10:02 a.m., revealed Resident #7 was inadvertently administered his roommate's (Resident #8's) medications on 6/20/25 at 7:45 a.m. The root cause identified was there was a new CNA-Med (CNA-Med #1) who was training and did not perform the two identifiers. Additionally, Resident #7's picture was not updated in the resident's chart. Preventative measures in place prior to the incident included having a registered nurse (RN) provide oversight for training the CNA-Med, Resident #7's name was on the door and the MAR was accurate with the resident's name and room number. New interventions included retraining all nursing staff on passing medications, including the six rights policy, medication error reporting process and using the two identifiers. A full audit was conducted on all nursing staff passing medications immediately prior to their next shift. CNA-Med #1 was suspended pending the incident investigation and the RN that was training CNA-Med #1 (RN #1) was reeducated as a corrective action.A medication error report, undated, revealed Resident #7 experienced a medication error on 6/20/25 at 7:30 a.m. The error was discovered at 7:45 a.m. by CNA-Med #1. Resident #7 was inadvertently given his roommate's medications by CNA-Med #1, who did not ask his two identifiers and addressed the resident by the wrong name. CNA-Med #1 said Resident #7 did not correct her when she addressed him by the wrong name. Contributing factors included lack of staff concentration, inexperienced staff and it being the trainee's (CNA-Med #1) first day with the trainer (RN #1) not being with her at bedside when the medications were administered. Resident #7 became hypotensive (low blood pressure) and hypoxic (low oxygen) and was sent to the hospital for treatment with fluids and pressors for support until the medications were no longer in his system. Resident #7 required 15 liters of oxygen with a nonrebreather mask, was placed in the Trendelenburg position, and required pressors and fluids in the ICU for several hours. Resident #7 was stabilized at the hospital and was admitted back to the facility the next morning (6/21/25).VI. Resident #8 interviewResident #8 was interviewed on 7/7/25 at 1:52 p.m. Resident #8 said Resident #7 was his roommate. Resident #8 said he took several medications including lisinopril, blood thinners, Seroquel (quetiapine), Percocet and oxycodone. Resident #8 said the nursing staff gave Resident #7 his medications by mistake and his blood pressure dropped really low. Resident #8 said he left the room and told the nurse Resident #7 had taken his medications by mistake and was acting funny. Resident #8 said Resident #7 kept saying he was tired.VII. Staff interviewsCNA-Med #1 was interviewed on 7/7/25 at 1:01 p.m. CNA-Med #1 said she arrived at the facility at 6:00 a.m. on 6/20/25 and waited at the nurse's station for thirty minutes for RN #1 who was supposed to train her. CNA-Med #1 said she and RN #1 started passing medications and RN #1 went through medications with her and let her pop medications out of their blister packs. CNA-Med #1 said she went into Resident #8's room with his medication cup in her hand. CNA-Med #1 said she addressed the resident who she thought was Resident #8 by name and administered his medications. CNA-Med #1 said she figured out her error when she went to administer Resident #7's medications and Resident #8 told her he could administer the medications to his roommate. CNA-Med #1 said she did not give Resident #7 his medications and went to the nurse's station to tell RN #1 what happened. CNA-Med #1 said RN #1 contacted the DON and assessed Resident #7's vital signs.CNA-Med #1 said that morning (6/20/25) was her first time ever administering medication and that she had not received any training prior to that morning on medication administration. CNA-Med #1 said RN #1 was using his cellphone and was not really paying attention to her that morning. CNA-Med #1 said she had taken her training for her medication authority two years prior but worked in a setting in which she did not get to pass medications.CNA-Med #1 said RN #1 had her continue to pass medications after the incident but she did not feel comfortable with doing so. CNA-Med #1 said the facility was going to have her come in to do training after the incident, but she said she later received a phone call to inform her she was relieved of her duties.RN #1 was interviewed on 7/7/25 at 1:21 p.m. RN #1 said he arrived at the facility that morning (6/20/25) and was not aware he was going to be training someone. RN #1 said CNA-Med #1 said she was a medication aide. RN #1 said CNA-Med #1 had worked at the facility for two weeks prior as a CNA and she had worked with him on Resident #7's unit the week prior. RN #1 said two other residents had to leave the facility for an outing and the bus was due to take off soon, so their morning was starting with a rush. RN #1 said the nurse from the previous shift administered medications to one of the residents leaving for the outing. RN #1 said he pulled medications for the other resident, checked them against the MAR, and wrote the resident's name on the cup. RN #1 said he observed CNA-Med #1 as she took the medication cup, asked the other resident his name and administered the medications to him. RN #1 said he showed CNA-Med #1 the facility's procedure for medication administration, got her familiar with the medication cart and let her get medications ready for the next residents. RN #1 said when it was time for Resident #8 to get his medications, CNA-Med #1 wrote the resident's name and room number on the medication cup and got his medications ready by cross-referencing the MAR. RN #1 said Resident #8 had almost 20 medications, so CNA-Med #1 took about 15 to 20 minutes to get the medications ready. RN #1 said he asked CNA-Med #1 if she felt comfortable giving Resident #8 his medications and CNA-Med #1 said she was and went to administer them. RN #1 said the medication cart was on the secured unit and Resident #8's room was on a different hallway, so CNA-Med #1 left the secured unit and administered the medications on the other hallway before returning to the secured area. RN #1 said he and CNA-Med #1 continued passing medications to other residents before getting to Resident #7. RN #1 said CNA-Med #1 prepared Resident #7's medications correctly, wrote his name and room number on the medication cup and went to the other hallway to administer the medications. RN #1 said CNA-Med #1 returned to the medication cart and initially lied to him and said Resident #7 took Resident #8's medications himself. RN #1 said CNA-Med #1 told him she handed Resident #8's medications to the resident, he set the medications on his bedside table, and Resident #7 must have taken them when she left the room. RN #1 said he tried to clarify the story with CNA-Med #1 but was not able to figure out what actually happened. RN #1 went into Resident #7 and Resident #8's room and spoke with them. RN #1 said the residents told him CNA-Med #1 walked into their room and gave Resident #7 the cup with Resident #8's medications. RN #1 said he realized Resident #8 took a lot of blood pressure medications, so he began taking vital signs on Resident #7. RN #1 said Resident #7 started to get fairly sleepy and his vital signs slowly started decreasing. RN #1 said he spoke with the DON who came and assessed the resident. RN #1 said while the DON was assessing Resident #7 he called emergency services. RN #1 said while these assessments were occurring, CNA-Med #1 was sitting in the DON's office.RN #1 said at other facilities he had worked at, he had gone through orientations on how to become a trainer, but had not received any information on how to train someone at the facility. RN #1 said he spoke with the DON after the incident and she told him he should have followed CNA-Med #1 and watched her pass medications. RN #1 said he asked the DON how many medication administrations he should have watched CNA-Med #1 for, but he said she could not provide a number, as there was no formal training program at the facility. RN #1 said he had assumed CNA-Med #1 would ask the residents their names.RN #1 said he had worked at the facility for four months prior to the incident. RN #1 said for medication administration he asked the residents their name and birthdate and confirmed their identity based on the picture in the resident's EMR. RN #1 said for residents with memory impairments, he would confirm the resident's identity by asking other staff members. RN #2 was interviewed on 7/7/25 at 2:53 p.m. RN #2 said she had worked at the facility since February 2025. RN #2 said she received three days of orientation when she first started working at the facility. She said during orientation, they went through a checklist of skills, including the six rights of medication administration. RN #2 said she had trained some new staff members since she started, but they were not new nurses, just nurses that were new to the facility. RN #2 said she had not received any training on how to train these newly hired staff, but would take the new person for a shift and go through the staff member's checklist with them. RN #2 said that was how she was trained her first few days. RN #2 said as a nurse, she was responsible for the CNA-Meds' actions. RN #2 said when she had a CNA-Med she knew she needed to make sure they were safe and did not overstep their scope of practice. RN #2 said CNA-Meds needed to know the six rights and administer medications as ordered to avoid any medication errors. RN #2 said if a medication error did occur, she needed to contact the DON and inform her of the error and follow any instructions the DON gave.CNA-Med #2 was interviewed on 7/8/25 at 10:01 a.m. CNA-Med #2 said for medication administration, she made sure she was administering the right medication to the right person at the right time. CNA-Med #2 said she had received training through an online training application on medication administration on the six rights, including right name, right date, right route. CNA-Med #2 said she had received a lot of training in-person lately on medication administration. CNA-Med #2 said she had not had to train anyone else on medication administration. CNA-Med #2 was interviewed a second time on 7/8/25 at 3:04 p.m. CNA-Med #2 said she checked the resident's name against the medication card and the chart when preparing medications. CNA-Med #2 said she then asked the resident what their name and date of birth were before administering their medications to ensure she correctly identified the resident.The DON and the regional nurse consultant (RNC) were interviewed together on 7/8/25 at 10:59 a.m. The DON said newly hired staff had an orientation and required training they needed to complete prior to working on the floor. The DON said once newly hired staff were on the floor, they had a competency checklist that their preceptor would go through and sign off on once each competency was completed. The DON said she had initiated an orientation process at the facility in which newly hired staff were taught the facility's rules and regulations.The DON said nurse preceptors or trainers were the most seasoned nurses, and were usually staff members who had been at the facility for a long time. The DON said she planned to develop a training plan for preceptors but had not yet launched one. The DON said training oversight was provided by herself and the assistant director of nursing (ADON). The DON said she or the ADON would check in daily and touch base with the staff member in training and their preceptor to see how they were doing. The DON said nurses and CNA-Meds needed to utilize the six rights of medication administration and use two identifiers. The DON said she did not think the facility had any formal training processes for medication administration, but it was in the checklist of competencies used for training newly-hired staff. The DON said precepting nurses were guided by the competency checklist and needed to have the training staff member give a verbal walkthrough or demonstration back to the preceptor to be signed off on the competency. The DON said for medication administration, the nurse or CNA-Med needed to have their computer open to the resident's EMR and check to make sure each medication was being passed to the right resident, medication, dose, route, time, and the correct documentation. The DON said the nursing staff member used those rights to check each medication against the MAR. The DON said the nursing staff member then used two identifiers to administer the medication to ensure it was the correct resident. The DON said the identifiers included asking the resident to say their name and date of birth , unless the resident needed different identifiers due to cognitive decline. The DON said in cases of cognitive decline, nursing staff could identify residents based on their photo in their EMR or confirm the resident's identity with other staff members. The DON said CNA-Meds and nurses were expected to know these steps from their schooling prior to being hired, and that medication administration was part of their competency checklist. The DON said it was important to keep the residents safe and ensure they did not get the wrong medications.The DON said on the morning of 6/20/25 CNA-Med #1 was training with RN #1. The DON said it was CNA-Med #1's first day on duty as a CNA-Med, but she had worked at the facility prior to the incident as a CNA. The DON said there were two residents going on an outing that morning, so RN #1 pulled the medications for the two residents that were going on the outing and observed CNA-Med #1 administer the medications to the resident. The DON said RN #1 watched a few more medication passes CNA-Med #1 performed and had her pull medications from the cart so she could use the six rights. When Resident #8's medications came up, CNA-Med #1 said she felt comfortable with administering the medications and knew the resident. The DON said CNA-Med #1 went into Resident #8's room and addressed the resident she thought was Resident #8 by calling him by his name. The DON said Resident #7 did not correct CNA-Med #1 when she called him by Resident #8's name, so she administered the medications and left the room. The DON said CNA-Med #1 did not ask Resident #7 his name or date of birth . The DON said CNA-Med #1 and RN #1 continued passing medications, and when Resident #7's medications came up and CNA-Med #1 tried to administer them the error was discovered. The DON said Resident #8 said CNA-Med #1 could give his roommate (Resident #7) his medications and identified himself as Resident #8. The DON said CNA-Med #1 did not administer Resident #7's medications and alerted RN #1 to the error. The DON said CNA-Med #1 told RN #1 something about setting the medications down on a table, and RN #1 figured out there was a medication error so he looked to see what medications Resident #8 took and left to assess Resident #7. The DON said she arrived at the facility at around 8:30 a.m. on 6/20/25. The DON said Resident #8 came to her office and told her Resident #7 had received his medications and that Resident #8 was worried about him. The DON said she went to assess Resident #7, who at that point was stable, but said he was a bit sleepy. The DON said she went to RN #1 who was talking with CNA-Med #1 to determine what happened, and the DON had RN #1 call Resident #7's family. The DON said she found the physician was in the building and brought the physician to Resident #7's bedside. The DON said her biggest concern at that point was the heart medications Resident #7 had received. The DON said they had taken a manual blood pressure and found Resident #7 had a blood pressure of 68/42 mmHg and his oxygen saturations were low. The DON said the facility staff put Resident #7 in the Trendelenburg position and gave him supplemental oxygen with a nonrebreathing mask. The DON said Resident #7's blood pressure rose to the 80s and his oxygen saturations improved. The DON said emergency services showed up shortly thereafter and started IV fluids.The DON said CNA-Med #1 did not continue to pass medications after the medication error was discovered. The DON said CNA-Med #1 was in her office panicking and the DON sent her home. The DON said Resident #7 returned to the facility the next morning (6/21/25). The DON said the facility staff had called poison control and the poison control consultants were not worried about any of the other medications' side effects aside from the isosorbide, as that medication caused blood pressures to drop. The DON said Resident #7 needed IV pressors which could only be given in the ICU. The DON said Resident #7 had not had any health outcomes related to the medication error since his return to the facility. The DON said the facility, immediately after the error occurred, started reeducating the nursing staff on medication administration, including the six rights and using two identifiers, and medication error reporting. The DON said she also reviewed preceptor expectations with the nursing staff. The DON said she and the ADON monitored and audited medication administrations for each nursing staff member prior to their next shift. The DON said RN #1 may have precepted at the facility prior to the medication error but she was not sure. The DON said there had not been any training on the expectations of preceptors at that point. The RNC said she thought seasoned nurses would know how to teach newly hired staff.The pharmacy consultant was interviewed on 7/8/25 at 2:29 p.m. The pharmacy consultant said the pharmacy was contacted on 6/20/25 at 3:17 p.m. via email regarding Resident #7 getting another resident's medications. The pharmacy consultant said the facility asked the pharmacy about signs and symptoms to look for given the medications Resident #7 received and any possible interactions. The pharmacy consultant said Resident #7 was given quite a few hypertension medications (medications used to lower blood pressure). The pharmacy consultant said the pharmacist on call told the facility to monitor Resident #7's blood pressure for any signs or symptoms of hypotension and to notify the physician if those occurred. The pharmacy consultant said the pharmacist on call told the facility to monitor for signs or symptoms of bradycardia (slow heartbeat), bleeding, falls and respiratory suppression with the other medications Resident #7 received.The pharmacy consultant said she recommended the nursing staff administering medications check the name of the resident against the card of medications, the resident's chart and the resident's date of birth . The pharmacy consultant said in cases of medication error, the usual procedure was to contact the physician first, which is what the facility did, and wait to notify the pharmacy. The pharmacy consultant said since the physician was in the facility at the time the error occurred, the physician immediately sent Resident #7 to the hospital. The pharmacy consultant said if the situation had not been so serious, the nursing staff would have contacted the physician then contacted the pharmacy sooner. The DON and the NHA were interviewed together on 7/8/25 at 4:11 a.m. The DON said RN #1 was educated on medication administration prior to his dismissal. The DON said CNA-Med #1 was sent home on 6/20/25 and did not return to the facility. The DON said all floor nursing staff were educated on medication administration by 6/23/25. The DON and the NHA said the incident with Resident #7 occurred on 6/20/25 and they started educating staff on medication administration that day. The NHA said the facility administration team immediately met to discuss training and how to proceed. The NHA said the quality assurance and performance improvement (QAPI) team met on 7/2/25 and discussed the incident and how to move forward during the meeting.The NHA said the total completion date of their performance plan was 6/23/25, which included observations and auditing of medication administration, education and inservicing of the nursing staff.

Based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one (#3) of three sample residents. Resident #3 was initially admitted on [DATE] and readmitted on [DATE]. The resident was at a high risk for falls related to being unaware of safety needs, paralysis, deconditioning, poor communication/comprehension, vision/hearing problems, gait/balance problems and incontinence. The resident was a substantial maximum assist of one staff member when the resident was able to use the bedside transfer pole. If the resident was unable to use the transfer pole, the staff were to use two staff persons with a Hoyer (mechanical) lift for transfers. The resident had a witnessed fall (lowered to the ground) during a transfer with the use of the transfer pole and one certified nurse aide (CNA) on 11/19/23 at 2:16 p.m. The resident was not assessed by a registered nurse (RN) before the resident was lifted from off the floor with a Hoyer lift and positioned into a chair. There was no documentation of injuries at the time of the fall. On 11/20/23 at 11:45 a.m., a nurse wrote that the resident complained of pain (10:30 a.m.) in the right leg, the right knee was swollen and painful to the touch. The nurse practitioner (NP) was contacted to determine the course of action. The NP ordered an x-ray of the resident's right hip and knee related to pain in these areas. The x-ray was taken at 4:23 p.m. (approximately four hours and 45 minutes later). At 5:00 p.m., the NP assessed the resident and reviewed the x-rays (approximately 24 hours after the fall). A fracture of the right femur was identified. The NP ordered the resident to be taken to the hospital using non-emergency transport. The transport service arrived at 5:20 p.m. and took the resident to the hospital. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 12/18/23 and 12/19/23, resulting in the deficiency being cited as past noncompliance with a correction date of 12/1/23. I. Facility action to 11/19/23 fall The Employee Huddle/Coaching for all nursing staff and leadership related to fall protocol was dated 11/20/23 (not timed) with signatures. The information that was presented included: after a fall, staff were to immediately notify a nurse; a registered nurse (RN) must assess the resident before staff assist the resident up from the floor; a total lift must be used to get the resident up; and neurological assessments were to be initiated for any falls, unless it was witnessed and there was no head involvement. For nursing staff: the RN in the building must assess the resident after a fall prior to assisting the resident up from the floor; a licensed practical nurse (LPN) may complete the risk management; a RN must place a note in the resident's chart of their assessment, a Fall Risk assessment must be completed after every fall; the provider/family must be notified after every fall and place this information in Risk Management; call the director of nursing (DON) for all falls; if injury or pain were noted, administer pain medication and obtain an order for x-rays as needed; and make sure this all information goes in your nursing note. The Action Plan for RN Assessment after a fall/fall process identified on 11/20/23. The identified concern was that during review of incidents, it was identified that a resident had a documented fall and the RN assessment was not documented. Plan one: reeducation was initiated with the nursing staff responsible for the documentation in regards to community expectations for documentation of assessment after a fall by a RN. The corrective action taken was education to nursing staff and was completed on 12/1/23. Plan two: the director of nursing ( DON) or designee was to audit all falls during clinical morning meetings to ensure a RN assessment was completed. If no RN assessment was documented, a late entry would be added. The corrective action taken was education to nursing staff and was completed on 12/1/23. Plan three: if a resident was noted to be on the floor, or had a change of plane, the resident should not be moved from that position until the RN completed an assessment. The nurse must be notified of the fall immediately, no one should get the resident up without a completed nurse assessment. The corrective action taken was education to nursing staff and was completed on 12/1/23. Plan four: the DON or designee would report the findings from the audits to the quality assurance performance improvement (QAPI) committee monthly for 90 days. The QAPI committee would identify any trends and take corrective action as needed. Agency staff would be educated to the process as it related to resident falls. This corrective action was ongoing until substantial compliance was achieved. II. Facility policy and procedure The Fall Management policy, dated 3/10/23, was provided by the DON on 12/19/23 at 11:51 a.m. The policy revealed the purpose of this fall management policy was to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. A fall reduction program would be established and maintained, to assess all residents to determine their risk for falls. A plan of care would be implemented based on the resident's assessed needs. Individualized care plan interventions would be implemented for those residents found to be at high risk for falls. The resident and the resident representative (if applicable) would be invited to all care plan meetings. Please note, interventions were to be re-evaluated when a resident fell for efficacy. Interventions that might be considered after identification of the root cause of a fall: assess the environment and make appropriate changes, bed in lowest position, placement of furniture, lighting personal items within reach, non-slip footwear, night light, walker, and wheelchair within reach if applicable. The call light and fluids should be within reach of the resident. Positioning devices (low bed, fall mat, defined perimeter mattress, cushions, seating system, wedges, pillows, and bolsters) utilized when applicable. Complete a thorough analysis of the fall to include the time of day, location of fall, and causative factors. Identify whether interventions were in place at the time of the fall. Interview staff and the resident if applicable to identify potential causative. The facility would review all falls during the morning QAPl meeting (Monday through Friday). A falls review would include the following: a review the Risk Management Incident form to ensure complete and appropriate parties were notified regarding the incident; review the interdisciplinary team (IDT) Risk Management form to ensure complete and appropriate interventions have been implemented; review that a care plan had been initiated; and provide revisions to the plan of care as necessary after falls. III. Resident #3 A. Resident status Resident #3, age 75, was initially admitted on [DATE] and readmitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included displaced comminuted fracture of the shaft of the right femur (hip), cerebral infarction (stroke) due to occlusion or stenosis of a cerebral artery, hemiplegia (paralysis) affecting right non-dominate side, abnormal posture, muscle weakness, mobility abnormalities, apraxia/aphasia (disorder of the brain) following cerebrovascular disease, attention and concentration deficit following cerebrovascular disease. The 11/30/23 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 with no behaviors. The resident needed staff assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation or injury (dependent-a helper completed all of the activities for the resident). The resident's upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) were impaired on one side. The resident had additional diagnoses of fractures and other multiple trauma. IV. Record review Transfer Pole consent form was signed by the resident on 1/10/23. Care plan for a high risk for falls related to being unaware of safety needs, paralysis, deconditioning, poor communication/compression, vision/hearing problems, gait/balance problems and incontinence was revised on 4/20/21. The pertinent interventions were to ensure proper positioning in bed and wheelchair to reduce falls, encourage the resident to lay down and rest when fatigued. An intervention initiated on 8/29/23 was for two staff persons to assist with transfers. Fall risk assessment dated [DATE] at 2:36 p.m. was 18 or a high fall risk. Care Plan for activities of daily living (ADLs) for self-care performance deficit related to a stroke, limited ranges of motion, fatigue, musculoskeletal impairment, hemiplegia, activity intolerance, limited mobility, history of cerebrovascular accident, confusion, pain in the back, and impaired balance was initiated on 5/14/15. A revision on 12/12/23 revealed a recent decline with ADL/transfers related to a femur fracture. Some of the interventions included to encourage active participation in tasks, provide cuing with tasks as needed, encourage the resident to participate to the fullest extent possible with each interaction, and praise all efforts of self-care. Transfer pole to aid in transfers was revised on 11/10/22. Substantial maximum assistance of one staff member if the resident was able to use the transfer pole was initiated on 11/19/19 and revised on 12/12/23. Staff were to use a Hoyer lift for safety until therapy recommendation with two staff initiated on 11/19/19 and revised on 12/12/23. Incident report for a witnessed fall on 11/19/23 at 2:16 p.m. This writer (LPN) came back from break and was informed the resident had been lowered to the floor during transfer by a CNA. The CNA said during the transfer, the resident pushed back and had to be lowered to the floor. The resident was assessed by this writer immediately upon arrival back to the area. The resident had no apparent injuries at his time. The resident was unable to give a description of the incident. The resident was helped off of the floor using a lift and placed into a chair. The resident sat up in a chair and was watching television. A physician was notified at 2:50 p.m. and the resident's son was notified at 2:53 p.m. Pain assessment dated [DATE] at 2:41 p.m. revealed a pain scale of 3 out of 10 (with 10 being the worse pain). The resident's acceptable pain level was 3 out of 10. A typed note by the DON revealed that on 11/20/23 at approximately 10:35 a.m., she spoke with LPN #2 related to the resident's swollen leg and the concern for a potential injury. A plan was discussed to call the resident's provider, notify them of the findings and ask if an x-ray would be appropriate. This typed note was dated 12/19/23 (not timed). Nurse note dated 11/20/23 at 11:45 a.m. by LPN #2 revealed the resident complained of pain in the right leg this morning. An as needed Hydrocodone-Acetaminophen tablet (analgesic) was administered to the resident this morning with her morning medications. At 10:30 a.m., the resident complained of pain in the same leg. The resident's knee was swollen and painful to the touch. The nurse practitioner (NP) was contacted to determine the course of action. The NP ordered an x-ray of the resident's right hip and knee related to pain in these areas. The resident's son was notified. Orders administration note dated 11/20/23 at 2:18 p.m. revealed an as needed Hydrocodone-Acetaminophen tablet (analgesic) was administered to the resident. It was ineffective and a follow up pain scale was 7 out of 10 (severe pain). Nurse note dated 11/20/23 at 4:54 p.m. by LPN #2 revealed the NP was at the facility and reviewed the resident's x-rays. The NP said there was a femur fracture. The resident's son was contacted and agreed for the resident to be sent to the emergency room using non-emergent services. Physician order dated 11/20/23 at 4:55 p.m. noted okay to send to the emergency room for evaluation. NP progress note dated 11/20/23 at 5:00 p.m. revealed this was a resident visit due to right knee pain. The NP opted to order an x-ray of the right hip and knee. This may be done using a portable unit at the facility. The resident was resting comfortably in bed and did not appear to be in any acute distress. Will base further treatment on the x-ray results, when available. Nurse note dated 11/20/23 at 5:35 p.m. revealed resident transported to the emergency room at 5:35 p.m. Nurse note dated 11/20/23 at 5:53 p.m. by LPN #2 revealed at 6:00 a.m. this nurse did not receive a report of this resident having been lowered to the floor the previous day (11/19/23). At 8:00 a.m., the resident was administered morning medication and complained of pain in her right leg with frequent complaints of pain the past morning. An as needed Hydrocodone-Acetaminophen tablet (analgesic) was administered to the resident. This LPN noted in the resident's chart, that the resident had a witnessed fall at approximately 9:00 a.m., on 11/19/23. The LPN went back into the resident's room around 10:30 a.m., to observe the effect of the as needed analgesic medication. The resident was awake and in pain. The bed sheets were off of the resident's leg and the right leg looked crooked. The resident's pedal pulses were assessed and were within normal limits. The right leg was cool to the touch and there was swelling around the knee. The DON was notified and wanted an x-ray to be done. This LPN asked if the resident should be sent to the emergency room , just in case the resident's leg was broken or should an in-house stat (immediate/rush) x-ray be performed. The LPN wrote that stat x-rays have taken upward of four hours to receive. The DON related to the LPN that it would be faster to do an in-house x-ray. The LPN notified the NP. The NP ordered a stat x-ray of the right hip and knee due to pain. The resident's son was notified, was okay with the orders and wanted updates. This LPN went back to the resident's room after lunch for the 2:00 p.m., medication administration. A member of social services was with the resident and the resident was complaining of pain in her right leg. The resident was administered another as needed Hydrocodone-Acetaminophen tablet (analgesic) with her other medications. It had been six hours since her first pain medication of the day. The resident slept on and off for the next two hours and still complained of pain in the right leg. At 2:30 p.m., this LPN came back to complete the resident's last medication administration for this shift. The x-ray technician had just completed taking the ordered x-rays. The technician notified this LPN that he/she wanted to view the resident's x-rays and acknowledged that he/she was not a radiologist. The x-rays revealed an apparent fracture of the right femur, with soft tissue swelling. This LPN notified the DON. The DON requested the NP review the x-rays and told the LPN not to call the family, until an official diagnosis of the x-rays was provided. This LPN was worried about it taking overnight (diagnosis results), when an apparent break was visible. The NP was in the facility and this LPN went to the provider's facility office to let her know what the x-ray looked like. The NP reviewed the x-rays and this LPN notified the resident's son. The son was notably upset. This LPN was told to call for a non-emergent ambulance for the resident. This LPN got all paperwork ready, called for a non-emergent transport and showered the resident's the x-rays, to help her understand why she was being sent to the emergency department. The DON and family were notified of the transfer. At 5:20 p.m., the non-emergent transport arrived at the facility. The non-emergent transport staff were upset that 911 had not been called to transport the resident related to a known fracture and the need for stabilization. Hospital admission history and physical dated 11/20/23 at 11:47 p.m. revealed the resident fell during a transfer. The resident was able to stand up on her own and was holding on to a pole. The resident decided to sit down and was assisted to the ground; unclear as to when the trauma happened. The resident's son reported that the resident was not assessed for 28 hours. The resident sustained a fall on 11/19/23 at her nursing facility. On 11/20/23 the resident was found to have the inability to ambulate, with a shortened and rotated right leg. The radiology report dated 11/20/23 at 4:23 p.m. revealed a nearly complete displaced distal femur metadiaphysis fracture. Hospital discharge summary dated 11/28/23 at 11:41 a.m. revealed the reason for hospitalization was a right hip fracture requiring acute intervention. The resident came to the hospital from an outside long-term care facility after experiencing a fall. The resident fell after trying to sit down on her own at the facility and was not evaluated for two days. The resident was a one-person wheelchair assist to a wheelchair at baseline. Upon presentation, x-ray showed a displaced fracture of the right femur. Orthopedics was consulted and performed an acute open reduction and internal fixation (ORIF) in the operating room with a successful surgery. Fall Risk assessment dated [DATE] at 3:32 p.m. noted a score of 12 or high fall risk. A physician progress note dated 12/14/23 at 2:39 p.m. revealed the staff requested the resident be seen today. The resident was a chronic long term care resident at the facility with a post cerebrovascular accident with right hemiparesis. The resident fell with a resultant right femur fracture. The resident had chronic pain. Care plan for alteration in musculoskeletal status related to fracture of the right femur was initiated on 12/12/23. Some of the interventions were for staff to anticipate and meet the resident's needs. Staff were to ensure the call light was within reach and respond promptly to all requests for assistance. Staff were to follow physician orders for weight bearing status. Staff were to monitor and document the risk for falls. The staff were to educate the resident/family/caregivers on safety measures that needed to be taken in order to reduce the risk for falls. Staff were to monitor/document/report as needed any signs or symptoms or complications related to arthritis, joint pain, joint stiffness (usually worse on wakening), swelling, decline in mobility, decline in self-care ability, contracture formation/joint shape changes, Crepitus (creaking or clicking with joint movement); and/or pain after exercise or weight bearing. IV. Staff interviews The director of rehabilitation (DOR) was interviewed on 12/19/23 at 8:25 a.m. She said she had provided services to the resident. She said the resident received physical therapy services on 11/30/23 related to a right distal femur fracture. She said the resident continued to receive services at this time. She said the resident's right side was impaired. She said at present, the resident did passive ranges of motion to the lower extremities, strength exercises, leg exercises and standing. She said before the resident fell , she had a ceiling to floor transfer pole to aid in transfers. The DOR said the resident was able to hold on to the transfer pole with her left hand and pivot to a chair with two staff members present. She said therapy recommended the facility use a Hoyer lift with this resident. She said the resident was a two person transfer with a Hoyer lift. A review of the physical therapy notes revealed the resident was a moderate assist with two staff persons for safety reasons. She said in the past six months, the resident needed two staff persons for transfers related to the resident being a moderate assist about 50% of the time. The MDS coordinator was interviewed on 12/19/23 at 8:48 a.m. She said the current MDS section GG (functional abilities and goals) did not specify the number of staff to use for a transfer. The staff would ask and assess the resident to determine the specific methodology to use for a transfer. LPN #2 was interviewed on 12/19/23 at 9:10 a.m. She said the resident had a transfer pole in her room, could stand up and pivot by herself. She said some days she needed one staff person to help transfer and this was not unusual, with the use of a transfer pole. She said she was the resident's nurse on 11/20/23. She said she did not receive a report of this resident having been lowered to the floor by a CNA on the previous day (11/19/23 at 2:51 p.m.). She said after she received this information, she assessed the resident at 10:30 a.m. She said her husband, who was an RN and worked for the facility, came and observed the resident at 10:30 a.m., but did not assess the resident. She said he did not document that he observed the resident. She said being lowered to the floor with assistance was considered a fall. She observed the resident's right leg and it was crooked. The resident yelled out in pain and pointed at her right leg. This LPN observed swelling around the right knee. A stat x-ray was ordered by the NP at 11:00 a.m. At 2:40 p.m., the resident still complained of right leg pain. The resident would point at the right leg and moan. At 4:30 p.m., she administered the resident's evening medications and this was also when the x-ray was taken. She said the DON and NP wanted an in-house x-ray and it took almost 4.5 hours for the x-rays to be taken. After the x-rays were taken, the NP reviewed them, confirmed there was a fracture and gave an order to send the resident to the emergency room using non-emergent transport. She said nursing staff were not allowed to call a family member, until the x-ray results had been read and confirmed. She said she heard the conversation with the son using a speaker phone. She said he was upset that the resident had not been sent to the hospital for the fall and the facility had just now found out the leg was broken. She said at 5:20 p.m., the non-emergent transport service came to pick up the resident. They were upset because the facility knew the resident had a fracture, why did they not send her to the emergency room sooner. She told them this was the order from the NP and the resident's son had agreed to this transfer. She said it took the two transport staff and herself to stabilize the resident's leg and two additional facility staff members to move the resident from the bed to the gurney. The DON and the director of clinical risk management (DCRM) were interviewed on 12/19/23 at 12:46 p.m. They said the resident had a fall on 11/19/23 at 2:51 p.m. This was a witnessed fall. A CNA lowered the resident to the floor during an assisted transfer with a transfer pole. They said there was no RN assessment of the resident before she was moved off of the floor, after the fall. An RN assessment should have been done prior to moving the resident form off the floor. They said the resident was assessed by a LPN and did not express any pain at the time of the fall. The resident started complaining of leg pain on 11/20/23 at 10:30 a.m. The LPN talked (11/20/23 at 10:30 a.m.) with the DON that the resident's leg was swollen and it was recommended to call the provider's office to get an x-ray. After the LPN told the DON about the resident's leg, the DON did not go and assess the leg. A stat x-ray was ordered by the NP on 11/20/23 at 11:45 a.m. and was taken at 4:23 p.m. (4.38 hours later). The NP assessed the resident on 11/20/23 at 5:00 pm. and reviewed the x-ray (fracture of the right femur). The NP gave an order for the resident to go to the emergency room using non-emergent transport services. The son was told that the resident would be sent non-emergent to the hospital and he agreed. The transport service arrived at the facility at 5:20 p.m. The non-emergent transport staff were not happy and stated 911 should have been called, because the resident had a known fracture and that needed stabilization. They said the facility was following the NP orders and the son had agreed with the order. The DON and DCRM said before the survey started, a lengthy discussion was conducted with the resident's representative and adult protective services (APS). The facility had identified on 11/20/23 there was an issue with a lack of an RN assessment after the resident's fall on 11/19/23. They did in-services starting on 11/20/23 for the facility's fall protocol for all nursing staff with signatures. The in-services were ongoing at this time. They said if a resident falls, an RN assessment must be performed and total lift must be used to move the resident off of the floor. They did a performance improvement plan (PIP) that started on 11/20/23 for the RN assessment after a fall and the fall process. This PIP had measurable goals and a timeline. They were still doing audits at this time and would evaluate again after 30 days. RN #1 was interviewed on 12/19/23 at 2:34 p.m. She said an RN should assess a resident after a fall before the resident was moved from off the floor. She said the assessment was done to look for any type of injuries, bleeding, bleeding from the head, other head injuries, neck injuries, fractures and broken bones. The DON was interviewed on 12/19/23 at 2:45 p.m. She said a RN should complete an assessment for a resident that had fallen before the resident was moved from off the floor and placed in a bed or chair. She said the RN looked for range of motion of extremity issues, fractures, bleeding, abhorrent pupil responses, extremity rotational abnormalities, pain, and for any visible or suspected injuries. An LPN could observe a resident and stay with the resident until the RN came to do the assessment. The LPN could not conduct an assessment for a resident that had fallen. The NP was interviewed on 12/19/23 at 2:50 p.m. She said the resident fell the previous day (11/19/23) before she assessed her on 11/20/23. She said the resident was unable to stand or bear her body weight on the side of the body that sustained the fracture. She said since she could not bear weight and had lost some strength, her bones had become brittle. She said she did not know how the fall occurred. She said the resident's leg might have caught or twisted while she was lowered to the floor. She said she assessed the resident, ordered an x-ray and reviewed the x-ray (displaced femur fracture). She said a stat x-ray of four hours was a good (acceptable) time in long term care facilities. She said she sent the resident to the emergency room with non-emergent transport services. The NP said the reason she ordered non-emergency transport services was that the fracture occurred the day before and the resident was stable. The resident's health would not have declined, while they waited on the non-emergent services. She said emergency services were for residents with chest pain, difficulty in breathing and a possible heart attack.

Based on observations, record review, and interviews, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight ranges, for two (#6 and #9) of three residents reviewed out of 10 sample residents. Resident #6, who was on hospice services and was known to be at risk for nutritional problems due to early onset Alzheimer's disease, weighed 145.8 pounds (lbs) upon his admission to the facility on [DATE]. On 11/19/21, the resident weighed 139 lbs, a weight loss of 6.8 lbs, or 4.7%, in one month. The weight loss did not meet the parameters of 5% or greater in one month for significant weight loss, and the facility failed to implement any nutritional interventions to prevent further weight loss. On 1/1/22, the resident weighed 136.6 lbs, a loss of 9.2 lbs, or 6.3%, in less than three months. The facility again failed to implement any nutritional interventions despite the resident's continued trend of weight loss. On 2/1/22, Resident #6 weighed 131.6 lbs, a loss of five pounds, or 3.7%, in one month, and a loss of 14.2 lbs, or 9.7%, in less than four months. The facility did not implement any nutritional interventions despite the resident's continued weight loss. On 3/1/22, the resident weighed 126.2 lbs, a loss of 5.4 lbs, or 4.1% in one month, and a severe weight loss of 19.6 lbs, or 13.4% in less than five months. The resident was not placed on any nutritional interventions until 3/9/22, when the facility obtained an order for a nutritional supplement. Due to the facility's failures to implement timely nutritional interventions, Resident #6 sustained a severe weight loss of 19.6 lbs, or 13.4% in less than five months. Additionally, Resident #9, who was known to be at risk for nutritional problems due to dementia and protein-calorie malnutrition (inadequate intake of food), weighed 127.3 lbs on 11/2/22. The resident weighed 115.6 lbs on 12/5/22. This was a severe weight loss of 11.7 lbs, or 9.2%, in one month. The resident weighed 112.4 lbs on 1/2/23, which was an additional weight loss of 3.2 lbs, or 2.8%, in less than one month. The resident had received a nutritional supplement one time per day since 7/1/22, however, the facility failed to increase the nutritional supplement or implement any other nutritional supplements or fortified foods after the resident sustained the severe weight loss on 12/5/22. Resident #9's nutritional supplement was not increased to two times per day until 1/19/23, after the resident had sustained the additional 2.8% weight loss. A fortified pudding was not ordered as an additional intervention until 1/19/23. On 12/9/22, the interdisciplinary team (IDT) recommended an occupational therapist (OT) evaluate the resident during meals, however, the OT assessment did not occur until 1/20/23. On 3/2/23, the resident weighed 114.0 lbs, a gain of 1.6 lbs, or 1.4%, in two months. Due to the facility's failure to provide timely nutritional interventions, Resident #9 continued to lose weight following her initial severe weight loss of 11.7 lbs, or 9.2%, in one month. Findings include: I. Facility policy and procedures The Weight Policy, revised May 2021, was provided by the nursing home administrator (NHA) on 3/15/23 at 2:16 p.m. It read in pertinent part, Weights will be regularly monitored to assure the identification, evaluation and initiation of care planning for residents who have experienced actual weight loss or weight gain. All residents will be weighed each month. More frequent weights will be obtained as ordered by the physician, or requested by a licensed nurse or registered dietitian (RD). Any residents with a significant weight change x 1 month (greater than or equal to 5%) will be reweighed. The RD will review residents' weights monthly. A review and evaluation will determine if the resident is at his/her desired body weight or has a significant, unintended weight change. Significant weight changes include: 5% loss/gain in weight in a month; 7.5% loss/gain in three months; or 10% loss/gain in weight in six months. The RD along with the interdisciplinary team (IDT) will review residents with significant weight changes and develop a care plan accordingly. Individualized interventions will be recommended and initiated to meet weight goals as clinically possible depending on the resident's status. II. Resident #6 A. Resident status Resident #6, age younger than 70, was admitted [DATE] and discharged to another facility on 7/14/22. According to the July 2022 computerized physician orders (CPO), diagnoses included early onset Alzheimer's disease. The 4/21/22 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) was not conducted. According to the staff assessment for mental status, the resident had a short term and long term memory problem, and his cognitive skills for daily decision making were severely impaired. He required two-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. He was totally dependent on the assistance of one person for eating. He coughed or choked during meals or when swallowing medications. According to the MDS assessment, he did not have, or it was unknown if he had, a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months. B. Record review Review of Resident #6's nutrition care plan, initiated on 10/19/21 and revised on 6/9/22, revealed the resident was at risk for nutritional problems related to early onset Alzheimer's disease. Pertinent interventions included assisting the resident with meals as needed, monitoring weight monthly or as indicated, providing and serving supplements as ordered, providing the resident with double portions at meals, and referring to the RD as needed. Review of Resident #6's weight records revealed the following documented weights: -10/14/21: 145.8 lbs; -10/26/21: 140.0 lbs (a weight loss of 5.8 lbs or 4.0% in less than a month); -11/2/21: 140.9 lbs; -11/19/21: 139.0 lbs; -12/6/21: 140.2 lbs; -1/1/22: 136.6 lbs (a weight loss of 9.2 lbs or 6.3% in less than three months); -2/1/22: 131.6 lbs (a weight loss of 5 lbs or 3.7% in one month, and 14.2 lbs or 9.7% in less than four months); -3/1/22: 126.2 lbs (a weight loss of 5.4 lbs or 4.1% in one month, and a severe weight loss of 19.6 lbs or 13.4% in less than five months); -4/1/22: 129.8 lbs (a weight gain of 3.6 lbs or 2.9% in one month, following the addition of a nutritional supplement on 3/8/22. See physician orders below); -5/1/22: 127.6 lbs (a weight loss of 2.2 lbs or 1.7% in one month); -6/1/22: 131.6 lbs (a weight gain of 4 lbs or 3.1% in one month); and, -7/1/22: 131.4 lbs (a weight gain of 5.2 lbs or 4.1% in four months, following the increases of the resident's nutritional supplement. See physician orders below). Resident #6's July 2022 CPO included the following physician orders: -Weights monthly every day shift starting on the 1st and ending on the 1st every month. The order date was 12/6/21; and, -House nourishment (nutritional supplement) four times a day 4 ounces with peanut butter for weight management. The order date was 5/6/22. Review of the Resident #6's physician order history revealed the following orders: -House nourishment one time a day for weight management with peanut butter. The order date was 3/8/22. The order was discontinued on 3/11/22 when the supplement was increased; -House nourishment two times a day for weight management 4 ounces with peanut butter. The order date was 3/11/22. The order was discontinued on 4/21/22 when the supplement was increased; -House nourishment three times a day for weight management 4 ounces with peanut butter. The order date was 4/21/22. The order was discontinued on 5/6/22 when the supplement was increased; and, -House nourishment four times a day for weight management 4 ounces with peanut butter. The order date was 5/6/22. Review of Resident #6's medication administration records (MAR) from March 2022 through July 2022 revealed the nutritional supplement was documented as being offered to the resident. -The MAR did not document how much of the nutritional supplements were consumed by the resident at each administration from 3/8/22 through 4/21/22. Review of Resident #6's electronic medical record (EMR) revealed the following progress notes documented in pertinent part: 11/2/21: Quarterly Assessment. Resident continues to have a good appetite with 76-100% oral intake daily with snacks everyday, and continues to be mainly a totally dependent eater. CBW (current body weight): 140.9 lbs. Weight trend: 3.36% weight loss since admission. Registered dietitian (RD) will continue to monitor resident's plan of care and nutritional status as needed. -There were no further nutrition notes documented until 3/17/22, after Resident #6 sustained a severe weight loss. 3/17/22: Significant weight change. 11.1% weight loss in three months. Etiology: Hospice, declining mental status. Intervention: House supplement one time per day with peanut butter. Goal: Maintain current body weight (CBW) +/-5% (weight changes) monthly, comfort care due to hospice. RD will continue to monitor resident's plan of care and nutritional status as needed. 5/6/22: Significant weight change. Supplements: House supplement three times per day. Weight trend:12% weight loss in six months. Oral intake: 76-100%. Feeding ability: Usually total dependence, sometimes independent. Interventions/Recommendations: Increase house supplement to four times per day, continue to encourage oral intake, and monitor weight. RD will continue to monitor resident's plan of care and nutritional status as needed. 5/10/22: Interdisciplinary team (IDT) met to review resident's weight loss. Resident is currently triggering for significant loss of 14 lbs lost in 180 days, representing 12% loss. Resident is encouraged to increase oral intake at meals, typically eats 76-100% at meals. Nutritional interventions include: increase house supplement to four times per day. RD evaluated on 5/6. Physician and resident/representative notified of weight loss on 5/6/22. Weight may fluctuate due to disease process. Will continue to monitor and encourage oral intake. 6/7/22: Weight review: Weight on 6/1/22 of 131.6 lbs triggered a 5.3% weight gain. CBW of 131 lbs on 6/5/22 did not trigger significant weight gain. Weight gain is beneficial. Continue house supplement with peanut butter four times per day, continue to encourage oral intake, and monitor weight. RD will continue to monitor resident's plan of care and nutritional status as needed. Review of Resident #6's nutritional assessments revealed the following documentation in pertinent part: 1/21/22: Weight trend: 6.7% weight loss in 3 months. Registered nurse (RN) reports resident has great oral intake, no gastrointestinal issues, regular bowel movements, and no chewing/swallowing issues. RD will continue to monitor the resident's plan of care, nutritional status, and weight as needed. -A nutritional supplement was not started despite the resident sustaining a 6.7% weight loss over three months. 4/22/22: Nonsignificant weight loss. Nursing reports the resident eats/drinks everything, he won't stop himself, including supplements. However, despite great appetite resident still has weight loss. RD will increase supplement to three times per day from two times per day. Recommendations: Increase supplement to three times per day, provide/offer preferred foods/snacks/meal assistance as needed, and monitor weight. -The assessment documented the resident had nonsignificant weight loss, despite the resident sustaining a severe weight loss of 19.6 lbs or 13.4% in less than five months. III. Resident #9 A. Resident status Resident #9, age 82, was admitted [DATE]. According to the March 2023 CPO, diagnoses included dementia and protein-calorie malnutrition. The 1/12/23 MDS assessment revealed that the resident had severe cognitive impairment with a BIMS of zero out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. She required supervision and set-up help for eating. She had a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months, and was not on a prescribed weight loss regimen. B. Observation On 3/14/23 at 11:45 a.m., Resident #9 was seated in her wheelchair in her room. A full plate of food and a bowl of pudding was on the bedside table in front of her. The resident was staring straight ahead and was not making any attempt to feed herself. Her silverware was unwrapped and lying on a napkin next to the plate. The silverware was not weighted, and there were no finger foods on her plate (see care plan below). At 11:51 a.m., certified nurse aide (CNA) #1 entered the resident's room, sat down on the resident's bed, and began to physically assist Resident #9 to eat. The resident accepted the food that was offered. C. Record review Review of Resident #9's nutrition care plan, initiated on 7/14/22 and last revised on 1/13/23, revealed the resident was at risk for nutritional problems related to poor oral intake and dementia. The resident did better with finger foods or handheld foods. The resident had a significant weight loss in December 2022 and January 2023, and occupational therapy was consulted. Pertinent interventions included assisting the resident with eating, providing a nutritional supplement daily and a fortified pudding daily, providing adaptive eating equipment as ordered/needed, monitoring/recording intakes each meal, monitoring/recording weights as ordered, and encouraging oral intakes and fluids. Review of Resident #9's weight records revealed the following documented weights: -7/9/22: 127 lbs; -7/17/22: 127.2 lbs; -7/24/22: 127 lbs; -There was no weight documented for August 2022; -9/6/22: 127.1 lbs; -10/3/22: 127.2 lbs; -11/2/22: 127.3 lbs; -12/5/22: 115.6 lbs (a severe weight loss of 11.7 lbs or 9.2% in one month); -12/7/22: 116.2 lbs (reweigh); -12/25/22: 116.2 lbs; -12/30/22: 117.7 lbs; -1/2/23: 112.4 lbs (an additional weight loss of 3.2 lbs or 2.8% in one month); -1/13/23: 112.4 lbs; -2/1/23: 112.6 lbs; and, -3/2/23: 114 lbs (a weight gain of 1.6 lbs or 1.4% in two months, following the increase in the resident's nutritional supplement and the addition of the fortified pudding on 1/19/23. See physician orders below). Resident #9's March 2023 CPO included the following physician orders: -Weights monthly every day shift starting on the 1st and ending on the 3rd every month. The order date was 7/25/22; -Pudding two times a day for weight loss 4 ounces after lunch and dinner. The order date was 1/19/23; -House Nourishment (nutritional supplement) two times a day for weight loss 4 ounces between meals. The order date was 1/19/23; and, -Resident to have a large handled bent spoon and built up handled fork for all meals to support self feeding. The order date was 1/24/23. Review of the Resident #9's physician order history revealed an order for House Nourishment one time a day for nutritional support. The order date was 7/11/22. -There were no other physician orders for nutritional supplements or fortified foods in the resident's physician order history prior to 1/19/23. Review of Resident #9's MAR from November 2022 through March 2023 revealed the nutritional supplement and the fortified pudding were documented as being offered to the resident. -The MAR did not document how much of the nutritional supplements were consumed by the resident at each administration. Review of Resident #9's EMR revealed the following progress notes documented in pertinent part: 12/9/22: Significant weight change. The Interdisciplinary team (IDT) met to review resident's weight loss. Resident is currently triggering for significant loss of 12 lbs lost in less than one and three months, representing 8.7% loss. Resident is encouraged to increase oral intake at meals, typically eats 26-100% at meals. Nutritional interventions include: encourage oral intake, consulted occupational therapy (OT) to assess resident during meals. Registered dietician (RD) evaluated on 12/8/22. Physician and resident/representative notified of weight loss on 12/8/22. Weight may fluctuate due to diuretic (medication which helps rid the body of salt and water) use/disease process. Will continue to monitor and encourage oral intake. -There was no OT evaluation for December 2022 in Resident #9's EMR, and the facility was unable to provide documentation that an evaluation had occurred (see therapy evaluations below). -Resident #9 did not have a physician's order for a diuretic medication despite the progress note documenting the resident's weight may fluctuate due to diuretic use. -The resident's nutritional supplement was not increased and no fortified foods were added as nutritional interventions despite the resident's severe weight loss (see physician's orders above). 12/27/22: Weight review follow-up. Current body weight (CBW): 116.2 lbs. Weight trend: 8.6% weight loss in almost three months. Full nutritional assessment on 12/8/22 for weight trend: 7.9% weight loss in one month, 8.3% weight loss in two months from weight of 116.6 lbs on 12/8/22. Weight stable and no changes in resident status or appetite since nutritional assessment. RD will continue to monitor resident's plan of care and nutritional status as needed. 12/31/22: Weight review follow-up. CBW: 117.7 lbs on 12/30/22. 1.5 lb weight gain in five days, weight gain is beneficial. Full nutritional assessment on 12/8/22. No other changes in resident status or appetite since nutritional assessment. RD will continue to monitor resident's plan of care and nutritional status as needed. 1/13/23: Significant weight loss. IDT met to review resident's weight loss. Resident is currently triggering for significant loss of 15.3 lbs and 15 lbs lost in less than two months and six months, representing 11.7% and 11.5% loss. Resident is encouraged to increase oral intake at meals, typically eats 26-75% at meals. Nutritional interventions include: encourage oral intake, super pudding daily, consult community OT. RD evaluated on 1/13/22. MD (medical doctor) and resident/representative notified of weight loss on 1/13/22. Weight may fluctuate due to diuretic use/disease process. Will continue to monitor and encourage oral intake. -Resident #9 did not have a physician's order for a diuretic medication despite the progress note documenting the resident's weight may fluctuate due to diuretic use. -The resident's nutritional supplement was not increased and no fortified foods were added as nutritional interventions until 1/19/23, despite the progress note documenting the resident was on a fortified pudding daily (see physician's orders above). 2/9/23: IDT met to review resident's weight loss. Resident is currently triggering for significant loss of 15 lbs lost in less than three months, representing 11.5% loss. Resident is encouraged to increase oral intake at meals, typically eats 51-100% at meals. Nutritional interventions include: finger foods when able, encourage oral intake, speech therapy consult, weighted utensils. RD evaluated on 2/9/23. physician and resident/representative notified of weight loss on 2/9/23. Weight may fluctuate due to diuretic use/disease process. Will continue to monitor and encourage oral intake. -Resident #9 did not have a physician's order for a diuretic medication despite the progress note documenting the resident's weight may fluctuate due to diuretic use. -There was no speech therapy evaluation for February 2023 in Resident #9's EMR, and the facility was unable to provide documentation that an evaluation had occurred (see therapy evaluations below). -The resident did not have a physician's order for finger foods and no finger foods were observed during observation of the resident at lunch on 3/14/23 (see observation above). -Resident #9 had a physician's order for weighted utensils, however, the resident had not been provided with weighted utensils at lunch on 3/14/23 (see observation above). 3/9/23: Significant weight change. IDT met to review resident's weight loss. Resident is currently triggering for significant loss of 13 lbs lost in less than six months, representing 10.2% loss. Resident is encouraged to increase oral intake at meals, typically eats 51-100% at meals. Nutritional interventions include: weighted utensils, continue house supplement two times daily, fortified pudding two times daily. RD evaluated on 3/9/23. Physician and resident/representative notified of weight loss on 3/9/23. Weight may fluctuate due to diuretic use/disease process. Will continue to monitor and encourage oral intake. -Resident #9 did not have a physician's order for a diuretic medication despite the progress note documenting the resident's weight may fluctuate due to diuretic use. -Resident #9 had a physician's order for weighted utensils, however, the resident had not been provided with weighted utensils at lunch on 3/14/23 (see observation above). Review of Resident #9's nutritional assessments revealed the following documentation in pertinent part: 12/8/22: Weight trend: 7.9% weight loss in one month, 8.3% weight loss in two months. Weight loss unintended and unfavorable. Resident appears thin. RD spoke with registered nurse (RN) due to resident's mental status. RN reports resident is doing well but has had a decreased appetite recently. RN reports resident eats less when she eats in her room and thinks it would be beneficial for resident if she had assistance during meals. RD will speak with OT about assessing resident. RD discussed with RN about adding another house supplement, RN reported resident doesn't finish the one she has now so she doesn't think she would drink another one. RN reports she thinks the most beneficial intervention for resident would be to have assistance during meals so her oral intake would increase. -There was no OT evaluation for December 2022 in Resident #9's EMR, and the facility was unable to provide documentation that an evaluation had occurred (see therapy evaluations below). -No other nutritional interventions were put into place despite the RD documenting, per the RN, that the resident did not drink the nutritional supplement she was receiving daily. 1/5/23: Weight trend: 11.7% weight loss in two months, 11.8% weight loss in six months. Weight loss unintended and unfavorable. Resident appears thin. Resident is now off of isolation due to COVID-19, nurse reported no adverse reactions at this time, lots of sleeping, some decreased oral intake due to lots of sleeping, good appetite when awake. Last note RD stated she would ask OT to assess resident, OT was not able to assess resident due to resident therapy provided by outside community provider. RD spoke with the outside provider's RD to consult OT. OT has been consulted. RD and outside provider's RD also agreed to try fortified pudding for resident. RD will order. -The OT consult did not occur until 1/20/23, 15 days after the nutritional assessment was conducted (see therapy evaluation below). -The physician's order for fortified pudding was not obtained until 1/19/23, two weeks after the nutritional assessment (see physician's orders above). 2/7/23: Weight trend: 11.5% weight loss in three months, 11.4% weight loss in six months. Weight loss unintended and unfavorable. Resident appears thin. RD spoke with resident RN. RN reports resident is doing well, has a good appetite, does well with finger foods and continues to need assistance with non-finger foods. RN reports resident may not need to be on pureed diet, RD will contact outside provider for speech consult. RN reports resident has not been getting weighted utensils, RD will contact outside provider also about putting weighted utensils order in. No other questions/concerns for RD at this time. RD will continue to monitor resident plan of care and nutritional status as needed. -There was no speech therapy evaluation for February 2023 in Resident #9's EMR, and the facility was unable to provide documentation that an evaluation had occurred (see therapy evaluations below). -The resident did not have a physician's order for finger foods and no finger foods were observed during observation of the resident at lunch on 3/14/23 (see observation above). -Resident #9 had a physician's order for weighted utensils, however, the resident had not been provided with weighted utensils at lunch on 3/14/23 (see observation above). 3/9/23: Weight trend: 10.2% weight loss in six months-unintended and unbeneficial. Few pound weight gain over one month, weight gain is beneficial. Resident appears thin. Resident reports she would like to maintain weight. RD informed resident of CBW and body mass index (BMI), resident still wants to maintain weight but will be okay with some weight gain. Resident reported she is doing well, appetite is 'pretty good' , and she is not always getting her house supplements. RD will speak with nursing staff about offering house supplement two times a day. Suspected etiology for initial weight loss was poor oral intake at the time. Weighted utensils have helped increase oral intake. Resident had no questions/concerns for RD at this time. RD will continue to monitor resident plan of care and nutritional status as needed. -Resident #9 had a physician's order for weighted utensils, however, the resident had not been provided with weighted utensils at lunch on 3/14/23 (see observation above). A physician's progress note dated 12/13/22 documented the following in pertinent part, Nursing concerns: No concerns expressed by unit nurses. Resident was seen at the lunch hour. She was eating her lunch. She had no concerns. Appearance: well-nourished, well developed, alert, in no acute distress, eating a hamburger. -The progress note did not indicate the physician was aware of the severe weight loss the resident had sustained on 12/5/22. An occupational therapy evaluation dated 1/20/23 documented in pertinent part: Situation: Review of eating set up due to weight loss. Background: Resident lives at skilled nursing facility. Facility reports 14 lb weight loss in three months. Assessment: Resident was in her room when OT visited. Resident was agreeable to trialing use of adaptive utensils for eating apple sauce and fruit cup. Resident demonstrated improved intake with curved spoon and built up fork. OT discussed with RN and kitchen staff. OT will send order for use. Recommendation: Provide order for use of adaptive silverware. Complete follow up if any changes in weight or staff concerns reports. -There was not an OT evaluation for December 2022 or a speech evaluation for February 2023 in Resident #9's EMR and the facility was unable to provide documentation that the evaluations had occurred (see nutritional assessments above). D. Staff Interviews Certified nurse aide (CNA) #1 was interviewed on 3/14/23 at 12:10 p.m. CNA #1 said Resident #9 usually ate pretty well when staff assisted her. She said she would usually eat the fortified pudding that was sent from the kitchen. Licensed practical nurse (LPN) #1 was interviewed on 3/14/23 at 12:22 p.m. LPN #1 said Resident #9 had lost a large amount of weight in December 2022. She said the resident's weight had been stable since January 2023. She said Resident #9's nutritional supplement was increased to two times per day on 1/19/23. LPN #1 said the resident also started on fortified pudding two times per day on 1/19/23. She said the resident could eat by herself, but usually required assistance. She said her meal intake was greater when staff assisted her. LPN #1 said the resident did drink her nutritional supplement and eat the fortified pudding. She said the amount of the nutritional supplements should be documented on the resident's medication administration record (MAR) every time the resident received the supplements. LPN #1 said Resident #9's MAR did not include documentation of how much of the supplements were consumed by the resident, however, she said that was supposed to be documented to determine if the interventions were beneficial. IV. Additional interviews The director of nursing (DON) was interviewed on 3/15/23 at 11:56 a.m. The DON said resident weights were obtained monthly. She said the RD monitored the weights. She said if a significant change in weight occurred for a resident, the RD would request a reweigh to ensure the weight was accurate. The DON said if the RD noticed a weight loss, or that a resident was not gaining back weight that was previously lost, then she would change the nutritional interventions. The DON said she was not working at the facility when Resident #6 resided there. She reviewed his weight records and confirmed the resident's weight had been trending down prior to his severe weight loss in March 2022. She confirmed the resident did not have any nutritional supplement orders put in place until 3/8/22 despite the resident's weight loss trends prior to 3/1/22. She further confirmed there was no documentation of how much the resident consumed of his nutritional supplement until 4/22/22. The DON said a nutritional intervention for Resident #6 should have been put into place sooner than it was. She said the amount of the nutritional supplement consumed by the resident at each administration should have been documented from the time the intervention was put into place on 3/8/22. The DON said Resident #9 used to eat on her own, however, the resident now required a staff person to physically assist her with eating. She said the resident would eat fairly well when someone assisted her. The DON said Resident #9 had a significant weight loss between November 2022 and December 2022. She said the resident was on a nutritional supplement one time a day, but did not have orders for any fortified foods prior to her weight loss. She said the nutritional supplement should have been increased or another nutritional intervention put into place at the time the weight loss was discovered on 12/5/22. The DON confirmed the resident's nutritional supplement was not increased and the fortified pudding was not ordered until 1/19/23. She said the percentage of the supplement should be documented for each administration so the RD could determine if the interventions were effective. The RD and the regional registered dietitian (RRD) were interviewed together on 3/15/23 at 12:31 p.m. The RD said she monitored resident's weights monthly or more frequently if needed. She said she conducted a monthly weight trends audit on residents in an attempt to catch insignificant weight losses before they turn into significant weight losses. She said if a significant weight loss was observed, she would have nursing staff obtain a reweigh on the resident to determine if the weight was accurate. The RD said if the weight was determined to be accurate then she would talk with the resident, or the nursing staff if the resident was cognitively impaired, to see if the resident had had a loss of appetite and if the resident would accept a nutritional supplement or fortified foods that added more calories and protein to the resident's diet. She said she would have a discussion with the IDT to determine what nutritional interventions should be put into place for the resident. The RD said residents were put on nutritional supplements or fortified foods on an individualized basis. She said residents could be started on nutritional interventions if they were at risk for weight loss, had poor oral intake, or had sustained a weight loss. She said nursing staff was responsible for documenting how much of a nutritional supplement was consumed by a resident at each administration of the supplement. She said if the amount consumed was not documented, she would talk to the nursing staff to see if the resident[TRUNCATED]

Based on observation, record review and interviews, the facility failed to ensure for one (#1) of three out of five sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan out of eight sample residents. Specifically, the facility failed to ensure the wounds on Resident #1's right toes were sufficiently covered so that flies were unable to access the resident's wound. The facility's failure to completely cover the wounds resulted in Resident #1 getting maggots in his wounds, requiring hospitalization and ultimately removal of two of his toes. Findings include: I. Facility policy The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin Management System policy, last revised July 2017, was provided by the ADON on 9/7/22 at 11:05 a.m. It read in pertinent part, Residents receive care to aid [NAME] the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed, and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. For pressure reduction: assist the resident to change position periodically in bed as indicated by the nursing assessment or as requested by the resident; utilize a pressure reducing mattress or pressure reducing overlay; provide a pressure reducing device on wheelchair/chair/recliner; consider elevating heels off of the bed with pillow or use of heel protectors. A weekly skin check will be completed in the resident's record using the Head to Toe Skin Check User Defined Assessment (UDA). II. Resident #1 status Resident #1, age 77, was initially admitted on [DATE] and readmitted on [DATE]. According to the September 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/29/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. He required extensive assistance of two persons with bed mobility, transfers, and dressing. He required extensive assistance of one person with locomotion on and off the unit, toilet use, and personal hygiene. He required set-up assistance with eating. He did not have any behaviors or rejections of care. The MDS identified the resident as being at risk of developing pressure injuries. III. Resident interview The resident was interviewed on 9/6/22 at 11:47 a.m. He said he had been in the facility for a few months, and he recalled the evening (7/9/22) when registered nurse (RN #1) found the maggots in the wound on his toes. The resident said he recalled the day he saw a fly on his foot, and assumed that had been the culprit fly. He said he had been in the therapy gym on 7/8/22 riding a stationary bike, and watched a fly land on his leg and foot. He said at the time, his foot was not wrapped, but was open and when he assumed the fly got into the wound and layed eggs. The resident said on 7/7/22 the wound care physician (WCP) had completed an assessment and treatment on the wounds, and the WCP wrapped the wounds, but the resident stated the wounds were not tightly wrapped, and the wrapping did not stay in place, and at some point he assumed the wrapping was removed although he could not recall when. The resident said he was very bothered by having maggots in his wounds, but thankfully he had no feeling in his feet due to [CONDITION(S)]. He said he was sent to the hospital the following [MEDICATION(S)] the maggots were found, and at that time it was determined that two of his toes needed to be amputated. He said the wounds in his toes were being treated by the facility, and he was not sure if they were improving, and was very concerned that he got maggots in the wound. He said the facility never interviewed him about how/why he got the maggots, rather they asked him if he wanted to move rooms. He said they told him his room window was close to the kitchen dumpster, and that he could move rooms further from the dumpster. He said they also taped up openings that were found around the window air conditioner in his room. He said he did not see a need to move rooms since he had never seen a fly in his room, and the only time he had seen a fly was in the therapy gym, which the facility would have known had they asked him. IV. Record review The 7/9/22 nurse skin/wound note documented the following: RN (registered nurse) changed wound dressings to right foot as per wound order. Removal of the dressing applied on 07/07/22 reveled (sic) several maggots within the wound beds between the 1st and 2nd toes, as well as the wound bed between the 2nd and 3rd toes. Maggots (were) also observed in (the) wound bed located (on the) lateral aspect of the right foot. RN notified DON (director of nursing) and spoke with (name of on call physician) from (name of physician clinic). RN received orders to clean (the) wound bed, apply dressings to (the) wound as per wound order and send resident to (name of hospital) in the following am to be evaluated by a vascular surgeon for treatment. The 7/10/22 hospital case information documented the following: The patient is a [AGE] year-old male with a significant past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He was admitted to the hospital for these chronic ulcerations with maggots noted to the wound sites (came from a facility like this). Due to the extent of wound breakdown and the presence of bone within the wound bases it was deemed necessary to perform amputations and an irrigation and debridement to remove all the necrotic (dead) and devitalized tissue. The patient was understanding of this. The risks and benefits as well as the recovery process were discussed in detail with the patient who expressed an understanding of the surgical plan and provided written and verbal consent. V. Interviews Registered nurse (RN) #1 was interviewed on 9/6/22 at 1:00 p.m. He said he was the nurse providing wound care treatment when the maggots were discovered in Resident #1's wound. He said he began the dressing change on 7/9/22 at about 8:30 p.m. He said the resident's toes were exposed when he was undoing the Kerlix (woven gauze) wrapping that was loosely on the resident's foot, as well as an ABD (abdominal pads, used for wounds requiring high absorbency). He said the dressing he removed was the same dressing that had been placed on 7/7/22 by the wound care physician (WCP). He said the wound had about 20 maggots in the wound bed, and several had fallen off onto the floor. He said when he found the maggots he immediately notified the director of nursing (DON), who was in the facility at the time, as well as the resident's physician. The RN said the physician told him to flush out the maggots with a wound cleanser and then complete the current wound orders. The physician told the nurse to contact the hospital the following morning so the resident could be sent out and seen by a wound specialist. The RN said that the wound appeared to be covered, but clearly was not covered completely if maggots were in the wound. The director of nursing (DON), assistant director of nursing (ADON), and corporate nurse consultant (CNC) were interviewed on 9/6/22 at 2:28 p.m. The ADON said she was the nurse who oversaw the wound care in the facility. She said Resident #1's vascular wounds on his toes were worsening, and on 7/7/22 the wound care physician (WCP) changed the wound care orders. She said the orders were to cleanse the wound, apply calcium alginate, cover with an ABD pad, and then wrap with Kerlix. The DON said she had been in the facility on 7/9/22 when RN #1 found the maggots in Resident #1's wound. She said starting on 7/9/22 she began an investigation to try to determine how the resident got the maggots in the wound. The DON said she did not specifically interview the resident as part of her investigation. The DON said they checked the gaps in between Resident #1's window air conditioner in his room and noted open spaces where flies could gain access into the facility. The DON said they offered Resident #1 a room change, and he declined. The DON said a facility wide window audit was completed on 7/11/22, and several other windows had been noted to have gaps, and those gaps were sealed. The DON said the facility had also completed a facility wide skin sweep to ensure no additional residents had maggots, and no additional concerns were found. The DON said the facility also began education with staff in the facility, although that education was focused on pressure injuries, and had nothing to do with maggots, or ensure wound dressings were placed correctly to ensure flies or other unwanted bacteria were not introduced into wounds. A frequent visitor with knowledge of the facility was interviewed on 9/7/22 at 9:30 a.m. She said she had spoken with the resident several times since he returned to the facility following his toe amputation. She said he repeatedly told her the same story of seeing a fly on his leg and foot in therapy. He said his leg had not been properly wrapped, and the fly was able to go in and out of the bandage. He repeatedly called the fly he saw in therapy the culprit who laid the eggs that resulted in the maggots in his wounds. The ADON was interviewed a second time on 9/7/22 at 10:55 a.m. She said the wound on Resident #1's toes should have been wrapped in a way that a fly and/or anything else would not have been able to gain access to the wound. She said the resident's toes should have been sandwiched in between the ABD pad and then wrapped with the Kerlix and then secured with a compression bandage to ensure it all stayed in place. The ADON said Resident #1 had a PRN (as needed) dressing change order, and staff should have done a dressing change if the Kerlix was loose or missing. The ADON said maggot treatment was used in wounds, but in no way was Resident #1 on any type of maggot treatment, and if he was, sterile maggots would have been used. The ADON said a fly with potential feces and bacteria on their feet was not what anyone would want on an open wound. The adult protective services (APS) staff member was interviewed on 9/7/22 at 11:05 a.m. She said she had met with Resident #1 while he was in the hospital following the amputation of his toes. She said the resident had told her he was in therapy, and watched a fly go in between his toes. She said the resident stated the wrapping on his foot was so loose that the fly was able to get in and out of the dressing and that fly was the culprit who laid the eggs that resulted in the maggots in his wounds. The DON, CNC, and ADON were interviewed again on 9/7/22 at 1:05 p.m. They said the resident was not on any type of maggot treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The CNC and DON said the maggots were good for the wound, although they were not sterile maggots, and no staff were aware there were maggots in the resident's wound until the dressing change was completed. VI. Medical director statement A statement from the facility medical director was provided by the ADON on 9/7/22 at 11:05 a.m. and read in pertinent part: I am familiar with Resident #1. He was discussed in detail at the August QAPI (quality assurance and performance improvement) on 8/17/22 which I attended in person. His wounds and amputation of (the) right foot toes 2-5 are unavoidable due to underlying ostromyelitis (sic). He also has atherosclerosis (build-up of fats, cholesterol, and other substances in and on the artery walls) with ulceration and [CONDITION(S)] (chronic obstructive pulmonary disease) which also contribute to the wounds being unavoidable. In addition the presence of maggots was beneficial to the overall treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . I have used maggots (in a foreign country) for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interviews and record review the facility failed to ensure the current CDC (Center for Disease Control and Prevention) guidelines; including social distancing, mask usage and hand hygiene occurred during the facilities' 1/12/21 COVID-19 (coronavirus disease) resident and facility staff vaccination clinic. Furthermore, the facility allowed outside community members into the facility, in resident common areas, to also participate in the COVID-19 vaccination clinic. During the time of the COVID-19 vaccination clinic the facility was in outbreak status as of 1/4/21. Due to the facility's failures, it created the likelihood of immediate and serious adverse outcomes for all of the residents in the facility who had yet to test positive for COVID-19. Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/1/21 and 2/3/21, resulting in the deficiency being cited as past noncompliance as of 2/2/21. During the onsite investigation, there were no other issues found in infection control. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy On 2/2/21 at approximately 8:00 a.m., it was identified that the facility had held their first COVID-19 vaccination clinic on 1/12/21. The facility was in outbreak status at the time, meaning they had identified, through testing, COVID-19 positive staff and/or residents in their facility beginning on 1/4/21. The facility held their vaccination clinic in one of the larger facility dining rooms. The facility transported all but five of the approximately 81 residents to the dining room for the clinic. Additionally, on 1/12/21, 11 outside community members were allowed access into the facility to participate in the COVID-19 vaccination clinic. Those 11 community members received their COVID-19 vaccination in the same dining rooms as the residents, although according to the facility, the community members received their vaccines after the residents. B. Facility plan to remove the immediate jeopardy situation The facility developed the following immediate plan: On 1/25/21, representatives from the facility met with the county health department and the state health department to discuss the status of their current outbreak. During the call, concerns arose regarding the facilities vaccine clinic held on 1/12/21. Those concerns regarded social distancing of residents and allowing members from the community to enter the facility to get their COVID-19 vaccine. Both health departments requested a plan for the 2/2/21 COVID vaccine clinic to ensure the concerns would be addressed. As a result of those concerns, the facility took the following actions for the vaccine clinic held on 2/2/21. Corrective Action: On 2/2/21 facility staff were vaccinated from 10:00-11:00 a.m. with appropriate social distancing maintained. Xs were on the floor to indicate a six-foot distance. The fifteen-minute waiting area was also marked off with Xs to maintain social distancing. On 2/2/21, all eligible residents received their vaccine in their rooms or in the doorway of their room. Three vaccinators were in place and they were escorted by a staff member. The vaccinators wore gowns, gloves, masks, and eye protection. Gowns and gloves were changed between each resident with hand sanitation completed before and after. In shared rooms residents in the window bed were vaccinated first and residents in the bed near the door were vaccinated second. Social distancing was maintained between the residents and they were monitored for 15 minutes by a designated staff member. Community members who received their second vaccine on this date were not permitted to enter the building or resident care area. Instead, they were taken to a separate office space in the basement of the building after appropriate screening was conducted. C. Removal of immediate jeopardy The immediate jeopardy situation was removed prior to the onsite investigation on 2/1/21 and 2/3/21. Interview and record review during the infection control survey investigation revealed corrective actions to ensure safer practices were followed during the 2/2/21 COVID-19 vaccination clinic. Systemic changes were in place to prevent a recurrence, and to ensure sustained correction with any upcoming vaccination clinic. Therefore, the deficient practice was correct prior to the onsite investigation and represented past noncompliance at L level, immediate jeopardy with a potential for harm that was widespread. II. Failure to ensure CDC recommendations were followed during 1/12/21 COVID-19 vaccination clinic A. Professional reference for mask use, social distancing and hand hygiene for residents According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last updated 11/20/2020, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html included the guidance that long term care facilities ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others, including whenever they leave the facility for essential medical appointments. Additional measures included that facilities should cancel communal dining and all group activities. Residents should be reminded to practice social distancing and frequent hand hygiene. Retrieved on 2/8/21. According to the CDC guidance Key Strategies to Prepare for COVID-19 in Long-term Care Facilities (LTCFs), last updated 11/20/2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html. Enforce social distancing among residents. Ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others .This approach is recommended because of the high risk of unrecognized infection among residents. Recent experience suggests that a substantial proportion of residents could have COVID-19 without reporting symptoms or before symptoms develop. Retrieved on 2/8/21. B. Facility policy The COVID-19 Vaccination Handbook: Infection Prevention Strategies and Guidance, dated 12/22/2020, was provided by the director of operations (DOO) on 2/3/21 at 10:22 a.m. and documented the following: Identify Vaccine Clinic Area for Staff and Residents: - Well-ventilated area - Allow 6-feet physical distancing while people wait (pre- and post- vaccine) - Seating to accommodate 15 minutes of observation time - Possible separate entrance and screening area for those getting vaccinated. Consider how to make the clinic space enjoyable: - Refreshments available - Identify a specific theme (i.e. holiday theme, Healthcare Hero, etc). C. Interviews The infection preventionist for the state health department (SIP) was interviewed on 2/2/21 at 6:43 p.m. She said she had been working with the facility following their outbreak in December 2020, and was continuing to work with them as they were still in a COVID-19 outbeak. The SIP said she had become aware of the concerns regarding the 1/12/21 COVID-19 vaccination clinic from the local health department who had received a complaint call regarding the lack of social distancing with the residents and family members of staff entering the facility during the vaccination clinic to also receive the vaccine. The SIP said the facility had a spike in COVID-19 positive residents following the COVID-19 vaccination clinic. The SIP said on 1/13/21 the facility identified 11 residents who were COVID-19 positive. On 1/18/21 the facility identified nine additional COVID-19 positive residents, and by 1/25/21 the facility identified an additional 19 COVID-19 positive residents. The SIP said those initial positive residents on 1/13/21 could not be linked to being exposed to COVID-19 during the COVID-19 vaccine clinic, but rather it was more likely they contributed to spreading COVID-19 to all the other residents participating in the COVID-19 vaccine clinic. The SIP said the facility was in outbreak status (meaning they had identified COVID-19 positive staff/and or residents), and rather than having all of the residents come to a common area for over 15 minutes, the better practice would have been having the immunizer going resident room to room, ensuring they had appropriate PPE (personal protective equipment) and performed hand hygiene between each resident. The SIP said having all of the residents in one common area was an unnecessary risk, especially for a facility that was in outbreak status. The county health department infection preventionist (CIP) was interviewed on 2/3/21 at 8:17 a.m. She said the county had received a call regarding the concern with the facility's COVID-19 vaccine clinic. The CIP said she had spoken with the facility management and corporate staff regarding the handling of the vaccine clinic. She said the biggest concern was having all of the residents waiting in the hallway prior to receiving their COVID-19 vaccine, and then having them all sit in the dining room for the 15 minute monitoring period following the vaccine administration. The CIP said several things were determined during the calls with the facility regarding the COVID-19 vaccine clinic. She said it was determined that all residents were brought to a common dining room for the COVID-19 vaccine clinic, and while residents were waiting their turn, they were basically lining the halls, which was the opposite of the current CDC recommendations for social distancing. The CIP said it was also identified that the facility's resident population was not very compliant with mask usage, and there were not many opportunities for residents to perform hand hygiene. The CIP said all of those factors were the likely reason for the facility's current COVID-19 outbreak numbers. The CIP said during the calls, she and the SIP determined it was necessary for the facility to come up with a plan to ensure their 2/2/21 COVID-19 vaccine clinic did not lead to an increase in COVID-19 cases. The CIP said the corporate managers had a party mentality regarding the COVID-19 vaccine clinic, which included corporate staff dressing in costume to celebrate the vaccine. The CIP said the facility did not take the first vaccine clinic seriously and she wanted to ensure they had a solid plan for the second vaccine clinic to ensure the community's safety. The director of nursing (DON) and the facility infection preventionist (IP) were interviewed on 2/3/21 at 8:00 a.m. They said concerns had been identified regarding the 1/12/21 COVID-19 vaccine clinic. The DON said all but five residents of approximately 81 residents were brought to a common dining room for the COVID-19 vaccine clinic. The DON said the staff attempted to bring the residents down in smaller groups to try to ensure six feet of social distancing. She said they also tried to have all of the residents wear masks, and the residents were mostly masked, but the resident population in the facility did have difficulty wearing masks and keeping masks on. The IP said she was on vacation the week of the COVID-19 vaccine clinic, but she was aware of concerns and had been working with facility staff and the county and state infection preventionists to ensure the clinic on 2/2/21 followed the CDC recommendations. The DOO was interviewed on 2/3/21 at 9:48 a.m. She said she was in the facility on 1/12/21 for the COVID-19 vaccine clinic. The DOO said she was assisting with filling out consent forms, and was only present for about one and a half hours during the vaccine clinic. She said the residents were assisted to the dining room by staff members, and they came down by units to the dining room. The DOO said they attempted to spread the residents out as much as possible, and tried to encourage them to keep their masks on. The DOO said the corporate staff member who had dressed in a costume was more of a celebration of getting the vaccine. III. Failure to ensure community members did not enter resident care areas to receive the COVID-19 vaccine A. Record review On 2/3/21 at 8:50 a.m., the visitor/vendor/surveyor COVID-19 screening forms from 1/12/21 were reviewed and revealed 11 community members had been screened prior to being allowed into the facility for the COVID-19 vaccine clinic. B. Interviews The SIP was interviewed on 2/2/21 at 6:43 p.m. She said one of the many concerns identified during the 1/12/21 COVID-19 clinic was the facility allowing community members into the COVID-19 vaccine clinic which was taking place in a resident dining room. The SIP said due to the facility's current outbreak status, visitors should have been restricted from entering the facility. The CIP was interviewed on 2/3/21 at 8:17 a.m. She said she did not have concerns with facilities offering remaining COVID-19 vaccines to community members, as she did not want any vaccine to go to waste. She said her concern was directly related to the facility allowing those community members to enter the facility and get the vaccine in resident care areas. The DON and the IP were interviewed on 2/3/21 at 8:00 a.m. They said after all of the residents and the staff had been vaccinated the pharmacist told them there were some remaining doses of the COVID-19 vaccine, and they were offered to vaccinate staff's family and/or friends. The DON said all of the community members were screened prior to entering the facility, and received their vaccine in the resident dining room. They waited appropriately 15 minutes in the resident dining room after the vaccine was administered to ensure they did not have any side effects. The DOO was interviewed on 2/3/21 at 11:18 a.m. she said the COVID-19 vaccine clinic was not perfect, The DOO said she was not present when the community members were allowed into the facility for the COVID-19 vaccine clinic. The DOO said at the time of the COVID-19 vaccine clinic, the facility was in a COVID-19 outbreak, and was not allowing communal dining, group activities or visitors into the facility. The DOO said the pharmacist who was vaccinating the residents during that time stated the preference was to have all of the residents come to him instead of him going from resident room to room. IV. Facility COVID-19 status As of 2/3/21 at 11:20 a.m. the facility had 14 COVID-19 positive residents and 15 COVID-19 positive staff.

Based on record review and interviews, the facility failed to protect one (#2) of three residents reviewed out of six sample residents from abuse and neglect. The facility failed to transfer Resident #2 in an appropriate manner consistent with physical therapy evaluation which determined the safest way to transfer Resident #2 was by utilizing a hoyer lift. Resident #2, was admitted to the facility on [DATE] with a history of [MEDICAL CONDITION] (stroke) that resulted in one sided weakness on her left side. In early morning of 8/1/2020 Resident #2 was transferred by two certified nurse aides (CNAs) without using the Hoyer lift, and by using an arm to arm method. The staff members failure to use a hoyer lift when transferring, contributed to the harm of Resident #2 sustaining a left hand fractured. Cross-reference to F609, (reporting of allegations of abuse and neglect), failure to timely report allegations of abuse and neglect. Cross-reference to F610, (investigation of allegations of abuse and neglect), failure to timely investigate allegations of abuse and neglect. Cross-reference to F637, failure to assess the resident after a change of condition. Cross-reference to F684, failure to monitor resident's cast after hand fracture. Findings include: A. Facility policy and procedure The Abuse and Neglect prohibition policy and procedure, with revision date July 2018, was provided by the nursing home administrator (NHA) on 8/25/2020. The policy read in part, Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin. Any observations of allegations of abuse, neglect or mistreatment must be immediately reported to the administrator. The facility will timely conduct an investigation of any alleged abuse/neglect in accordance with state law. B. Resident #2 status Resident #2, age [AGE] years old, was admitted [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 8/7/2020 minimum data set (MDS) assessment documented the resident was moderately cognitively impaired with the brief interview for mental status score (BIMS) of 13 out of 15. The staff assessment indicated the resident had no symptoms of [MEDICAL CONDITION] or difficulty concentrating on activities, no disorganized thinking and rejected care. She required extensive assistance from two staff for transfers, she had functional limitation in range of motion (ROM) on both sides and used an electric wheelchair for mobility. C. Record review The resident's care plan, initiate on 11/16/19 and revised on 11/29/19, documented resident had an activities of daily living (ADL) self-care performance deficit due to decreased physical mobility secondary [MEDICAL CONDITION] and [MEDICAL CONDITION] from the stroke. Resident required a total staff assistance of two staff for all ADL's. Interventions included to use mechanical lift for transfers with the assistance of two staff members. The resident's care plan, initiated on 8/18/2020 (after the incident on 8/1/2020), documented resident had a history of [REDACTED]. Interventions included to encourage recommended method of transferring and provide means of completing transfer safely, when resident declines to use the mechanical lift for transfers, provide education regarding the risk of making this choice. If she continues to decline, inform the director of nursing (DON) prior to transfer. Interdisciplinary progress notes and behavior notes were reviewed between June and August 2020. There were no documented notes that resident refused the recommended method of transfer. The late entry progress note, created on 8/2/2020 (one day after the incident), with effective date of 8/1/2020 documented by RN #1 read: Resident requesting rising per usual at 400 a.m. Aids reported bed making a noise, that the resident thought was her (left) arm. Resident riding (wheelchair) to nurses' station, asking for a sling. Inquiring of need, resident stated, my arm got caught. Able to move (left upper extremity) at paralysis baseline, while already in tears (about) the delivery of Retinol cream alternative. While inquiring of further concerns, resident returned to room, never mind!. -There was no thorough nursing assessment, Situation- Background-Assessment-Recommendation (SBAR) note, or further investigation of the resident's arm and her overall condition after she reported that her hand got caught. The progress note documented by RN #2 on 8/1/2020 at 3:56 p.m., read: Patient complaining of pain of the left hand. Unable to move (left hand), patient refusing passive range of motion. Arm wrapped with (curlex) unable to visualize. Patient states her arm was caught while getting (out of bed) this (morning). XRAY stat (immediate) ordered. Will continue to monitor. -There were no thorough nursing assessment, SBAR note, or further investigation of the resident's arm and her overall condition after she reported to the second nurse that her hand got caught. The progress note documented by RN #2 on 8/1/2020 at 10:00 p.m. (18 hours after the incident) read that x-ray results demonstrated an acute [MEDICAL CONDITION] hand. Physician was notified and the resident was transferred to the emergency room (ER) for evaluation. The SBAR note completed on 8/1/2020 at 10:20 p.m. documented resident's vital signs, and the same note as in the above progress note. The note stated that the resident experienced pain with movement of the left hand, the level of pain was not recorded. According to the admission note dated 8/1/ from the ER, resident was admitted on [DATE] with the following clinical impression: closed fracture of distal end of left radius. D. Resident interview Resident #2 was interviewed on 8/24/2020 around 11:00 a.m. She said during the transfer on 8/1/2020 she was transferred by two CNAs, she said it was done that way because it was faster. She said after the incident, on 8/1/2020 when her papralyzed left hand hit the frame of the bed, from now on she was transferred only by mechanical lift. Resident did not answer the question if she refused to be transferred by mechanical lift on the day of the incident or before that. E. Facility investigation On 8/24/2020, during the survey, facility investigation provided by NHA. The root cause analysis read: (Resident #2) got a fractured wrist because she chose for CNAs to transfer her without a lift. CNAs transferred resident without recommended lift. Interventions implemented: Staff and resident education, ad hoc (when necessary) regarding transfer, briefing sheets for CNAs, and transfer sheets. IDT recommendations: continue education for staff, including at orientation. Ad hoc QAPI meeting summary read: Staff are frequently unclear of transfer orders for residents related to safety. Need method for staff to know transfer techniques for residents needing to use mechanical lift assistance especially. Systemic changes were listed as: update care plans, update white boards for residents in rooms with proper transfer technique, and develop briefing sheets for CNAs where resident's transfer status will be indicated. F. Staff interviews Physical therapy director was interviewed on 8/25/2020 around 2 p.m. He said the most recent evaluation for the resident was completed on 1/15/2020. At that time it was recommended to use a mechanical lift for residents for all transfers. He said in general, mechanical lift was recommended for individuals who are not able to bear weight, and Resident #2 was not able to bear weight on her legs due to paralysis on one side of the body. He said arm to arm transfer would only be appropriate for residents who are able to bear weight on their legs, rotate and make few steps. He said resident #2 was not able to do any of the above and should have been transferred only by mechanical lift. DON was interviewed on 8/25/2020 around 1:00 p.m. She said she was notified about the incident on 8/1/2020, she said the investigation was done by the administrator and the education part to staff was done by staff development coordinator (SDC). She said she was not aware of any delayed education to the staff on proper transfers. SDC was interviewed on 8/31/2020 around 2 p.m. She said she was notified about the need for education to staff by NHA around 8/14/2020. She said that was the time when she started her education on proper transfer status for residents who used mechanical lifts. NHA was interviewed on 8/25/2020 at 2:06 p.m. He said after the investigation the allegations were substantiated as a neglect. He said two involved CNAs were re-educated on proper transfers at the time of the investigation 8/14/2020. He said the delay in the investigation was due to the confusion that it was the resident's choice to be transferred without lift and he needed to clarify the specifics with the corporate team. After it was clarified on 8/14/2020, he reported it to the state department, police and started the investigation and education to staff.

Based on observations, record review and interviews; the facility failed to ensure residents' right to be free from abuse for three (#13, #206 and #103) of five residents investigated for abuse out of 40 sample residents. The facility failed to ensure Resident #13 was free from verbal abuse and mental anguish. The resident was unable to speak for herself. The resident was observed, by staff, as crying and tearful following the allegation involving certified nurse aide (CNA) #10. Additional allegations of abuse were discovered during the investigation for CNA #10. A resident alleged CNA #10 yelled at other residents and verbally abused resident #102. In addition, the facility failed to ensure safety for Resident #206 and Resident #103 resulting in physical abuse. Cross-reference F610: Evidence that all alleged violations are thoroughly investigated. Findings include: I. Facility policy and procedure The Abuse and Neglect Prohibition policy revised [DATE], provided by the nursing home administrator (NHA) on [DATE] at 11:30 a m. revealed, in part, Each resident has the right to be free from abuse .Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation .Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking . II. Resident #13 status Resident #13, age 72, was admitted on [DATE]. According to the [DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) score completed. No behaviors were marked. For functional status, the resident was extensive assistance for bed mobility, transfers, eating, toileting and personal hygiene. a. Observations The resident was observed from [DATE] through [DATE]. She was in a wheelchair. She was observed in the dining room during meals and in front of the television at times. She was dependent on staff. She was limited in movement and was unable to engage in a conversation. She was able to nod her head yes or no. b. Record review and interviews The care plan, revised [DATE], revealed, (Resident) has a history of emotional trauma. Interventions included: Watch for signs of distress while in a group setting and while conversation is going on around her .staff will refrain from asking details about (residents) past trauma but rather simply know that it exists. The care plan, revised [DATE], revealed, (Resident) has a communication problem related to [MEDICAL CONDITION]. Interventions included: Anticipate and meet needs .Observe/document for physical/nonverbal indicators of discomfort or distress and follow up as needed . Review of the abuse investigation revealed the following: -Date of incident: [DATE]. Time of incident: 5:00 p.m. -Date the investigation initiated: [DATE]. Time investigation was initiated: 2:12 p.m. -Resident involved: Resident #13. Type of investigation: Verbal. -Suspected perpetrator: CNA #10 -Description: Staff indicated that a CNA was helping a resident to bed when he turned to another CNA and said, I can make her really upset. It was reported that he proceeded to say, Resident's name, I am going to the bank and I am going to take all of your money. Nursing has reported that this resident has been crying more recently. Investigation was initiated. Notably, the reporting party did not hear this first hand. CNA who witnessed this is being contacted. CNA accused of the incident has been suspended. -Staff interviewed: CNA #8, CNA #6 and licensed practical nurse (LPN) #1 (documented as RN) -Residents interviewed: four residents were listed including Resident #15 -Summary: There were conflicting stories about what happened. Therefore, the incident could not be substantiated. Residents interviewed denied witnessing event/behavior. RN (LPN) denied witnessing. CNA #6 denied any concerns of verbal abuse. CNA #8 expressed that assailant antagonizes residents at times. And tries to get responses out of them. -Conclusion: Due to conflicting stories, the incident could not be substantiated. -Action: CNA#10 was suspended for the duration of the investigation. Police were informed of the incident. Management will be watching the accused closely. CNA #10 educated on verbal abuse and reassigned to a different hall. Review of the progress notes revealed the following: -[DATE]: Social services note- (Resident) was unable to provide any sort of answer to the questions and complete the BIMS. Staff reported she was not able to be oriented by the season or location of her room, but she was able to recognize staff's faces and was aware she was in the nursing home. Staff reports she is easily irritated approximately once a day. -[DATE]: Nursing note- Resident tearful, following reported verbal abuse in the dining area. Staff provided comfort measures and tender loving care (TLC) at night (HS) with some good effect. This was completed by registered nurse (RN) #3. c. Interviews completed during the survey Resident #41 was interviewed on [DATE] at 11:25 p.m. She said when she was first admitted , she was in a lot of pain. She said a male CNA came in and said, Those aren't even real tears. You dont even sound like you are crying. She was unable to remember who the CNA was. Staff was aware. CNA #2 was interviewed on [DATE] at 8:37 a.m. She said she had heard of verbal abuse occurring. She said she did not witness it but it was dealt with that day by administration. She said this incident occurred about three weeks ago with CNA #10. She said CNA #10 was making inappropriate jokes to Resident #13 about stealing her identity. She said Resident #13 had spent the rest of that day crying and in her room. She said this resident did not want to come out of her room. She said nobody should have said that to her. The director of nurses (DON) was interviewed on [DATE] at 3:04 p.m She said she was unable to remember this incident. The NHA was interviewed on [DATE] at 4:25 p.m. He said they had an investigation completed for this allegation. He said he talked to CNA #10 but did not ask him about this particular incident. He said he asked this CNA if he had seen anything related to abuse. CNA #8 was interviewed on [DATE] at 5:07 p.m. She said this incident occurred at the dining room table. She said they were helping feed the residents at the dinner meal. CNA #10 looked at her and said You want to see me make her mad? She said he was teasing her about taking all of her money. She said she felt uncomfortable with the event. She said she had seen retaliation before. She said CNA #10 had picked on a couple of other residents. She said other residents had also witnessed him being rude. CNA #6 was interviewed on [DATE] at 5:11 p.m. She said they were helping feed the residents in the dining room. She said she was focused on her own financial difficulties. She said this resident did get agitated and tried to hit CNA #10. Resident #15 was interviewed on [DATE] at 11:19 a.m. She said she was usually focused on her own things. She was unable to provide any feedback related to the event in the dining room. Resident #9 was interviewed on [DATE] at 11:54 a.m. He said he had observed verbal abuse. He said it seemed to be more rampant. He said CNA #10 had been verbally abusive to some of the aides and the residents. He said Resident #102 was at the dining table one time being picky with her food and she had been missing her daughter. CNA #10 told her Either shut up and eat or go to your room. He said this CNA scared the residents. He said CNA #10 would go up behind them and [MEDICATION NAME] loudly in order to scare them. The NHA was interviewed on [DATE] at 12:45 p.m. He said CNA #8 reported this incident to LPN #1 and then this LPN reported the incident to the NHA. He said they suspended CNA #10 pending investigation. He said he interviewed three residents that were down the same hall as this CNA worked. He said the fourth resident interviewed was in the dining room at the time of the incident. He said they usually tried to interview six residents. He said that he was the one who was in charge of completing the investigations. LPN #1 was interviewed on [DATE] at 1:05 p.m. She said she was not the nurse on duty during the incident. She did not see or hear of any abuse. LPN #4 was interviewed on [DATE] at 1:12 p.m. She said CNA #8 had told another CNA about the incident and that Resident #13 had been crying a lot. She said CNA#10 told one of the CNAs, I know how to make her cry. She said he told the resident he was going to take all her money. She said this was not the first time she had heard this happening from CNA #10. She said resident #13 was unable to advocate for herself. She said residents had reported that CNA #10 had yelled at them. She said Resident #13 had been crying all day, the next day. The NHA was interviewed on [DATE] at 1:31 p.m. He said they focused on the hall this CNA worked for his investigation. He said he was not aware the LPN he interviewed was not on duty the time of the incident. He said Resident #13 always acted upset with CNA #10. He confirmed he failed to prevent further allegations of abuse by CNA #10 by not completing a thorough investigation. He said now that he was aware of a pattern, they would do a more thorough investigation. He said he had not initiated an investigation for the incident with Resident #102. He said he was going to lump the allegations together for one investigation involving CNA #10. He said he also recently discovered some allegations of CNA #10 treating other staff members in an appropriate manner leading to an additional investigation. He said CNA #10 was suspended pending investigations for the additional allegations discovered during the survey process. II. Resident #206 A. Resident status Resident #206, over the age of 50, was admitted on [DATE]. According to the December, 2019 CPO, [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed the resident did not have a BIMS assessment conducted. He did not have verbal and physical behaviors directed at others documented. He required extensive two person assistance with all activities of daily living (ADLs). He was always incontinent of bowel and bladder. B. Record review The behavior care plan, initiated [DATE] revealed Resident #206 had a potential psychosocial well being problem related to [DIAGNOSES REDACTED].#206 also had inpaired visual function related to [MEDICAL CONDITION]. Interventions included to give Resident #206 time to answer questions and to verbalize feelings perceptions, and fears as needed. Give resident opportunities to talk with others. Provide a quiet place for him to have conversations. Resident #206 prefered to have room and things arranged to promote independence. 1. Facility failure Record review revealed the facility was aware Resident #206 did not have verbal and physical behaviors against others. However, the facility was aware that the assailant in the incident did have previous verbal and physical behaviors prior to admission to the facility. The facility put interventions in place such as moving resident #206 to a quiet environment, and giving the resident opportunities to talk to others. However, there was no discussion of moving the assailant from the room instead of the victim.The facility intervention was to let the assailant choose future roommates to prevent behaviors. The facility also did not ensure that resident #206 was safe from the assailant's escalating behaviors by checking on the resident during the night and day and did not interview staff regarding any commotion during the night and day. 2. Investigation review The investigation report of resident physical abuse dated [DATE] revealed the LPN #1 notified the DON that Resident #206 reported being hit three times in the head in his bedroom by his roommate that night. Resident #206 and the assailant were interviewed the morning of [DATE]. The DON and NHA were notified of the events. The police were notified and an occurrence report to the state regulatory agency was reported. Resident #206 was checked for any injuries and was assigned to a different room. There was no evidence the assailant was educated about his behaviors or any monitoring of resident #206 and no assessments to ensure resident #206 had any injuries. a. Facility interviews LPN #1 interview dated [DATE] revealed the morning of [DATE] that Resident #206 approached her and said he was hit in the head three times by his roommate during the night.The roommate was questioned by LPN #1 who admitted hitting Resident #206. She said she immediately reported the incident to DON, NHA, and the two residents were separated. The facility interviewed five residents on the hall who said they were not afraid of the assailant. However the facility did not interview all residents on the hall. The facility also did not interview any certified nurse aides (CNAs) during the night shift or morning shift to see if there were any mention or observations of incident during the night. b. Facility conclusion The facility felt the incident that occurred on around ,[DATE]//19 was substantiated and considered physical abuse as Resident #206 was physically attacked by roommate and LPN#1 reported incident timely and residents were separated. The NHA said he felt the facility was justified in their actions and the investigation. However, the facility failed to keep Resident #206 safe from being physically abused and did not interview all staff on the shift. III. Resident #103 A. Resident status Resident #103, age 66, was admitted on [DATE]. According to the [DATE] CPO, [DIAGNOSES REDACTED]. According to the [DATE] MDS assessment, the resident had intact cognition with a BIMS score of 15 out of 15. The resident did not demonstrate any behaviors. The resident required staff supervision for bed mobility, transfers, dressing, eating, toileting and personal hygiene. B. Record review The care plan for the potential to be physically aggressive (slapping others) related to cognitive deficits and confusion secondary to intellectual or developmental disability was initiated on [DATE]. Some of the interventions were to provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of the source of the agitation, assist to set goals for more pleasant behavior and encourage the resident to seek out a staff member when agitated. The resident had physical aggression triggers that included being asked overwhelming questions, being questioned and not receiving an adequate explanation of a situation. When the resident became agitated; intervene before agitation escalates, guide the resident away for the source of distress, and engage the resident calmly in conversation. A summary of the facility's abuse investigation dated [DATE] at 4:00 p.m., revealed that on [DATE], Resident #103 and Resident #7 were engaged in a conversation related to the death of their relatives. Resident #103 was slapped with an open hand on the left arm by Resident #7. Then Resident #103 responded by slapping with an open hand Resident #7 on the left arm. After the incident, both residents were separated by staff members and both residents were placed on frequent checks by staff. The police were contacted and a case number was assigned. Resident #103 was moved to another room per her request. There was no pain evaluation assessment performed after the incident on [DATE]. A pain evaluation assessment was performed two days after the event on [DATE] at 1:03 p.m. The pain scale on this date was zero or no pain. There was no skin - head to toe assessment performed after the incident on [DATE]. The next skin assessment was performed four days after the event on [DATE] at 11:47 a.m. This assessment revealed the resident had a rash under her pannus. C. Resident interview Resident #103 was interviewed on [DATE] at 2:09 p.m. She said she was seated in the dining room, Resident #7 walked by and started talking about how all of her family were dead. She told the resident all of her family were also dead and to stop talking about this issue. She said Resident #7 slapped her on the left upper arm. She retaliated with a slap/push to Resident #7's arm. She said there were no further problems between them and she just tried to ignore or walk away from Resident #7 when she came near her. IV. Resident #7 A. Resident status Resident #7, age 90, was admitted on [DATE]. According to the [DATE] CPO, the resident had [DIAGNOSES REDACTED]. According to the [DATE] MDS assessment, the resident had severe cognitive impairment with a BIMS score of two out of 15. The resident did not demonstrate any behaviors. The resident required staff supervision for bed mobility, transfers, eating, toileting and personal hygiene. The care plan for agitation when the resident became confused or scared was initiated on [DATE]. The plan revealed the resident's memory was significantly impaired. The resident relearned about her family's deaths several times each day which could lead the resident to express verbal or physical aggressive behavior. Some of the interventions were to assist the resident to develop more appropriate methods of coping and interacting (talking through issues). Staff were to intervene as necessary to protect the rights and safety of others. Staff were to approach the resident and speak in a calm manner. Staff were to divert the resident's attention and remove the resident from a potential situation by taking the resident to an alternate location as needed. The resident had verbal and physical aggression triggers related to confusion and/or disorientation. The resident was able to de-escalate by talking with staff truthfully about the death of her family members and her placement in the facility. There was no pain evaluation assessment performed after the incident on [DATE]. There was no skin - head to toe assessment performed after the incident on [DATE]. The next skin assessment was performed two days after the event on [DATE]. This assessment revealed the resident had a rash redness to both eyes. The occurrence report completed by the facility on [DATE] at 4:00 p.m., revealed Resident #7 had a history of [REDACTED]. The incident between the two residents was witnessed and therefore substantiated. C. Staff interview The social services director (SSD) was interviewed on [DATE] at 8:50 a.m. He said this incident occurred on [DATE] after the dinner meal, in the smaller of the two dining areas. He said a male resident told him that he witnessed Resident #7 attempt to push Resident #103. The SSD said his investigation concluded that Resident #7 was telling Resident #103 that all of her family members were deceased . He said due to Resident #7's memory she relearned this information several times each day. Resident #103 told Resident #7 not to talk about that issue anymore. Resident #7 slapped Resident #103 on her left upper arm and then Resident #103 retaliated by slapping Resident #7 on her left upper arm. He said both residents were separated and he talked with Resident #103 regarding some residents were very sensitive about certain types of information and maybe she should try to keep her distance from Resident #7. He said Resident #103 had previously put in a request for a room change and she moved to the room she was in now. The facility failed to protect residents from resident-to-resident physical abuse.

Based on observations, record review and interviews; the facility failed to ensure all alleged violations for abuse were thoroughly investigated for one (#13) of five residents reviewed for abuse out of 40 sample residents. The facility failed to thoroughly investigate verbal abuse allegations and the staff person continued to work with residents. The facility failed to interview the appropriate staff proceeding the allegation of abuse. The facility failed to interview the appropriate residents under the care of certified nurse aide (CNA) #10. The facility failed to document an accurate array of events for the allegation of abuse for Resident #13. The facility failed to complete a thorough investigation of CNA #10's alleged verbal abuse which resulted in additional allegations of abuse made by multiple residents. Findings include: I. Facility policy and procedure The Abuse and Neglect Prohibition policy revised July 2018, provided by the nursing home administrator (NHA) on 12/18/19 at 11:30 a m. revealed, in part, Each resident has the right to be free from abuse .Facility supervisors will immediately investigate and correct reported or identified situations in which abuse .is at risk for occurring . Cross-reference: F600 Free from abuse II. Resident #13 status Resident #13, age 72, was admitted on [DATE]. According to the December 2019 computerized physician orders [REDACTED]. The 12/8/19 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) score completed. No behaviors were marked. For functional status, the resident was extensive assistance for bed mobility, transfers, eating, toileting and personal hygiene. III. Observations The resident was observed from 12/16/19 through 12/18/19. She was in a wheelchair. She was observed in the dining room during meals and in front of the television at times. She was dependent on staff. She was limited in movement and was unable to engage in a conversation. She was able to nod her head yes or no. IV. Record review The care plan, revised 11/2/17, revealed, (Resident) has a history of emotional trauma. Interventions included: Watch for signs of distress while in a group setting and while conversation is going on around her .saff will refrain from asking details about (residents) past trauma but rather simply know that it exists. The care plan, revised 8/27/17, revealed, (Resident) has a communication problem related to [MEDICAL CONDITION]. Interventions included: Anticipate and meet needs .Observe/document for physical/nonverbal indicators of discomfort or distress and follow up as needed . Review of the progress notes revealed the following: -11/21/19: Nursing note- Resident tearful, following reported verbal abuse in the dining area. Staff provided comfort measures and tender loving care (TLC) at night (HS) with some good effect. This was completed by registered nurse (RN) #3. The abuse investigation, provided by the facility, did not include an interview from RN #3. Review of the abuse investigation revealed the following: -Date of incident: 11/20/19. Time of incident: 5:00 p.m. -Date the investigation initiated: 11/21/19. Time investigation was initiated: 2:12 p.m. -Resident involved: Resident #13. Type of investigation: Verbal. -Suspected perpetrator: CNA #10 -Description: Staff indicated that a CNA was helping a resident to bed when he turned to another CNA and said, I can make her really upset. It was reported that he proceeded to say, Resident's name, I am going to the bank and I am going to take all of your money. Nursing has reported that this resident has been crying more recently. Investigation was initiated. Notably, the reporting party did not hear this first hand. CNA who witnessed this is being contacted. CNA accused of the incident has been suspended. -Staff interviewed: CNA #8, CNA #6 and licensed practical nurse (LPN) #1 (documented as RN) -Residents interviewed: four residents were listed including Resident #15 -Summary: There were conflicting stories about what happened. Therefore, the incident could not be substantiated. Residents interviewed denied witnessing event/behavior. RN (LPN) denied witnessing. CNA #6 denied any concerns of verbal abuse. CNA #8 expressed that assailant antagonizes residents at times. And tries to get responses out of them. -Conclusion: Due to conflicting stories, the incident could not be substantiated. -Action: CNA#10 was suspended for the duration of the investigation. Police were informed of the incident. Management will be watching the accused closely. CNA #10 educated on verbal abuse and reassigned to a different hall. The abuse investigation, provided by the facility, revealed the incident occurred in the dining room and not the residents room as documented in the investigation. Four residents and three staff members were interviewed. The LPN interviewed in the investigation was not the LPN on duty the day of the incident. The LPN on duty the day of the incident was not included in the investigation. CNA #10 was scheduled over two halls and only four residents were interviewed. Details of the interview specifics were not included in the investigation for both the staff and residents. The incident occurred at 5:00 p.m. on 11/20/19 and the investigation did not start until 2:12 p.m. on 11/21/19. V. Staff and resident interviews CNA #2 was interviewed on 12/18/19 at 8:37 a.m. She said she had heard of verbal abuse occurring. She said she did not witness it but it was dealt with that day by administration. She said this incident occurred about three weeks ago with CNA #10. She said CNA #10 was making inappropriate jokes to Resident #13 about stealing her identity. She said Resident #13 had spent the rest of that day crying and in her room. She said this resident did not want to come out of her room. She said nobody should have said that to her. CNA #2 was not included in the facilities investigation for staff interviews. The director of nurses (DON) was interviewed on 12/18/19 at 3:04 p.m She said she was unable to remember this incident. The NHA was interviewed on 12/18/19 at 4:25 p.m. He said they had an investigation completed for this allegation. He said he talked to CNA #10 but did not ask him about this particular incident. He said he asked this CNA if he had seen anything related to abuse. CNA #8 was interviewed on 12/18/19 at 5:07 p.m. She said this incident occurred at the dining room table. She said they were helping feed the residents at the dinner meal. She said CNA #10 looked at her and said You want to see me make her mad? She said he was teasing her about taking all of her money. She said she felt uncomfortable with the event. She said she had seen retaliation before. She said CNA #10 had picked on a couple of other residents. She said other residents had also witnessed him being rude. CNA #6 was interviewed on 12/18/19 at 5:11 p.m. She said they were helping feed the residents in the dining room. She said she was focused on her own financial difficulties. She said this resident did get agitated and tried to hit CNA #10. Resident #15 was interviewed on 12/19/19 at 11:19 a.m. She said she was usually focused on her own things. She was unable to provide any feedback related to the event in the dining room. Resident #9 was interviewed on 12/19/19 at 11:54 a.m. He said he had observed verbal abuse. He said it seemed to be more rampant. He said CNA #10 had been verbally abusive to some of the aides and the residents. He said Resident #102 was at the dining table one time being picky with her food and she had been missing her daughter. CNA #10 told her Either shut up and eat or go to your room. He said this CNA scared the residents. He said CNA #10 would go up behind them and [MEDICATION NAME] loudly in order to scare them. Resident #9 was not included in the facilities investigation for resident interviews. This resident resided on a hall covered by CNA #10's. The NHA was interviewed on 12/19/19 at 12:45 p.m. He said CNA #8 reported this incident to LPN #1 and then this LPN reported the incident to the NHA. He said they suspended CNA #10 pending investigation. He said he interviewed residents that were down the same hall as this CNA worked. He said they tried to interview six residents. LPN #1 was interviewed on 12/19/19 at 1:05 p.m. She said she was not the nurse on duty during the incident. She did not see or hear of any abuse. LPN #4 was not included in the facilities investigation for staff interviews. LPN #1 was included in the facilities investigation but was not present during the incident. LPN #4 was interviewed on 12/19/19 at 1:12 p.m. She said CNA #8 had told another CNA about the incident and that Resident #13 has been crying a lot. She said CNA#10 told another CNA, I know how to make her cry. She said he told her he was going to take all her money. She said this was not the first time she had heard this happening from CNA #10. She said the resident was unable to advocate for herself. She said residents had reported that CNA #10 had yelled at them. She said Resident #13 had been crying all day, the next day. The NHA was interviewed on 12/19/19 at 1:31 p.m. He said they focused on the hall this CNA worked for his investigation. He said they interviewed around six residents with higher cognition. He said he was not aware the LPN he interviewed was not on duty the time of the incident. He said Resident #13 always acted upset with this CNA. He said now that he was aware of a pattern, they would do a more thorough investigation. He said he had not initiated an investigation for the incident with Resident #102. He said he was going to lump the allegations together for one investigation involving this CNA. He said CNA #10 had been doing better since being moved to another hall. The CNA continued to provide care for the residents.

Based on observation, record review and interviews, the facility failed to provide treatment and services in a timely manner to prevent worsening of a pressure injury, for one (#99) of one resident reviewed for pressure injury out of 40 sample residents. Specifically the facility failed to: -Document a thorough assessment of a newly identified pressure injury to the resident's left heel upon discovery; -Ensure Resident #99 received timely treatment for [REDACTED]. -Implement timely pressure reduction interventions for a newly identified pressure injury to the left heel; and -Notify the physician and responsible party timely of the pressure injury. The facility's failures led to the worsening of a pressure injury from a blister to an unstageable wound covered with black eschar. Findings include: Cross-reference F657, failure to develop a comprehensive care plan. I. Facility policy and procedure The Skin Management policy, dated July 2017, was received from the director of nursing (DON) on 12/19/19 at 7:48 a.m. The policy documented in pertinent part, Management of tissue load through positioning, use positioning devices. Devices should be used to completely raise the pressure area, i.e. heel, completely off the support surface . Consider elevating the heels off the bed with pillow or use of heel protectors. Assess for risk of developing additional pressure ulcers. Totally relieve heel pressure by elevation of the heel completely off the bed surface. The resident, resident representative and the attending physician are notified. The care plan and care Kardex are updated to reflect new interventions. II. Resident status Resident #99, age 77, was admitted on [DATE]. According to the December 2019 computerized physician's orders [REDACTED]. The 12/2/19 minimum data set (MDS) assessment documented the resident was severely cognitively impaired and was unable to complete a brief interview for mental status (BIMS). The assessment documented he had short and long term memory loss and was cognitively moderately impaired for daily decision making. He required extensive two person assistance with bed mobility and transfers. He required extensive two person or more assistance with dressing, toileting, personal hygiene and bathing. He was at risk for developing pressure injury and had one unstageable pressure injury. III. Record review The resident's skin assessments were reviewed. On 11/16/19 the nurse documented on the skin assessment the resident had a new skin issue, a blister to the left heel. There was no further description of the blister. The nurses' notes were reviewed. There was no documentation on 11/16/19 that any interventions were put into place for the blister to the left heel. There was no documentation that the physician or responsible party were notified. A communication form/progress note dated 11/18/19 was reviewed. The note documented the resident had an area on the left heel that was discolored and soft. He had redness extending in the instep of the foot and upper foot. The note documented it appeared to be due to his feet being clamped together. There were no measurements of the blister.The physician, resident's wife, and hospice were notified. The note documented the wound occured on 11/18/19. However, the wound was noted two days prior on 11/16/19. The resident's orders were reviewed. The resident did not have orders to treat the wound until two days after it was initially observed on 11/16/19. On 11/18/19 skin prep (protective film) was ordered to the heel every shift and the resident was to be placed on an unspecified type of air mattress. The care plan was reviewed. The care plan dated 11/27/19 addressed the pressure ulcer developed to the left heel. However, there was no care plan that addressed the resident's risk for skin breakdown prior to the development of the left heel wound or a current care plan that addressed the resident's risk for skin breakdown. The resident had a Braden skin risk assessment dated [DATE]. The skin risk assessment indicated the resident scored a 13 out of 18 (highest risk) and was at moderate risk for developing skin breakdown. The assessment documented he had limited sensory perception, skin was occasionally moist, he was chairfast, his mobility was very limited, nutrition was probably inadequate, and friction and shearing was a potential problem. The facility failed to develop a care plan after this assessment and the resident developed a pressure ulcer to his left heel on 11/16/19. On 11/20/19, four days after the wound was observed, a boot was ordered to the left lower leg to offload the pressure to the heel. On 11/23/19 the weekly pressure ulcer record documented the blister was a 14.88 cm blood-filled blister. The plan was to offload the heels. Use an offloading boot and pillows. The wound was being treated with skin prep. On 11/25/19 the nurse's note documented the resident had eschar (dead tissue) to the heel. IV. Observation and interviews The resident's left heel was observed with registered nurse (RN) #2 on 12/17/19 at 9:40 a.m. The wound covered the entire left heel and was black. The RN said the wound was caused because he would move all over the bed and with his contractures, they could not float his heels. She said he now wore a boot to keep pressure off the heel. She could not explain why there had been a delay in treatment of [REDACTED]. Licensed practical nurse (LPN) #5 was interviewed on 12/18/19 at 1:33 p.m. He said when a new wound was discovered the physician and family were notified immediately. He said the nurse should measure the wound and obtain treatment orders for the wound and notify the director of nursing (DON) and the wound care nurse. The wound care nurse was interviewed on 12/18/19 at 3:01 p.m. She said she does wound rounds one time a week with a wound care physician. She said if a nurse finds a wound they should notify the physician for treatment orders right away and not wait for her. She said this has been our process for a long time, but I have to keep educating the nurses because they do not always call for orders right away. She reviewed the documentation of the wound occurring on 11/16/19 and the physician and family not being notified until 11/18/19 and the boot was not ordered until 11/20/19. She said I see where this is a problem. She further stated, I have educated the nurses regarding this multiple times. The DON was interviewed on 12/18/19 at 3:43 p.m. She said the nurse who finds a new wound or worsening wound should notify the physician for orders immediately. She reviewed the documentation of the wound occurring on 11/16/19 and the physician and family not being notified until 11/18/19 and the boot was not ordered until 11/20/19. She said timely notification and treatment was an area for improvement. The DON further said after reviewing the care plan that she did not see a care plan for the resident prior to the wound that describes interventions to prevent skin breakdown. She said he should have had a care plan in place for skin integrity to prevent skin breakdown prior to the left heel wound because he was at risk. She was unable to locate one.

Based on interviews and record review, the facility failed to implement interventions to prevent pressure injuries for two (#3 and #4) out of four sample residents who were admitted without pressure injuries but who had risk factors placing them at risk for pressure injuries. Resident #3, admitted with a right femur fracture with surgical repair but no pressure injuries, was identified with an unstageable deep tissue injury (blister) of her left heel 6/18/19, 16 days after admission. The pressure injury worsened, was assessed as a stage 4 pressure injury on 7/17/19 and thereafter became infected, requiring two courses of antibiotics. Although Resident #3 was assessed with [REDACTED]. injury was identified. The pressure reducing preventative intervention specific to reducing pressure to heels (pressure reducing boot) was ordered on [DATE], which was 21 days after the identification of the blister to the left heel and 11 days after the blister opened. Although a performance improvement plan (PIP) initiated 6/19/19 following the development of Resident #3's pressure injury, it was ineffective in addressing the facility's failure to ensure timely implementation of interventions to prevent pressure injuries for residents, such as Resident #3, with risk factors, as evidenced by Resident #4, who was admitted [DATE] with a left femur fracture but without pressure injuries. She developed a painful, mushy heel nine days after admission. The discovery of the pressure injury was not timely communicated to the in-house wound care team and an order obtained two days after discovery to assist the resident with application of pressure reducing boots, was not transcribed until 14 days later. The facility's failure to implement interventions to prevent pressure injuries for residents at the time of admission with evident risk factors for pressure injury and further failure upon identification of pressure injuries to timely implement interventions to prevent deterioration of wounds, as revealed by Resident #3's stage 4 wound, created an immediate jeopardy situation for serious injury to recur if immediate corrective action was not taken. Findings include: I. Immediate Jeopardy [NAME] Findings of immediate jeopardy Resident #3, admitted with a right femur fracture with surgical repair but no pressure injuries, was identified with an unstageable deep tissue injury (blister) of her left heel 6/18/19, 15 days after admission. The pressure injury worsened, was assessed as a stage 4 pressure injury on 7/17/19 and thereafter became infected, requiring two courses of antibiotics. Although Resident #3 was assessed with [REDACTED]. injury was identified. The pressure reducing preventative intervention specific to reducing pressure to heels (pressure reducing boot) was ordered on [DATE], which was 21 days after the identification of the blister to the left heel and 11 days after the blister opened. Although a performance improvement plan (PIP) initiated 6/19/19 following the development of Resident #3's pressure injury, it was ineffective in addressing the facility's failure to ensure timely implementation of interventions to prevent pressure injuries for residents, such as Resident #3, with evident risk factor on admission. The facility's failure to implement interventions to prevent pressure injuries for residents at the time of admission with overt risk factors for pressure injury and further failure upon identification of pressure injuries to timely implement interventions to prevent deterioration of wounds, as evidenced by Resident #3's stage 4 wound, created an immediate jeopardy situation for serious injury to recur if immediate corrective action was not taken. On 10/4/19 at 7:05 p.m., the nursing home administrator (NHA) was notified that the findings above created a situation of immediate jeopardy for serious harm. B. Plan to remove immediate jeopardy On 10/5/19 at 3:58 p.m., the facility submitted the following plan to remove the immediate jeopardy situation: -Any resident admitted since 9/1/19 will have their Braden assessment reviewed by the director of nursing (DON)/designee to determine if they are at-risk. If identified at-risk, preventative interventions will be implemented. The DON/designee will be responsible for updating the care plans to reflect preventative interventions. -All nurses will receive education regarding Braden assessments and timely interventions for residents identified at-risk. Preventative interventions will be implemented (i.e., heel floating, appropriate mattress, etc.) upon at-risk identification. This education will begin on 10/4/19 during the evening shift and will continue until all nurses have received education prior to working on the floor by the staff development coordinator (SDC)/designee. -Upon hire and during facility orientation, SDC or designee will train new licensed nurses on the procedures for pressure ulcers. If the SDC is not present, the DON will be responsible for the education. C. Removal of immediate jeopardy On 10/5/19 at 4:20 p.m., the NHA was informed the facility's plan to remove the immediate jeopardy was accepted and the immediate jeopardy situation was removed. However, deficient practice remained at a G level. II. Facility policy and procedure The Skin Management policy, (MONTH) (YEAR), was provided by the nursing home administrator (NHA) on 9/26/19 at 10:22 a.m. It read in pertinent part, Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. If a new pressure ulcer is identified, either upon admission, readmission, or during the resident's stay, the wound is assessed and documented on the Weekly Pressure Ulcer Record (UDA). Appropriate preventive surfaces (e.g., beds, wheelchair, etc.) will be implemented for residents identified at risk. III. The facility failed to implement interventions to prevent pressure injuries for two (#3 and #4) out of four sample residents who were admitted without pressure injuries but who had risk factors placing them at risk for pressure injuries. [NAME] Resident #3 Resident #3, under age 95, was admitted to the facility from the hospital on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 6/10/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status score of 13 out of 15. Resident was observed on 9/19/19 at 10:00 a.m. She was sitting in her wheelchair watching television in a common area and had a boot on her left foot. The resident was interviewed on 9/23/19 at 11:50 a.m. She said she had a wound on her left heel that came on suddenly and she did not expect it. She said sometimes the wound hurt her and would interfere with her participation in activities. 1. Resident skin status on admission - no pressure injuries but risk factors The resident's hospital discharge records reviewed on 10/5/19 revealed no documentation of pressure injury. The 6/3/19 Admission Head to Toe Skin Check documented no pressure injuries and/or open areas only various sizes and stages of bruising to the resident's skin. The 6/3/19 Nurse Admission Data Collection under Physical Examination: Skin Integrity revealed the skin was intact and the resident used toe cushions for two to four toes. Tenderness to the right hip. The 6/3/19 Braden Scale for Predicting Pressure Sore Risk documented the resident was at mild risk for developing a pressure injury. -However, it also identified a number of risk factors including: slightly limited sensory perception; severely limited or non-existent ability to walk (spends the majority of each shift in bed or chair); frequent though slight changes in body or extremity position independently; during a move skin probably slides to some extent against sheets, chair, restraints or other devices. -The focus of the resident's skin integrity care plan was the resident had potential skin issues related to: friable skin, immobility and weakness. Goal: Resident's skin will remain intact without signs of breakdown by next review. Intervention: Skin checks weekly per facility protocol, document findings. The 6/10/19 MDS assessment revealed the resident required extensive assistance of two persons with mobility, transfers, toileting, personal hygiene, and bathing. No pressure injuries were identified during this assessment period; however, she was identified as at risk for developing pressure injuries. 2. Failure to address identified pressure injury risks on admission and development of an unstageable pressure injury to the resident's left heel 16 days after admission. a. Development of pressure injury The 6/18/19 Situation, Background, Assessment, Recommendation (SBAR) Communication form read, Blister on 4th toe and heel of left foot. Family and physician notified. The 6/18/19 Administration Note documented skin protection wipe to the left heel blister until healed. The 6/19/19 Wound physician progress notes [REDACTED].#3) has an unstageable DTI (deep tissue injury) of the left, posterior heel for at least 1 day duration. There is no exudate. There is no indication of pain associated with this condition. - Initial Evaluation-Unstageable DTI for the left, posterior heel .This is a partially blood-filled and partially fluid-filled blister superimposed on the blood-filled blister. Recommendations to float heels in bed; off-load wound; multi-podus boot when up with PT (physical therapy). - Initial Evaluation-Wound of the left, proximal, dorsal, fourth toe. My goal for this wound is healing as evidence by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. This is an intact fluid-filled blister, which appears to have developed from rubbing on her shoes. Recommendations off-load wound; no shoes at this time. The 6/19/19 Weekly Pressure Ulcer Record documented a newly identified pressure injury to the left heel and described it as a partially fluid-filled blister on top of a blood blister, unstageable. The pressure reducing intervention was for the bed, did not list type and encouraging off-loading. The 6/19/19 physician order [REDACTED]. The (MONTH) 2019 computerized physician orders [REDACTED]. start date 6/19/19. b. Failure to develop and implement interventions to prevent the development of the resident's pressure injury. Review of the resident's electronic and paper records on 9/23/19 and 10/4/19 did not reveal any documentation regarding the preventative measures established to prevent the blister from forming on 6/18/19, only interventions after the formation of the pressure injury. Specifically: The resident's care plan initiated 6/6/19 identified the resident had potential skin issues related to fragile skin, immobility, and weakness. Interventions included weekly skin assessments, document findings, wound care team to round weekly and monitor for signs and symptoms of wound deconditioning and notify the physician immediately. However, the care plan did not include pressure injury reducing measures to prevent the formation of a pressure ulcer for a resident with a femur fracture. Likewise, the 6/10/19 MDS assessment, which also had identified the resident was at pressure injury risk, failed to identify any pressure reducing measures. 3. Further decline in Resident #3's pressure injury to a stage 4, with infection - failure of facility to implement timely interventions to promote healing. a. Decline in status of Resident #3's left heel pressure injury Record review revealed a 6/30/19 nurse progress note that read in pertinent part, Blister broke open on heel; bandage applied. Record review revealed the first documentation after the resident's blister opened was in the 7/3/19 Weekly Pressure Ulcer Record, four days after the blister opened. It documented the date of onset of the resident's pressure injury was 6/18/19 and it was acquired while in the facility. The injury to the left heel was categorized as unstageable. It read, Wound surface area 16.80 cm2 (centimeters squared), cluster wound with moderate serous exudate, 15% thick adherent necrotic tissue, 25% slough, 40% sq (subcutaneous) dermis, 20% skin, improved. The (MONTH) 2019 CPOs listed a number of treatment orders in addition to an order with a start date of 7/10/19 for Multi Podus boot when out of bed, float heels when in bed related to right femur fracture. The July, (MONTH) and (MONTH) 2019 treatment administration records (TAR) documented the following pertinent orders: -Pressure-reducing boot to be used when the resident was out of bed, order start date 7/10/19; and -Float the resident's heels using pillows while in bed, order start date 7/10/19. The 7/3/19, 7/10/19, 7/17/19, 7/24/19 Wound physician progress notes [REDACTED]. The 7/7/19 nurse progress note read, Drsg changed to lt heel d/t (due to) bleeding and bandaged rolled. Dated 7/3//19, w/no (with no) Santyl ([MEDICATION NAME] ointment) available at this time. Off-loaded, w/no signs of pain during tx (treatment). The 7/17/19 Weekly Pressure ulcer Record identified the pressure injury on the left heel at a stage 4, which was 18 days after the blister opened and 14 days after the blister was identified as unstageable. The 7/18/19 MDS Note documented, Upon interview and review of documentation identified that during the observation period of 7/4/19 to 7/10/19, the resident required extensive assistance of 2 people for bed mobility, toileting, and transfers. Supervision with assistance of 1 person for eating. (Resident's name) takes scheduled Tylenol to help keep her comfortable. (Resident's name) C[NAME] (change of condition) is a newly acquired DTI (deep tissue injury) to the left heel. The 7/20/19 nurse progress note read in part, During room check, left foot noted swollen from tight Coban (self adhesive dressing) to heel/ankle. Removed with stated relief, while BLE (bilateral lower extremity) remains off-loaded. No odor or drainage present to dressing. The 7/21/19 Situation, Background, Assessment, Recommendation (SBAR) Communication form read, Inflammation on left heel ulcer: area above heel purplish-red, swollen. Ulcer draining smelly pus. All of the left foot is swollen. MD notified at 10:00 a.m. and daughter notified at 10:10 a.m. The 7/21/19 nurse progress notes read that the doctor recommended sending the resident to the emergency department for evaluation. However, the daughter, who was the resident's medical power of attorney did not agree to the emergency department visit so the nurse called the doctor on-call to obtain an order for [REDACTED].>The 7/24/19 Wound physician progress notes [REDACTED]. There is moderate serous exudate. The 7/24/19 Weekly Pressure Ulcer Record read that, the onset of left heel pressure injury was 6/18/19. It read, Wound surface area 3.99 cm2 (centimeters squared), periwound with moderate serous exudate and maceration, 20% thick necrotic tissue, 40% slough including biofilm, 15% granulation tissue, 25% subcutaneous, improving. The 7/25/19 Nutrition Note read, Continued follow-up due to wounds: Per most recent pressure injury assessment (7/24) stg (stage) IV (4) PU (pressure ulcer) to L (left) heel noted be improved. Nutritional interventions remain in place to aid in healing. Will cont (continue) to coordinate care with the wound team. To cont with P[NAME] (plan of care) and f/u (follow-up) prn (as needed). The 7/31/19 Wound physician progress notes [REDACTED]. Empiric therapy with [MEDICATION NAME] 100 mg (milligram) BID (twice a day) x (for) 7 days, pending culture results. The 7/31/19 nurse progress note read, Resident seen by wound team. Left posterior heel debrided, culture pending. New orders for calcium alginate with silver to wound bed and cover with foam dressing change daily, and [MEDICATION NAME] (antibiotic) 100 mg (milligram) by mouth twice daily for 7 days. Provider notified. The 7/31/19 physician orders [REDACTED]. The 8/1/19 nurse progress note read, Resident is on AB (antibiotic) treatment for [REDACTED]. No adverse reactions noted; treatment is going successfully, new dressing applied. The 8/3/19 nurse progress note read, Resident continues on antibx (antibiotic) therapy for wound to Lt (left) heel, w/no (with no) noted ASE (adverse side effects). BLE (bilateral lower extremities) off-loaded while in bed, and boot worn when up in WC (wheelchair). No ? (complain of) pain at this time, and pleasant w/cares (with cares). Fluids offered w/each (with each) encounter. The 8/5/19 and 8/6/19 Infection notes read, Resident continues on ABX (antibiotic) therapy for wound tx (treatment). Resident has not made any ? (complain of) pain in the wound, upset stomach, N/V (nausea and vomiting), diarrhea of decreased appetite. VS (vital signs) are WNL(within normal limits) and resident is afebrile. VS were given to charge nurse for review. Will continue to monitor. The 8/7/19 Wound physician progress notes [REDACTED].Coli (escherichia coli) and moderate growth [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant staphylococcus aureus) on 8/7/19. The 8/9/19 nurse progress note read, No noted ASE (adverse side effects) [MEDICATION NAME] (antibiotic) therapy for wound to Lt (left) heel. VS (vital signs) recorded while on 1-L 02 (1 liter of oxygen), and the resident denies malaise. BLE (bilateral lower extremities) off-loaded while on bed, and boots worn when out of bed. No ? (complain of) pain, while check and change performed by staff. The 8/10/19 Infection note read, Resident continues on antibx (antibiotic) therapy for Lt (left) heel wound, w/no (with no) noted ASE (adverse side effects). VS (vita signs) recorded while on RA (room air), and no ? (complain of) BP (blood pressure) issues. Fluids provided and accepted. Heels off-loaded, w/drsg (with dressing) change d/t (due to) saturation and noted odor. Maceration to wound edges, and left OTA (open to air) while computer down, needing orders. Alginate w/silver (with silver) placed and secured w/[MEDICATION NAME] foam drsg (dressing) and no ? pain during tx (treatment). The 8/10/19 nurse progress note read, Resident continues on antibx (antibiotic) therapy for Lt (left) heel wound, w/no (with no) noted ASE (adverse side effects). VS (vital signs) recorded while on RA (room air), and no ? (complain of) BP (blood pressure) issues. Fluids provided and accepted. Heels off-loaded, w/drsg (with dressing) change d/t (due to) saturation and noted odor. Maceration to wound edges, and left OTA (open to air) while computer down, needing orders. Alginate w/silver (with silver) placed and secured w/[MEDICATION NAME] (with [MEDICATION NAME]) foam drsg (dressing) and no c/o pain during tx (treatment). The 8/15/19 Nutrition Note read, Per most recent pressure injury assessment (8/7) stg IV to L (left) heel noted to be improved. Recommend to cont (continue) with current nutritional interventions at this time. Care plan updated. b. Facility failures (1) Review of facility records provided by the director of nursing (DON) on 9/23/19 at 1:18 p.m. revealed a Performance Improvement Plan (PIP) was initiated 6/19/19 to address an increase in acquired pressure injuries. However, cross-reference F867; the facility failed to identify the root cause of facility acquired pressure injuries, which resulted in increased incidents of facility acquired pressure injuries developing, primarily to the heels. Although there was an improvement in healing the current pressure injuries, the plan did not identify the need for preventative measures to be implemented to prevent the development of pressure injuries. Review on 10/4/19 of the medical records of residents admitted from 9/1/19 to 10/4/19, after the PIP was implemented, and who were identified at risk two residents out of five reviewed (#15 and #16) were identified as having risk of development yet did not have preventative measures implemented. (2) Review of Resident #3's electronic and paper medical records on 9/23/19 and 10/4/19 did not reveal an investigation into the cause of the resident's pressure injury. (3) The pressure reducing preventative interventions for the heels, offloading, air mattress, wheelchair cushion ordered on [DATE] and pressure-reducing boots ordered on [DATE], 21 days after the formation of the blister to the left heel and 11 days after the blister opened, were not care planned. (4) Review of the resident's care plan revealed the intervention of a pressure-reducing boot was not incorporated into her care plan. c. Although the facility's regional clinical consultant (RCC), interviewed on 10/4/19 at 6:48 p.m., felt the facility acted appropriately and timely with preventative measures for Resident #3, interview with the DON and the wound care physician were consistent with the failures identified above at the time of Resident #3's admission and thereafter. (1) The director of nursing (DON) was interviewed on 9/24/19 at 11:00 a.m. She said the facility had an increased number of heel pressure injuries in (MONTH) 2019 so they started a performance improvement plan (PIP). She said the wound care nurse (WCN) and physician brought this to her attention. She said she instituted the use of pillows for offloading and relieving pressure, which resulted in a decrease in the number of PU to the heels. She said she realized the nurses were not doing complete skin assessments when the residents were taking showers so she was working with the wound care physician (WCP) to develop a program for systematically checking off body parts to ensure that the nurse saw the area. She said this program had not been developed yet but was in the stages of being developed with the wound care physician. She agreed the PIP did not capture all of the areas of concern regarding the reduction of wounds in the building. She said the PIP was successful in reducing the number of already facility-acquired pressure injuries however, did not focus on preventing future facility-acquired pressure injuries. She said she recognized the facility still had facility-acquired pressure injuries developing in the facility even though the residents had been identified at risk. She said she felt the nursing staff required more education to help them understand what they were looking for when they did skin checks and once something was identified, to get preventative measures in place quickly. She said there was a list of options available to the staff like wheelchair cushions, air mattresses and therapy services. She said she felt the reason for the acquired pressure injuries after knowing a resident's pressure injury risk was due to the nurses not doing complete and thorough skin checks to identify pressure injuries and implementing interventions timely. She said once the wound was identified on Resident #3's left heel they implemented the air mattress and wheelchair cushion. She said she felt the staff focused on the resident's post hip surgical care more than the resident as a whole. (2) The wound care physician (WCP) was interviewed over the phone on 10/8/19 at 9:32 a.m. He said he was called in to evaluate and treat Resident #3 when the resident was identified with a fluid filled blood blister. He said the blister was a deep tissue injury (DTI) and was considered unstageable because he could not see what was happening below the surface of the blister. He said the wound was currently healing. Once he debrided the blister, after it opened, he was able to stage it at a 4. He said he was not given the information when he asked the nurse staff about the cause of the pressure injury to the left heel. He said the nursing staff told him that they did not know, the pressure injury showed up like that. He said that wounds do not just show up out of nowhere. He said at that time, the staff did not know or find out the cause of the wound. He agreed that by the staff not identifying cause of the pressure ulcer they would have a difficult time in preventing the worsening of the wound. He felt because at the time the wound formed, there was no staff in charge of wound monitoring and management, it was inevitable that the resident sustained [REDACTED]. He said Resident #3's pressure injury might have been prevented if the interventions put in place concentrated on the increased dependency on the left heel since the resident admitted post-surgery to the right hip. He said that the resident would have increased dependency on the non-surgical leg, including an increase in friction on surfaces. He said the post-surgical care would increase the resident's risk of developing a pressure injury and should be considered when implementing interventions. He said around (MONTH) 2019, but was not positive on time frame, the facility hired a wound care nurse (WCN). He said her days to monitor the wounds at the facility were increased from once weekly to twice weekly sometime in (MONTH) or (MONTH) 2019. He said the WCN's time was increased after the facility had an increased number of facility-acquired heel pressure ulcers. He said the wounds healed faster since the WCN involvement in the management of the wounds. There was an improvement in the number of wounds he was being referred to by the facility but did not have exact numbers. He said he was working with the DON on a skin assessment type of template to identify skin problems. He said they had not developed yet and had future meetings set-up. He said when he provided sharp debridement on 7/3/19, he was not able to complete debridement due to increased pain to the resident, right before ordering another round of antibiotics for the wound infection. He said it was infected twice and treated with antibiotics each time. He was not able to identify the cause of the wound infection. B. Resident #4 Resident #4, under age 75, was admitted to the facility from the hospital on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 7/22/19 MDS assessment revealed the resident with moderate cognitive impairment with a brief interview for mental status score of 12 out of 15. 1. Resident status on admission - no pressure injuries but identified risk factors The 7/15/19 (admitted ) Certification Order for Continued Care (discharge orders) from the hospital, the recommendations for care to the facility included skin assessment on arrival, monitor daily for [DIAGNOSES REDACTED] (redness), induration (hardening of soft tissue), warmth, maceration (moist tissue causing deterioration to tissue), skin temperature changes and drainage, keep head of bed less than or equal to 30 degrees unless contraindicated; change position every two hours while in bed; use heel protectors or offload heels with pillows. The 7/22/19 MDS assessment revealed the resident required extensive assistance with bed mobility, transfers, personal hygiene, toileting, and bathing. She was continent of bowel and had frequent incontinence of the bladder. The resident experienced pain almost constantly that limited daily activities and she received as needed and scheduled pain medications. The resident was at risk for pressure injuries. No pressure ulcers/injuries identified in the assessment. Pressure reducing device for bed and application of dressings. 2. Failure to address resident's risk for pressure injury on admission Review of the resident's Actual Skin Impairment care plan, initiated 7/16/19, documented the resident was at risk of skin impairment due to a surgical wound. Interventions included monitoring dressing to ensure it is intact and adhering and to observe the site for redness, swelling, increased drainage and pain. The care plan failed to include the admission orders [REDACTED] Likewise, the resident's 7/15/19 admission orders [REDACTED]. 3. Development of pressure injury five days after admission - failure to ensure timely communicated of the pressure injury to the in-house wound care team and to transcribe an order obtained two days after discovery to assist the resident with application of pressure reducing boots. a. Delay in transcribing and initiating order for pressure reducing boots. A 7/22/19 SBAR Communication form read that as the resident returned to the facility from the [MEDICAL TREATMENT] center, the resident reported to the facility staff that her right heel was hurting her. The form read the registered nurse (RN) from the [MEDICAL TREATMENT] center confirmed with the facility nurse the resident complained of right heel pain. The facility RN assessed the resident's right heel and concluded it was boggy (mushy). The form was not complete and failed to include documentation of notification of physician, wound care team and any measure to improve the condition of the pressure ulcer, however the interview with the DON showed the nurse did notify the physician. The 7/24/19 physician orders [REDACTED]. Removal for any necessary mobility, such as night-time toileting, with boots reapplied following task. This order was not transcribed or initiated until 8/6/19, 14 days later, when a physician order [REDACTED]. (Cross-reference F684) b. Other delays The 8/2/19 [MEDICAL TREATMENT] Communication Record documented that the right heel dressing was dated 7/28/19, which was five days prior, had fallen off. It read that the wound size was approximately 4x4 (4 centimeters (cm) by 4 cm), purple/black pressure injury noted. The 8/4/19 SBAR communication form documented a new unstageable deep tissue injury (DTI) to the right heel. It read that the pressure injury existed on 8/3/19; however, the 7/22/19 SBAR showed the facility was aware of the pressure injury at that time. It read that the outside managed care clinic was notified of the pressure injury on 8/8/19 at 10:30 a.m., which was 17 days after its initial identification on 7/22/19 (see 7/22/19 SBAR above). 2. Staff interviews confi

Based on record review and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Specifically, the facility failed to identify the root cause of facility acquired pressure ulcers, which resulted in increased incidents of facility acquired pressure ulcers developing, primarily to the heels. The facility initiated a performance improvement plan (PIP) to address the increase incidents of pressure ulcers to the heels, although there was an improvement of healing the current facility acquired pressure ulcers; the plan did not identify the need for preventative measures to be implemented to prevent the development of pressure ulcers. Findings include: Cross-reference to F686 Treatment/Services to Prevent/Heal Pressure Ulcers because the facility's failure to identify and implement pressure reducing interventions for Resident #3 upon admission and once identified interventions not implemented timely. The resident was known to be at risk for skin impairment, decreased mobility due to a [DIAGNOSES REDACTED].#3 sustaining a stage 4 pressure ulcer (PU) after admission. The pressure reducing preventative intervention, specific to reducing pressure to heels, was ordered on [DATE], which was 21 days after the formation of the blister to the left heel and 11 days after the blister opened. Furthermore, the facility failed to investigate the cause of the PU, which may have resulted in the delay of care. I.Facility policy and procedure The QAPI/QAA Process policy, dated (YEAR), was provided by the nursing home administrator (NHA) on 10/4/19. It read in pertinent part, The Quality Assurance and Performance Improvement Process (not dated) documented an effective QAPI process at all levels of our organization was vital for our success. Organizational implementation of the QAPI process helps ensure a consistent flow of importation form facility QAPI to district QAPI to the Field Support Quality Council and back again. This process enables the identification of Opportunities for Improvement (OFIs) at every level with appropriate actions taken. Once root cause and corrective actions have been determined, monitoring and follow up will ensure that improvements are sustained. Facilities are encouraged to look at their resident population as a whole, rather than addressing individual resident matters in the QAPI committee. The district teams; focus was to collect information from each facility in the district, review data and identify both individual facility and district wide OFIs. The division QAPI process collects information from each district, reviews data and identifies facility, district and division wide OFIs. The ultimate goal of all committee was to identify trends, perform root cause analyses and implement Performance Improvement Project (PIP) teams that address areas identified. Once the root cause of an OFI was identified an effective and sustainable PIP should be developed, implemented, monitored and sustained using the PDSA cycle of process improvement. (See the Performance Improvement Project Instructions and the Process Improvement - PDSA Instructions in the QAPI Tools section of the toolkit). CMS has established specific goals and expectations for facility QAPI programs referred to as the Five Elements of QAPI. Our QAPI program was designed to meet these expectations. The five elements of QAPI are (1) design and scope, (2) governance and leadership, (3) feedback, data systems, and monitoring, (4) performance improvement projects and (5) systematic analysis and systemic action. [NAME]Record review The Performance Improvement Plan, dated 6/19/19, was provided by the director of nursing (DON) on 9/23/19 at 1:18 p.m. It read: -Opportunity for improvement: There has been an increase in acquired pressure injuries in the past week, especially heel injuries. -Root cause: Need for re-education and practice in pressure injury prevention. -Desired result: Acquired pressure injuries will be reduced by 50% with minimal new acquired pressure injuries occurring. -What will be implemented: Provide adequate number of pillows to offload heels. Multi pillows given to the units and more pillows ordered. Who implemented: housekeeping supervisor. Status of action: Initial done and pillows ordered 1st of July. -What will be implemented: Staff educated on offloading resident heels and position changes when residents up in chair. Who implemented: staff development coordinator (SDC). Status of action: Started with yearly competencies for RCS (resident care coordinator, also known as certified nurse aide (CNA) on 7/16/19. -What will be implemented: Audit weekly with rounds with wound care physician (WCP). Who implemented: wound care nurse (WCN). Status of action: initiated 7/1/19, still inconsistent with off loading of heels. -What will be implemented: Education by WCP on positioning devices. Who implemented: WCP. Status of action: Cancelled and rescheduled for 9/25/19. -What will be implemented: Add extra day per week to wound nurse for rounds and oversight. Who implemented: WCN. Status of action: initiated (MONTH) 2019. - What was learned: Still having difficulty with off-loading of heels. Dressings not being done timely. Will initiate PIP for dressing changes. - Progress towards goal: Heel pressure injuries have been reduced but continue to have issues. - Was outcome achieved: Improvement but not consistent. - What will be done differently: Will initiate weekly heel rounds on the evening shift starting 10/1/19. Review, on 10/4/19, of the residents' medical records and a list of residents admitted from 9/1/19 to 10/4/19, after the PIP was implemented, that were identified at risk and did not have preventative measures in place. A total of five residents were reviewed and three were identified as not having risk of pressure injury development and two (#15 and #16) were identified as having risk of PU development but did not have preventative measures implemented. B.Staff interviews The director of nursing (DON) was interviewed on 9/24/19 at 11:00 a.m. She said the facility had an increased number of heel PU occurrences in (MONTH) 2019 so they started a performance improvement plan (PIP). She said the wound care nurse (WCN) and physician brought this to her attention. She said she instituted the use of pillows for offloading and relieving pressure which resulted in a decrease in the number of PU to the heels. She said she realized the nurses were not doing complete skin assessments when the residents were taking showers so she was working with the wound care physician (WCP) to develop a program for systematically checking off of body parts to ensure that the area was seen by the nurse. She said this program had not been developed yet but was in the stages of being developed with the WCP. She said that the PIP did not capture all of the areas of concern regarding the reduction of wounds in the building. She said the PIP was successful in reducing the number of already facility acquired pressure ulcers however, did not focus on preventing any facility acquired pressure ulcers. The nursing home administrator (NHA) was interviewed on 10/8/19 at 10:44 a.m. He said the facility held QAPI/QAA meetings monthly. The attendees included the medical director, pharmacist, registered dietician, dietary manager, housekeeping manager, environmental manager, staff development coordinator (SDC), director of nursing (DON), NHA, unit managers from the units, and therapy manager. He said the facility did not have a certified nurse aide (CNA) attending the meetings but would consider it in the future. The NHA said that he was involved in the performance improvement plan (PIP) that was established in (MONTH) 2019 from an increase incidents of pressure ulcers to the heels. He said the wound care physician (WCP) brought the issue to the DON's attention. The DON developed and the interdisciplinary team (IDT) implemented the action pieces. He said he felt that the PIP was successful since the goal was to decrease the number of pressure ulcers and they were successful in decreasing the number in half. He said that the nurses did the Braden scales to determine risk and then implement interventions already. He said not all pressure ulcers were preventable, however had no evidence that Resident #3's pressure ulcers were not preventable. He was not able to explain that during the process of following the PIP they recognized that wounds continued to form and did not address the interventions to determine changes to yield and expected improvement. He agreed preventing the pressure ulcers to begin with would be cost effective in the long run because it would be cheaper to prevent then to pay for wound treatments. The NHA said he would continue to review the Braden scale risk assessment during the QAPI/QAA meetings. He said by reviewing the form the IDT would be able to ensure risk factors were identified and appropriate interventions were put in place.

Based on observations, interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that residents received adequate supervision and assistance to prevent accidents. The facility's failures affected 18 ( #3, #5, #8, #10, #16, #20, #21, #24, #30, #31, #32, #33, #36, #37, #38, #39, #43 and #46) residents reviewed out of 48 sampled residents. Specifically: Failure to ensure at-risk residents received adequate supervision to prevent elopement: Resident #21 was known to exhibit behaviors that put her at risk for serious injury. Specifically, she was documented almost daily as confused, wandering, and exit seeking. Record revealed the resident was found outside of the building on 5/28/17. Record review also revealed the facility failed to reassess the resident's elopement risk after the incidents in 5/17 and failed to review, revise, and implement interventions to ensure the resident's safety. Finally, observations and interviews revealed failures in the facility's system to ensure the safety of the ten additional residents (#8, #10, #16, #24, #30, #31, #32, #33, #38, #39, and #43) with WanderGuards. Record review, observations and interviews revealed the facility failed to ensure a log of residents with WanderGuards was maintained. The facility failed to monitor the WanderGuard use, failed to ensure staff understood important properties of the WanderGuard, such as battery life span and range. Residents had no physicians orders and failed to complete accurate assessments The facility's individual and systemic failures in ensuring residents' safety from elopement created a situation of immediate jeopardy (IJ) with the potential for serious harm. The facility failed to have an effective system to investigate and implement timely interventions for resident #5 after multiple falls. The facility failed to have an effective system to ensure adequate supervision for medications were left at the bedside for residents #20 and #46, who were not assessed for medication self-administration. The findings included: Immediate Jeopardy - Failure to ensure at-risk residents received adequate supervision to prevent elopement: a. Notification of Immediate Jeopardy At 6:31 p.m. on 9/12/17 the nursing home administrator (NHA), interim director of nurses (IDON) and the regional clinical director were informed that the failure to have an effective system to prevent resident elopement created a situation of immediate jeopardy with the potential for serious harm. b. Plan to Remove Immediate Jeopardy The facility's sixth plan to remove immediate jeopardy was submitted on 9/14/17 at 2:37 p.m. The plan read: Action Plan to Abate immediate jeopardy related to Spring Creek Health Care Center failure to keep an at risk resident safe and from eloping from the building. 1:1 supervision immediately Initiated by facility for sliding door off of main dining room on September 12, 2017. This supervision will continue 24 hours a day, 7 days a week until the smoking courtyard is secured with a gate with keypad. The projected finish date for this project is September 21, 2017. Identification of Others: The Interdisciplinary Team including the Director of Nursing (DON), Assistant Director of Nursing (ADON), Resident Care Management Director (RCMD) and District Director of Clinical Services (DDCS), will review current facility residents starting September 12, 2017 to ensure that they have an accurate and current elopement evaluation. The elopement evaluations will be up to date and completed for all facility residents by September 14, 2017. Care plans for residents identified at risk will be updated and individualized to reflect elopement evaluation and any required interventions, these will be completed by September 14, 2017. The facilities Interdisciplinary Team, including the DON, ADON, RCMD and DDCS will review all current residents who utilize a Wanderguard to ensure appropriate orders are in place to visually check placement of wanderguard every shift, check functionality of device via electron machine once a day and change out device every 90 days per manufacturer recommendations. This will be on an audit tracking form and completed by September 14, 2017 and monitored by the Director of Nursing. Resident who refuse to wear the wanderguard on person and have the wanderguards placed on assistive devices will have the device checked at the door to verify function every shift. Rehab Program Manager conducted an audit of current facility residents who utilize a Wanderguard to ensure appropriate placement of device. Residents who refused to wear Wanderguard on person, had Wanderguards placed on assistive device, away from metal and Wanderguard company was contacted to verify alternate placement. Placement location will be documented in resident record under the physician orders by September 14, 2017. Residents who choose to have the wanderguard on their assistive device have been reviewed and determined to not be able to exit the facility without their assistive device. The Maintenance Director made rounds with Health Compliance Inspector on September 12, 2017 of all facility alarmed exits to ensure Wanderguard system was functioning appropriately. The maintenance director increased the sensitivity range on the front door alarm . The elopement book at each Nurses station was audited on September 14, 2017 by the Social Services representative to ensure accuracy of records based on current residents identified at risk and current room placement. This book will be updated with any change of condition regarding elopement risk, including room change of an at-risk resident and information communicated via the 24 hour report. Systemic Changes: Director of Nursing provided education to other designees who will provide verbal education to all facility staff and contracted/agency staff on September 13, 2017 and September 14, 2017 on elopement policy, including but not limited to, providing appropriate supervision and adequate interventions to minimize elopement risk, appropriate placement of a Wanderguard and back-up systems in the case a Wanderguard is not functioning. This education will occur prior to the start of a staff members shift. For agency staff members education will included verbal instruction to the location of the elopement book. A copy of the elopement management policy will be added to each elopement book for additional reference. DON or Designee will provide education to licensed nursing staff regarding documentation of wanderguard placement, including resident refusal of wanderguard placement on person, following physician orders in relation to the wanderguard, such as, visually check placement of wanderguard every shift, check functionality of device via electron machine once a day and change out device every 90 days per manufacturer recommendations. New admissions to the facility will be evaluated for elopement risk upon admission. Based on risk score the facility will follow policy to ensure appropriate supervision and adequate interventions are in place and individualized to minimize elopement risk. After admission resident will be re-evaluated quarterly, annually and with significant change or elopement event to determine elopement risk. DON or Designee will complete an audit to check Treatment Administration Records Daily Monday thru Friday to ensure nursing staff are following physician orders for Wanderguard placement and functionality. Maintenance Director or Designee will check all facility exits daily Monday thru Friday to ensure Wanderguard system is functioning appropriately. Weekend checks will be done by scheduled Manager on Duty. The Manager on Duty will receive education in regards to checking facility exits via the electronic tester to ensure the system is functioning properly, this education will be provided by the Maintenance Director prior to their scheduled coverage. In the case of a power outage the 7 wanderguard alarmed doors will be supervised by a staff member via line of sight until the power is restored . c. Removal of Immediate Jeopardy The facility's plan to abate immediate jeopardy was accepted on 9/14/17 at 2:37 p.m. and the immediate jeopardy removed. However, deficient practice remained at an E level, potential for more than minimal harm at a pattern. I. Failure to provide residents adequate supervision to prevent elopement. a. Pertinent Facility Policies - expectations 1. The facility Elopement policy (revised July 2017) was provided on 9/13/17 at approximately 4:00 p.m., by the social work consultant and read in pertinent part. The facility strives to provide a safe environment and preventative measures for elopement. Personnel must report and investigate all reports of missing residents. Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident with adequate supervision, activity/functional programs as appropriate and safety interventions to minimize elopement risk. Signaling devices may be used if available in the facility and determined to be an appropriate intervention. The interdisciplinary Team (IDT) evaluates each resident to identify elopement risk. Care Kardexes (resident information to assist certified nurse aides (CNA) with resident care) are updated and communicated to staff. The Administrator (NHA) and Director of Nursing are responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk assessment, treatment, evaluation, and monitoring of exit-seeking behavior. The goal of the Elopement Management System is to identify residents with potential exit-seeking behavior, to assure the care Kardex reflect effective and consistent interventions and safety measures, and to assure staff are educated regarding the Elopement Management System and resident specific interventions. While alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision. Following admission, residents are evaluated for elopement risk quarterly, annually, and with significant change of condition or status using the Elopement Risk and resident assessment instrument (RAI) process. Check placement and function of the signaling device routinely. The resident care specialist will verify the presence and function of the signaling device and document in Point of Care. On a daily basis, the licensed nurse will validate documentation through the Clinical Dashboard. Important: Signaling devices should be placed on the resident Not on a wheel chair, geri-chair, walker, merry-walker, etc. Only one device should be placed to avoid malfunction of the device. The licensed nurse will notify the attending physician of the implementation of signaling device. b. Facility Geography The facility was located on the corner lot of two streets. One street was a divided two-lane street with a posted speed limit of 30 miles per hour. The other street was a divided four-lane street with a posted speed limit of 40 miles per hour. The roads were two main thoroughfares with steady traffic observed throughout survey. The facility had four doors with wander guard system installed, as well as two elevators with the wander guard system in place. Two of the doors with the wander guard system in place were sliding glass patio doors. The one set of doors lead out to an enclosed patio. The other set of patio doors (main dining room) lead out to an opened courtyard area. That courtyard was the designated smoking area, and was not fully fenced. The sliding glass doors were unable to lock when a resident with a wander guard came near. The facility had four other exit doors, which were locked with a key pad. These doors did not have the WanderGuard system. Resident #17 was interviewed on 9/11/17 at 9:41 p.m., she stated that the sliding glass door to the smoking area remained unlocked at all times so that the smokers in the facility could go out any time that they liked. She stated that she frequently came outside around 1:00 a.m. and 2:00 a.m. to smoke. The maintenance director (MTD) was interviewed on 9/12/17 at approximately 4:00 p.m. He stated that the doors to the smoking area should be locked every night at 10:00 p.m., but he stated that did not occur because the residents who smoked liked to go out during the night to smoke. The group interview was held on 9/25/17 at 2:15 p.m. with seven alert and oriented residents, selected by the facility. The residents in the group all confirmed that the sliding glass door in the main dining room which led to the open courtyard, was open at all times, so they could go outside if they choose. c. WanderGuard Functionality The MTD was interviewed on 9/12/17 at approximately 4:00 p.m. The MTD said that the Wander Guard system was used in the building for residents that would wander or exit seek, however, did not need the secured unit. He said that the WanderGuard was at the main door, the two elevators, the main dining room, and east lobby. He said that when a resident with a WanderGuard approached the door, that it begin to beep and as the resident got closer to the door it would lock the door. The MTD said that he checked the system one time a week, to ensure it was functioning properly. He said that he checked the system with a remote control that would indicate if the system was working correctly. He said that the system could also be checked using a bracelet. He said the Wander Guard bracelet was put onto wheelchairs, walkers and on the residents' wrists or ankles. The MTD demonstrated how he checked the main door utilizing resident #30's wheelchair. The WanderGuard bracelet was secured to a metal bar on the back of the wheelchair on. The MTD brought the wheelchair to the door. The system did not audibly alarm to indicate that a WanderGuard was within the range. The MTD said the WanderGuard system did not recognize the bracelet which was attached directly to the metal chair. He moved the wheelchair closer to the door; it was approximately one foot from the door when it began to alarm and the door than locked. The MTD said that at times he had to adjust the sensor to the WanderGuard. The NHA and the MTD were interviewed on 9/13/17 at 3:46 p.m. The MTD said that he adjusted the sensor last night (9/12/17) after it did not recognize resident #30's WanderGuard. The MTD and the NHA were interviewed on 9/25/17 at approximately 12:00 p.m. The MTD said that each nurses' station had a universal tester. The MTD said that the tester was reliable. He said that if the universal tester was not working, then the batteries were not good. He confirmed that he had no system in place to ensure batteries were available to staff in event the universal tester was not functioning. On 9/12/17 at approximately 4:15 p.m. a medication aide (CNA-Med) #2, attempted to demonstrate how the facility tested the residents WanderGuards to see if they were functioning properly. She took a universal tester from the medication cart that she was working and approached resident #1; she held the universal tester to the Wander Guard on the resident's right foot. The CNA-Med stated that the universal tester has a light on it thatwill light up if the WanderGuard was working. She stated that she was unsure why the resident's WanderGuard was not making the universal tester light up. The CNA-Med stated she was sure that the resident's WanderGuard was working because the resident had an appointment that morning and her WanderGuard had made the door beep. 3. Resident #30 was observed on 9/12/17 at 7:18 p.m. She was in her wheelchair with her WanderGuard on a metal bar on the bottom of the wheelchair. She was touching the front doors with her hands. The alarm did not sound and the doors did not lock. The WanderGuard pad on door displayed a green light, which indicated the doors were unlocked and egress was permitted. A representative from the company, which manufactured the WanderGuard departure alert system, was interviewed on 9/14/17 at 10:25 a.m. He stated that the WanderGuard bracelet was designed to be worn on the residents' dominant wrist. He stated the bracelet device should not be placed directly onto metal, like the metal of a wheelchair or walker, because the WanderGuard was a radio device that emitted a radio frequency. He stated the radio frequency emitted from the bracelet to the Wander Guard unit on the door caused the door alarm and lock, thus preventing the resident from going out the door. He stated that when the bracelet is placed directly onto metal, the metal could disrupt the radio frequency. Disruption of the radio frequency may cause the system to fail, and not lock the door. He stated if a WanderGuard bracelet must be placed on a resident's wheelchair or walker, that a facility must put something in between the WanderGuard bracelet and the metal of the wheelchair or walker. He suggested that the facility use foam or plastic on the wheelchairs in between the bracelet and metal. He stated the WanderGuard manufacturer would not guarantee that the WanderGuard system would function properly if the bracelet was not placed directly onto the resident. According to the Stanley Healthcare solutions, WanderGuard ID system, User and Installation Manual copy right 2012, page 17 the manufacturer guidelines documented, .no more than one bracelet should be placed on a resident Two bracelets, if brought close together, may not be received by the door modules and the alarm will not sound .The bracelet should also be kept away from metal jewelry such as watches and bracelets . the wander guard bracelet should not be placed directly onto the metal of a wheelchair . d. Resident #21 Resident #21, age 73, was admitted on [DATE] and readmitted [DATE]. According to the September 2017 computerized physician orders (CPOs) [DIAGNOSES REDACTED]. According to the 6/6/17 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident required supervision with one-person assist for bed mobility, transfers, locomotion on and off the unit and personal hygiene; limited assistance with two-person assist for toilet use; and extensive assistance with two person assist for dressing. The MDS identified the resident was at significant risk of wandering to a potentially dangerous place. The resident's wandering did not intrude on the privacy or activities of others. Record review The facility staff documented nine events regarding elopement attempts from 4/1/17 to 9/2/17. The nurses' progress notes failed to provide evidence that the WanderGuard was checked for placement and function after each elopement attempt. The medical record failed to show evidence that an investigation was completed when the resident was found outside of the facility. The facility moved the resident into the secure unit to prevent further elopements. Record review demonstrated the resident continued exit the building even after the elopement prevention device was placed on 5/3/17. The care plan, initiated 8/20/14 and revised 9/13/17, identified the resident was an elopement risk related to impaired safety awareness. She had a history of [REDACTED]. The resident was disoriented to place related to dementia diagnosis. The interventions included: distract from wandering by offering pleasant diversions, structured activities, food, conversation, television and books; identify the pattern of wandering to include is wandering purposeful, aimless or escapist, looking for something, indication of need for more exercise; intervene as appropriate; observe location at regular and frequent intervals; offer emotional and psychological support; and provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. The care plan, initiated 8/20/14 and revised 9/13/17, identified the resident was admitted to the facility for long term care (LTC) placement and plans to remain at LTC. Resident resided on the special secured neighborhood for LTC. The interventions included: involve the resident and her family in the care planning process; orient to surroundings, as needed; and personalize resident's room per their wishes. The care plan failed to identify the resident had a wander guard bracelet. The elopement risk was completed 4/6/17 and revealed the resident was an elopement risk with a score of 12. A score from zero to 11 meant the resident was at a low risk to elope. The elopement risk was completed 6/10/17 and revealed the resident was an elopement risk with a score of 12. The nurses' progress notes were reviewed from 4/1/17 to 9/14/17 and read in pertinent part: - 4/12/17 at 12:04 p.m. During report this morning this nurse was informed that resident was already exhibiting behaviors, had begun exit seeking. - 4/16/17 at 1:45 p.m., Exit seeking behaviors exhibited, able to redirect for the time being. Will continue to monitor. - 4/17/17 at 3:24 p.m., She then was noted speeding up and down hallways in w/c (wheelchair) slapping at her knees repeatedly and laughing hysterically then exit seeking behaviors by front door. Assisted to secure unit where she could roam about courtyard. She remained there for about an hour. No further outbursts. - 5/28/17 at 8:40 a.m. Was giving report to oncoming nurse when someone reported that resident was outside. When nurses got outside a CNA had already gotten to (resident name), she was refusing to come back inside and was holding her WC (wheelchair) wheels and not cooperating with staff in any way. Several attempts made to help and resident still refusing. Staff then began to pull resident back and she started hitting and biting staff. Got as far as the front door with resident still resisting and at that time she ripped the keys from around my neck and broke them and threw them. Staff was able to get resident back into the building at which time staff noted she did not have a wander guard on. A new wander guard was placed on her ankle that was patent. Staff returned back to the unit and resident was still able to make her way outside again. Then we went to get her back in and she became aggressive again. Refusing to stay inside at all. Still being aggressive and hitting and biting at staff. She was still very aggressive and refusing to stay in the building. - 6/1/17 at 5:49 p.m. did state she was looking for a new home and would like to know the way out of here. Diversional activities prevented elopement attempts. - 6/8/17 at 2:51 p.m. Resident was hanging out in the lobby of the rehab unit when all of a sudden she started toward the double doors. - 6/10/17 at 2:28 p.m. Resident went out the front doors this afternoon and attempted to leave the property. This nurse noticed her sitting outside and immediately sent an RA (resident aide) to go sit with her. While that RA was sitting with her (resident name) started wheeling very fast down the sidewalk. The RA called this nurse and we both walked (resident name) around the building. After 10 minutes she did come inside with us. Once inside her wander guard was immediately checked and was in working condition. No more attempts to elope have occurred at this time. - 6/11/17 at 5:32 p.m. She has been in her w/c (wheelchair) all afternoon, no attempts to elope. Wg ( WanderGuard) in place to ankle. - 8/15/17 at 1:12 p.m. Resident got out the front door this morning right after breakfast. The alarm did sound from her wander guard and resident was accompanied the entire time by staff. Staff was out with her but could not get her back inside without her becoming combative. Resident kept stating that she didn't live here and that she wanted to go to church. Staff were out with resident for 2+ hours trying to keep her calm and redirect her inside. Staff had to keep pushing her otherwise resident would try to go into the street. When staff were able to get resident back inside an order was obtained to allow her to be on the memory care units locked courtyard. She has remained in the courtyard for several hours with supervision. Lunch was brought to her out there and she has no desire to come back inside at this time. This nurse will continue to monitor and do frequent checks on this resident. - 8/23/17 at 9:10 p.m. At secured unit doors knocking and telling staff to let her out, staff attempted to redirect her to the outside/backyard area and she stated she didn't want to go outside, but she wanted to go to her bedroom. Redirected and staff showed resident her new bedroom with all of her personal belongings in it and she calmed down. - 9/2/17 at 10:15 a.m. Check wander guard placement and test every shift. Every shift check placement and test wonder (sic) guard every shift. DC'd (discontinued) resides in locked unit. Physician Telephone Orders (TOs) - 5/3/17 Device: Check wander guard placement and function Q (every) shift for poor safety awareness, elopement risk. Replace if missing or not functioning. Discontinue 5/3/17 reason: restorative will check wander guard. - 5/3/17 at 1:04 p.m. WanderGuard for elopement risk. - 7/27/17 check WanderGuard placement and test every shift. Every shift check placement and test WanderGuard every shift. Interview The nursing home administrator (NHA) was interviewed on 9/12/17 at approximately 3:00 p.m. The NHA said that an investigation was not completed when the resident was found outside of the facility. She said that an investigation did not have to be completed, as the resident had not left the facility grounds and area surrounding the facility. e. Resident #32 Resident Status Resident #32, age 86, was admitted on [DATE] and readmitted on [DATE]. According to the September CPO, [DIAGNOSES REDACTED]. According to the 6/21/17 MDS assessment the resident had moderate cognitive impairment with a BIMS score of eight out of 15. He had no behaviors, did not reject care, and did not wander. He used a walker and a wheelchair for mobility and was able to walk with staff supervision. Although the resident wore a WanderGuard bracelet, restraint section of the MDS failed to indicate the use of the wander or elopement alarm. Record Review The care plan, updated on 8/24/17, identified the resident as being at risk for falls due to weakness, altered mental status (AMS), paranoia, history of falls, potential for elopement, and wander risk. The interventions included observe for exit seeking behaviors and provide diversion activities, observe for placement and function of wander guard per facility protocols and electronic safety device as deemed necessary by observation. Elopement risk assessment The resident's elopement risk assessments were reviewed. According to the elopement tool, score of 12 or higher indicated the resident was at risk for elopement. An elopement risk assessment dated [DATE] showed a score of seven, which put him at a low risk for elopement. The assessment documented no risk identified. The elopement risk assessment dated [DATE] showed the resident scored a ten, which put him at a low risk for elopement. The assessment documented no risk identified. The assessment was requested from the facility. The paper assessment received from the facility on 9/26/17 was reviewed. Although the date and time stamp on the electronic assessment and the paper assessment showed 9/12/17 at 6:52 p.m., the paper assessment received from the facility revealed the score was changed to 13, which put the resident at risk for elopement. A physician order was received on 5/13/17 showed an order for [REDACTED]. The orders were updated on 9/13/17 which included to check the wander guard placement and function. The nursing note dated 8/16/17 documented the resident made multiple attempts to open the door at the end of a hallway. The note documented staff redirected him multiple times while attempting to open the door. He was returned to his room and remained in pleasant mood throughout entire process. A nursing note written on 9/13/17 revealed on 9/10/17 at 11:50 a.m. the resident was observed exiting the facility through the door at end of the hall. According to the documentation, the electronic alarm bracelet set off the door alarm. When staff responded to the alarm and arrived at the door, the resident was observed at the end of the sidewalk turning towards the front of the facility. It was noted the resident was pleasant, friendly, easily redirected and stated, just want to sit in sun. The nurse sat with resident outside on patio by the dining room for approximately 15 minutes. The facility staff documented one event regarding elopement attempts from the facility. The nurses progress notes failed to provide evidence that the WanderGuard was checked after the elopement attempt and failed to investigate when the resident was found outside of the facility. Additional Residents In addition to the above residents, the following residents were identified by the facility to have a risk for elopement and had a WanderGuard in place. The failures for the residents below included failure to obtain physician orders for placement of an elopement prevention device and failure to monitor the functionality and/or placement of the WanderGuard bracelet. a. Resident #38, age 94, was admitted on [DATE]. According to the September 2017 CPO, [DIAGNOSES REDACTED]. According to the 8/1/17 MDS assessment, the resident had moderately impaired cognition with a BIMS score of eight out 15. According to the 5/8/17 admission and the 8/1/17 MDS assessment, under the restraints section, the resident was not identified as having a wander/elopement alarm. According to the 9/12/17 annual elopement risk, the resident scored ten points indicating the resident was at no risk for elopement. According to the September CPOs there were no physician orders for the WanderGuard. The resident was interviewed on 9/12/17 at approximately 11:00 a.m. The resident was observed in bed, she had a WanderGuard on her right wrist. She stated that she had worn the WanderGuard since she was admitted to the facility. She stated that she hated the thing and was unsure why she had to wear it. b. Resident #39, age 70, was admitted on [DATE]. According to the September 2017 CPOs, [DIAGNOSES REDACTED]. According to the 8/2/17 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. Under the restraints section, the resident was not identified as having a wander/elopement alarm. According to the September 2017 WanderGuard function checklist, resident #39, was identified as having a WanderGuard that was applied on 8/30/17. Review of the medical record failed to show that the WanderGuard was checked for functionality and placement. A new physicians order was obtained on 9/13/17 to change the residents WanderGuard every 90 days. c. Resident #16, age 83, was re-admitted on [DATE]. According to the September 2017 CPO [DIAGNOSES REDACTED]. <br(TRUNCATED)

Based on record review, observations and interviews, the facility failed to ensure 16 (#1, #3, #8, #10, #16, #21, #24, #30, #31, #32, #33, #35, #36, #37, #38, #39) out of 49 total sampled residents were provided the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically: The facility failed to take steps to manage resident #35 bilateral lower leg pain related to swelling. The facility's failures contributed to the resident experiencing unrelieved, severe pain at a level of 8 out 10 (10 being the worst pain). The facility failed to have an effective system to obtain written consents for the use of the WanderGuard elopement prevention devices for residents #1, #3, #8, #10, #16, #21, #24, #30, #31, #32, #33, #36, #37, #38, #39. The findings included: 1. Pain The survey team has written F425 for the facility's failure to have pain medications timely ordered and available to administer for relief of resident #35's severe pain. Failure to have medication timely ordered and available from pharmacy resulted in two instances of the resident experiencing severe, unrelieved pain for prolonged intervals of time. Professional References According to Potter and Perry, Fundamentals of Nursing, 8th ed., Elsevier, St. Louis Missouri, 2013, pp. 966-996: Attitudes of nurses and other health care providers affect pain management .(The nurse and other health care providers) must accept a patient's report of pain and act according to professional guidelines, standards, position statements, policies and procedures, and evidence based research findings. Facility Policy In pertinent part, the facility pain policy, dated July 2017 stated, The facility recognizes the inter-relationship between uncontrolled pain and the decline in functional abilities, leading to impaired quality of life. The facility will evaluate and identify residents experiencing pain .and develop a care plan for pain management consistent with the comprehensive care plan .the care plan is implemented and evaluated for its effectiveness. The staff monitors and documents the resident's response to pain management interventions. Pain screening is done upon admission using the Pain Evaluation user defined assessment .the goal of pain management is to effectively and consistently identify and treat pain . Resident Status Resident #35, age less than [AGE] years, was admitted on [DATE]. According to the September 2017 computerized physician orders [REDACTED]. The 8/8/17 minimum data set (MDS) documented the resident had a brief interview for mental status score of 13 out of 15, which indicated the resident was cognitively intact. The MDS identified the resident as having a pain regimen. The pain questionnaire was not completed. Resident Interview The resident was interviewed on 9/25/17 at 10:15 a.m. The resident said, I would like to work on this puzzle but I can't concentrate because of the pain, you would think they would have an emergency stock they can give me. I have been in severe pain since last evening. (See record review below showing the resident received his last dose of pain medicine on 9/24/17 at 11:04 a.m.) The resident said his current pain level was eight out of ten. He said he was having leg pain due to swelling in his lower legs. Observation The resident's lower legs were observed on 9/25/17 at 10:35 a.m. with registered nurse (RN) #8 present. Both of the resident's left and right lower legs were [MEDICAL CONDITION] (swollen) and reddened with indentation observed at the sock line. The resident grimaced as the RN touched his legs. The resident again voiced his pain level was at an eight out of ten. Previous Unrelieved Pain Before 9/25/17, the medical record documented the resident had another incident of unrelieved severe pain due to the unavailability of prescribed pain medication. The nurses' progress note dated 9/1/17 documented, the resident was complaining of pain and that the [MEDICATION NAME] (see record review below for medication orders) was not available. The night nurse submitted an authorization to pharmacy for access the emergency kit. The authorization had not come in as of 10:01 a.m. The resident had been offered Tylenol, but it was refused. The progress note did not document any offer of non-pharmacological interventions to relieve the resident's pain. The note documented the resident called his wife and his wife called 911 to take him to the emergency room . Record Review The pain assessment completed on 8/29/17 showed the resident had pain almost constantly, which resulted in loss of sleep and limitations of his day-to-day activities. The pain assessment showed his acceptable pain level was zero, which indicated no pain. (See below for medication administration review that documented the resident had an average reported pain level of seven out of ten in September 2017.) The care plan, dated 8/31/17, failed to identify that the resident had pain. No approaches were included to direct staff on how to manage the resident's pain or as to what interventions could be employed to provide pain relief. Review of the September 2017 medication administration record (MAR) revealed the resident was prescribed as needed (PRN) medication. Although the resident experienced almost constant pain, the MAR documented the resident did not have any scheduled pain medication. The pain regimen was as follows: -[MEDICATION NAME] tablet 10-325 mg ([MEDICATION NAME] - [MEDICATION NAME]) give 1 tablet by mouth every four hours PRN). The start date for the [MEDICATION NAME] was 9/6/17. -Tylenol 325 mg two tablets by mouth every six hours as needed for pain. The September 2017 MAR showed the resident received the PRN [MEDICATION NAME] medication 83 times from 9/6/17 to 9/24/17. The MAR showed the resident did not receive the Tylenol during the month. The record did not show that Tylenol had been refused from 9/6/17 through 9/24/17. The September 2017 MAR documented the resident's average reported pain level was seven out of ten. The September 2017 CPO documented an order to evaluate the resident's pain level every shift. The MAR and medical record failed to show any non-pharmaceutical interventions were offered in order to relieve the resident's leg pain. The September MAR showed the resident had received his last dose of [MEDICATION NAME] 9/24/17 at 11:04 a.m. The MAR for 9/24/17 showed the resident had a pain scale of seven out of ten. The MAR showed that he did not receive any medication to relieve his pain, as the [MEDICATION NAME] was unavailable. The MAR does not show the resident refused the Tylenol. The medical record failed to show any documentation of pain assessment and any interventions, or notify the physician on 9/24/17 and 9/25/17 when the medication was unavailable. Staff Interviews The RN #8 was interviewed on 9/25/17 at 10:30 a.m. The RN said that the resident has been in pain since 2:00 a.m. She said that the resident did not have the PRN [MEDICATION NAME] available because it was not ordered timely. The RN said the night shift nurse sent over the authorization to the pharmacy to obtain the medication from the emergency kit; however, the RN had not heard anything yet from the pharmacy. She said when she had called the pharmacy they said they had not received the authorization. The RN said she had complied with the pharmacy's request to resend it. She said the resident had pain from his bilateral lower legs. The RN confirmed she was aware the resident's pain level was severe at a level of eight out of ten. She denied offering any non-pharmaceutical interventions. The RN denied offering the resident to the hospital. The interim director of nurses (IDON) was interviewed on 9/25/17 at 11:10 a.m. The IDON said she had just been informed by RN #8 that resident had been experiencing severe, unrelieved pain since approximately 2:00 a.m. (The represents a nine hour time elapse from when the resident reported pain and the nursing staff discovered [MEDICATION NAME] discovered to be unavailable for the resident.) She said that she would expect to be notified immediately when a medication was not available. She said a back-up pharmacy was available, and also the medical director could be utilized to facilitate timely pain intervention. The pharmacist was interviewed on 9/26/17 at 3:00 p.m. The pharmacist said the medications should be ordered seven days in advance. Once the medications were ordered, then the turn around period was 48 hours or less. She said the narcotics were delivered in 30 day bubble packs. Facility follow-up The physician for resident #35 called in approval to pharmacy for a one-time order of two 5/325 [MEDICATION NAME] to be dispensed from the emergency drug kit at 11:50 a.m. which was then dispensed to the resident. (This was more than nine hours after the resident made his pain known to nursing staff.) Approximately 1:15 p.m. the resident reported acceptable pain relief. 2. WanderGuard Consents Record Review The facility provided a list of residents who used a WanderGuard for residents who were at risk for elopement. Review of the records for residents #1, #3, #8, #10, #16, #21, #24, #30, #31, #32, #33, #36, #37, #38, and #39 showed no signed consent forms for the WanderGuard. Staff Interviews The nursing home administrator (NHA) was interviewed on 9/14/17 at approximately 9:25 a.m. She stated the facility would get an order from the resident's physician to place the WanderGuard on a resident. She stated the facility spoke with the resident or the family of the resident and the facility received verbal consent however, did not receive written consent. The regional nurse consultant was interviewed on 9/14/17 at approximately 9:30 a.m. She said the facility did not have consents to place the WanderGuards on residents because the WanderGuard was not a restraint. She stated in worst case scenario, a resident with a WanderGuard could get out of the facility by pushing on a door with a WanderGuard alarm system for an undetermined amount of time and the door would open. The social service assistant (SSA), and the regional social service consultant (SW) were interviewed on 9/26/17 at 1:00 p.m. The SSA stated the facility did get consents for several different things such as visiting ancillary services like dentists, and podiatrists. The facility would also get signed consents when a resident was taking a [MEDICAL CONDITION] medication. The SSA stated the facility did not get consents for the WanderGuard bracelet that was placed on residents. The SSA stated the facility would complete an elopement risk assessment, and if the resident was an elopement risk the facility would get a doctors order for the WanderGuard. The SW stated the facility did not get a consent for the WanderGuard because the facility did not believe that it was a restraint. The medical director (MD) was interviewed on 9/26/17 at 4:00 p.m. The MD said that a written consent should be obtained for the use of the WanderGuard because it prevented the resident from going out the front door.

Based on record review and interview, the facility failed to provide necessary care and service to attain and/or maintain the highest practicable level of well-being for one (#4) of four sample residents. Specifically, the facility failed to: -Provide adequate and timely emergency care for the treatment of [REDACTED].#4, contributing to resident pain. -Provide x-rays for resident #4 after a fall with injuries. The resident fell at approximately 1:40 a.m. but did not receive an evaluation and treatment by a physician until she was sent to the hospital at 4:00 p.m. with increasing pain. Treatment at the hospital discovered the resident had acute right intertrochanteric [MEDICAL CONDITION] from the fall. Cross Reference F 157 The findings include: Resident #4, age 77, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the minimum data set ((MDS) dated [DATE], a brief interview for mental status (BIMS) was not able to be completed by the resident, indicating impaired cognition. However, the MDS indicated that resident #4 usually was able to make self understood and usually was able to understand others. The resident required assistance of two staff for transfers, and one staff for bed mobility, walking on and off the unit, dressing, toileting, and personal hygiene. Record Review Review of physician orders [REDACTED]. 4/13/14 - send resident to hospital for evaluation and treatment - (no time recorded on this telephone order) 4/13/14 - x-ray of right hip due to pain (no time recorded on this telephone order) Resident Transfer Form revealed that on 4/13/14 at 4:15 p.m., the resident was transferred to the hospital for severe pain in right hip. Hospital records revealed that the emergency department physician examined the resident on 4/13/14 at 4:32 p.m. with clinical impressions for right hip x-ray of acute right intertrochanteric [MEDICAL CONDITION] and fall. The emergency department physician's report also noted that the resident was given [MEDICATION NAME] for her discomfort; she was kept still in bed because of her pain. The chief complaint was hip pain and fall at around 2:00 a.m. on 4/13/14; she was given some [MEDICATION NAME]-[MEDICATION NAME] and [MEDICATION NAME] (pain medications), but continues to have a significant amount of pain in the right leg, especially with movement. Review of systems noted significant right hip pain since this morning's fall. Review of Nursing Notes revealed: -4/13/14 8:00 a.m. entry: at 1:40 a.m. staff heard the bed alarm sounding for resident #4. Staff found her walking down the hall way. As staff approached her, the resident turned and fell to her right side on the floor. Staff reported that she did not hit her head. She was assessed for injuries and complained of right side soreness but had range of motion. Two staff assisted her back to bed. [MEDICATION NAME]-[MEDICATION NAME] and [MEDICATION NAME] (pain medications) were administered for complaint of soreness. Resident slept until she got up for breakfast. -4/13/14 2:00 p.m. entry: resident continues on follow-up for witnessed fall on night shift. Order received to obtain x-ray for right hip. Family notified of fall. Resident is complaining of increased right hip pain. Scheduled pain medicine was given with some relief obtained. -4/13/14, with no time noted: resident presented with increasing level of pain. [MEDICATION NAME]-[MEDICATION NAME] and [MEDICATION NAME] (pain medications), administered at 2:00 p.m. ineffective. Pain appears to be centralized in right hip. Portable x-ray called at approximately 10:00 a.m. At 4:00 p.m. family approached nurse very distressed, stating that they wanted the resident to go to the hospital and that the portable x-ray would not be timely enough. Call to physician's office; order received to send resident to hospital. -4/13/14 3:50 p.m. entry: paramedics called, [MEDICATION NAME]-[MEDICATION NAME] and [MEDICATION NAME] (pain medications) given with no relief of pain. Resident was unable to sit up in bed. 4:00 p.m. paramedics here for transfer to hospital emergency room . Review of x-ray express orders revealed that the order for a hip x-ray was received on 4/13/14 at 9:37 a.m. and portable x-ray service dispatched on 4/13/14 at 11:20 a.m. This order was cancelled at 8:50 p.m. Review of Incident/ Accident Report revealed that the resident fell at 1:40 a.m. on 4/13/14. The resident's bed alarm sounded and staff found her walking in the hall. As the staff approached her, she turned and fell to her right side on the floor, did not hit head. Resident complained of right side/hip pain, but had movement, range of motion intact. Pain was not out of ordinary until a few hours passed, when the resident complained of increased pain. The physician was notified at 7:00 a.m. Review of the 4/2014 Medication Administration Record [REDACTED] - [MEDICATION NAME]-[MEDICATION NAME] 5 mg-325 mg tablet - 1 tablet three times per day - scheduled at 7:00 a.m., 12 noon, and 6:00 p.m. 4/2014 MAR indicated [REDACTED]. -[MEDICATION NAME] to area of pain on back, on for 12 hours, off for 12 hours. 4/2014 MAR indicated [REDACTED]. Pain was monitored using the pain scale of 0-10 every 8-hour shift. 4/2014 MAR indicated [REDACTED]. Through 4/12/14, the remaining 32 of 36 shifts, the resident was assessed at 0 for pain. On 4/13/14, the night shift nurse assessed her pain at 6; the day shift nurse assessed her pain at a 0. Review of the 4/2014 PRN (as needed) Pain Medication Administration Record [REDACTED] -[MEDICATION NAME]-[MEDICATION NAME] 5 mg-325 mg tablet - 1 tablet every four hours PRN (as needed for pain. 4/2014 PRN Pain MAR indicated [REDACTED]. On 4/13/14, this pain medication was administered at 1:40 a.m. and the resident was assessed at a pain level of 6. Post-administration pain level was 2. On 4/13/14, this pain medication was administered at 3:50 p.m. and the resident was assessed at a pain level of 8. Post-administration pain level was 4. There was no evidence in the medical record that documented the resident ' s pain level was assessed between 1:40 a.m and 3:50 p.m. -[MEDICATION NAME] 50 mg tablet - 1 tablet every six hours PRN (as needed) for pain. 4/2014 PRN Pain MAR indicated [REDACTED]. On 4/13/14, this pain medication was administered at 1:40 a.m. and the resident was assessed at a pain level of 6. Post-administration pain level was 2. On 4/13/14, this pain medication was administered at 3:50 p.m. and the resident was assessed at a pain level of 8. Post-administration pain level was 4. . There was no evidence in the medical record that documented the resident ' s pain level was assessed between 1:40 a.m and 3:50 p.m. Interviews Interviews with family member, on 5/8/14 at 4:00 p.m. and on 4/29/14 at 11:20 a.m., revealed that the family came to the facility for a visit in the late morning of 4/13/14. The family was then notified by the nurse that the resident had a fall in very early morning at 1:40 a.m., was experiencing pain and that an x-ray was ordered, but that the portable x-ray service had not yet arrived. The family member stated that the resident was having increasing pain, and by 3:00 p.m. the x-ray still was not obtained. The family requested to have the resident sent to the hospital for x-ray, evaluation and treatment. On 5/9/14 at 9:00 a.m., the Director of Nursing (DON) stated that the nurse called the physician's office at 7:00 a.m. to notify him of the fall and the resident's pain. A physician's orders [REDACTED]. The nurse called in the x-ray order at 9:37 a.m., per the x-ray express order sheet. This was not called in as an immediate (STAT) order, so the window of time allowed is 4 hours, which meant that the portable x-ray services should have arrived by 1:37 p.m. (Which they did not do.) The nursing staff did not call back to the portable x-ray services to change the order to immediate (STAT) or find out why the x-ray services had not arrived, when the resident's pain was increasing. On 5/9/14 at 11:30 a.m., the DON stated that the nurse should have called in the x-ray order as immediate (STAT) and clarified the order with the physician. When the x-rays were so delayed and the resident's pain was increasing, the nurse should have called the physician again. She stated that the resident was then sent to the hospital for the x-ray, evaluation and treatment at approximately 4:00 p.m. on 4/13/14.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two of 40 sample residents (#50 and #5). Specifically: -For resident #50 - The facility failed to recognize the resident was experiencing pain and failed to manage the resident's pain in a manner consistent with facility policy, the comprehensive assessment, the plan of care, and the resident's goals and preferences. The resident complained of pain in his knees that interfered with sleep and mobility. -For resident #5 - The facility failed to ensure staff were consistently trained on the resident's assistance needs. Findings include: A. Pain management 1. Facility Policy Review of a facility policy titled pain management, dated 2/10, disclosed in pertinent part: -the facility recognizes the inter-relationship of uncontrolled pain and the decline in functional abilities, leading to an impaired quality of life. -the facility will evaluate and identify residents experiencing pain, evaluate the existing pain and the causes, determine the type and severity of the pain and develop a care plan for pain management. -the care plan is implemented and continually evaluated for its effectiveness. -the staff monitors and documents the resident's response to pain management interventions. -residents are evaluated for pain regularly by inquiring if they have pain and observation of the resident for signs and symptoms of pain. -the goal of the pain management program is that pain is identified and treated effectively and consistently. -steps for pain: evaluation for the presence of pain, in depth evaluation of pain (have to do an in-depth evaluation any time the resident has a new complaint of pain or when you suspect pain may be present), develop individualized care plan (pain is whatever the resident states that it is), putting the plan into action (to be successful, your team must be consistent, everyone must provide the same type of care to that resident every day, and be proactive to make sure the resident achieves relief and remains free from pain) and re-evaluate pain on a regular basis (need to re-evaluate the resident on a regular basis. This will be done each time you administer a pain medication to the resident, evaluating the effectiveness of the medication and making changes if the medication or approach is not effective). 2. Resident #50 Resident #50, age 70+, was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident's recent minimum data set (MDS) assessment, dated 8/21/11, disclosed: -the BIMS (brief interview for mental status) was not completed. -short/long-term memory problems and moderately impaired cognitive skills for daily decision making. -needed supervision with eating; limited assistance with bed mobility, transfers; extensive assistance with dressing, toilet use, personal hygiene and was totally dependent on staff for bathing. -no impairment in range of motion of the upper extremity and had impairment of the lower extremity on one side. -use of a walker and wheelchair for mobility. -in the last five days the resident had been on a scheduled pain medication regimen, received prn (as needed) pain medications and had not received non-medication intervention for pain. -should pain assessment be conducted-yes -any pain or hurting in the last five days=yes -how much of the time have you experienced pain or hurting in last five days=four (rarely) -over the past five days, has pain made it hard for you to sleep at night=no -over the past five days, has the pain limited your day to day activities because of the pain=no. -numeric rating scale (rate pain on a zero to ten scale, one being no pain and ten the worst pain you can imagine)=06. a. Pain Management Plan Review of physician orders [REDACTED]. -11/24/10 Tylenol 325 mg by mouth (po) every six hours as needed (prn) for pain, not to exceed (nte) 4 grams in 24 hours. -6/16/[MEDICATION NAME] 1.3% adhesive patch (medicated) to both knees every day, remove old patch. (Flector is a non-steroidal anti-[MEDICAL CONDITION].) -4/1/11 [MEDICATION NAME] 5/325 mg po 2 tabs every four hours prn pain nte 4 grams in 24 hours. ([MEDICATION NAME] is a narcotic pain relief medication.) -4/1/11 [MEDICATION NAME] 5/325 mg po 1 tab every four hours prn pain nte 4 grams in 24 hours. Review of care plans disclosed the following: -10/18/10 Actual pain/discomfort related to joint pain, abdominal pain, knee pain. Medications listed included [MEDICATION NAME] prn, [MEDICATION NAME] routine, Tylenol prn,[MEDICATION NAME]. Approaches included provide non-pharmacological interventions (checked were positioning/support, recreational therapy/activity programming, relaxation), administer [MEDICATION NAME] as ordered, see physician orders, implement pain management flow sheet, observe resident for signs and symptoms of pain (frequency of monitoring every shift and prn), notify the physician it interventions are not consistently effective, medicate resident for pain prior to treatments and therapy if ordered. The care plan was signed off as reviewed on 8/23/11 and 10/24/11. -10/29/10 Requires staff assistance and intervention for completion of ADL (activities of daily living) needs. Approaches included ensure effective pain management prior to ADL activities. b. Observations and Resident Interview During observation and interview on 10/18/11 at 3:14 p.m., resident #50 was fidgeting, grimacing and groaning. He said he did not sleep the last two nights because of the pain in his knees. He pulled his pants legs up above his knees and stated he got shot in the knee. There were white patches (Flector patches) on his knees. He said the pain is bad. He said he could not rate the pain numerically (such as 5 out of 10 and 10 the worst kind of pain). The resident said he could not get up out of the chair without a great deal of pain. On 10/19/11 at around 8:55 a.m., the resident revealed his knees were hurting and he did not sleep well last night. He pulled his pants legs up again, showing patches on his knees. He said he felt like he was in the war because his knees were hurting badly. The resident was sitting in a chair in his room and said he got around his room with bad pain when he walked. On 10/19/11 at around 1:15 p.m., 2:50 p.m. and at 4:35 p.m., the resident disclosed that his knees were still hurting and he had been unable to rest because of the pain. He said he could not remember the last time he got pain medication by mouth. On 10/20/11 at around 9:50 a.m., the resident asked the surveyor to look into how the facility manages his pain. He said his knees hurt all the time. He groaned during the interview. He said he did not get pain medication on a regular basis except the knee patches (Flector patches). On 10/20/11 at around 1:15 p.m. and at 4:45 p.m., the resident revealed his knees were hurting and he did not sleep well last night because of the knee pain. On 10/23/11 at 6:16 p.m., the resident said he sometimes used the bathroom on his own and it hurt a lot when he got out of the chair. He was sitting in a chair in his room. c. Record Review (1) Medication Administration Records (MAR) Review of medication administration records/treatment administration records (MAR/TAR) disclosed the following: -7/11 [MEDICATION NAME] 2 tabs prn was given x 7 doses for pain rating of 5. [MEDICATION NAME] 1 tab prn was given x 1 dose for pain rating of 5. -8/11 [MEDICATION NAME] 2 tabs prn was given x 1 dose for pain rating of 6. [MEDICATION NAME] 1 tab prn was not given. -9/11 Tylenol prn was given x 2 doses for pain rating of 3. [MEDICATION NAME] 2 tabs prn was not given. [MEDICATION NAME] 1 tab prn was given x 3 doses for pain rating of 6. -10/11 Tylenol prn was not given, [MEDICATION NAME] 2 tabs prn (for pain in the knees, shoulder or headache) was not given, [MEDICATION NAME] 1 tab prn (for generalized pain and in the knees) was not given and [MEDICATION NAME]es were applied to both knees at 6:00 a.m. daily. MARs for 3/11, 4/11, 5/11, that revealed the resident's pain was to be monitored every shift. Ask or assess for pain or discomfort level every shift, assess (resident's) nonverbal indicators using Wong baker faces scale, use 0-5 pain scale. Documentation revealed nurses were signing off the monitoring and documenting level of pain. Review of the MARs after 5/11 revealed no documentation/written evidence that staff were monitoring/assessing the resident's pain routinely. (2) Nurses' and Social Service notes Review of nurse's notes revealed from 9/6/11 to 10/12/11, there was no documentation of assessment of the resident's experience of pain. There was no nursing note documentation after 10/12/11. Additional nurse's notes from 7/11 to 10/11 were requested from medical records staff but not received prior to the end of the survey. Review of social service notes disclosed that prior to 10/21/11, there was no mention of the resident's experience of pain. On 10/21/11 (during survey), the note read that the resident said he had to go to war tonight and his knees were blown off in the war. Talked about going to war again. (3) Pain Evaluations Review of Pain Evaluations revealed no evaluations after 3/18/11, until 10/24/11 (during survey). The pain evaluation completed during survey revealed an increase in the resident's pain level and the effect of the pain on the resident's activities of daily living and sleep. -10/16/10 Been on scheduled pain regimen in last five days=blank; received prn pain medications in last five days=yes; received non-medication interventions for pain in last five days=blank. Pain or hurting in the last five days=yes; how much of the time have you experienced pain or hurting in last five days= occasionally; over the past five days, has pain made it hard for you to sleep at night=no; over the past five days, has the pain limited your day to day activities because of the pain=no; location of pain joint and generalized, prior history of pain/hurting=blank. Potential underlying causes (arthritis). Numeric rating scale present pain=02. Numeric rating worst pain/hurting gets=04. Best pain/hurting gets=0. Goal for managing pain or hurting=0. Satisfied with current level of pain/hurting control=yes. What relieves pain/hurting=rest, positioning, medication administration. Describe quality of pain/hurting=soreness, throbbing, aching. Timing and contributing factors=exercise, mobility range of motion. Manner of expression of pain and associated symptoms=verbalization. Has pain interfered with the following=blank. Laxative ordered blank. Side effects/adverse consequences experienced blank. -11/24/10 Been on scheduled pain regimen in last five days=blank; received prn pain medications in last five days=yes and received non-medication interventions for pain in last five days=blank. Pain or hurting in the last five days=yes; how much of the time have you experienced pain or hurting in last five days= occasionally; over the past five days, has pain made it hard for you to sleep at night=no; over the past five days, has the pain limited your day to day activities because of the pain=no; location of pain joint and generalized, prior history of pain/hurting=blank. Potential underlying causes (arthritis). Numeric rating scale present pain=02. Numeric rating worst pain/hurting gets=04. Best pain/hurting gets=0. Goal for managing pain or hurting=0. Satisfied with current level of pain/hurting control=blank. What relieves pain/hurting=rest, position, medication administration. Describe quality of pain/hurting=aching, soreness throbbing. Timing and contributing factors=exercise, mobility range of motion. Manner of expression of pain and associated symptoms=verbalization. Has pain interfered with the following=blank. Laxative ordered blank. Side effects/adverse consequences experienced blank. -1/5/11 Been on scheduled pain regimen in last five days=yes; received prn pain medications in last five days=no and received non-medication interventions for pain in last five days=yes. Pain or hurting in the last five days=yes; how much of the time have you experienced pain or hurting in last five days=occasionally; over the past five days, has pain made it hard for you to sleep at night=no; over the past five days, has the pain limited your day to day activities because of the pain=no; location of pain joint, knees, prior history of pain/hurting=blank. Potential underlying causes (arthritis). Numeric rating scale present pain=0. Numeric rating worst pain/hurting gets=8-10. Best pain/hurting gets=0. Goal for managing pain or hurting=0. Satisfied with current level of pain/hurting control=yes. What relieves pain/hurting=rest, position, medication administration. Describe quality of pain/hurting=tenderness, soreness, throbbing. Timing and contributing factors=not applicable. Manner of expression of pain and associated symptoms=verbalization. Has pain interfered with the following=blank. Laxative ordered prn only. Side effects/adverse consequences experienced blank. -3/18/11 Been on scheduled pain regimen in last five days=yes; received prn pain medications in last five says=no and received non-medication interventions for pain in last five days=yes. Pain or hurting in the last five days=yes; how much of the time have you experienced pain or hurting in last five days=occasionally; over the past five days, has pain made it hard for you to sleep at night=no; over the past five days, has the pain limited your day to day activities because of the pain=no; location of pain joint, knees, prior history of pain/hurting=blank. Potential underlying causes (arthritis). Numeric rating scale present pain=0. Numeric rating worst pain/hurting gets=10. Best pain/hurting gets=0. Goal for managing pain or hurting=0. Satisfied with current level of pain/hurting control=yes. What relieves pain/hurting=rest, position, relaxation techniques, medication administration. Describe quality of pain/hurting=tenderness, stabbing, soreness, throbbing. Timing and contributing factors=not applicable. Manner of expression of pain and associated symptoms=verbalization. Has pain interfered with the following=blank. Laxative ordered routine stool softener. Side effects/adverse consequences experienced blank. Initial plan-monitor pain every shift. -10/24/11 Been on scheduled pain regimen in last five days=yes (Flector patches daily), received prn pain medications in last five days=no and received non-medication interventions for pain in last five days=no. Pain or hurting in the last five days=yes; how much of the time have you experienced pain or hurting in last five days=frequently; over the past five days, has pain made it hard for you to sleep at night=yes; over the past five days, has the pain limited your day to day activities because of the pain=no; location of pain joint (knee), prior history of pain/hurting=yes. Potential underlying causes (old war injury, gunshot wound per resident, no scarring noted). Numeric rating scale present pain=06. Numeric rating worst pain/hurting gets=10. Best pain/hurting gets=3. Goal for managing pain or hurting=0. Satisfied with current level of pain/hurting control=no. What relieves pain/hurting=medication administration, other (topical patches). Describe quality of pain/hurting=aching. Timing and contributing factors=exercise, mobility range of motion. Manner of expression of pain and associated symptoms=verbalization. Has pain interfered with the following=sleep. Laxative ordered routine, stimulant laxative. Side effects/adverse consequences experienced blank. (4) Physician/nurse practitioner (NP) progress notes disclosed there were no physician/NP notes after 6/16/11 until 10/25/11 (during survey). The notes revealed: -11/1/10 Positive for joint stiffness. Mobilizes in wheelchair (w/c). -11/17/10 Positive for joint stiffness and limb pain (bilateral knee pain). Negative for back pain. Mobilizes in wheelchair (w/c). -11/19/10 Positive for joint stiffness and limb pain (bilateral knee pain). Negative for back pain. Mobilizes in wheelchair. Tenderness noted in knees. -11/22/10 Complains of joint pain, muscle aches. Complains of abnormal gait, localized weakness. Neck muscles normal, range of motion normal. Musculoskeletal-no cogwheeling but only 4/5 strength in upper and lower extremities. Kyphotic. -11/22/10 Positive for joint stiffness and limb pain (bilateral knee pain). Negative for back pain. Mobilizes in wheelchair. Tenderness noted in knees. -1/24/11 Negative for back pain, joint stiffness and limb pain. Tenderness noted in knees. -2/9/11 Negative for back pain, joint stiffness and limb pain. Tenderness noted in knees. -2/22/11 Seated comfortably in chair, no distress. Musculoskeletal-arthritis knees. DJD ([MEDICAL CONDITION] joint disease) knees. Will increase [MEDICATION NAME] to 2 tabs every six hours to see if this gives him some more pain relief. -3/28/11 Medical history is positive for knee pain. Negative for back pain, joint stiffness and limb pain. Crepitus. Tenderness, Effusion. Tenderness noted in knees. -3/30/11 Presents with knee pain. Patient notes joint pain. This has been a problem for the past many years. He describes the discomfort as moderate in severity. Symptoms have been managed with current treatment. Primary joints affected include the knees. Aggravating factors include inactivity. Associated symptoms include joint stiffness and swollen joints. He denies associated redness or joint warmth. Musculoskeletal positive for arthralgias and (knees) joint stiffness. Negative for back pain or limb pain. Tenderness noted in the knees. [MEDICATION NAME] was changed from 5/500 to 5/325 mg to avoid overdose of [MEDICATION NAME]. Recommendations include avoid kneeling, squatting and active range of motion. -4/1/11 Negative for arthralgias, back pain and myalgias. No tenderness in major joints. -6/3/11 Negative for back pain, joint stiffness and limb pain (complains of knee pain). Tenderness noted in knees. -6/16/11 Continues to have knee pain and failed increased dose of medication (narcotic) due to tiredness. Musculoskeletal-arthritis knees, with DJD in knees, will [MEDICATION NAME] today. On 10/23/11, physician notes for the past year were requested from the medical records staff. Review of documentation sent by the facility on 10/26/11 (following survey exit 10/25/11) by fax disclosed: -10/25/11 Physician note-patient with bilateral knee [MEDICAL CONDITION] bone on bone and [MEDICAL CONDITION] with dementia. He has failed on injections, topical treatment. In the past, he was tried on [MEDICATION NAME] routinely with increased confusion and agitation. Will cautiously try low dose of routine [MEDICATION NAME] (he has [MEDICATION NAME] prn) if patient has increased psych issues, will need to back off again. -10/25/11 Physician order [REDACTED]. (5) Review of therapy notes Therapy notes (PT/OT) notes were requested from the medical records staff on 10/24/11. There were no therapy notes dated after 1/12/11. -10/16/10 Occupational therapy (OT) evaluation-knee pain with dull ache/stiffness, neck pain and stiffness. Pain present-neck pain with rotation movement (hurts a little bit-using the faces scale). -10/16/10 Physical therapy (PT) evaluation-knee pain with dull ache/stiffness, pain none at rest, pain present with gait, unable to rate. -11/11/10-11/17/10 OT weekly therapy progress-no documentation regarding pain experience. -11/29/10 OT evaluation-no pain. -12/28/10-1/3/11 OT weekly therapy progress-complains of knee pain. -12/31/10-1/7/11 PT weekly therapy progress-no documentation regarding pain experience. -1/12/11 PT evaluation-pain present-eye pain from strain, severe unable to rate (both knees day and night). 3. Interviews On 10/20/11 at 2:40 p.m., the regional nurse consultant (RNC) revealed the resident was independent with ADLs (activities of daily living). On 10/24/11 at around 11:15 a.m., the director of nursing (DON) and regional nurse consultant (RNC) were interviewed. The DON revealed the resident had not been getting [MEDICATION NAME] prn and had no scars from a war injury. She said the resident received [MEDICATION NAME] this morning after the surveyor talked to her about the resident's pain and said staff would make sure they were assessing him regularly for pain. She said [MEDICATION NAME] prn was effective this morning. The DON revealed the resident's physician saw the resident today and changed his orders for pain management (see above). On 10/24/11 at 1:40 p.m., a licensed nurse revealed residents were to be assessed for pain but she did not know where to document the assessment other than the prn pain flow sheet. She said she asked residents only when they had routine medications. -She checked the prn pain flow sheet and said the facility used to require nurses document pain assessment every shift but did not know when or how the documentation requirements had changed. -She said she did not routinely assess residents for breakthrough pain and did not know where that kind of documentation might be. She said the prn pain flowsheets were a new kind of sheet for documenting prn pain meds. -She checked the 10/11 MAR and said the resident received [MEDICATION NAME] one tab at 9:45 a.m. on 10/24/11, which was effective and the resident reporting no pain. A certified nurse aide (CNA) revealed on 10/24/11 at 1:50 p.m., when residents complain of pain, she checks the resident for positioning, and tells the nurse about the pain. She said resident #50 complained of knee pain and she told the nurse when he complained. She said the resident required some assistance with ADLs. Three licensed nurses were interviewed on 10/24/11 at 2:10 p.m., -one nurse revealed she worked on the acute skilled care side, not long-term care. She assessed and documented pain on the daily skilled nursing notes. -another nurse revealed she sometimes floated to the long-term care side of the facility and said pain assessments were supposed to be documented in the nursing notes if the resident was having pain. She said occasionally there is an order for [REDACTED]. Another licensed nurse disclosed on 10/24/11 at 2:30 p.m., that nurses were supposed to assess and document every shift on the resident's pain level. She then checked resident #50's MAR and could not find documentation of the resident's pain level. The nurse said, "I guess we do not do it for him." She said she did not know where the nurses were supposed to document pain assessment/intervention unless it was on the MAR. She revealed she was not aware of non-pharmacological interventions for the resident. On 10/24/11 at 4:15 p.m., the unit manager (where resident #50 resided) revealed the resident complained of pain in his knees and had a hard time sleeping per the pain assessment done today. She said she made sure the resident received a dose of [MEDICATION NAME] prn after the pain assessment and checked later and the resident said he had no pain after the medication was given. She said she would have to look into how the facility wanted nurses to document pain assessments to ensure the resident's pain was managed adequately. B. Staff Assistance Resident #5 Resident #5, age 49, was admitted to the facility on [DATE] with diagnoses, according to the face sheet of:[MEDICAL CONDITIONS], hypertension (HTN), allergic rhinitis, spasm of muscle, [MEDICAL CONDITION] bladder, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. The 9/6/11 quarterly Minimum Data Set (MDS) documented that the resident was able to understand what was being said to her and was able to make herself understood. The resident scored a 15/15 on the Brief Interview for Mental Status, which indicated that she was cognitively intact. The resident needed supervision for eating, limited assistance with locomotion on and off the unit, she needed extensive assistance with bed mobility, dressing, toilet use, and personal hygiene, she was totally dependent with transfers. a. Record Review The 1/20/11 sling care plan documented, "Pt. to use sling provided by family for transfers r/t (related to) dx ([DIAGNOSES REDACTED]." The approaches were: "Pt. will be comfortable during all transfers. Monitor pain & placement of sling during transfers." The 6/23/11 transfers care plan documented that the resident had a potential for injury because of an impairment to self-transfer related to: -weakness -predisposing diseases -[MEDICAL CONDITION] -Scoliosis -Dislocation of L hip -Mechanical lift -Sling type (has her own) -(Transfers) to and from bed/to and from chair The pertinent approaches were: -Encourage resident to obtain assistance for transfers -Provide mechanical lift for transfers -Full body lift -Transfers to and from bed/chair -Provide appropriate sling, has her own sling -Interdisciplinary referral PRN -Educate resident to mechanical lift -Educate family to mechanical lift -Use calm, patient approach when using mechanical lift The 6/23/11 Activities of Daily Living (ADL) care plan documented that the resident required staff assistance and intervention for completion of ADL needs. She required extensive assistance, utilizing one to two staff members. The pertinent approaches included: -Allow individual adequate time to complete tasks -Refer to therapy services as indicated -Individual/caregiver education as needed -Has electric w/c for mobility The 5/6/11 Concern Form documented, "(A Licensed Practical Nurse LPN) always does it right (changing her [MEDICATION NAME]) with different staff on A hall unit is it possible for (the LPN) to inservice other staff." The section regarding whether the concern was previously voiced or not was left blank. The resident wanted to meet with someone about the concern. The Unit Manager/Restorative Nurse/SDC met with the resident regarding her concern on 5/10/11. She completed the Concern Form - Action section on 5/11/11. It documented, "Spoke with resident who states it is only one new eve nurse who needs trained. Training is set up for this employee. Resident to let unit manager know if anyone else requires training." b. Resident Interview During an interview with the resident on 10/18/11 at 3:38 p.m., she stated, "I feel like I am the one that train the staff on how to work with me because my care is specialized due to my medical history. I do not have a hip and moving me can be a challenge. I just wish the staff would train the staff how to work with me, I do not want to have to train people all of the time. Also some of the newer staff members do not like to be told what to do and then when I tell them what to do, because I know me and know what they need to do, they get upset." During another interview with the resident on 10/24/11 at 4:00 p.m., she stated she would like for the staff to be trained by the facility prior to working with her. When someone new came in to work with her, the resident said she felt like they were intimidated because of all of her medical complications [REDACTED]. missing hip, a shorter leg, suprapubic catheter, etc). She stated that in the past, she had brought up videotaping herself so that the staff could be trained on how to take care of her prior to being placed on the floor to work with her. The Director of Nursing (DON) had spoken with her regarding training. The resident said the DON stated that it had never occurred to her that staff should be trained specifically on how to work with the resident. c. Staff Interview During an interview with the DON on 10/24/11 at 12:11 p.m., she stated that if residents needed special care, therapy may get involved and train the staff. Regarding the sling care plan she stated, " ... If it is something new we will train the staff on that. I think that the sling is pretty old, I will have to look into that though." During another interview with the DON on 10/25/11 at 9:52 p.m., she stated, " ... I do rounds two times a day to ensure that staff is providing care correctly. I have assisted with care for the resident (when they are turning her related to pain). She is up in the morning and then gone to work and will come back late in the evening. I will at least say hello daily, I do not always have time to stop and talk..." -The DON said the resident had never voiced any concerns to her regarding the training of staff with cares, and there were no concerns from staff regarding providing care for the resident. The DON stated that upon researching the training issue, she had discovered that the last training on the resident's sling was about five years ago, when she first got to the facility. The DON could not answer whether the staff was trained on using this sling, specifically. During an interview with the Activity Director (AD) on 10/25/11 at 10:18 a.m. (who was the resident's ambassador), she stated that the resident had spoken with her regarding her feelings that she was the one that was training the staff on working with her. -The AD said the resident had some tricks on how to work best with her and she would teach the staff how to do it when she had room changes and was working with new staff. The AD said the resident had not told her that she would prefer for the facility to be showing the staff how to work with her instead of having to do it herself. -The AD, when asked when the resident had first talked to her about feeling like she was training the staff, stated, "I think that it was the last move from the J&M hall to the A hall that she talked to me about feeling like she had to train the staff on working with her. I think that was approximately a year and a half ago ... The resident does not come to her care conferences; her mom comes. The training issue may have been brought up in the past but I am not sure ... The resident did have a concern in the past regarding training. She had a favorite staff member that worked with her the way that she wanted her to and she wanted the staff member to train others. I did write a concern form and the staff member was asked to train other staff members." -The AD said, "I do think if she wanted it to happen every time that there was a new staff member, she would need to write a concern form every time ... With different shifts, staff changing, and so on, (training) does not happen every time but it is do-able and we can do it ..." During an interview with the Unit Manager/Restorative Nurse/Staff Development Coordinator on 10/25/11 at 10:40 a.m., she stated that she observed the certified nurse aides (CNAs) providing care for the residents all of the time. -She said the last time that she observed care for the resident was that morning for a part of the time but for the entire care session, it was a couple of months (ago). "... She stated, "The resident is very particular in how she wants things done. Most of the time, she will tell the staff how she wants her care to be done. Most of the time, the staff will do what she wants." -She further stated, "(The resident) does tell people that she trains the staff on how to work with her. In May, she asked for a nurse to train the staff on how to change (her) [MEDICATION NAME] as (that nurse) did it correctly and she wanted others to be trained by that nurse. The nurse then did train an evening nurse that the resident wanted to be trained. The SDC told the resident that she could train staff members on working with her but that the resident would need to tell her who needed to be trained as the resident had a habit of telling people step by step how to do her cares even if they worked with her daily." On 10/25/11 at 11:45 p.m., the SDC followed up regarding the sling care plan that stated that the staff was to be trained on use of the sling from January of 2011. She stated that it was an old care plan that had been re-written and that was not currently being used. She stated that the care plan had been initiated i

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision for one of three sample residents (#1). Specifically, staff failed to secure hall C during a fire drill (on 6/13/11) and resident #1, identified as a wanderer, pushed open an exit door on hall C and fell down a flight of steps. The resident sustained [REDACTED]. A concern was filed with the health department regarding this event. An onsite visit occurred on 6/28/11 to the facility. This event had not been reported to the state occurrence line for incidents in the facility (cross-reference F225 for lack of reporting to the state). The findings include. Resident #1, [AGE] years old, was admitted to the facility on [DATE]. According to the face sheet, the medical [DIAGNOSES REDACTED]. 1. Resident #1's residence The resident was admitted to the facility's D hall on the Northwest unit (rehabilitation wing). This unit consisted of three hallways: C, D and E. Observations on 6/28/11 revealed hall C was not visible from the nurses' station. Upon entering hall C, there were fire doors located towards the entrance of this hall. Upon initial entrance, the resident rooms were not visible. The hallway veered to the left and then straightened out to the end of the hall where it opened into a day room, approximately 65 feet long. The day room was not completely visible unless someone walked down hall C, turned to the left and visually checked the whole room. The exit door on hall C was alarmed and locked with a key code entry pad. This door was located at the end of hall C and was visible from the straight portion of the hall (after the turn to the left). Posted on the exit doors, there was a key pad code for staff to enter codes which would unlock the door. Posted on the door, "Exit door - Emergency exit only - push until alarm sounds, door can be opened in 15 seconds." The door would be pushed inward to open onto a stairwell. There was an upper landing and then 10 steps down to a lower landing. 2. Resident #1's status prior to 6/13/11 a. Record Review Closed record review of sample resident #1 identified the resident as a wanderer with dementia. An alert bracelet was placed on the resident for exit seeking behaviors. The resident experienced a change in condition 6/10/11. -On 3/22/11, the physician ordered a wander guard for safety. Also, the resident had a safety alarm (no order) due to fall risk. -The 3/29/11, elopement risk review showed a score of 10. A score of 12 or higher is 'at risk' for elopement. -Review of a 3/21/11 resident care plan identified problems with loss of short- and long-term memory related to dementia. Handwritten on this care plan was the following information, "confusion, disorientation, forgetfulness, decreased ability to make self understood and impulsive, behaviors may be associated with not being understood." The goal of this care plan was for the resident to be able to identify his room and for effective communication related to needs. -A 4/8/11, toileting care plan directed staff to assist the resident with toileting upon rising, before and after meals (last reviewed on 6/10/11). -A 3/8/11, elopement care plan (last reviewed on 6/10/11) revealed the resident wandered due to dementia. On 5/16/11, the resident attempted to follow his wife outside the door. Approaches included the use of a wanderguard, orientation to environment and redirection, observations of elopement attempts, provide safe location for wandering behaviors, increase observation of individual during and after visitors and check placement of safety devices. -A 3/8/11, wandering care plan (last reviewed on 6/10/11) revealed the resident wandered related to dementia. Approaches included observing for safety risks, wandering into other rooms, constant wandering without rest and exit seeking behaviors. -According to the 5/27/11 Minimum Data Set, the resident had memory impairments, no behaviors and required supervision with locomotion. -According to hospital report, on 6/10/11, the resident was seen in the emergency room and diagnosed with [REDACTED]. The resident had been lethargic, irritable and refusing to eat on 6/7/11 and a urinalysis was ordered. b. Interview On 6/28/11 at 2:47 p.m., the Unit Manager (UM) for C, D and E halls was interviewed. The UM stated sample resident #1 was pleasantly confused, friendly and had dementia. Staff would anticipate his needs. The UM stated the resident liked to look out windows, enjoyed the sunlight and watched the birds. The resident was wheelchair dependent and could self propel in the facility. She stated the resident wore a wanderguard (a device worn to alert staff if he would attempt to leave the building), but was not a flight risk. She also stated that it was typical for the resident to go down hall C and sit in the day room looking out the windows. On 6/30/11 at 10:53 a.m., the UM stated again, 'the resident liked to hang out in the day room (at the end of C hall) and look out the windows.' On 6/28/11 at 12:25 p.m., one resident care specialist (RCS) who was familiar with the resident, stated resident #1 wandered and was very confused. The resident liked to sit in the day room by the window (on hall C). 3. Unannounced Fire Drill 6/13/11 On 6/13/11, the facility conducted an unannounced fire drill at the facility, starting around 6:29 p.m. The dinner meal was over with some residents still residing in the dining room or having just left the dining room. Review of the 6/13/11 staffing assignment sheet for the facility showed two aides and two nurses were working on halls C, D and E at the time of the fire drill. Four residents resided on the C hall. Nine residents resided on D hall (including resident #1) and seven residents resided on E hall. At 6 p.m., there was a staff change and one aide left and another aide started working on the unit. The staff member that started on this unit at 6 p.m., took over hall D. Specific assignments were made for halls D and E, but hall C coverage was shared among all four staff members. (Confirmed through interview with Registered Nurse #2 - see below) Through interview, on 6/28/11 at 11:55 a.m., with a RCS who worked on 6/13/11 and had just started at 6 p.m. on this unit, the resident was last seen around that time in the dining room. Record review showed the last charting of the resident occurred at supper time (meal intake). The Nursing Home Administrator, interviewed on 6/28/11 at 3:28 p.m., stated that the fire drill was planned through the Environmental Director and usually the alarm was disabled. The alarm system was transferred off-line (so the fire department would not show up for their drill). The facility system was taken offline around 6:25 p.m. and the alarm was pulled at 6:29 p.m. The fire (simulated) was located on halls A and B. Both nurses from halls C, D and E went to halls A and B to help while the aides secured the halls on C, D and E. The NHA clarified staff would close resident doors and ensure residents were in their rooms. The aides secured halls D and E. Upon return to the unit, one nurse returned a resident to hall C and did a visual check of the hall, which seemed clear. Around 6:38 p.m., a staff member from the Assisted Living unit (directly below the long term care unit) heard a loud noise at the back stairwell (hall C) and saw resident #1 on the ground at the bottom landing. The staff member immediately went up to the skilled nursing facility and found nursing staff at the station. Medical assistance (resident not moved) was provided and 911 called. The resident was transported by the paramedics to the hospital. According to hospital records, the resident sustained [REDACTED]. 4. Failure to secure C hall during the fire drill on 6/13/11 a. Facility Expectations (at the time of the fire drill on 6/13/11): (1) Policy and Procedure Review Review of the facility's fire emergency procedures revealed that fire drills were to be held at least once a month to help ensure that all staff on all shifts participate in drills each quarter and become familiar with procedures in case of an actual fire emergency. Procedures were grouped around the word 'RACE:' Rescue (removing residents from immediate danger), Alarm (activity the fire alarm system), Contain (moving residents and equipment out of hallways), and Evacuate (moving residents from the involved area). Each drill was to be responded to as if it was a real fire emergency. Understand that the level of reaction will be greater during a 'real' emergency. The staff must also understand that a high level of confusion and anxiety will exist during a 'real' emergency, and practice is the only way to minimize problems. Staff members were expected to: "Place the RACE program into action..Confine - After removing endangered residents, close the doors of the threatened room or area. Close smoke/fire doors when exiting each area ..." (2) Interview On 6/28/11 at 2:47 p.m., the UM (for C, D and E halls) was interviewed. -The UM stated her expectations during a fire drill were as follows: staff should follow the RACE procedure, collect the residents and place residents behind fire doors; a staff member should stay behind each fire alarm door. The unit would be cleared and secured and then a staff member would announce all clear overhead. The staff member would be responsible for making sure the halls were clear and maintain oversight of the hall. On 6/28/11 at 2:58 p.m., the Staff Development Coordinator also stated the alarmed exit doors disengage during a fire drill/alarm (Alarms sound throughout the facility but one would not be able to discern if a door was opened during an actual alarm/drill). On 6/28/11 at 3:28 p.m., the NHA was interviewed. He stated nursing staff should not leave their unit (as part of the facility policy) during a fire alarm and the RNs provided oversight to the residents. The NHA stated the doors release (unlock) upon a fire drill/alarm and was part of life safety code. b. Failure to secure C hall during the fire drill on 6/13/11 as expected Interviews with staff that worked the C, D, and E halls 6/13/11, as well as administration, revealed that when the fire alarm was pulled, both nurses left their unit without first securing the residents on their unit. No staff member secured hall C, and hall C was left unattended during the drill. (1) RN #1 On 6/28/11 at 3:12 p.m., Registered Nurse (RN #1), (working the evening of 6/13/11 on halls C, D and E) was interviewed. The RN #1 stated there were three other staff members working on this unit the night when the alarm sounded. -RN #1 stated that when the fire alarm went off, he looked at the fire panel next to the nurse's station and saw the fire alarm was on halls A and B. Both nurses left the unit to proceed over to halls A and B to see if help was needed. The RN stated they wanted to confirm if this was a drill or if a resident pulled the alarm (which had happened previously this month). When halls A and B were secure, the RN stated both nurses returned to the unit. Some residents were assisted from the dining room that resided on halls C, D and E. -RN #1 stated he returned one resident to her room on hall C and did a visual check of the hallway. The RN did not conduct a walk through down the hall to ensure all residents were secure or if the hall was secure (closing doors to resident rooms). -RN #1 stated he returned to the nurse's station and did not provide supervision for hall C. Halls D and E did receive direct supervision from a staff member; however, no staff member remained behind the fire doors of hall C to monitor the hallway. (2) RCS On 7/5/11 at 3:33 p.m., a RCS who worked 6/13/11 during the fire drill was interviewed. -She stated she secured the D hall (her primary assignment) and did not go down the C hall, because RN #2 stated RN #1 went down the hall. The RCS stated a staff member was supposed to stay on the individual hall during a fire alarm, but RN #1 came back to the station and sat down. -The RCS stated if you don't go down C hall, you can't see the area (referring to the day room). The RCS stated the resident seemed to be wandering more that day and was more confused. The RCS stated she last saw resident #1 in the dining room. (3) RN #2 On 7/6/11 at 9:50 a.m., RN #2 was interviewed. -RN stated she felt RN#1 was a little unsure of what to do when the fire alarm sounded on 6/13/11, so they proceeded together through the process of looking at the fire panel, walking to the other unit and fire procedures. -RN #2 stated they left the unit when the alarm sounded to check if a resident had pulled the alarm by accident or if it was a drill. RN #2 stated residents on halls A and B had pulled the alarm before. -RN #2 stated all staff split hall C (four staff) and not one specific person was assigned to cover the hall (with D and E halls, there were individual assignments). -RN #2 stated RN #1 went to hall C to return a resident into her room. When asked about resident #1, RN #1 stated the resident wandered due to his dementia and could self propel around. RN #2 said she saw the resident in the dining room and had administered his evening medications. (4) Nursing Home Administrator (NHA) The NHA was interviewed, on 6/28/11 at 10:58 a.m. and again at 3:28 p.m. -He stated the nurse (RN #1) was responsible for securing the halls and they were not completely secure on 6/13/11. He said a staff member should have secured the C hall. He stated that on 6/1/11, a resident on hall A had pulled the fire alarm and that was the reason the nurses (covering halls C, D, and E) went to investigate. -He stated he was not sure why staff did not know where resident #1 was the evening of 6/13/11. c. Failure to ensure all staff received training on emergency procedures, including fire safety (1) The NHA, during the interview on 6/28/11 (see above) stated RN #1 had transferred to the facility from a sister facility about a month ago, but did not go through general orientation at this facility. Fire safety was instructed to employees during general orientation. (2) Interim Environmental Director, during an interview on 7/5/11 at 1:01 p.m., stated employees receive training on fire safety through general orientation and the facility policy would be reviewed during this time. Also, employees would walk through the building for a tour of fire exits and extinguishers. 5. Facility follow-up after the incident on 6/13/11: At the time of the surveyor entrance on 6/28/11, the facility shared parts of their investigation with the survey team. The facility shared typed staff interviews, the revised facility policy, reasons for not reporting to the state and in-services/fire drills the facility had conducted since the occurrence on 6/13/11. On 6/28/11 during a 3:28 p.m., meeting with the NHA and Director of Nursing (DON), they stated that after they were contacted about the incident both of them returned to the building. The team met that night to review the incident, review the policies and involved the Medical Director. A new component was added to the policy which included staff conducting a head count and checking stairwells. Staff would remain on the unit (behind the fire doors), observe all doors and check around corners. Review of the new facility fire policy (undated) for "Fire," revealed that "RACE" (rescue, alarm, confine, evacuate/extinguish) procedures, specifically "Confine," now read, in pertinent part: "Check all stair wells, elevators, and exit doors at the sound of the alarm. During the fire drill procedure at least one staff member must remain on each hall to monitor conditions. Reminder in the event of a fire or disaster drill all doors to the building will automatically unlock and will need to be monitored for resident safety. After the all clear is announced re-check the elevators, stairwell doors and exit doors . . . A charge nurse for each unit will conduct a facility head count utilizing a report sheet or resident roster to validate all residents are accounted for and safe." Fire drills were conducted, on 6/23/11 and 6/24/11. In-services about the revised fire policy were initiated on 6/14/11. On 6/30/11 at the 10:58 a.m., meeting with the NHA stated the issue with the staff member not attending facility orientation was discussed in QA, but no further information was shared. There was no documentation presented that revealed the orientation of staff that transferred from a sister facility had been revised to ensure staff would be educated and tested for competency on emergency safety procedures prior to beginning on-site employment.

Based on observation, record review, resident and staff interviews, the facility failed to provide adequate supervision to prevent an accident for one of 10 sample residents (#6). Specifically, on 12/27/10, sample resident #6 was not properly secured in the van when being transported back to the facility from a physician's appointment. The resident fell backwards and hit her head. The resident complained of pain at the time of the fall. Immediately after the fall in the van, the facility transported the resident back to the building in the van unsecured on the floor. The distance to the facility from the scene of the incident was 7/10 of a mile (one turn onto the street of the facility). Upon arrival back at the facility, the physician was called and the resident was transported to the hospital via ambulance and experienced pain for several weeks. In addition, a previous incident occurred in February 2010, where the facility van driver failed to secure the resident before transporting the resident in the van. The resident fell back in the van. Review of the state reporting system showed the facility had reported the incident. The findings include: On 1/10/11 at 12:45 p.m., sample resident #6 was interviewed about the incident. The resident made the following comments, "as far as I know, she did everything she was supposed to do, strapping me down. I don't know." She said the administrator told her the van driver missed a step. She recalled the chair tipping back and hitting the ground with her head, "there was pain." She thought the ambulance would be coming, but the administrator and nurse showed up. The resident recalled the administrator told them to head back to the facility and "then call the physician." The resident stated, "I was uncomfortable on the floor, unrestrained, something could have happened to me on the way back." The resident stated they sent her out by ambulance after her return to the facility and she spent about six hours in the hospital. The hospital transferred her back to the facility that evening and staff had to wake her every two hours for neurological checks. The resident stated she experienced hip pain the next morning and was sent out for x-rays (ultimately negative for a fracture). The resident felt something was still wrong with her hip (documentation showed staff was assessing for pain). I. Facility Expectations and Policies Review of the resident transport policy read in pertinent part, "The facility should take every precaution to ensure the safety of the resident at all times during transport. Consistent safety practices are crucial to minimizing vehicle-related exposures and injury ... The safety guidelines in the Facility Vehicle Safety program manual should be followed regardless of the vehicle used for transport ... 5. Prior to every trip, inspect the vehicle. a. If using the facility vehicle follow procedure in Facility safety program manual ... 6. Secure the resident. a. If using the facility vehicle, follow securement procedures in facility vehicle safety program manual." Review of the securement checklist document was reviewed in pertinent part, "Complete this form each time you place a resident in a wheelchair in the van. This means each segment, including the trip to the destination and the trip from the destination. Remember: Every resident, every trip gets a completed checklist. Pre-securement steps 1. Check that you have all the equipment you need for this trip. 2. Are the securement tracks clean and free or debris? 3. Is all the equipment above in good condition? Securement steps 1. Get wheelchair into position and lock wheelchair brakes. 2. Front strap securements - 2 straps are required. a. Anchor straps on the floor track 3" outside front wheels. b. Ensure straps are at a 30-45 degree angle. c. Secure close to the seat surface, to a welded junction. d. Ensure track fittings and straps are secure by pulling on them ... 4. Ensure all 4 track fittings are positioned in correct orientation with release facing away from the wheelchair. 5. Unlock w/c brake. Check that wheelchair does not move more than 2" in any direction. If needed, re-tighten straps and test again. 6. Lock the wheelchair brakes. Final Check 1. Two front straps 30-45 degree angles ... 3. All straps are not touching any adjustable or removable parts of the wheelchair. No straps are attached to the footrests, armrests, or wheels." Review of the Facility Vehicle Safety Program revealed in pertinent part, "Consistent safety practices are crucial to minimizing vehicle-related exposures and injury ... Pre-trip checklist: Prior to each trip in the van the driver should review the Pre-trip checklist found in this book. 2. Motor Vehicle Record questionnaire - complete annually for every employee who will be operating the facility vehicle and file in the employee personnel file (however, this could not be located for the van driver of this incident). Resident Securement - 11. Lock the wheels of the wheelchair. Locate the rear and front belts for securing wheelchair to the floor. 12. Ensure latch is positioned in correct orientation with the release tab facing away from the wheelchair. 13. Tug on the strap after having latched it to ensure it will not pop out. 14. Make sure both front and back straps are placed on wheelchair and that the strap goes around the frame of the chair not the wheel. 15. Ensure all straps are pulled tight. 16. Make sure the resident has a lap seatbelt around them that is pulled across the residents lap under the wheelchair armrest to fit snugly. Pre-trip checklist - Is everyone secure?" II. Review of the Medical Record: Sample resident #6, [AGE] years old, was admitted to the facility on [DATE]. According to the medication administration records, the medical [DIAGNOSES REDACTED]. Review of the 4/13/09 resident's care plan noted the resident was non-ambulatory, wheelchair bound and required a mechanical lift for transfers. A. Review of the medical chart (nurse entries in order) revealed: On 12/27/10 at 1:00 p.m., the nurse documented, "incident occurred at 1230 (12:30 p.m.); this writer received call for need of assistance with incident. Upon arriving to stoplight of Drake and Lemay found resident's w/c (wheelchair) tipped backwards. Resident still in w/c, back straps of bus still attached to w/c. Front straps detached still in rail. Neuro (neurological) checks WNL (within normal limits) - no visual injuries noted. C/O (complained of) pain to back of head, shoulders, back and hips. Accompanied resident back to facility - resident in sitting position on bus floor. Upon arrival received assistance x2 aides; Viking lift to assist back to w/c. Neuro checks continued. V/S (vital signs) 154/80, 18, 91, 97.6. O2 (oxygen saturations) sats at 3 L (liters) via N/C (nasal cannula). Notified MD on call for (MD name), (name of guardian) LPN (Licensed Practical Nurse) left message - Not available, obtained orders to send to (hospital name) ER (emergency room ) for evaluate and treat. Sent via stretcher to ER for eval (evaluate and treat). Sent via stretcher to ER." On 12/27/10 at 9:00 p.m., the nurse documented, "VS 148/79, 96.9, 80, 20, 96% O2. Resident c/o pain to head - gave pain med with results. Increase appetite. Order from (hospital) to f/u (follow-up) with (name of physician). Resident resting in bed with eyes closed. Call light within reach and able to make needs known." On 12/28/10 at 4:45 p.m., the nurse documented, "VS 130/80, 98.3 - 79 - 18 - 93% 3L. Received in report that res(ident) reported hip pain and fax was sent requesting an x-ray. Received fax back to do Left hip x-ray at (name of x-ray office). Resident was transported to (office name) via non-emergent ambulance." On 12/28/10 at 7:00 p.m., the nurse documented, "received call from POA (power of attorney) stating that resident is at (hospital name) due to a fractured hip. Dr.'s office was called for clarification and (MD name) reported that she felt left hip could possibly be fractured. The Dr. stated the radiologist felt it is degenerative joint disease. (MD name) stated she decided to admit resident to (hospital name) orthopedic floor due to suspicious x-ray and because resident told her that she has not been able to stand or bear any weight today." On 12/29/10 at 11:45 a.m., the nurse documented, "all x-rays negative for any fx (fracture) or dislocation." On 1/12/11, the resident saw the physician. The notes were reviewed in pertinent part, "With regards to hip pain - (resident name) complains of left hip pain. The location of the pain is deep. It does not radiate. She describes it as severe and constant. The initial onset of pain was three weeks ago. The apparent precipitating event was a fall; pt. was riding in the van and her wheelchair was not strapped in well enough and pt. fell backwards in her wheelchair in the van. Aggravating factors include any movement ... The resident received an arthrocentesis/ injection for hip pain." Review of the December and January medication administration records (MARs) showed the resident received the following medications for pain relief - a medication for muscle spasms routinely, a lidoderm patch to lower back and shoulder routinely, hydrocodone every evening, Tylenol ES and hydrocodone as needed (prn) for pain. Review of the documentation showed nursing staff was assessing pain levels and administering medications as resident allowed (cross-reference Tag F514 regarding incomplete documentation with medication administration). B. Observations of the Resident: On 1/10/11 at 8:40 a.m., sample resident #6 was observed in her wheelchair. The resident sat in a wheelchair (appropriate for her height and weight) with foot rests and no anti-tippers. C. Review of the facility's investigation and employee record: On 1/10/11 at 4:30 p.m., the facility's investigation was reviewed. Through the facility's investigation, the driver was ill and had not filled out the securement log. The interim NHA stated the corporation had an internal certification program and the van drivers were expected to perform the securement check with each transport and fill out the log. The interim NHA stated the van will be modified to lengthen the straps to accommodate wider wheelchairs. The interim NHA stated the van drivers were expected to remove the buckles, from the floor strip each time, to ensure the mechanism was re-applied appropriately. The corporate risk manager was also out to the facility and assessed the situation. The interim NHA stated the pin would need to be down all the way for the ties to be secure. The facility concluded the incident was operator error as the resident had not been fully secured and no pre-trip inspection had been completed. Review of the employee file showed she had received training on 10/14/09 and 2/22/10 for transport safety. There was no evidence the employee completed a motor vehicle record questionnaire, according to their safety policy. D. Staff Interviews: On 1/10/11 at 11:35 a.m., the previous van driver (involved in this incident) stated she received van training from the previous van driver and corporate. The van driver related the following comments: she mentally performed her seven point check when securing the resident in the van. The mechanism had to be just right for it to lock. When they were about one block from the facility, as she was turning a corner, the resident's wheelchair tipped backwards and she heard a thump. She stopped immediately. She checked on the resident and the resident was complaining her head hurt. She was frantic, calling 911 and/or the facility. The van driver got through to the facility and the administrator (NHA) was on his way. A nurse and the NHA showed up on the scene. The resident remained on her back (still in the wheelchair) on the floor of the van. The van driver stated the resident's chest/lap belt was still attached around the resident, but the two front hooks were hanging off the front of the wheelchair (the mechanism detached from the floor joints). She does not know how it happened. When the administrator and nurse showed up, the nurse assessed the resident. We attempted to sit her back up in the van, but we were unable to sit her up. The NHA asked me if I could drive back to the facility. The van driver stated she was expecting the ambulance to show up, "but they didn't." The van driver stated she drove back to the facility with the resident and nurse positioned on the floor, out of her wheelchair and unrestrained. On 1/10/11 at 1:30 p.m., the nurse, who showed up at the scene, was interviewed and made the following comments: The nurse stated she accompanied the administrator to the scene and assessed the resident. She checked the resident's range of motion and performed neurological checks. The resident was verbal. The nurse stated the resident complained of pain and said she was hurting in her neck, back and legs. The nurse stated, "I know it hurt." The nurse acknowledged the front straps were in place on the wheelchair without any damage, hanging/dangling. The component detached from the floor. The nurse stated they removed the wheelchair from underneath the resident and helped the resident long sit in the van. The nurse stated she sat behind the resident, supporting her trunk, while transporting her back to the facility. The resident was not restrained. Once they returned to the facility, the physician was called and recommended the resident be sent to the hospital. The resident was sent to the hospital, non-emergent. The nurse stated it was not the protocol to transport the resident that way in the van (on the floor unrestrained). On 1/10/11 at 3:35 p.m., the previous van driver stated she mentally went through her checklist when securing the resident, but the securement book was not in the van to fill out. On 1/11/11 at 8:24 a.m., the regular van driver stated the vans did not have the "check point books," but "now" each van had a book. The van driver stated she had a week of orientation and watched a video for van driver training. On 1/11/11 at 2:05 p.m., the regional clinical director (RCD) stated the administrator would be responsible for providing oversight of the van drivers. The RCD stated there was a previous van incident (in February 2010) and it was a similar situation. With the previous incident in February, the resident fell backwards in her wheelchair while riding in the van. The RCD stated the locks came out of the tracks. The RCD stated the corporation conducted an inspection of the van after the February and December incidents. The van's hardware was checked and noted to be in working order. The RCD stated, with this incident in December, the operator of the van did not perform a pre-trip inspection. Per the facility's protocol, there was no evidence this van driver had received all the training. This van driver did receive in-service related to transportation safety in February 2010. The surveyor had asked the facility if the resident was transported back to the facility appropriately - unsecured and on the floor. The RCD responded it was not the recommendation of how the resident should be transported back to the facility after the incident. The RCD stated the resident could utilize van services again once modifications to the van had been completed. The facility was going to lengthen the locking strip on the floor of the van to better accommodate larger wheelchairs. On 1/12/11 at 10:15 a.m., the RCD stated the previous administration failed to implement disciplinary action (although she was suspended pending investigation and removed from the position) for the van driver and there had been no re-training with the current drivers. The previous Nursing Home Administrator (NHA) was unavailable for interview and no longer worked at the facility.